What Do We Know About Suicide In Military Veterans?

Military veterans are at elevated risk for suicide.

Source: Eric Ward/Unsplash

It is fairly well known that military veterans consistently experience higher rates of suicide attempts and suicide deaths. The most recent Department of Veterans Affairs suicide report shows that the military veteran suicide rate is more than double that of civilians. Another stark fact illustrates the problem: In 2019 about 17 military veterans died by suicide each day. It’s safe to say for many of us that military veteran suicide prevention remains a high priority.

Given the need to solve the military veteran suicide problem, it is not surprising that the topic has been the subject of considerable empirical research in the last 20 years. For instance, a simple search of a leading scholarly search engine (PubMed) using the terms “military veteran” and “suicide” yields 815 unique article hits since the year 2000. The military veteran suicide research literature, however, is quite complicated. A range of topics covered includes identification of risk and protective factors, clinical assessment and screening practices, intervention development, and many others.

Alcohol use is among the few well-documented suicide risk factors for military veterans.

Source: Paolo Bendandi/Unsplash

What Do We Know About Military Veteran Suicide?

Identification of risk and protective factors specific to military veterans is a critical first step. The Department of Veterans Affairs recently commissioned an important review of existing evidence on the subject to risk and protective factors for military veteran suicide. Through a systematic process, such reviews are designed to (1) summarize key findings of, (2) assess potential bias in, and (3) illuminate gaps and future research directions for, a large body of research.

What did the Department of Veterans Affairs investigators find? Disconcertingly, not much in terms of strong evidence for risk and protective factors. Consistent with much of the overall suicide literature, authors of the report concluded the only robust risk factors for military veteran suicide were:

• Prior suicide ideation or attempt
• Depression
• Anxiety
• Substance, alcohol, or tobacco use

Interestingly, post-traumatic stress disorder (PTSD) was not consistently related to suicide among military veterans. I should note a caveat in interpreting these findings. PTSD can be related to an individual’s experience of suicidal ideation or behavior; however, many veterans have PTSD and never experience suicidal thinking or behavior. As such, the report’s conclusions should not be taken to mean that PTSD is never implicated in a military veteran’s experience of suicidal ideation, attempt, or death. The strength of the evidence in the totality of the data is just inconsistent across a large group of studies.

What Steps Can the Suicide Prevention Field Take?

I see two paths to move the science and practice of military veteran suicide prevention forward.

1. Fill the gaps in the research.

Authors of the Department of Veterans Affairs report noted vital gaps in the military veteran suicide research literature. Namely, there is a concerning lack of studies evaluating community- and societal-level risk and protective factors.

A social-ecological approach to suicide prevention accounts for upstream and downstream factors.

Source: BMJ Open/Open Access

A social-ecological view of suicide emphasizes factors beyond the individual person that can impact suicide. For example, community or societal level influences such as healthcare policies, rural geographic region, support systems for community reintegration after separation from the military, public attitudes about suicide and mental health, and a variety of other factors may be associated with military veteran suicide.

The Department of Veterans Affairs report, however, notes that research on such possible contextual factors is lacking. Many suicidologists are of the opinion that suicide prevention for any population absolutely needs to shift attention to the community and societal levels. Next stage military veteran suicide research needs to build the evidence base on the upper levels of the social-ecological model.

2. Capitalize on emerging risk screening and intervention development efforts.

Some of the individual-level factors—such as depression, anxiety, and substance use—linked to military veteran suicide are quite treatable. Also, many recent innovations have taken place in the area of suicide-specific and other therapeutic intervention development. Some of these advancements have been developed with current or former service members. Other novel suicide prevention approaches are based on civilian-focused research, but may be translatable.

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Two suicide-specific therapeutic approaches are Brief Cognitive-Behavioral Therapy for Suicide (BCBT) and the Collaborative Assessment and Management of Suicide (CAMS). BCBT is short-term, 12-session individual therapy developed for active-duty military personnel. Key components of the intervention include tailored understanding of one’s unique risk for suicidal behavior and crisis response planning, mastery of evidence-based coping skills from a cognitive-behavioral framework, and completion of a relapse prevention exercise prior to the termination of therapy. Crisis response planning alone has shown promise to reduce suicide attempts in emergency department patients and military active-duty personnel. CAMS is an adjunctive assessment and intervention framework that targets a veteran’s specific drivers of suicidality. The patient is empowered to take ownership of their treatment through collaborative work with the therapist. Although CAMS was not developed specifically for the military, recent evidence suggests it has promising outcomes for active-duty military personnel.

A third advancement specific to military veterans is seen in the use of predictive analytics of existing medical records. The REACH VET program utilizes an algorithm to detect a variety of health problems for military veterans, including risk for suicide. A recent study suggests the REACH VET program is not only successful in identifying veterans at risk for suicide, but is associated with the implementation of evidence-based crisis safety plans and fewer veteran suicide attempts.

A comprehensive approach to military veteran suicide requires attention up and down the social-ecological model. Attention to policy, social norms, and other upper-level influences needs to take place. At the same time, emerging risk detection and therapeutic interventions represent some of the best chances we currently have to continue to lower the military veteran suicide rate. Federal agencies and foundations should invest in research funding, military-community partnership, and training to test and validate programs like BCBT, CAMS, and REACH VET in Veterans Affairs and veteran-serving community health settings. At the same time, further research and policy-making need to scale up focus on upstream public health and policy influences on military veteran suicide.

The author wishes to thank Dr. Ray Tucker of LSU for comments on an earlier draft of this piece.