Daniel R. Gaita, MA
February 21st, 2017
Identification of Articles Importance
Recently released research by the herein reviewed 2016 Department of Veterans Affairs (VA) and 2015 Journal of American Medicine (JAMA) studies on veterans suicide include data sets of over 54 million veterans. This new information now supersedes the previous 2012 VA Suicide Data Report. By converging the outcomes of each respective data set we appear to not only garner a greater understanding of the veteran population segment most likely to kill themselves, but may have also effectively pin-pointed the primary causes of and therefore solutions to the ongoing tragic suicides of nearly 20 US military veterans every day.
Overview of Articles
This work will examine three articles specific to the most recent research on veteran’s suicide. The first, Suicide Data Report (Kemp & Bossarte, 2012) is known as the study that brought awareness to the 22 veterans suicides a day. Second, Suicide Among Veterans and Other Americans (VA, 2016) relies upon a much larger data set. Third, Risk of Suicide Among US Military Service Members Following Operation Enduring Freedom or Operation Iraqi Freedom and Separation From the US Military (Reger, Smolenski, Skopp, Metzger-Abamukang, Kang, Bullman, Perdue, & Gahm, 2015) looks deeper into the sub categories of service members and suicide rates.
Article 1: Suicide Data Report, 2012
This study (Kemp & Bossarte, 2012) began in 2007 following a Mental Health staffing expansion through the Joshua Omvig Bill. It would also result in the development of data systems used to increase understanding of suicide among veterans in order to develop and improve suicide prevention programs. But for most of the US veteran Population it is known as the “22 A Day” study, which became a call to action at the VA and catalyzed veterans to look out for one another and to reach out for help.
The final report, with a cumulative price tag of $46,771.29 contains a systematic overview of data obtained from the State Mortality Project, Suicide Behavior Reports for fiscal years 2009-2012 and sought to determine the number of veteran deaths from suicide between 1999-2009. The end result was clean data from twenty-one states containing information on over 147,000 suicides. The data was then drilled-down to conclude that an estimated 22 veterans had died from suicide every day in 2010.
The study places emphasis on the significantly higher rate of male suicides. With the highest risk factor for veterans with an average age 54.5 years. 79% of suicides aged 18 or older were male and 44% of those suicides were among those aged 50 or older with 69% of all veteran suicides among those aged 50 years or older. Veterans that were married, separated or divorced had higher rates of suicide while those that were either widowed or single had the lowest rates. Veterans with a High School diploma or less represented 45% of suicides, while those with at least one year of college or more were far less likely.
Caution is advised not to make broad interpretations of the data based on proxy type reports of military history from only 21 states. Moreover, the study demonstrated wide variability across states with veteran suicides rates ranging from 7% to more than 26% of all suicides and warned that such findings prevent conclusions. Furthermore, the report articulates that it is a first attempt to formulate a comprehensive review; that it was not a research-based analysis and did have significant limitations specific to the data collected.
One detail of importance to note for future article analysis and discussion, is the study’s conclusion that the percentage of people who die by suicide in America that are veterans has decreased slightly from 2009-2012. This is a vital observation as the report then makes the inference that this finding provides preliminary evidence supporting the effectiveness of VA programs outcome specific to suicide prevention and mental health treatments. However, keep in mind that only those eligible to receive VA care are represented in that inference. This will be an important consideration as we review the next two articles.
Article 2: Suicide Among Veterans and Other Americans 2001-2014
This joint Department of Defense & Department of Veterans Affairs, Office of Suicide Prevention analyses (VA, 2016 & Thompson 2016) is inclusive of over 55 million Veteran records from 1979 to 2014 from each of the 50 states in the nation. The data reduces the prior 2012 findings of 22 suicides per day down to an average of 20 Veterans a day in 2014. Of those, only 30% were utilizing VA services.
This is a vital observation, as it again calls into awareness that utilization of VA services is restricted to those eligible. Not all veterans are eligible for VA services. Those released dishonorably are not eligible for care, service or programs. In the next article we will identify how vital this observation may be in the future paradigm of veterans suicide prevention.
This 2016 VA report provides a brief summary of additional findings. Again, in this study we see that the highest rate, 65%, of all 2014 suicides were committed by those aged 50 years or older. Further, that the two highest VA utilizing groups to commit suicide have either a 50% or greater disability rating or are non-service connected and, non-compensable service-connected.
This is another key observation demonstrating that those who have the worst service-connected injuries are more likely to commit suicide along with those with injuries that are not eligible for any type of compensation. For the 50% and higher rated disabled I would contend it is a matter of suffering physically and or mentally regardless of economic compensation while for the non-service connected, non-compensable it may very well be a combination of both pain and suffering coupled with a lack of economic resources due to injury or disability, which often worsen with age.
In addition, this study also demonstrated a substantial increase in rates of suicide for younger veterans 18-29 and those aged 50-59. Also of interest to note, suicide rates of those aged 70-79 and 80+ represented the only veteran sub-groups with suicide rates lower than the civilian rate. However, an 85.2% increase since 2001 in suicide rates amongst the female veteran population was observed when compared to the 30.5% increase in the male veteran suicide rate since 2001.
The report highlights enhancements to the VA 24/7 crisis line, improved mental health services for females and the expansion of TeleMental Health Services. In addition, the report describes new free mobile applications deployed to help both veterans and their families while detailing the contributions of over 350 community and mobile based Vet Centers across all 50 states.
But again, while this report has shed light on who is committing suicide, little is provided to answer the question of why. For that answer we look at the next article.
Article 3: Risk of Suicide Among US Military Service Members Following Operation Enduring Freedom or Operation Iraqi Freedom and Separation From the US Military
This final article which appeared in the June 2015 Journal of the American Medical Association Psychiatry publication, (Reger, Smolenski & Skopp, et. al, 2015) may very well hold the proverbial key to unlocking the primary causes of veterans suicide while offering us a paradigm shifting insight on the solution to the problem.
The study sought to answer the question of whether or not deployment in support of Operation Enduring (OEF) or Iraqi Freedom (OIF) related to suicide risks. To do so they examined the records of all 3.9 million US military personnel between 2001- 2007 that served during either OEF or OIF, including suicides that occurred after separation. The main conclusion and finding was that Deployment was not associated with suicide but rather that separation status of a less than an honorable discharge, and serving less than 4 years was. Further study data also demonstrated that officers and senior enlisted members as well as those with more than 20 years in service had significantly far lower rates of suicide. In addition, those with a four year college degree or higher showed the lowest rate of suicide risk.
How does this tell us why veterans are killing themselves? To get to that answer we must next assimilate the meaning behind the data in these studies.
Article Summary and Analysis
Prior to the release of the data in the third article (Reger, Smolenski & Skopp, et. al, 2015), the standard paradigm for veterans’ suicide had connected Combat to Post Traumatic Stress (PTS) to suicide. Proof of such is measured in the enormous outlay of funds for these investigations and resultant implementation of evidence based treatments for PTS and Mental Health treatment leading up to the publication of the first study (Kemp and Bossarte, 2012) to present. Instead, what the convergence of article data suggest is the pathway for veterans’ suicide is connected as follows: Dishonorable or less than honorable Discharge –> Lack of access to available service -> (education, healthcare, compensation) –> Mental Health Crisis -> Suicide.
While the first two VA studies tell us who is committing suicide by way of age, gender and population demographics it is the third study, which concludes who is not. It is not due to deployment and thus not wholly due to combat. If it is not due to combat or deployment, how can it be attributed to combat PTS? It’s not, and here is why.
The third study data sets (Reger, Smolenski & Skopp, et. al, 2015) demonstrate that service members who serve less than four years and do not receive an honorable discharge have exponentially higher rates (3 or 4:1) of suicide than those serve at least four or more years and earn an honorable discharge. Service members with less than a year of service have the highest rate of suicide. Additionally, service members with an alternative high school diploma also have a 3:1 rate of suicide when compared to those with a four-year degree or higher. Thus the dilemma of veterans’ suicide is more a function of access to education and resources than a function of combat trauma.
This determination effectively flips the current paradigm of suicide prevention though mental health interventions on it’s head. In doing so it enables us to look at the real predictors and address them before a mental health crisis emerges.
To better understand, the reader must comprehend the culture of the armed forces specific to the Uniform Code of Military Justice as it pertains to how veterans are separated from service and further understand how various separation codes (Honorable, Less Than Honorable, Bad Conduct, Dishonorable etc) impact post service eligibility to VA programs and services.
If a veteran serves less than four years, it is most likely due to some form of administrative or other than honorable discharge determination. As a result the separated service member may not eligible for many programs that include but are not limited to VA Disability Compensation, Education and Healthcare benefits. Looking back at the first two studies, it was observed that veterans that did not use the VA Healthcare System committed 70% of veteran’s suicides. Perhaps lack of eligibility due to less than honorable discharge is a culprit? It is certainly worth further investigation. That is the first argument.
The second is based on educational attainment. The next highest risk group for veterans suicide in the third study was veterans with no high school or an alternative diploma. While the lowest rate of risk of veterans suicide was observed by those with a 4-year degree or higher, and again confirmed by the observation that Officers made up the group with the lowest risk for suicide. In order to be an officer you must have a four-year degree.
Lack of access to post service education benefits or vocational rehabilitation opportunities due to separation and discharge status determination may be a primary factor and precursor to the later mental health challenges that result in suicide. It is certainly worth further investigation.
Deductive reasoning lends us to better understanding of the actual simplicity of the problem of veterans suicide which, when observed through the convergence of these data sets can be summed up in these eight words: Get an Honorable Discharge and a College Degree.
Implications of Analysis
With the convergence of data from these three reports it appears possible the current paradigm of federal funding targeting towards stopping veterans suicides may be misdirected towards the treatment of PTSD and Mental Health interventions. This is in no way meant to diminish the value of the work being conducted in the fields of Mental Health, as they are essential and the data supports the efficacy of that work. But rather as a means to enable further consideration of other possible root causes of suicide that may better be addressed through improved Officer and Staff Non-Commissioned Officer leadership training in order to help correct the behavioral deficits that may be the primary cause of early separations from the armed forces as a result of avoidable behavioral and disciplinary outcomes.
Perhaps less emphasis on non-judicial and court martial proceedings and more emphasis on behavioral modification strategies that many in the Armed Forces leadership ranks have argued have been recently replaced due to shifting political and social ideologies. This is not to diminish the effectiveness of military type leadership, but rather re-embolden it to again be effective at ensuring mission readiness through discipline and purpose. While at the same time evolving it through a deeper understanding of human psychology via evidence-based interventions at the Department of Defense level. This type of effort has the capability to shape a potential suicide candidate into a respectable member of the armed forces worthy of the programs, service and benefits that come with an honorable discharge. Such programs and services, the data shows, are associated with far lower risk of suicide.
Kemp, J., & Bossarte, R. (2012) Suicide Data Report, 2012. Department of Veterans Affairs, Mental Health Services, Suicide Prevention Program. Retrieved from http://www.va.gov/opa/docs/suicide-data-report-2012-final.pdfReger, M.A., Smolenski, D. J.,
Skopp, N. A., Metzger-Abamukang, M. J., Kang, H. K., Bullman, T. A., Perdue, S., & Gahm, G. A. (2015) Risk of Suicide Among US Military Service Members Following Operation Enduring Freedom or Operation Iraqi Freedom Deployment and Separation From the US Military. JAMA Psychiatry. 2015; 72(6):561-569. doi:10.1001/jamapsychiatry.2014.3195 Published online April 1, 2015.
Thompson, C. (2016) VA Suicide Prevention: Facts about Veterans Suicides. Suicide Prevention and Community Engagement. Retrieved from http://www.va.gov/opa/publications/factsheets/Suicide_Prevention_FactSheet_New_VA_Stats_070616_1400.pdf
VA (2016) VA Office of Suicide Prevention. Suicide Among Veterans and Other Americans. US Department of Veterans Affairs, Washington, DC. Available online: http://www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf