EXAMINING FACTORS THAT MAY CONTRIBUTE TO INCREASED SUICIDE RISK FOR VETERANS

John McCarthy (Department of Psychiatry, University of Michigan; VA Office of Mental Health and Suicide Prevention) described VA’s ongoing efforts to prioritize suicide research, evaluation, and surveillance to inform clinically-based and community-based suicide prevention efforts. He and his colleagues began working with veteran suicide analytics in 2004 in an effort to better understand suicide risks among all VHA patients with depression. As congressional and media concerns about veteran suicide intensified, this research expanded in 2007 to a study of suicide risks among all VHA patients—work that generated comprehensive information for the VA health system. A predictive algorithm for suicide risk among VHA patients was developed in 2014 and the first annual report on veteran suicide across the entire veteran population was released in 2016. He emphasized that although researchers try to investigate questions broadly and quickly to inform action to prevent suicides among veterans, data sources for all veterans are not uniformly available. For example, much more is known about suicide risk factors among veterans who receive VHA care than among those who do not receive VHA care.

McCarthy indicated that veterans are at a greater risk for suicide than non-veteran U.S. adults, noting that age- and sex-adjusted suicide rates for veterans were 57.3 percent higher than those for non-veterans in 2020. Suicide has many causes, he continued, and the increased rate among veterans might reflect factors related to entry into the military service and to experiences prior to, during, and after military service. Furthermore, he said that suicide rates among veterans are associated with demographic, social, diagnostic, contextual, service branch, service exposure, housing, and health care use indicators. He suggested prioritizing future research on community, occupational, and economic factors.

McCarthy revealed that the number of veterans who have not sought recent VHA care is higher than those who have—in 2020, only 5.9 million veterans had received care from VHA recently, while 13.4 million veterans had not received care from VHA recently (Department of Veterans Affairs, 2022). He added that rates of suicide among veterans who have received VHA care are higher than for those who have not (Figure 4-1) but noted that VA is serving the highest-risk veterans.

FIGURE 4-1

Age- and sex-adjusted suicide rates for veterans and non-veteran U.S. adults, 2001–2020. SOURCE: Department of Veterans Affairs, 2022.

McCarthy shared other significant data collected over the period of 2001–2020: (a) in general, male veterans are at a higher risk for suicide than female veterans, but the differential in risk is higher for female veterans relative to female non-veterans than for male veterans relative to male non-veterans; (b) the rates of suicide among younger veterans (ages 18–34) have been steadily increasing and are now higher than those of older veterans; and (c) White veterans had the highest suicide rates in 2020 as compared to veterans of all other races. He mentioned that what drives these differences in suicide rates remains an important but unresolved question. Additional data indicate that firearm suicides among veterans have substantially increased over the last two decades; firearms are also used more often than other methods among veterans who die by suicide, as well as used more often by veterans than by non-veterans who die by suicide (71% vs. 50.3% in 2020). Furthermore, he said that rural and urban differences in suicide rates of recent veteran VHA users might be related to race and other demographic differences of veterans in those areas.

McCarthy explained that electronic health records are an important tool in understanding suicide risk factors, as they include markers of increased suicide risk such as screening, diagnostics, medication, and treatment setting measures. He provided an example of the use of VA electronic health system data to distinguish patient subpopulations by mental health and substance use disorder diagnoses in terms of suicide deaths and rates. For instance, in 2020, the suicide rate among veterans in VHA care with any mental health or substance use disorder diagnosis was 55.5 per 100,000 compared to 29.8 per 100,000 for those without any such diagnosis. These rates can also be tracked at a finer level by the specific mental health and substance use disorder diagnosis.

McCarthy described another useful tool to help identify veterans with increased risk for suicide: the REACH VET (Recovery Engagement and Coordination for Health—Veterans Enhanced Treatment) program, which uses a predictive model (see Kessler et al., 2017; McCarthy et al., 2015, 2021). Risk indicators in this model include: demographics, prior suicide attempts, diagnoses, VHA use, medications, and interactions.

In closing, McCarthy reiterated that VA operational analyses since 2007 have substantially advanced understanding of veteran suicide. He urged assessment of how these findings might generalize to other health systems and how those systems could expand their surveillance of both veteran and non-veteran patient populations to increase suicide prevention.

EXPLORING THE CONNECTION BETWEEN THE TRANSITION FROM MILITARY SERVICE TO CIVILIAN LIFE AND THE RISK FOR SUICIDE

Rajeev Ramchand provided an overview of two studies that explored whether a connection exists between periods of elevated suicide risk among veterans and their separation from the military. In the first study, Reger and colleagues (2015) collected data on veterans who served from October 7, 2001, through December 31, 2007, and tracked them until December 31, 2009. Among the veterans in the cohort who separated from the military during the time frame of interest, the researchers found an elevated risk of dying by suicide upon separation from service—a finding that was consistent across all service branches. They also found that veterans who served for shorter periods of time were at an increased risk of suicide, and this risk decreased the longer that the veterans served. Veterans with “not-honorable” discharges were also found to have an increased risk of suicide (Reger et al., 2015). In the second study, Ravindran and colleagues (2020) collected data on veterans who served after September 11, 2001, and separated between January 1, 2010, and December 31, 2017, and tracked them either for six years or until December 31, 2017. The researchers found that the veterans’ suicide risk peaked at 6–12 months postseparation and decreased only modestly over the following several years (Figure 4-2). They also found an elevated risk for suicide among veterans who separated after having served for less than two years (Ravindran et al., 2020). Ramchand highlighted the value of such data analysis in advancing the work to define and understand the transition period for veterans.

FIGURE 4-2

Suicide rates by time since separation and service branch with 95 percent confidence intervals. SOURCE: Ravindran et al., 2020.

Ramchand also described The Veterans Metrics Initiative (TVMI),¹ a public-private partnership to identify the needs of veterans as they transition from military service to civilian life. TVMI recruited nearly 10,000 service members within 90 days of separation in fall 2016 and conducted six surveys over a period of three years. He summarized six key findings from TVMI’s final report (Henry M. Jackson Foundation, 2020), noting that these factors could also be useful to identify veteran suicide risk during the transition period:

1.

Employment: Veterans expressed initial satisfaction with their employment after separation, but perceived underemployment three years following separation.

2.

Finance: Veterans with a problematic financial status at discharge were more likely to experience difficulty adjusting during their transition, and this difficulty remained high through two years postmilitary separation.

3.

Education: Veterans with problematic financial risk and those with posttraumatic stress disorder were less likely to complete their education if pursuing a bachelor’s degree.

4.

Physical health: Chronic pain and sleep problems were the most commonly endorsed conditions; and health functioning and satisfaction declined over the three years of study.

5.

Mental health: At each assessment, approximately 10 percent reported thoughts of suicide; this was not the same 10 percent across assessments. Veterans with ongoing mental health problems were more likely to have difficulty adjusting during their transition to civilian life.

6.

Social connections: Overall, the veterans’ social well-being declined over the three years of the study.

Interested in exploring the issue of social connections in greater depth, Ramchand noted that RAND recently released a report based on web surveys and follow-up phone interviews with veteran-serving organizations. In this RAND report, Werber and colleagues (2023) indicated that these organizations build camaraderie by providing a context for social connections, brokering connections on behalf of veterans, and restoring veterans’ capacity to connect with others. They also found that these organizations struggle to measure social connectedness, particularly for evaluations (Werber et al., 2023).

Ramchand highlighted another relevant RAND publication, which includes the proceedings of the Roundtable on How Military Service Affects Veterans’ Posttransition Outcomes (Ramchand et al., 2023). The discussions of this roundtable uncovered several key influences on a veteran’s experience transitioning from military service to civilian life, such as preenlistment factors (e.g., motivations for serving in the military, adverse childhood events), military experiences (e.g., military occupational specialty, variability in support services across installations), military cultural norms (e.g., discouragement to seek help until a crisis, concealment of disability, poor leadership and infrastructure), and organizational responsibilities (e.g., DOD, community services).

Ramchand noted that one challenge for studying the veteran transition experience is that to investigate transition processes, researchers need to start following service members before separation and continue to follow them for a period after separation, which requires access to both DOD data and VA data. He added that in terms of who funds this research, co-ownership between DOD and VA is needed.

Ramchand presented two additional research areas that are key to identifying and managing suicide risk among veterans, especially as they transition from military service to civilian life: (a) more attention could be given to alcohol and substance misuse and abuse as well as the influence of military cultural norms on these behaviors; and (b) transition programs could be re-envisioned to focus on the junior enlisted, who are at a higher risk for suicide than officers and the senior enlisted.

USING THE VA/DOD CLINICAL PRACTICE GUIDELINE FOR THE ASSESSMENT AND MANAGEMENT OF PATIENTS AT RISK FOR SUICIDE TO INFORM SUICIDE PREVENTION EFFORTS

Lisa A. Brenner² discussed two VA suicide prevention programs that were driven by evidence and for which evidence continues to be collected for their improvement.

Brenner first provided an overview of the VA Suicide Risk Identification Strategy (Risk ID). Risk ID is a national, standardized process for suicide risk screening and evaluation using high-quality, evidence-based tools and practices. Risk ID policy details who should be screened and evaluated, when screening and evaluation should occur, and how screening and evaluation should be conducted and documented. Noting that work to develop this initiative began in 2016 and continues today, she underscored the significant time and patience required to change a system. For example, after new evidence emerged in November 2022, the Risk ID requirements were updated to both ensure compliance with Joint Commission requirements to screen all veterans at least annually and to widen the breadth of providers and staff who can conduct suicide risk screening. Although annual suicide risk screening can be completed in any health care setting (e.g., during an audiology visit), certain health care settings have additional requirements, and screenings might be given more often when clinically indicated.

Brenner asserted that universal screening is essential in the VA health care system for several reasons. Suicide rates are higher among veterans with recent VHA use than among veterans without recent VHA use; suicide rates increased 8.6 percent from 2018 to 2019 among veterans with recent VHA encounters; suicide rates increased in 2019 among patients who had not received mental health or substance use disorder diagnoses; nearly all individuals who die by suicide see a health care provider in the year prior to their death and half have contact with a health care provider in the month prior to their death; and screening facilitates veteran connection with mental health treatment (Ahmedani et al., 2019; Bahraini et al., 2020; Department of Veterans Affairs, 2019). She emphasized that the health care contact individuals have prior to suicide is often not in mental health care settings, meaning that there is the chance to reach people at risk; since these interactions may not be occurring in mental health care settings, keeping mental health screening only in mental health specialty care is not sufficient. Mental health screening needs to be integrated into primary care. Conducting universal screening within the VA health care system is especially valuable because the system has the capacity to provide follow-up mental health care—universal screening might be less effective in other health care systems that do not have this capacity to provide follow-up care.

Brenner explained that, based on the best available tools, Risk ID currently employs a two-stage screening and evaluation process:

1.

The Columbia Suicide Severity Rating Scale (C-SSRS) is a structured method used to determine who might be at risk of suicide and in need of further evaluation (i.e., screening questions focus on severity and recency of suicidal ideation and behavior such as wish to die, suicidal thoughts without intent, suicidal thoughts with specific plan and intent, and recent preparatory behavior or suicide attempt).³

2.

The VA Comprehensive Suicide Risk Evaluation (CSRE) is a collaborative and therapeutic method used for those who have a positive C-SSRS to inform clinical impressions about acute and chronic risk and associated disposition (i.e., allows a veteran to share narrative around suicidal thoughts and past behavior, helps stratify a veteran’s current risk as acute or chronic, and helps identify individually tailored risk mitigation strategies that map onto the level of risk).

She underscored the importance of attention to both acute and chronic suicide risk—noting that some individuals have chronic suicide risk.⁴ There are instances where an individual might be discharged from an inpatient mental health facility with a note that the person is at low risk for suicide, yet die by suicide soon after. Brenner explained that this note means the individual has been deemed safe at the time of discharge and not at acute risk of an immediate suicide attempt, but that providers also need to attend to whether the individual is at chronic risk over time, and follow up appropriately when chronic risk is present.

Brenner presented an overview of the data collected during an initial implementation⁵ of universal screening in 2018–2019 (Bahraini et al., 2020). The screening involved a three-step process: (a) primary screening using the PHQ-9;⁶ (b) secondary screening using the C-SSRS for those with positive primary screening results; and (c) evaluation using the CSRE for those with positive secondary screening results. Approximately 4.1 million veterans were screened in ambulatory care settings: 3.5 percent screened positive during primary screening; 0.4 percent screened positive during secondary screening and were identified as in need of evaluation and intervention. Another cohort of approximately one million veterans was screened in emergency departments and urgent care centers: 3.6 percent screened positive during primary screening; 2.1 percent screened positive in secondary screening and were identified as in need of evaluation and intervention. The ambulatory care cohort was 92 percent male and 73 percent White, with a mean age of 62; and the emergency department/urgent care center cohort was 89 percent male and 66 percent white, with a mean age of 59 (Bahraini et al., 2020). Brenner noted that these data indicate that universal screening is a manageable practice for health systems, but that questions about the implementation of screening, evaluation, and intervention based on race/ethnicity, gender, and age will continue to be addressed over time.

Before highlighting key research on mental health follow-up and treatment engagement following suicide risk screening, Brenner shared that the median number of mental health care visits after people seek mental health care is only one. In data collected in ambulatory care settings in 2018–2020, Bahraini and colleagues (2022) found that veterans who were screened were significantly more likely to follow up with one mental health visit within 30 days and were significantly more likely to engage in care (i.e., two or more mental health visits). Although more work remains, Brenner said that these data demonstrate the value of universal screening. In another study, Gujral and colleagues (2023) found that 20 percent of a cohort of veterans seeking mental health care in 2020 had been screened and identified to be at risk of suicide by primary care providers, not by mental health care providers—a finding that Brenner described as especially important for veterans in rural areas with lower access to mental health care providers.

Brenner introduced the Safety Planning in the Emergency Department program, another VA initiative for suicide prevention. This initiative, which emerged in 2018 and was updated in 2021, is an evidence-based intervention for veterans whose suicide risk is identified during a VHA emergency department or urgent care center visit. She noted that emergency department patients presenting without self-harm or suicidal ideation are two times more likely to die by suicide than matched controls (Goldman-Mellor et al., 2019). Thus, at-risk veterans who visit a VHA emergency department or urgent care center are identified and evaluated via the Risk ID process, starting with the C-SSRS; if an acute or chronic risk is determined to be intermediate or high based on a subsequent CSRE and the veteran is discharged to go home, the veteran receives follow-up phone calls, including a discussion of the safety plan, until the veteran is engaged in mental health care (see Stanley et al., 2018). She underscored that this initiative requires collaboration between emergency departments/ urgent care centers and outpatient mental health to support engagement in mental health care and potentially minimize repeat emergency department visits.

Brenner explained that the Safety Planning in the Emergency Department program is monitored via metrics that are disseminated to the care facilities—for example, the percentage of patients with timely completion of the annual suicide risk screening, the percentage of patients with timely completion of the CSRE following a positive C-SSRS screen, the number of emergency department or urgent care center visits during which a veteran completed a new or updated an existing CSRE within 24 hours of a positive C-SSRS screen, and the number of visits after which a patient attempted a Suicide Prevention Safety Plan within 24 hours of the visit. She emphasized that all of this information is built into the electronic medical record, and can be added to dashboards and used in real time to improve program facilitation and implementation.

Brenner mentioned several ongoing VA efforts to support suicide risk identification and management more broadly, including weekly community of practice calls; a national technical assistance team; regional and facility site visits; external facilitation; SharePoint with training, orientation, and guidance; provision of data feedback for performance improvement; and maintenance of clinical decision support tools. Now that initial data are available, she continued, researchers could focus on how different cohorts are affected to better tailor suicide prevention efforts. She stressed the importance of attention to risk during the time of transition from the military that had been discussed in Ramchand’s earlier presentation, and mentioned a paper she had co-authored with Rachel Sayko Adams (Department of Health Law, Policy & Management, Boston University School of Public Health; workshop planning committee member) and others examining transition and race over time. She and her colleagues found that patterns of risk are different for different racial and ethnic groups over time; some groups stay particularly high over time, which highlights the need for personalizing suicide prevention care (Brenner et al., 2023).

Brenner identified female veterans as another group that would benefit from more personalized care for suicide prevention (Hoffmire & Denneson, 2018). As with male veterans, firearms are the leading method of suicide for female veterans (Monteith et al., 2020). Considerations of gun ownership for this group are complicated by female veterans’ unique perspectives about the use of firearms for survival in the military and for personal safety at home. Therefore, she proposed developing a better understanding of where women seek health care and which providers they trust (e.g., a gynecologist could discuss lethal-means safety) in order to improve suicide prevention efforts. [Note: As defined in the U.S. Department of Veterans Affairs online resource Lethal Means Safety and Suicide Prevention,⁷ lethal-means safety is “an intentional, voluntary practice to reduce one’s suicide risk by limiting access to those lethal means” such as firearms, sharp objects, and medications.] Brenner encouraged adopting a “whole health care approach,” in which mental health care is integrated into primary care, to save more veterans’ lives.

DISCUSSION

Rachel Sayko Adams moderated a discussion among the session’s speakers.

Jeannette E. South-Paul expressed her concern that most people have only one follow-up visit after a positive suicide risk screening. She asked how primary care clinicians could work more closely with behavioral health providers to better facilitate follow-up visits for these patients. Brenner championed integrated primary care settings that have a mental health care provider on site. Ramchand urged consideration for additional models of integrated care that do not further strain an already constrained health care system. For example, Collaborative Care is an evidence-based strategy for reducing mental health symptoms that does not require an on-site mental health professional (see Archer et al., 2012). Brenner added that not all patients need continual specialized mental health care; after a patient has one visit with a psychologist, for example, a primary care provider could administer and oversee medication moving forward. She encouraged the development and evaluation of multiple pathways to enhance patient care.

Brian K. Ahmedani (Center for Health Policy & Health Services Research, Henry Ford Health) asked about VA protocols for discussing lethal-means safety during clinical visits, especially among populations with high exposure to firearms. Brenner asserted that providers should become more educated about firearms, which will help them to build trust over time with the patient and work with that patient to create a safe environment—the goal is for the veteran to choose safety. She emphasized that a veteran’s peers also play an important role in improving lethal-means safety. Ramchand added that many veterans might not want to have a conversation about lethal-means safety with a medical provider; they would rather discuss it with another veteran. He noted that little evidence exists to demonstrate that current approaches to lethal-means safety in terms of safe storage practices are preventing suicide, especially considering some people’s concerns about the need for firearms for personal safety and protection.

Delving deeper into a discussion about lethal-means safety, Matthew Miller posed a question about the practical implications of REACH VET suicide risk predictions as they relate to firearm deaths by suicide. McCarthy explained that VA patients predicted by the algorithm to be in lower-risk categories for suicide used firearms more often as lethal means than those predicted by the algorithm to be in higher-risk categories for suicide, who more often used lethal means other than firearms. Therefore, he stressed that for people identified by the algorithm as “high risk,” suicide prevention efforts should include not only firearm safety but also other aspects of suicide prevention and lethal-means safety.

Eric Caine (Department of Psychiatry, University of Rochester Medical Center; workshop planning committee member) provided examples of both effective and ineffective lethal-means safety efforts in various parts of the world. He noted that the use of lock boxes to restrict access to highly lethal pesticides in order to prevent suicide by this method in areas of Asia was unsuccessful—personal safety measures are difficult to induce when individuals are suicidal (Pearson et al., 2017). However, when national policies were implemented in Sri Lanka to restrict access to these highly lethal pesticides, suicide rates related to those lethal means decreased (Gunnell et al., 2017). In Finland, where firearms are part of the culture and access is not restricted, he said that a series of suicide prevention programs proved to be highly effective (Lewitzka et al., 2019). He expressed support for lethal-means safety but encouraged realistic approaches. Few data demonstrate that education on lethal-means safety at the population level will effectively prevent suicide, even if education does make a difference at the individual level.

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