Running head: Veterans Suicide Article Reviews

What Caused The Veteran Suicide

Epidemic of 22-A-Day?

Daniel R. Gaita, MA

April 20, 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.
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Overview of Articles

This work will examine three articles specific to the most recent research on veterans

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.

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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 studys

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

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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
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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
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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? Its 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
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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 its 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 veterans

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.

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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
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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.
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References:

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.pdf

Reger, 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