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Suicide Risk Remains Much Higher for Military, Veterans Than Civilian U.S. Population

by U.S. Medicine

October 12, 2016

Firearms Used in Two-Thirds of Servicemember, Veteran Suicides

By Annette M. Boyle

MONTEREY, CA—Suicide rates in the general U.S. population rose to their highest level in 30 years in 2014, but among both active-duty servicemembers and veterans, the rates were higher still.  

Two recently-released studies provide new insights into the risk of suicide for current and former members of U.S. armed forces, which groups are most affected and how they die.

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According to the U.S. Centers for Disease Control and Prevention, the age-adjusted suicide rate for all Americans rose from 10.5 to 13.0 per 100,000 between 1999 and 2014, with an uptick in the rate after 2006. Among veterans, the rate was three to four times as high during that interval. The suicide rate among veterans fluctuated between a high of 39.9 per 100,000 in 2001, a low of 34.9 per 100,000 in 2005 and 39 per 100,000 in 2014, according to an August report detailing the results of the VA’s analysis of 55 million veteran records from 1979 to 2014. The rate may be a more important indicator of the effectiveness of VA programs developed to reduce these deaths than the number of veteran suicides per day, which the VA recently recalculated as 20 rather than the 22 previously reported.

“Mathematically, we had 700 fewer deaths in 2014 than we estimated in 2010,” said David J. Shulkin, MD, the agency’s VA under secretary for health in a teleconference with reporters. “We’re not saying this is progress, the rate is actually increasing, because the number of veterans is decreasing. This is one of those situations where you don’t want to declare victory or say we’re making progress; that’s why we’re being so aggressive.”

Indeed, despite expanded mental health programs, same-day access for urgent mental health care and predictive modeling designed to identify the veterans at greatest risk of suicide for targeted early interventions, the suicide rate has remained stubbornly high. Without those programs, however, the rate could have been markedly worse. Veterans who did not use VHA services saw a nearly 40% increase in suicides during the period, compared with less than 9% among those who received VHA services, according to Shulkin.

“When you look at female veterans, it’s even more apparent,” Shulkin said. “From 2001 to 2014, the suicide rate for female veterans who used VA services rose 4.6%. If they did not use VA services, there was a 98.4% rate of increase of suicide over this period.”

Women veterans are 240% more likely to die as a result of suicide than American women who have never served in the armed forces, according to the VA report. Among men, veterans have a dramatically lower increase in suicide risk compared to civilians, at just 18%.

Still, the percentage of U.S. suicides made up by veterans has decreased in the past few years. “In 2010, veterans accounted for 20.2% of American suicides; in 2014, that percentage had dropped to 18%,” Shulkin said.

The burden of suicide falls disproportionately on older veterans, with about 65% of veteran suicides occurring among those age 50 or older. The highest rate of suicide, however, occurs among veterans ages 18 to 29, noted Shulkin. Among civilians, adults age 50 and up have the highest rates of suicide.

Veterans who have a mental health or substance abuse diagnosis and are receiving mental health treatment have the highest risk of suicide overall, but the rates have dropped significantly over the past 13 years. In 2001, this group had an 89.8 per 100,000 rate of suicide. By 2014, the rate per 100,000 had dropped to 67.5. Veterans who had a mental health or substance abuse diagnosis and did not receive treatment had much lower suicide rates, 52.9 per 100,000 in 2001 and 34.3 per 100,000 in 2014. Those who had neither a mental health or substance use diagnosis nor received treatment had the lowest suicide rates, 24.2 per 100,000 in 2001 and 24.7 per 100,000 in 2014.

While the use of firearms in civilian suicides has dropped modestly since the start of the century, their use has risen slightly in veteran suicides. Today, 40.5% of all female veteran suicides and 67.8% of male veteran suicides resulted from a firearm injury.

Active-Duty Statistics

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A study published this summer in the Annals of Internal Medicine found that servicemembers overall had a somewhat greater risk of suicide than civilians. That’s a big reversal from 1980 to 1991, when active duty forces had only half the risk of their civilian counterparts.1

The lower rate seen in earlier studies was attributed to the “healthy warrior effect” that assumed the health screening required for entry and regular health assessments mandated for servicemembers would result in lower suicide rates. That assumption has been upended by new data showing that the rate of suicide has risen sharply in all branches of the U.S. military, despite continued health assessments.

Researchers analyzed 1,455 suicides reported among active duty forces from 2005 and 2011. Because of the small number of female suicides, they did not look and men and women separately.

The Navy and Air Force have seen the least change, with an increase in suicide rates from 9.79 and 9.95 per 100,000 in 2005 to 14.86 and 13.99 per 100,000 in 2011, respectively. Among Marines, the rate rose from 14.79 to 16.11 per 100,000 in that same time period.

The highest suicide rate by far occurs among soldiers, who had the greatest increase in the six-year study period, as well. In 2005, the suicide rate in the Army was 13.81 per 100,000. By 2011, it was 28.36 per 100,000, more than twice the average of the general U.S. population. Deaths of Army personnel accounted for more than half of all the suicides.

Among soldiers, approximately two-thirds of suicides occurred in the E1 to E4 enlisted ranks, and 70% of Marine suicides were also in lower ranks. In the Navy and Air Force, by contrast, fewer than half of suicides were in lower enlisted ranks.

White servicemembers accounted for 75% of all suicides, with 85.2% of Marine suicides being white. Nearly nine in 10 suicides occurred among servicemembers with only a high school diploma. The median time in service was four years, although Army personnel had the shortest median length of service at just two years.

As with veterans, firearms were the most common cause of death. Firearms were the cause of death for 62.3% of all those with a known cause. Among soldiers and marines, infantry or special operations members were twice as likely to commit suicide with a firearm than those in any other job classifications.

The authors recommended that clinicians assume that all military personnel are at risk for suicide and assess them using a validated screening tool that uses military-specific questions regarding mental health. They further urged clinicians apply a similar construct to conversations with veterans and to “recognize the unique risks that firearms pose in this population: Not only do veterans have four time more firearms than nonveterans, they are more likely than nonveterans to use them to commit suicide.”

 

1 Anglemyer A, Miller ML, Buttrey S, Whitaker L. Suicide Rates and Methods in Active Duty Military Personnel,2005 to 2011: A Cohort Study. Ann Intern Med. 2016 Aug 2;165(3):167-74.


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