Suicide Rate Six Times Higher Than Civilian Peers

By Annette M. Boyle

DENVER — Suicide among women veterans is six times higher than among their civilian peers, according to a recently published study, and Congress wants to know why.

The Female Veteran Suicide Prevention Act (H.R. 2916) passed the House with overwhelming bipartisan support and moved to the Senate earlier this year. The bill, introduced by Rep. Julia Brownley (D-CA), directs the VA to identify the most effective mental healthcare and suicide prevention programs and that have the highest satisfaction rates.

“We can and we must do more to address the epidemic of suicide among our women veterans,” said Brownley. “We know that suicide can be prevented, but we need to work harder to understand the root causes. This bill is an important step forward toward that goal.”

A companion bill was introduced by Sens. Barbara Boxer (D-CA), Joni Ernst (R-IA), Richard Blumenthal (D-CT) and Sherrod Brown (D-OH).

“Our bill will focus attention on which VA mental health and suicide prevention programs are working and which are not, so we can better serve the women who courageously served our country,” Boxer said.

The high level of congressional interest was prompted by a VA study that analyzed data from death certificates in 23 states and the VA’s Suicide Repository on 173,969 suicides from 2000 to 2010.

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The VA researchers, led by Claire A. Hoffmire, PhD, an epidemiologist and health science specialist at the Denver VAMC, found that suicides among women veterans increased by 40% from 2000 to 2010. The rate rose from 24.7 per 100,000 in 2000 to 34.6 per 100,000 in 2010. During the same time period, the suicide rate for nonveteran females rose 13%, from 4.8 to 5.4 per 100,000 lives.1

Overall, women veterans had 4.9 times the risk of suicide as nonveteran women in 2000. That elevated risk rose to 5.9 times that of civilian women by 2010.

Statements from members of Congress drew particular attention to the dramatically greater risk of suicide among the youngest women veterans. Those aged 18 to 29 years old have nearly 12 times the suicide risk of their peers who have not served in the Armed Forces.

Researchers have started to identify the primary drivers for the increased risk of suicide among female veterans. “It’s a challenging question to answer, because suicide is a rare event, especially among women,” Hoffmire told U.S. Medicine.

While the rate of suicide is rising among women veterans, it remains much lower than the rate among male veterans. In 2011, the suicide rate was 14.4 per 100,000 among women veterans who received care through the VA, compared with 40.4 among former servicemen using VA health services.

A few factors contributing to the rise in suicides among women veterans stand out.

“The firearm suicide rate among women veterans has increased faster and to a greater degree than suicide rates among women veterans using other methods,” Hoffmire explained. Women veterans are 18% more likely to use firearms as the method for death than civilian women. Firearms are far more lethal than methods favored by civilian women, such as drug overdoses and poison, which have greater potential for discovery and reversal before death occurs.

Hoffmire also noted that “among veterans using VHA services, rates of suicide are higher among women who report having experienced military sexual trauma (MST), as opposed to those who have not experienced MST.” Comparable data was not available for women who did not use VHA services.


Lower Among VHA Patients

The study by Hoffmire and her colleagues found that women who receive VHA services are 75% less likely to die by suicide than women veterans who do not, suggesting that the VA’s suicide-prevention efforts are having a positive impact. Veterans using VA services were the only subgroup to see a drop in suicides during the period, and it was substantial at 20%.

Based on the study’s findings, enrolling more eligible veterans into the VA system — and getting them into those suicide-prevention programs — could perhaps head off many suicides. That would require a substantial outreach effort, although, as 70% of veterans who die by suicide are not receiving VA care, said VA Under Secretary for Health David Shulkin, MD, at the Veterans Suicide Summit in February.

Some of those VA programs directly affect the factors that increase the risk of suicide in women. The VA offers MST screening for all veterans and “is committed to ensuring that appropriate services are available to meet the treatment needs of women and men veterans who have experiences MST and may be at risk for suicide,” Hoffmire pointed out.

More than 24% of women veterans who received services from the VA in 2013 reported experiencing MST, which the VA defines as sexual assault or repeated, threatening sexual harassment during military service. Another VA study published in 2015 found that veterans who report MST have more than double the risk of suicide.2

The VA also has a gun safety program that provides free gun locks to any interested veteran and includes firearm safety as a component of safety planning for veterans believed to be at high risk for suicide, she said.

In addition, all staff and clinicians receive training on suicide prevention, and every VAMC and large outpatient facility has at least one suicide-prevention coordinator on site to assist with identifying and tracking patients at high risk and conducting outreach activities in the community. The VA also staffs a 24/7 crisis hotline and online chat.

Hoffman described the important steps the VA can use to increase understanding by medical staff of the elevated suicide risk among women veterans and determining which programs produce the best outcomes.

“We want to ensure all of our clinicians are aware of the elevated suicide risk among women veterans, that they are comfortable talking with their patients about suicide and that they are familiar with VA’s suicide prevention program and the resources available to all veterans in crisis, both women and men,” she said.

The VA should have updated data shortly. Hoffmire said that the VA’s Suicide Data Repository includes mortality information for all veterans through 2014, which will enable the researchers to see trends since 2010.

1 Hoffmire CA, Kemp JE, Bossarte RM. Changes in Suicide Mortality for Veterans and Nonveterans by Gender and History of VHA Service Use, 2000-2010. Psychiatr Serv. 2015 Sep;66(9):959-65.

2 Kimerling R, Makin-Byrd K, Louzon S, Ignacio RV, McCarthy JF. Military Sexual Trauma and Suicide Mortality. Am J Prev Med. 2015 Dec 14. pii: S0749-3797(15)00703-5.