Expert Commentary

Suicide among patients treated by the Veterans Health Administration

2012 study in the American Journal of Public Health comparing suicide rates among veterans to those among the general public.

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The issue of military suicide has received significant attention recently, primarily because of the high number of suicides among active-duty service members. As the 2012 Time magazine cover story “One a Day” notes, “More U.S. military personnel have died by suicide since the war in Afghanistan began than have died fighting there. The rate jumped 80% from 2004 to 2008, and while it leveled off in 2010 and 2011, it has soared 18% this year.” These problems prompted the Senate Veterans Affairs Committee to add an amendment to the 2013 Defense Authorization Act, which would require that the Pentagon create a comprehensive suicide prevention program for members of the Armed Forces.

In February 2012, the Department of Veterans Affairs issued the “Suicide Data Report, 2012” (PDF), which for the first time sought to estimate the number of suicides by all veterans, not just those who access VA services. The report notes the following: “While the numbers of veterans who die from suicide each day has remained relatively stable over the past 12 years (varying from 18 -22 per day), the percentage of people who die by suicide in America who are veterans has decreased slightly. At the same time, the number of Americans who die by suicide each day has increased.” The document concludes that “this provides preliminary evidence that the programs initiated by VA are improving outcomes.”

Still, the psychological trauma veterans often suffer even after leaving the battlefield remains an issue of growing concern. A 2012 study, “Suicide Mortality Among Patients Treated by the Veterans Health Administration from 2000 to 2007,” published in the American Journal of Public Health, stands as the “the first comprehensive study of suicide mortality among patients receiving health care in a large national health care system.” The researchers, from the University of Michigan Medical School, the University of Rochester Medical School and the Department of Veterans Affairs, compare suicide rates between veterans treated by the Veterans Health Administration (VHA) and the general population. They analyzed data from Veteran Affairs’ National Patient Care Database, as well as the Centers for Disease Control and Prevention’s National Death Index (NDI) and Web-based Injury Statistics Query and Reporting System (WISQARS). This data allowed them to compare suicide rates by age and gender. To compare VHA rates to those of the general population, the authors calculated Standardized Mortality Ratios for veterans in different age and gender subgroups and then used the WISQARS data as the reference. This included using “indirect standardization,” which allowed the authors to take age-specific mortality rates from the general population and use them to derive expected deaths in the veterans population.

Key study findings include:

  • Between 2000 and 2007, there were 13,626 suicides among those veterans treated by the VHA. This figure represents 5.5% of the total 248,179 U.S. adult suicides during this time period. The VHA provides care to only 2% of the U.S. population (approximately 5 million patients per year).
  • In each of the eight years from 2000 to 2007, suicide was more common among those who were treated by VHA than in the general “age-and gender-matched” population. Annual VHA rates of suicide mortality ranged from 34.3 to 39.8 suicides per 100,000 person-years. Among male VHA users, the annual rates of suicide ranged from 36.4 to 43.1 suicides; among female VHA users, the annual rates of suicide ranged from 9.8 to 13.7.
  • The suicide rate for female VHA users was “less stable over time” than it was for male VHA users; it was not possible to discern a common trend in rates compared to the general U.S. female population.
  • Overall rates of rates of veteran suicide were “significantly lower” after 2003 than those found in the earlier part of the observation period.
  • However, although suicide rates decreased among middle-aged male veterans over the given time period, their rates remained consistently higher than the “young” or “older” male veterans; this contrasts with the typical pattern observed in the general U.S. population, where the rates of suicide are “highest in older males.”

Despite some limitations of the study — including the fact that sample data for certain subgroups is less precise given that the veteran population is “predominantly male and of middle age” — the researchers conclude that, of those treated by VHA, “middle-aged men were at the highest risk for suicide.” They offer some possible explanations, including: “these individuals represent Vietnam-era veterans who may be a cohort at higher risk for suicide caused by overall morbidity, or to ongoing social, economic or psychiatric difficulties.” They also note that in general, suicide rates have risen among middle-aged adults in the U.S.

Given their findings, the researchers advocate for “comprehensive approaches to suicide prevention in the VHA,” that “focus not only on recent returnees but also on middle-aged and older Veterans.”

For additional information on military suicide, the following studies provide perspective: “The War Within: Preventing Suicide in the U.S. Military,”  from the Rand Corporation; and “Losing the Battle: The Challenge of Military Suicide,” from the Center for a New American Security.

Tags: PTSD, veterans, war, mental health

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