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Commentary

Preventing Suicide among Veterans Will Require Clinicians and Researchers to Adopt a Public Health Approach

In the United States, suicide is the 10th leading cause of death, and rates across populations continue to rise. Compared to members of the general population, Veterans have been found to be disproportionally affected by suicide. The VHA Office of Mental Health and Suicide Prevention's 2017 report "Suicide among Veterans and Other Americans 2001-2014" sheds light on a number of concerning trends. In 2014, Veterans comprised 8.5 percent of the US population, and accounted for 18 percent of deaths by suicide. Within the Veteran population, many cohorts are at high risk for suicide, including those between the ages of 18 and 29, those who are older than 60, and those living in rural communities.1 Particularly concerning are data that suggest a 62.4 percent increase in the age-adjusted rate of suicide among female Veterans from 2001 to 2014.

When comparing firearms to other methods of suicide, the former are associated with the highest case fatality rate. This finding holds true for both male and female Veterans. As firearm training is common among military personnel, this shared experience has been identified as a possible contributor to the more frequent use of this method among Veteran cohorts. For example, among female Veterans, firearms were used by 40.5 percent of those who died by suicide. This is compared to a 31.1 percent firearm use by female non-Veterans who died by suicide. Moreover, nearly 70 percent of male Veterans who died by suicide used a firearm compared to approximately 50 percent of non-Veteran males who died by suicide.

Enhancements in Care to Prevent Suicide

As one of the nation's leaders in suicide prevention efforts, VHA has implemented diverse strategies to identify and enhance care for those at risk at both the population and clinical levels. These strategies include establishing the 24/7 Veterans Crisis Line, placing full time Suicide Prevention Coordinators at hospitals and large Community Based Outpatient Clinics, using predictive modeling to identify and engage Veterans believed to be at high risk for suicide, and facilitating trainings for mental health providers regarding lethal means safety. It is our belief that these efforts have contributed to promising data regarding suicide trends among Veterans who seek VHA care as compared to those who do not. Before 2006, rates of Veteran suicide (adjusted for age and sex differences) were lower than that of civilians. From 2001 to 2014, the risk for death by suicide among Veterans increased relative to non-Veterans, to where Veterans were 22 percent more likely to die by suicide than non-Veterans. However, clear differences have also emerged regarding estimates of relative risk for death by suicide between Veterans who use VHA services and those who do not. Between 2001 and 2014, suicide rates among Veterans who recently used VHA services increased by 5.4 percent compared to a 38.4 percent increase for Veterans who did not use such services. Moreover, among female Veterans who used VHA services, suicide rates decreased by 2.6 percent. This is compared to a striking increase of 81.6 percent in suicide rates among female Veterans with no recent use of VHA services.

Suicide as Public Health Problem

Historically, public health approaches were most frequently implemented to prevent acute and chronic diseases. Over time, scientific knowledge has contributed to the understanding that complex health-related problems, including suicide, are influenced by a wide range of factors. Importantly, many of these factors exist outside healthcare systems and can be addressed using a public health approach to prevention. Integral to the public health model is the idea that negative outcomes can be prevented by health promotion. That is, empowering individuals via policies, education, and interventions to improve their own health can lead to overall reductions in negative outcomes.

As such, there is wide-spread agreement among researchers and clinicians that a public health approach to suicide prevention is essential to meaningfully reduce suicide rates. Adoption of such an approach does not preclude traditional healthcare-based interventions, focusing on those seeking treatment within VHA, but rather provides the opportunity to expand suicide prevention efforts to meet the needs of those not currently seeking VHA care. Comprehensive suicide prevention programs, like the one being promoted by the VHA Office of Mental Health and Suicide Prevention, are comprised of multiple strategies, with interventions ranging from those aimed at health promotion (e.g., improving sleep), to universal prevention (e.g., media campaigns aimed at changing beliefs regarding suicide), to treatment and recovery (e.g., cognitive behavioral therapies for suicide prevention among those with a history of a suicide attempt).

Health Services Research and the Public Health Approach to Suicide Prevention

A 2009 article by Schutchfield and colleagues argues that health services research has focused on "the production and consumption of medical care, while giving comparatively little attention to another important component of the health system—that of public health services."² While this article is nearly ten years old, and there has been an increase in focus on public health (e.g., rates of influenza during the 2017/2018 flu season), additional efforts, particularly pertaining to suicide prevention, are warranted. This will require the adoption of methods that may be less familiar to suicide prevention researchers within the health services research community (e.g., pragmatic trials, quasi-experimental community-based studies), as well as those that have not yet been sufficiently deployed (e.g., social network analysis).

For example, using a population dataset and Empirical Bayes standardized mortality ratios, Liu examined the effects of sociodemographic factors on suicide by neighborhood composition.³ Liu's findings suggest that the impact of individual attributes (e.g., low income) on suicide depends on social contexts (e.g., neighborhood composition by income). As Liu noted, "this study contributes to the literature by showing administrative data can be used to study the effect of small-area interaction on rare outcomes." The author also suggested that our ability to focus on potential underlying contextual mechanisms of suicide are limited by a "lack of administrative datasets" that include information for populations as a whole.

Another limitation to existing information stems from the separation of clinical data, such as that maintained by VHA, from community indicators such as economic, crime, and other social determinants data. Utilizing data resources within VA, as well as in partnership with others, health services researchers could lead the way in merging community indicators and survey data with electronic medical record and administrative data to prevent Veteran suicide. Moreover, additional innovative strategies are needed to evaluate components of the VHA suicide prevention program that have already been implemented, as well as reach Veterans who are not currently seeking VHA care.

We encourage members of the VHA research community to explore these and other novel means to better understand suicide, with the aim of developing health promotion, universal prevention, and treatment interventions to decrease the rate of Veteran suicide.

References

1. McCarthy, J. F., et al. "Suicide among Patients in the Veterans Affairs Health System: Rural–urban Differences in Rates, Risks, and Methods," American Journal of Public Health 2012; 102(S1): S111-S117.
2. Scutchfield FD, Mays GP, Lurie N. "Applying Health Services Research to Public Health Practice: An Emerging Priority," Health Services Research 2009; 44(5 Pt 2):1775-87.
3. Ka-Yuet Liu, "To Compare is to Despair? A Population-Wide Study of Neighborhood Composition and Suicide in Stockholm," Social Problems 2017; 64(4): 532–57.