In the United States and in the Department of Veterans Affairs (VA), suicide prevention has been declared a national priority. The current national statistics indicate a suicide rate of 11.5 per 100,000 with 34,598 Americans dying by suicide in 2007. In a study of VA healthcare seeking Veterans as compared to the general population, the suicide rate among Veterans was 43.13 and 10.41 per 100,000 person-years for men and women, respectively. Although this study is limited to Veterans seeking VA health care in 2001 prior to Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) and prior to suicide prevention initiatives in the Veterans Health Administration (VHA) facilities, this data confirms that both older and younger Veterans using VA health care services are at heightened risk for death by suicide.
Among those Veterans who die each year by suicide, it is still unknown how many of these deaths are among community-dwelling Veterans who do NOT go to VHA for care. Epidemiological data on previous combat Veteran cohorts and data on underutilization of VHA services among OEF/OIF Veterans suggest that suicide risk among our newest cohort of Veterans as well as other Veterans not enrolled in VHA care, is of great concern.
The overall objective of the study was to examine the need for suicide prevention services in the local communities where Veterans live from the perspective of a diverse group of VHA and community providers. The study identified provider and organizational barriers to care with a focus on those unique to older Veterans and those living in rural areas that may be at risk for suicide.
Using purposeful sampling, this Rapid Response Project (RRP) recruited and gathered survey and interview data from a diverse group of stakeholders (N=70) that represented key VHA and non-VHA community-based agencies that provided a range of health and psychosocial services to veteran and/or military populations living in the Central and Eastern Regions of the State of Missouri. Interview questions focused on the perception of Veteran's needs for VHA and/or community-based suicide prevention services. Providers completed a survey assessing demographic and individual level factors such as exposure to suicide, contact with and relationship to someone suicidal, and organizational characteristics of the providers' employing agencies. Thematic content analysis methodology was used to analyze the interview data while survey data was analyzed using bivariate and multivariate statistics.
This project assessed a total of 70 community and clinical providers (VHA and non-VHA) focusing on Veterans need for services, and in particular suicide prevention services, from the Central and Eastern Regions of the State of Missouri. The sample comprised well-educated, Caucasian, social workers with a fairly even distribution of males and females. About one third were veterans themselves, and nearly a quarter currently work for the VA. Nearly three quarters had a master's degree or higher education level (73.1%, n=51), and almost 90% had attended a previous suicide prevention training (n=62).
Organizationally, most of the participants represented medium-sized, government and non-profit organizations. The organizations provided services across the lifespan, from birth to the elderly, although the majority focused their services on middle-aged clients aged 25-64 (91.4%, n=64). Many also provided veteran-focused services (74.6%, n=50), although those were not necessarily specific to providing mental health services.
Most providers (94%) had some prior contact with someone who was suicidal, and nearly three quarters (77%) knew someone who died by suicide. Given that some relationships tend to be more personal in nature, the sample reported that they knew more family (35.9%, n=23) than friends, neighbors, or acquaintances. Conversely, for professional relationships, the majority of respondents reported knowing mostly patients (81.3%, n=52) who were suicidal, but also noted co-workers, students, veterans and others as well. About half (46.3%) of the sample had a personal contact with someone who was suicidal, and nearly all (89.1%) had a professional contact with someone who was suicidal.
The great majority of study participants endorsed the need for suicide prevention services for veterans. Yet, there is a limited understanding of suicide prevention strategies and suicide prevention services offered by the VHA among non-mental health care professionals. For example, those individuals lacking significant experience with suicide and/or mental health issues tended to think of prevention as intervention (i.e. visiting an emergency room in a crisis moment). When asked what a suicide prevention program would entail, they were less likely to mention proactive strategies, such as broad and/or targeted educational efforts or particular mental health programs offered within the community or by the VA.
Within the VA health care system, suicide prevention services are well-known and utilized by clinical providers, yet in the community, barriers related to lack of awareness and referral procedures to VHA's services exist.
The study also identified 10 different service sectors with typical examples of agencies who's clinical and community providers may come into contact with Veterans in need of suicide prevention services. First, the mental health service sector was defined by VA and non- VA mental health clinics, inpatient and outpatient psychiatric treatment facilities, and community mental health centers, such as those run by the state department of mental health and by private providers. The substance abuse sector consisted of in-patient and out-patient substance abuse prevention and treatment settings. The aging sector comprised agencies whose primary populations include those over 60 years of age with services focusing on older adults. The homeless sector included agencies whose primary population included those who were homeless or at risk of homelessness. The employment sector consisted of those organizations whose primary concern is assisting with (un) employment, self-employment and/or business development. The justice system sector comprised law enforcement, courts and other legal agencies whose primary population includes those involved in the criminal justice system. The education sector consisted of organizations whose primary mission is adult post-secondary education. The military sector consisted of agencies whose primary population includes current military service members. The benefits sector consists of agencies that provide information, referral, benefits assistance, and/or civic engagement opportunities for Veterans. Finally, the policy sector included agencies whose primary mission is advocacy and/or specific policy, research, or allied services targeting service delivery for vulnerable and at-risk populations.
Results indicate that although there are statistically significant differences in the percent of Veterans served by the different service sectors (F(9, 55)=2.71, p=0.04), exposure to suicidal Veterans and providers' referral behavior are consistent across the sectors. Agencies that provide Veteran-specific services, such as those in the benefits sector, had the highest percentage of Veteran clients. Yet, providers are encountering suicidal Veterans in all service sectors, not only in mental health.
Most participants consider the VA to be the foremost experts on veteran care, especially in the area of mental health, and they recommend that their clients use VA services when possible. However, participants with no existing direct contacts at the VA encounter barriers when referring clients for services, including not knowing who specifically to contact within the VA and having to navigate the general telephone number system for the local VA facility or the VA's national toll free 1-800 numbers.
Overall, community providers desire more direct contact with the VHA for referral and care coordination purposes, as well as for information sharing regarding Veterans at heightened risk of suicide. While some study participants enjoyed enhanced communication with the VA due to joint grant or community ventures (especially in the justice and homeless service sectors), others voiced the need for more direct communication, better relationships, and information sharing with their VA counterparts.
Participants suggested a variety of platforms to be employed in reaching different cohorts of veterans with suicide prevention materials, including targeted interventions for providers, public service announcements for the community, social media and smart phone apps, word of mouth and greater presence of outreach or services in locations where veterans congregate.
Veterans in need of social services may access many different community agencies within the public and private sectors. Each of these settings has the potential to be a pipeline for attaining needed health, mental health, and benefits services, however many service providers lack information on how to conceptualize where Veterans go for services within their local community. This study developed a service sector segmented approach to aid recruitment, yet it has applicability for other community providers who may work with at-risk Veterans to care. The approach can be useful in informing outreach strategies to engage the public and private sectors in identifying and referring Veterans to needed and appropriate services. Challenges to using this framework include isolating the appropriate sectors and targeting outreach efforts.
The public health impact of preventing suicide among Veterans requires the ongoing development of professional relationships and direct referral pathways to VA care, particularly for providers who work with Veterans in their local communities. The ability to look beyond the health care sector to identify where Veterans may present in their community for services offers great promise for enhancing VHA's suicide prevention efforts.
A future Service Directed Project (SDP) is planned to test innovative inter-organizational strategies for reducing community level barriers to suicide prevention services for at risk Veterans. Clinically, we know that enrolled and non-enrolled Veterans are often engaged in community-based services in addition to VHA care; therefore, a community-based intervention designed by the stakeholders who work with our Veterans is much needed. By examining the interaction between stakeholder groups and pathways to VHA care, future research using the results of this study will also provide Suicide Prevention Coordinators with information on which community agencies are most in need of VA outreach and suicide prevention services.
- Matthieu MM, Gardiner G, Ziegemeier E, Buxton M, Han L, Cross W. Veterans’ mental health: Personal and professional knowledge of and experience with suicide and suicide prevention among Veteran stakeholders in community and clinical practice. Social work in mental health. 2014 May 30; 12(5-6):443-456.
- Matthieu MM, Gardiner G, Ziegemeier E, Buxton M. Using a service sector segmented approach to identify community stakeholders who can improve access to suicide prevention services for veterans. Military medicine. 2014 Apr 1; 179(4):388-95.