May 6, 2008 – The purpose of this testimony is to provide information on the issues related to veterans suicide: what VA knows, including the sources of information we use; what we do not know, and what we intend to do about that problem; and what we have been doing to directly address the issues of suicide from a clinical perspective, and how we are expanding our outreach, even as we seek better ways to measure the problem.
The language used to talk about suicide is complex. Suicidal behavior exists along a continuum; from thinking about ending one’s life, to developing a plan to do so, to non-fatal suicidal behavior, to actually ending one’s own life. The Centers for Disease Control (CDC) has come up with some definitions of suicidal behavior which the Department of Veterans Affairs (VA) has adopted.
CDC has defined suicidal ideation as having thoughts of harming or killing oneself; a suicide attempt is a non-fatal, self-inflicted destructive act in which a person has either an explicit or an inferred intent to die; self-inflicted injuries are suicidal and non-suicidal behaviors such as self mutilation; and suicide itself refers to a fatal self-inflicted destructive act in which there is an explicit or an inferred intent to die.
Suicide is a relatively infrequent act. Although suicide is the 11th leading cause of death among Americans of all ages, when studying any group over short periods of time the number of actual suicides will be low. Only very large studies conducted over long periods of time allow the accumulation of enough observations to make meaningful comparisons.
Suicide risks vary by age, gender and other factors. For Americans in general, the highest rates of suicide are among older men, but middle-aged veterans appear to take their own lives in greater proportions than their elders.
Suicides often occur in close proximity, especially after media attention. This kind of behavior is called “copycat behavior,” or the “Werther effect,” after a wave of suicides in 18th century Europe following the publication of a book by Goethe. It can be difficult to tell when a cluster represents a temporary trend, or a sustained trend.
Official suicide rates based on death certificate data can be incomplete. There are regional differences in how suicides are defined; how ambiguous cases are classified; and how thoroughly coroners or medical examiners investigate causes of death. In some areas religious traditions, life insurance policies, or legal sanctions may lead to underreporting. The increased awareness of the relationship between mental illness and suicide may cause an apparent increase in the reported number of suicides—without the rates actually differing.
And finally, reconstructing the events leading up to a death is difficult. Death certificates provide only a limited amount of information about actual causes of death, so researchers need to contact those closest to the victim to understand the true circumstances of death, and the factors that contributed to a death. Family members and others can often provide inaccurate or incomplete information.
The way researchers determine incidences for suicide is to express the number of suicides in a population per hundred thousand people per year. Because suicide rates vary by age, with both older and younger people at higher risk, any rates that attempt to make comparisons across different populations by year must be adjusted to allow for accurate comparisons. One way to do so is to look at age specific rates of suicides and compare them to the U.S. population as distributed by age. CDC uses the U.S. population census figures for 2000 to do this.
Another method of adjustment is called the standardized mortality ratio. This ratio compares the number of observed deaths in a defined group with the number of deaths that would be expected if that group had the same age-specific rates as a standard population.
Finally, there are sophisticated statistical techniques which can be used to derive a relative risk that take into account multiple characteristics of individuals, such as gender, race and ethnicity, medical conditions and other factors.
Each of these methods of adjustment has their strengths and their weaknesses. Each is potentially misleading when comparing populations with very different age or gender distributions. A careful analysis of suicide rates that is age and gender specific is both necessary and appropriate.
Because of this, VA has long subjected its own data, that of the Department of Defense, and data from nationally-accepted statistical sources to careful and painstaking analysis to obtain the truth about veterans’ suicide.
A suicide rate is normally calculated by describing the number of cases occurring in a defined group over a specific period of time. These are called incidences of suicide, and to avoid expressing incidences as very small fractions, suicide rate is typically expressed in terms of the number of suicides per 100,000 persons per year.
To make accurate comparisons of suicide rates, such as trends over time or comparisons among veterans and non-veterans, three important elements are needed. First is an accurate count of events for both groups, called the numerator. Second is an accurate estimate of the total population at risk, called the denominator. And third, as already mentioned, there needs to be an adjustment for age and gender differences between populations.
HOW VA COLLECTS SUICIDE DATA
VA relies on multiple sources of information to identify deaths that are potentially due to suicide. This includes VA’s own Beneficiary Identification and Records Locator Subsystem, called BIRLS; records from the Social Security Administration; and data compiled by the National Center for Health Statistics in its National Death Index.
This is a painstaking and difficult process for VA and for others, best illustrated by the fact that suicide data from the Centers for Disease Control and prevention are available only through 2005. Calculating suicide rates specifically for veterans is made even more difficult by the fact that the National Death Index does not include information about whether a deceased individual is a veteran or not.
The National Death Index is simply a central computerized index of death record information on file in the vital statistics offices of every state. The Index is compiled from computer files submitted by State vital statistics offices. Death records are added to the file annually, about twelve months after the end of a calendar year. CDC uses this data to compile its statistics on American death rates.
Given that the NDI does not indicate veteran status, VA regularly submits requests for information to NDI. Because the system contains a list of all Americans who have died, and because of the capabilities of its Electronic Health Record system, VA is able to send NDI a list of all patients who have not been treated at any VA medical centers in the past twelve months and before, to see if they are still among the living.
NDI checks this list against their records, and tells VA which veterans have died, and the cause of their death as listed on the veterans’ death certificates. From this information, VA is able to learn the approximate number of veterans under its care who have died of suicide, and to use that information to make comparisons on rates of suicide among those veterans and all other Americans.
This information tells VA about the suicide rates among veterans under its care, but says nothing about the rates of suicide among veterans who are not currently in the system. For those veterans, an even more complicated process has to be followed in order to estimate rates. VA obtains regular updates from the Department of Defense’s Defense Manpower Data Center on soldiers separating from the military. Those new veterans immediately become part of total population and suicide calculations.
In 2002, the CDC established the National Violent Death Reporting System, or NVDRS. NVDRS today is fully implemented in 16 states, and collects data on violent deaths, including suicides. NVDRS collects data on violent deaths from a variety of sources, including death certificates, police reports, medical examiner and coroner reports, and crime laboratories. Veteran status is included in the database.
Together, these sources offer a comprehensive picture of the circumstances surrounding homicides and suicides. This, too, is a time-consuming and difficult task, and standard reports from NVDRS are available only through 2005.
Because NVDRS is a comprehensive source of data, and because it indicates whether or not a coroner has indicated that the deceased is a veteran, VA is able to obtain counts of the number of suicides among all veterans in the sixteen stats that have fully implemented this system, broken down by sex, age, race and state. To summarize, determining suicide rates among veterans is a challenging puzzle. Multiple data sources must be used, and data must be carefully checked and rechecked. Each system helps obtain a piece of the complicated puzzle that constitutes the process of accurately estimating rates of veteran suicides.
These are time-consuming processes—but they are the best ways VA knows to obtain aggregate data on suicide. The weaknesses inherent in this method are clear.
First, the CDC’s manual for completion of death certificates states that the determination of whether or not someone is a veteran should usually be done by funeral directors. The information available to directors is limited, and their willingness to investigate the question of veteran status varies. Generally, these directors allow families to self-certify their response to the question of whether their loved one was a veteran; an approach fraught with pitfalls. In addition, funeral directors may not be clear on whether a young person died on active duty, or shortly after leaving the service.
Second, the classification of a death as suicide is dependent on the work of coroner’s offices throughout America. This paper has already discussed issues related to coroner determinations: regional differences in definitions; the manner in which ambiguous cases are classified; the level of investigative determination; religious traditions, and legal sanctions all create difficulties in data reliability.
And third, data takes a very long time to assemble. Neither NDI nor NVDRS has released reports of data newer than 2005—and it is midway through 2008 at present.
There are actions VA can take, and is taking, to improve the reliability and the speed of the data the Department is obtaining and providing to Congress. First, VA has begun negotiations with NVDRS staff that will provide information from all of NVDRS’ sources (death certificates, police reports, medical examiner and coroner reports, and crime laboratories) on a monthly and quarterly basis, as they are received by NVDRS.
VA will not be able to determine when there is sufficient information to provide full and publishable data—only NVDRS can do that—but will be able to examine and analyze these reports in a way that will allow the Department to spot suicide trends by age, sex and even region more quickly and to take action in those areas.
The Department will also systematically assess its efforts to inform funeral directors about the importance of determining whether or not a person who has died of suicide is or is not a veteran, and what sorts of information to consider in making that determination.
VA will also investigate working directly with state vital records offices, as the NDI does, to obtain information on veteran suicides directly from them.
And finally, VA has a new way of obtaining information on both suicides and suicide attempts: the Department’s suicide prevention coordinators.
Until VA committed itself last year to providing full time suicide prevention coordinators at each of its 153 hospitals, it could provide no useful number of attempted suicides among patients. Last October, a standardized definition of suicide attempts was developed and coordinators were asked to begin to count the number of such attempts of which they were aware.
VA’s definition of a suicide attempt included any behaviors that might have potentially allowed veterans to injure themselves, when there was evidence that the veteran had the intent to kill himself or herself—whether or not he or she was actually injured. The definition also included events in which a veteran was rescued, an attempt thwarted, or a veteran changed his or her mind after taking an initial action.
On February 13, 2008, an internal email from VA’s Deputy Chief of Patient Care Services for Mental Health discussed the existence of this information. In this email, he suggested 1,000 veterans a month under VA care were being reported as attempting suicide, and was concerned about disclosing the information.
The data was not sent to CBS because of his concerns.
The number of attempts referenced was based on only three months worth of data, too short a time period to determine if it was reliable.
The data was demonstrably not accurate. Even now, six months after collecting data began, the reports indicate that a number of states have suspiciously low reporting rates—and there is remarkable variability among individual VA facilities throughout the United States, due either to regional variability in suicide rates, differences in the manner in which individual suicide coordinators reported data, or both.
VA’s suicide prevention coordinators were new to their jobs, and new to their tasks. There was a great deal of uncertainty over “borderline calls,” and many of them were just beginning to make the community and in-hospital contacts that are essential in making an accurate count of the number of suicide attempts among patients.
VA is addressing the problem of the accuracy of suicide coordinators’ data in a number of important ways; by regularly reviewing the data the Department receives, and educating coordinators on the proper way to collect and report this information;
And VA is regularly reviewing difficult “calls” with its suicide coordinators—and encouraging them to meet the right people in their communities to obtain additional data.
In the near future, the Department intends to ask suicide prevention coordinators for the names of all those in their facility who have attempted suicide. This will allow further refinement of this data by checking the electronic medical records of individual veterans whose names have been reported as having attempted suicide. VA will learn how this information has been entered into the health record, and how practitioners have incorporated this information into the treatment plan for the individual whose record is being reviewed—with important implications for preventing suicide throughout VA’s system.
VA’s suicide coordinators are providing another important service; they are providing an additional source of data on the number of completed suicides at their facilities. This data, too, has significant problems: while VA can tell with considerable accuracy how many veterans commit suicide within its facilities, suicide coordinators have both limited time and contacts among coroners and funeral directors to provide accurate counts of the numbers who have died of suicide in the community.
While coordinators will be encouraged to continue to make those contacts, and to attempt to refine the accuracy of the numbers of dead they submit, VA believes that the focus of suicide prevention coordinators must be on preventing suicide among the living. Epidemiologists and researchers, using the data sources described above, will be the ones to learn more from those who have been lost.
Before turning to the actual data, here is a brief explanation of some data which has been widely attributed to VA, but which, in fact, is not the Department’s. On March 20, 2008, CBS aired a story on veterans’ suicide which included a statement in which the network said it had “obtained from VA” the information that there had been 790 attempted suicides among veterans under the Department’s care in all of 2007.
VA has since reviewed its records to try to understand where CBS might have gotten their information, and believes the number stemmed from a response to a Freedom of Information Act Request CBS made to the Veterans Health Administration’s Freedom of Information Act Officer on December 20, 2007; a request that was subsequently modified on January 29, 2008. VA provided CBS with the information they asked for–information in the Department’s National Patient Care Data base for the years 2000 through 2007, broken down by year, state, age group, gender and race.
This data provides a breakdown of why veterans were seen in VA’s hospitals and clinics by International Classification of Diseases code. Once such code is “Suicide and other Self-Inflicted Injuries.” CBS apparently counted the total number of veterans for whom that code was entered—and came up with 790 attempts for 2007.
That number, unfortunately, is not at all useful if the purpose of the count is to determine the total number of suicides and attempts among veterans under VA’s care. Some people who attempt suicide, but do not die, do not then present directly to VA for care. Others do not admit that their injuries were due to suicide attempts until a counselor discusses their situation with them. And still others treat their own wounds without seeing a clinician; the attempt is only revealed later, during counseling. CBS’s number, while arithmetically correct, is actually misleading.
VA’s DATA ON SUICIDES AND ATTEMPTS
To review what we do know specifically, let us compare veterans’ rates of suicide to non-veterans rates. The source of the base data is the National Death Index, a product of the National Center for Health Statistics of the Department of Health and Human Services. The most current complete data in this area is from 2005; 2006 data should be released soon. The overall rates of suicide for men and women from 2001 through 2005 are shown in Tables 1 and 2. It is important to separate the rates for men and women. By doing so, we see that men have a higher rate of suicide than women; a rate that is statistically significant. It is also important to separate these figures by age groupings, because there are significant differences in that area as well. These tables provide that information as well.
Table 1: Suicide Rates Per 100,000 Male U.S. Citizens by Fiscal Year and Age
2001
2002
2003
2004
2005
All men
23.18
23.63
23.20
23.20
23.19
18-29
20.14
20.08
19.38
20.21
19.35
30-64
22.45
23.10
23.13
23.00
23.19
65+
31.42
31.81
29.76
29.01
29.53
Table 2: Suicide Rates Per 100,000 Female U.S. Citizens by Fiscal Year and Age
2001
2002
2003
2004
2005
All women
5.22
5.44
5.42
5.81
5.65
18-29
3.40
3.67
3.56
3.91
3.90
30-64
6.28
6.47
6.57
7.09
6.78
65+
3.88
4.09
3.79
3.79
3.99
Source: CDC’s WISQARS Injury Reporting System and CDC’s National Center for Health Statistics’ National Death Index
Tables 3 and 4 provide overall rates of suicide for male and female Veteran VA users, broken down into three age groups: 18 to 29; 30 to 64; and 65 and older.
Table 3: Suicide Rates Per 100,000 Male Veteran VA Users by Fiscal Year and Age
2001
2002
2003
2004
2005
All Male VA users
36.49
41.58
32.92
35.40
37.19
18-29
27.75
36.54
35.64
42.54
26.94
30-64
41.37
46.32
39.57
38.44
40.66
65+
32.03
37.03
26.77
32.09
34.27
Table 4: Suicide Rates Per 100,000 Female Veteran VA Users by Fiscal Year and Age
2001
2002
2003
2004
2005
All Female VA users
9.87
12.49
9.00
12.28
13.59
18-29
2.12
15.75
5.93
7.41
7.81
30-64
11.99
11.17
10.76
14.88
13.96
65+
6.58
15.66
3.95
4.31
17.60
Source: CDC’s National Center For Health Statistics’ National Death Index
These tables show that men, whether or not they are veterans, have a higher rate of suicide than women, in numbers that can be considered statistically significant. In addition, there are significant differences by age groupings. VA is able to make these comparisons, because it is able to match the names of veterans under our care whom we have not recently seen against the National Death Index. The Death Index then provides information on which of these men and women have died, and the cause of their death, including suicide.
What cannot be learned from this table is how the rates of suicide compare among all veterans, not only those in the VA system, to the general population. Doing so would require matching the full list of 24.5 million veterans against the National Death index to see how many of them have committed suicide. That currently is not possible. However, VA has matched up general population rates of suicide in the sixteen states reporting to NVDRS in 2005 against the rate of veteran suicide in those states.
Table 5: Suicide Rates per 100,000 in 16 States Among General Population vs. Veteran Population (Males) in 2005
18-29
30-64
65+
All male VA users
53.18
36.85
36.00
All male veterans
44.99
25.60
31.52
All men
20.36
23.28
30.51
Table 6: Suicide Rates per 100,000 in 16 States Among General Population vs. Veteran Population (Women) in 2005
18-29
30-64
65+
All female VA users
25.02
15.81
—
All female veterans
15.35
11.41
3.66
All women
4.35
7.04
3.63
Sources:
General Population: CDC’s Web-based Injury Statistics Query and Reporting System
OEF/OIF: DoD’s Defense Manpower Data Center
Suicide Data: CDC’s National Center for Health Statistics National Death Index and CDC’s National Violent Death Reporting System
At this time, there is no firm explanation of the reason for the disparity in rates between VA’s patients and other Americans. However, the veterans VA serves—as opposed to the overall population of American veterans—are older, sicker, and poorer than the general population of the United States. VA researchers believe this may account for at least some of the apparent differences.
VA’s summary of this data from 2001 through 2005 yields the following hypotheses:
Male veterans commit suicide at a somewhat higher rate than other men, but with varying statistical significance by age and over different years.
Within the group of male veterans there are differences in the age at which veterans die of suicide compared to what is seen in the general population—especially in the ages between 30 and 64, at which ages veterans have a statistically significant higher rate. This finding is reproducible over time.
Male veterans commit suicide at a higher rate than female veterans.
Within the group of female veterans, there is nearly a twofold increase over the rate of suicide for women in the general population, which is also variably statistically significant over the years and by age.
Clearly, returning service men and women represent a group of particular interest to the Nation. VA has a particular sense of urgency to understand why these men and women might be taking their own lives—and to intervene to prevent even a single suicide. To better understand suicide in this particular cohort, Dr. Han Kang of VA’s Environmental Epidemiological Service conducted a study that matched those service members who had served in the theater of operations, and who separated from service between 2002 and 2005 against the National Death Index.
Using this method, Dr. Kang found that 144 out of 490,346 separated OEF/OIF servicemembers committed suicide during that time, for an overall rate of 21.9 per 100,000. These are deaths only of men and women who separated from the military, and the data does not include any suicides while a servicemember was on active duty.
To compare this to other national norms, Dr. Kang looked at this cohort against the national averages discussed above. For OIF/OEF veterans who had deployed and separated from 2002-2005, the rate was slightly higher than would be expected in an age, gender and race matched general population, but not by a statistically significant amount. (Standardized mortality Ratio of 1.15 (p>.05.)
Dr. Kang also examined this data for differences in suicide rates between those who have used VA for care and those who have not. He found that 17.0 of every 100,000 OEF/OIF veterans who use VA for care take their own lives, compared to 24.0 of every 100,000 OEF/OIF veterans who do not use VA for care. This apparent advantage of VA care, though encouraging, is not statistically significant. In this group, the same is true for vet center users.
Male veterans 18-29 who used VA care took their own lives at a rate of 21.0 per 100,000, compared to veterans of that age who did not use VA for care, a group which died of suicide at a rate of 30.4 per 100,000—a statistically significant difference. Male veterans aged 30-64 who used VA for care died of suicide at a rate of 17.5 per 100,000, compared to a rate of 22.8 per 100,000 for their fellow veterans who did not use VA for care—not a statistically significant difference. Since only 3 women OEF/OIF veterans died of suicide through 2005, accurate rates within age groups cannot be calculated.
VA statisticians have worked with this now-older data in anticipation of follow-on data when the updated National Death Index information is available. Some of the insights they have found include the knowledge that there appears to be little variation in suicide risk by branch of service. Statisticians also found that a diagnosis of a mental disorder predicted a nearly 1.8 times higher suicide risk than the general population. This is consistent with what has been published in research journals regarding the non-veteran population, and emphasizes the importance of the Department’s mental health efforts.
All of this data comes from national data for suicide against those who are known, from VA’s data sources or from Department of Defense records, to be veterans. These national numbers must be used because VA’s clinical records do not capture, in any reliable or complete way, such events as suicides or suicide attempts.
The National Death Index, a national roll-up of information from coroners through the states, offers the most complete compilation of deaths among veterans and their causes—since VA may not know of a death even if it occurs in an area in which the Department has a facility. Because information on deaths continues to be updated as reports come in over time, confidence in the completeness of those numbers only comes after several years of data collection. VA is awaiting at this time the release of National Death Index compilations for 2006 for further analysis.
Regarding inpatient deaths: from 2000 through 2007, exactly 50 VA inpatients took their own lives while under the Department’s care, based on root cause analyses of the deaths received by VA’s Office of Patient Safety. That number varies from a high of 14 such suicides in 2002, to a low of 2 in 2007, when Veterans Health Administration officials demanded that all facilities pay special attention to improving their environment of care to reduce opportunities for suicide.
VA’s SUICIDE PREVENTION EFFORTS
The steps VA is taking to prevent suicide among veterans are important and significant. All VA employees have been given the message that even strong and resilient people can develop mental health conditions; care for those conditions is readily available and should be immediately provided; and treatment works.
VA has held two National VA Suicide Prevention Awareness Days throughout its system to focus all 200,000 health care employees on this issue. The first event focused on enhancing overall awareness of the issue. The second coincided with National Suicide Prevention Awareness Week. During that week, VA staff was trained on how to work with available prevention resources, including the hotline and the suicide prevention coordinators. VA will continue participating in Suicide Prevention Awareness Week activities every year, with a special focus on veterans and ways VA can continually improve its suicide prevention efforts.
The Department is in the process of adding 23 new vet centers throughout the Nation to provide more individual, group and family counseling to veterans of all wars who have served in combat zones, bringing the total number of vet centers to 232.
VA’s suicide prevention program includes two centers that conduct research and provide technical assistance in this area to all locations of care. One is the Mental Health Center of Excellence in Canandaigua, New York, which focuses in developing and testing clinical and public health intervention related to suicide risk and prevention. The other is the VISN 19 Mental Illness Research Education and Clinical Center in Denver, which focuses on research in the clinical and neurobiological sciences with special emphasis on issues related to suicide risk.
VA’s system of care also includes a suicide prevention call center, also located in Canandaigua, and the suicide prevention coordinators previously discussed, who are located at each of VA’s 153 hospitals. Altogether, VA has more than 200 mental health providers whose jobs are specifically devoted to preventing suicide among veterans.
To develop the suicide prevention call center, the Department has partnered with the Lifeline Program of the Substance Abuse and Mental Health Services Administration. Those who call 1-800-273-TALK are asked to press “1” if they are a veteran, or are calling about a veteran.
Unlike other such hotlines, VA’s hotline is staffed solely by mental health professionals—24 hours a day, seven days a week. Hotline staff is trained in both crisis intervention strategies, and in issues relating specifically to veterans, such as traumatic brain injury and post traumatic stress disorder. In emergencies, the hotline contacts local emergency resources such as police or ambulance services to ensure an immediate response.
Cards, pamphlets and posters—even refrigerator magnets—bearing the number are distributed by suicide prevention coordinators to at-risk veterans and their family members.
In addition, posters with hotline information are located throughout VA medical centers and clinics, and in all residential rehabilitation programs there are stickers on phones and by doors with the hotline number. Vet Centers also make this information available.
If the caller is a veteran enrolled with VA for care, the hotline staff is able to use the veteran’s electronic medical record during the call, if the veteran is a VA patient and willing to identify himself or herself. These records provide information that is invaluable during a crisis, including information on medications; the patient’s treatment plan; and who to contact during this emergency.
Staff can talk directly to the facility that is treating the veteran. They can place consults in the patient’s medical record, and are able to make arrangements to directly refer veterans to a Medical Center or Community-based outpatient clinic to be seen if that’s appropriate.
And hotline staff follows up on these referrals. They check patient’s records to see if consultations were completed; actions are taken; and follow-ups are ongoing. If the record does not show this information, the suicide prevention coordinator is called, ensuring that no referral is lost in the process.
From its beginnings in July, 2007 through the end of April, 16,414 calls have come to the hotline from veterans and 2125 family members or friends have called. These calls have led to 3464 referrals to suicide prevention coordinators and 885 rescues involving emergency services. 493 active duty servicemembers have also called.
Besides keeping track of veterans who have tried to take their own lives, suicide prevention coordinators receive referrals of those at risk for suicide from both the hotline and from providers in their facilities. They also ensure that care for these veterans is appropriate for their situations.
Coordinators educate their colleagues, veterans and families about risks for suicide. They provide enhanced treatment monitoring for veterans at risk and ensure that any missed appointments are followed up on. The coordinators work with the entire staff of their medical centers to maintain awareness of those who have previously attempted suicide, and ensure their care is enhanced to reduce the risk of renewed attempts.
They also work with patient safety officers to conduct quarterly safety inspections of inpatient psychiatry units, and coordinate staff education programs about suicide prevention. These coordinators are in the process of organizing a system of flags in the electronic medical record system to alert providers about those at high risk. They are also conducting training for community members who have frequent contact with veterans to help them recognize those at risk and encourage them to seek treatment.
There is a large body of scientific literature on suicide. Over the years, VA has been a prime contributor to the knowledge that has been developed in the scientific community on this issue. Our research has helped us target our efforts to reduce suicide. Some of the information our researchers have developed includes:
Among veterans receiving care from VA who died from suicide, almost 60{cd9ac3671b356cd86fdb96f1eda7eb3bb1367f54cff58cc36abbd73c33c82e1d} of those under age 65 had a mental health or substance abuse diagnosis on their medical records—but only 24{cd9ac3671b356cd86fdb96f1eda7eb3bb1367f54cff58cc36abbd73c33c82e1d} of those 65 or over had such a diagnosis.
There is significant variability in suicide rates among veterans by geography. In general, rates are lowest in the Northeast and highest in the West.
Firearms are the most common means used by veterans who died of suicide, accounting for nearly two-thirds of all deaths.
There appears to have been an increase in suicide rates among Vietnam veterans during the first two years after these veterans returned home. After a few years, however, Vietnam veterans’ rates of suicide were comparable to those of the general population.
There was no increase in suicide rates among veterans who returned from the first Gulf War.
Those veterans who are wounded in combat are at higher risk of suicide.
5. FUTURE ACTIVITIES
In the near future, the Department will continue to educate its employees; through additional Suicide Prevention Days; through posters identifying the warning signs of suicide; and through its continuing Employee Education process to identify those at possible risk of suicide to ensure they get proper care. As new data on suicide rates, risk factors for suicide and regional variations become available, VA will use that data to refine its programs, and to better evaluate their level of success.
VA will increasingly reach out to the newest generation of veterans, by using communications outlets familiar to them. VA now has a virtual office on “Second Life;” and recently collaborated with MTV on a video on readjustment issues for returning veterans that can be found on their web site.
VA will continue its efforts to meet the mandate of the President’s New Freedom Commission to reduce the stigma that surrounds mental illness.
VA will also continue the expansion of its mental health program that has enabled the Department to hire more than 3800 new mental health employees in the past three years, and expand hours of operation for mental health clinics beyond normal business hours. These efforts to better identify and treat mental illness will help prevent contemplation of suicide and suicide attempts—and will help ensure that veterans in crisis are already involved in VA’s system and have somewhere to turn when they need help.
The Department will aggressively follow up on patients in mental health and substance abuse programs who miss appointments to ensure they are not lost to follow up care. VA will also monitor the standards the Veterans Health Administration has set for itself: to provide initial evaluations of all patients with mental health issues within 24 hours, provide urgent care immediately when that evaluation indicates it is needed, and to complete a full evaluation and initiate a treatment plan within 14 days for those not needing immediate crisis care.
On May 2, VA began contacting nearly 570,000 combat veterans of the Global War on Terror to ensure they know about VA medical services and other benefits. The Department will reach out and touch every veteran of the war to let them know it is here for them. The first of those calls are going to an estimated 17,000 veterans who were sick or injured while serving in Iraq or Afghanistan. If any of these 17,000 veterans do not now have a care manager to work with them to ensure they get appropriate health care, VA will offer to appoint one for them.
All case managers for OEF/OIF veterans will be trained in suicide risk recognition and management for their patients, and encouraged to establish a personal relationship with those veterans to support their health care needs.
I have also directed the creation of a work group on suicide prevention in the veteran population. This work group will look at all matters relating to VA’s ability to prevent suicide among veterans. They will be given all the data VA has, and access to the best experts VA knows.
The work group will be asked to provide a report within fifteen days of the completion of their meeting on how VA can better approach suicide prevention, suicide research, and suicide education.
All work group members will come from outside the Department of Veterans Affairs. Some will be DoD specialists; others will be from other government agencies. Nationally recognized clinical treatment, research and public health experts on suicide and suicide prevention will augment them. The work group will provide an additional level of advice and oversight to all the issues described above.
There is nothing more tragic than the loss of even one of those great men or women who have served this nation. The VA is committed to doing all that we can to serve the individual while we continue to try to understand a very complicated problem that is also a national problem. We owe this committee and the nation accurate information and carefully studied, thoughtful conclusions while we provide the “best care anywhere” to our Veterans.
