Veteran suicide remains a critical issue in the United States, claiming more than 6,000 lives annually. The suicide rate among veterans exceeds that of nonveterans and for two decades has been rising at a faster pace. Despite significant efforts by government and private sectors, the problem persists.
In recent research, we took stock of existing efforts in the United States trying to make a dent in this epidemic. We identified 156 programs: Some provide therapy, group fitness, spiritual counseling, and offer retreats for veterans. Others train peers or health care providers how to identify veterans at risk of suicide and intervene. There are also campaigns to encourage veterans to store their personal firearms unloaded and locked. In addition we identified 226 programs on the horizon that are seeking to address suicide risk by offering emerging forms of treatment such as psychedelic therapies or heart rate monitoring to identify periods of distress.
Our report recommended that organizations and entities actively working to reduce veteran suicide continue to prioritize offering, promoting, and funding those with the strongest and most robust evidence base. They are primarily mental health care strategies. One type of strategy helps providers assess veterans for suicide risk so they can ensure that veterans at elevated risk are offered and receive targeted treatments. The other strategy is delivering evidence-based psychotherapy and pharmacotherapy that can prevent people from attempting to take their lives, as tested under experimental conditions.
The suicide rate among veterans exceeds that of nonveterans and for two decades has been rising at a faster pace.
We've received positive feedback from our report, but our recommendations also drew ire. Critics have told us that the approaches we recommend don't work. They note that these are the strategies our country has been prioritizing for years, even as the veteran suicide rate has worsened. Moreover, they argue that by continuing to stress these evidence-based treatments, we are eclipsing novel approaches to suicide prevention.
We want to explain why we prioritized these mental health strategies, and how we also see room at the table for other efforts.
We are both passionate about preventing suicide. As scientists, we generate and follow evidence about how veterans' lives can be saved. We assess the quality of research and prioritize in our assessments experimental designs that produce the strongest evidence of effectiveness, like randomized controlled trials. Over the past 50 years there have been rigorous experiments that have shown that individuals at risk of suicide who were randomly assigned to receive one of three specific psychological treatments (collaborative safety planning, cognitive behavioral therapy (CBT), or dialectical behavioral therapy) were less likely to attempt suicide than those in a comparison group. For example, Army soldiers at risk of suicide who received CBT were 60 percent less likely to attempt suicide over two years than those who received “treatment as usual.” Certain classes of psychiatric medications (e.g., clozapine and lithium) have also shown benefits in similar experimental conditions.
VA offers many of these evidence-based mental health strategies. However, 60 percent (PDF) of veterans who died by suicide had no contact with the VA in the two years prior to their death, and there are many barriers in the community to accessing high-quality treatments. This suggests that many veterans who could benefit from these treatments are not accessing them.
So, suicide prevention also needs to include activities that can help identify those at risk and refer them, as appropriate, to evidence-based treatments like those offered by VA. Our vision of suicide prevention also includes mental health supports—activities that do not directly reduce suicide attempts but do create the conditions for ensuring veterans at risk of suicide can access evidence-based treatments and participate fully in them.
It also includes far-ranging efforts that support treatment in vital but indirect ways. Without the security of a roof over one's head, for example, it will be difficult for veterans to be compliant with prescription regimens or manage their psychotherapy homework. Case management to help veterans find accessible housing or direct financial support for housing should be considered as supportive of suicide prevention. Peers can also help veterans understand how to navigate treatment regimens and decrease their suicide risk.
Evidence-based treatments are not perfect; we'd be the first to admit that. They can be inaccessible to veterans, and veterans don't always benefit from them. For this reason, we believe the door should be open to new treatments with emerging evidence. However, these need to be approached with some caution. We have a clear sense of the benefits and risks of evidence-based treatments, which let veterans work collaboratively with health care providers to determine what is best for them. There's no such information for many experimental therapies.
Finally, we acknowledge that focusing solely on mental health treatments is insufficient. Most evidence-based suicide prevention strategies are to prevent those who are already thinking about suicide from making an attempt. It is just as important to prevent individuals from thinking about ending their lives in the first place. Our vision of preventing suicide includes wellness activities and environments that help veterans thrive: for example, arts classes, sporting events, spiritual gatherings, and programs that bring veterans together to build social bonds.
Our vision of preventing suicide includes wellness activities and environments that help veterans thrive.
This “upstream” prevention is understandably controversial as a component of suicide prevention. For example, should taxpayer funds allocated to the Staff Sergeant Parker Gordon Fox Suicide Prevention Services Grant Program be spent on things for which there is no evidence of a direct effect on suicide outcomes?
Maybe so. Plentiful research documents which groups of veterans have higher risk factors for suicide, such as having depression, being socially isolated, or having a gun at home. Programs that can reduce such known antecedents of suicide may be worthy of investment.
More controversial are programs that have yet to demonstrate concrete results on what they are trying to accomplish, let alone an impact on reducing suicide. For example, many programs offered to veterans seek to build social connections—thereby reducing isolation—but few have proven that they have achieved even this goal. It could be that these programs primarily attract those who are already well-connected rather than serving those who are truly isolated. We call this “selection bias” and it is a concern for many programs offered to veterans, including those that bring veterans to sporting events and other types of entertainment, offer fitness classes, spiritual counseling, and couples retreats.
Like our critics, we are alarmed at rising veteran suicide rates. But we believe that the United States hasn't yet optimized strategies to get veterans into evidence-supported treatments. There is also room at the table for other approaches—so long as policymakers and other entities committed to preventing veteran suicide are strategic about which to invest in and promote.
