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Submission For The Record of Richard McCormick, Ph.D., Senior Scholar, Center for Health Care Policy, Case Western Reserve University, Cleveland, OH

Suicide is a tragedy. It is the ultimate ending for some of the very large numbers of veterans who face the challenges and problems that result from deployment and combat.

The Department of Veterans Affairs (VA) and the Department of Defense (DoD) have worked hard to develop programs to reduce suicidal behavior among returning service members and veterans. Still, the challenge remains to discover and implement additional measures to further reduce the risk of suicidal behavior.

Research has established that the suicide of a particular individual is very difficult to predict and anticipate.  We do, however, have increasingly knowledge about the conditions that precede and contribute to suicidal behavior and other serious emotional problems, such as PTSD and depression, in veterans and service members. These include notably:

  •  Problems in marital and other important relationships
  •  Hazardous use of alcohol and other drugs
  •  Risky/impulsive behaviors including: gambling, hazardous driving, and outbursts of angry behavior

Research has shown that all of these problems occur in returning service members and veterans, and that all are related to the degree of exposure to stress during time in service and immediately after.

The harmful use of alcohol is a major public health problem, and is a particularly serious problem for those serving in the current war on terror. A recent report on 48,481 active duty, reserve and national guard indicates that rates of heavy weekly drinking (9%), binge drinking (53.4%) , and problems related to alcohol use (15.2%) were particularly high in Reserve and National Guard members  who are veterans immediately after return from deployment (Jacobsen, Ryan, Hooper, et al, 2008). Both the degree of exposure to combat and the degree of exposure to human trauma are related to increased drinking (Kilgore et al, 2008; WIlk et al 2010). Surveys of active duty military members have noted that between 6.3% and 8.1% report at least one gambling related problem in their lifetime (Steenbergii et al 2008). In a study of returning OIF/OEF service members, the intensity of combat experience and exposure to violent human trauma were predictive of verbal and physical aggression towards others three months after deployment (Kilgore et al, 2008). Aggressive and unsafe driving are significant problems for active duty members (Kilgore et al 2008). Even controlling for age personnel deployed to Iraq have higher rates of dangerous driving than older veterans.

These problems are often among the first indicators of serious distress. If left unattended they can fester and expand to other areas of the veteran’s life and functioning. As the problems snowball, helplessness and hopelessness can set in, leading to suicidal behavior.

A comprehensive program of early prevention for suicide and other serious emotional problems should include readily accessible, hassle-free assistance with these problems.  Historically, the Vet Centers have been more assertive in addressing these early problems than has the VA core medical care system. With some notable exceptions, VA medical centers and clinics have traditionally focused on diagnosable pathology. If services such as marital counseling or early intervention into hazardous drinking exist, they may be embedded in other programs.

Further complicating the prevention effort is a lack of awareness, and at times limited motivation, of the veteran to address the early precursor problems. Present programs, including the Vet Centers, rely on the veteran seeking help for a self-identified problem.  

More can and needs to be done to identify and offer early intervention for problems which have been demonstrated to be related to later serious emotional problems and suicidal behavior.         

The first practical steps would be to build on current efforts in the VA and DoD to screen for early occurring problems.  VA currently screens all patients in primary care for hazardous alcohol use, depression and PTSD. Positive screens for depression and PTSD are expected to trigger further screening and intervention, including identifying and addressing suicidal behavior. Returning service members, including those in reserve components, are screened immediately after deployment and again within 90 days for general mental health issues, including PTSD and alcohol use. VA outreach workers are present at screens for those in the reserve components when they are conducted at their home training sites.

Short reliable and valid screening tools exist for other early identifiable problems including relationship issues, problem gambling and other risky behaviors. Screening for these additional problems would raise the awareness of veterans, significant others and providers of care. It would also assure that a conversation is initiated about these problems and early intervention considered n all venues where veterans may be encountered, including primary care settings and outreach efforts.

Screening is a necessary, but not sufficient, step in a comprehensive prevention effort. Still greater challenges exist in assuring that those who screen positively are in fact engaged into an appropriate level of intervention. Hazardous alcohol use provides the currently best documented example of this issue.  A recent study of 1508 OIF/OEF veterans using VA medical, surgical or mental health services found that 40% screened positive for hazardous alcohol use (Calhoun, Elter, Jones, et al, 2008).  This study also documented that only 31% of those who screened positively for an alcohol use problem ever received a follow-up intervention to address the problem.

This lack of follow-up underscores the need to assure that readily accessible intervention services exist, and that all providers are aware of them and able to seamlessly refer to them.

VHA’s recent efforts to increase the placement of mental health staff in primary care settings provides the platform to deliver accessible services to intervene with these early problems. 

Suicide prevention efforts in VA and DoD could be enhanced by the following:

  • Expand screening efforts to include a wider variety of problems and behaviors that are potentially related to serious emotional problems including suicidality
  • Assure that readily accessible services are available to intervene immediately when a problem is identified, and that these services are widely advertised to both veterans and providers
  • Assure that all staff understand that addressing these behaviors is a critical part of providing comprehensive health care prevention services in the health care setting, they are not someone else’s responsibility
  • Increase the awareness of veterans and their significant others about these early indicator problems and urge them to bring them up with their health care provider (this could include, for example, handouts in primary care areas)
  • Conduct periodic quality assurance studies assessing whether veterans screening positively for problems actually access interventions services

Expanding screening efforts and establishing robust marital/relationship programs, specific programs addressing hazardous drinking, and programs tailored to other risky behaviors would involve further funding. Establishing these programs is part of our responsibility to restore returning veterans to full function. It needs to be done immediately, since the need is now before they can fester into additional serious issues, including, for some, suicidal behavior.  This immediate investment is also the wise fiscal choice, since it will offset not only human suffering, but future greater healthcare costs.


References:

Preliminary Normative Data for the Evaluation of Risks Scale-Bubble Sheet Version (EVAR-B) for Large-Scale Surveys of Returning Combat Veterans MAJ William D. S. Killgore, MS USAR; COL Carl A. Castro, MS USA; COL Charles W. Hoge, MC USA, MILITARY MEDICINE, 173, 5:452, 2008

Gambling and Health Risk-Taking Behavior in a Military Sample:
Timothy A. Steenbergii, PhD*; James P. Whelan, PhDf; Andrew W. Meyers, PhDf;
Robert C. Klesges, PhDf; Margaret DeBon, PhD, Military Medicine [Mil Med], ISSN: 0026-4075, 2008 May; Vol. 173 (5), pp. 452-9.

Lifetime Prevalence of Pathological Gambling Among American Indian and Hispanic American Veterans:
Joseph Westermeyer, MD, PhD, MPH, Jose Canive, MD, Judith Garrard, PhD, Paul Thuras, PhD, and James Thompson, MD, MPH,  Am J Public Health. 2005;95:860–866.

Daghestani, A. N., Elenz, E., & Crayton, J. W. (1996). Pathological gambling in hospitalized substance abusing veterans. Journal of Clinical Psychiatry, 57, 360–363.

Levens S., Dyer A. M., Zubritsky C., Knott K., Oslin D. W. Gambling among older, primary-care patients. An important public health issue. Am J Geriatr Psychiatry 2005; 13: 69–76.

Factors associated with pathological gambling at 10-year follow-up in a national sample of middle-aged men, Jeffrey F. Scherrer, Wendy S. Slutske, Hong Xian, Brian Waterman, Kamini R. Shah1, Rachel Volberg& Seth A. Eisen, Addiction, 102, 970–978, 2007

Post-combat invincibility: Violent combat experiences are associated with increased risk-taking propensity following deployment: William D.S. Killgore a,*, Dave I. Cotting , Jeffrey L. Thomas a, Anthony L. Cox, Dennis McGurk , Alexander H. Vo , Carl A. Castro , Charles W. Hoge .Journal of Psychiatric Research 42 (2008) 1112–1121

Relationship of combat experiences to alcohol misuse among U.S. soldiers returning from the Iraq war:Wilk JE; Bliese PD; Kim PY; Thomas JL; McGurk D; Hoge CW, Drug And Alcohol Dependence, 2010 Apr 1; Vol. 108 (1-2), pp. 115-21.

Hazardous alcohol use and receipt of risk-reduction counseling among U.S. veterans of the wars in Iraq and Afghanistan.; Calhoun PS; Elter JR; Jones ER Jr; Kudler H; Straits-Tröster K, J Clin Psychiatry 2008 Nov; Vol. 69 (11), pp. 1686-93.

Alcohol use and alcohol-related problems before and after military combat deployment; Jacobson IG; Ryan MA; Hooper TI; Smith TC; Amoroso PJ; Boyko EJ; Gackstetter GD; Wells TS; Bell NS, JAMA: The Journal Of The American Medical Association, 2008 Aug 13; Vol. 300 (6), pp. 663-75.