Ronald William Maris, Ph.D.
What Causes Suicide? Suicide is not one thing, but is a multidimensional outcome (including a continuum of self-destruction from unintentional self-harm, partially self-destructive behaviors, ideas about suicide, plans to suicide, lethal and non-fatal suicide attempts, and finally, to suicide completions; which themselves can be escape, revenge, altruistic, and/or risk-taking) resulting from several risk factors interacting over time (what I call a “suicidal career,” Maris, 1981). Risk factors for suicide include relatively chronic vulnerabilities ( like being an aging male, owning a gun, having a history of depressive disorder, being an alcoholic, etc.) and more acute stressors (like post-traumatic stress disorder, recent losses, pharmacological crises [such as serotonergic dysfunctions], inability to get effective health care, etc.).
From my case-control surveys I have derived about 15 evidence-based risk factors for suicide outcomes (the following list includes statistically significant risk factors compared to controls of nonfatal suicide attempts and natural death in a random sample of 2,153 suicides (Maris, 1969 and 2002). There could be more than just fifteen risk factors for suicide (See Maris, 2000, Chapter 17) and the list below is not necessarily ranked (although factors 1 and 2 tend to be the most prevalent in suicides). The factors that cause most suicides are (See Maris et al., 2000:80; Maris, 2002; Maris, 2007):
- Depressive and affective disorders, schizophrenia
- Alcohol and substance abuse
- Suicide ideas, plans, preparations
- Prior suicide attempts (caveat: many white males die after one attempt)
- Available lethal methods (especially, firearms)
- Social isolation, loss of social support
- Hopelessness (Beck claims hopelessness is more predictive of a suicide outcome than depression is; See Maris et al., 1992)
- Being an older white male (generally the older, the more likely suicide is)
- History of suicide or mental disorder in one’s first degree relatives
- Work problems, unemployment, lower SES, homelessness
- Marital problems & discord, separation, divorce, widowhood
- Stress, PTSD, negative life events, traumas
- Feelings of anger, aggression, impulsivity, serotonergic dysfunction
- Physical illnesses; like spinal cord, brain injury, epilepsy, arthritis, ulcers
- Repetition and co-morbidity of above risk factors; “suicidal careers”
Obviously, what causes veteran suicides has both common and unique factors compared to the general population in the United States. Murphy and Robins (1970, 1981) found in St. Louis county that about 47% of all suicides had an affective disorder and 25% had alcohol problems. Rates of depression, alcohol abuse, having a firearm, isolation, marital disruption, and trained aggression are all more prevalent in veteran populations. Zivin (12/7/07 @ 2193) estimated that veteran depression symptoms are 2 to 5 times higher than those in the general population.
Kang (12/11/07) states that as of 9/2007 among vets in healthcare at the VA, 40% had major depression diagnoses and 20% had diagnoses of PTSD (DSM IV code 309.81).
Post-traumatic stress disorder is extremely important among combat veterans (about 33% of female veterans experience sexual trauma, which can also cause PTSD) because it is common (15 to 50% of vets have PTSD; See Vets for Common Sense et al. v. Peake et al. Complaint, 7/23/07 @ 18-69) and it is interactively related to other suicide risk factors. CBS (11/13/07) reports that 28.3 percent of Iraq vets had mental health problems. Kang (12/11/07 @ 445) claims that of the approximately 1.6 million troops deployed in Afghanistan and Iraq 3,444 (now over 4,000) have been killed and 90% have been “traumatized.”
PTSD was first stated as a psychiatric anxiety diagnosis in 1980 in the DSM-III (code 309.81). It involved the following symptoms or criteria:
- Being exposed to a traumatic event where death or serious injury occurs accompanied by feeling of intense fear and helplessness.
- The event is persistently re-experienced.
- The victim avoids trauma-associated stimuli.
- The victim experiences symptoms of increased arousal.
- The symptoms last one month or more (acute v. chronic) and are characterized by social and occupation dysfunction
PTSD is one of the unique suicidogenic factors among veterans and interactively raises other suicide risk factors. Note, too that the percentage of all USA general population deaths that are suicides is 2.1% (AAS, 1/24/08). But among 15 to 24 year-olds 12.3% of all death are by suicide. Kang reminds us that the median vet suicide age is 20 to 29 (12/11/07 @ 441) and 18-24 year-old soldier suicides make up 26.3 % of all suicide [about twice that of the non-soldier population]. Thus, obviously, the prompt and accurate diagnosis and treatment of vet PTSD (and related depressive and substance abuse disorders) is a major condition for veteran suicide prevention.
One reason I cannot answer definitely about what causes veteran suicides is that the Office of Veteran Affairs has not provided me or the courts crucial data that are needed. For example, each time there is a military death, suicide attempt, or other serious incident, the VA produces a short “incident brief” which summarily describes the suicide or suicide attempt (Feeley, 4/9/08 @ 158). Then about 45 days later each incident undergoes what is called a “root cause analysis” and a 3-page report is generated (Feeley @ 160). On April 22, 2008, when I was an expert for the Plaintiff in the Veterans…v. Peake trial in San Francisco, I was given only 170 of the estimated 15,000 incident briefs and none of the root cause analyses. Clearly these VA documents could go a long way in establishing what causes veteran suicides and whether or not there is an “epidemic” (Dr. Katz denies that there is an epidemic, 11/13/07). It seems that these personal, clinical documents could be redacted, with patients’ names and other identifying information removed, and then supplied to independent scientific investigators, like myself. Clearly such crucial documents would help clarify how many vet suicides there are and what the VA thinks causes them (i.e., what are the root causes).
How High is the Veteran Suicide Rate and Is It An “Epidemic”? Virtually everyone agrees that the Iraq & Afghan vet suicide rates are higher than those of the general USA population. One problem in getting a consistent answer to our question is that there are shifting veteran populations (all vets, WWII, Korea, Viet Nam, Gulf War, Afghanistan, and Iraq), shifting times frames (e.g., yearly, 01-05, 06-08, etc.) and various samples based on different data sets (e.g., incident briefs, death certificates from the US Department of Vital Statistics, Department of Defense data, etc. Consequently there is a very wide range of estimates of vet suicides.
Nevertheless, there is consensus that the vet suicide rates (especially in OEF/OIF veterans; viz., Afghan and Iraq vets) are higher that those of the general population; high enough to constitute a serious national problem that demands resolution (Katz, 11/13/07).
Some of the estimates of veteran suicides rates and how much higher they are than those of the general population are;
- Katz (VA Deputy Chief of Patient Care Services) (2/21/08) says 3.2 times higher (suicide rate of 34.6 /11, N= 8,218, VHA patients from 2001-2005).
- OIG Mental Health Strategic Plan for Suicide prevention (5/10/07) says 7.5 times higher (viz., 83/100,000/11), page 8.
- Rathbun/CBS (2/28/08) says 1.8 to 2.3 times higher (6,256 vets of any war surveyed in 45 states = about 120 vet suicides per week).
- Zivin (12/7/07 @ page 2194) says 1683 of 807,694 vets suicided = 208/100,000 or about 19 times higher than the general population.
- Katz (2/13/08 in an e-mail to Ev. Chasen) says that “VA suicide prevention coordinators are identifying about 1,000 suicide attempts per month among vets seen in VA medical facilities (note: usually suicide attempts exceed completed suicides about ten to twenty-five times [AAS, 1/24/08]).
- Katz (e-mail to Kussman [Under Secretary for Health] on 12/15/07) reports 18 suicides per day out of 25,000,000 total vets.
- Kang (12/11/07) simply says “the risk of death for vets from suicide and motor vehicle accidents is higher that for the general population” (page 444, N= 144, 01-05, OIF/OEF vets only).
How high is a high enough vet suicide rate to merit national concern? From one perspective even one suicide is too many, since suicide is one of the leading causes of unnecessary death (See Maris et al. 2000). William Feeley, Deputy Under Secretary for Health Care Operations at the VA, said in a deposition (4/9/08, p. 38): “Suicide occurs like cancer occurs.” Wrong! We all have to die (some by cancer, some by heart disease, etc.), but no one needs to suicide. The VA seems to think that a certain number of vet suicide deaths are inevitable and that there is not much we can do about them.
When I consulted with Columbia University and the FDA to determine if 9 antidepressant medications caused child and adolescent suicide, the FDA decided that a relative risk of 2.1 of higher was sufficient to require a Black Box warning be put in the drug’s package insert and in the Physician’s Desk Reference. While there is no arbitrary bright line for danger, note that almost all of the relative risks for vet suicide are above 2.0.
Webster says an “epidemic” means prevalent and spreading rapidly among many people in a community (like the US military) at the same time.” Although we often reserve the concept of epidemic for extreme cases like the plague, smallpox, influenza, polio, etc. It does seem that veteran suicides are the product of a disease process and are increasing. For example, Kang (12/11/07 @ 441) claims the following percentages for vet suicides (OIF/OEF) from 2002 to 2006:
2002 = 7%
2003 = 21%
2004 = 48%
2005 = 68%
This looks a little like an epidemic to me (although one would need to control for the numbers of vets and calculate rates).
The Office of the Inspector General’s Mental Health Strategic Plan for Suicide Prevention (by John Daigh, Jr., M.D., Assistant Inspector General. 5/10/07).
The purpose of this ambitious document is to assess implementation of action pertaining to suicide prevention in the VHA’s mental health strategic plan (p. 1). Overall I found this plan to be a systematic, well-organized survey, but in fact it points out many of the VA’s shortcomings in suicide assessment and prevention. For the record in the VA there are (1) 21 regions (“VISNs), (2) 154 hospitals or medical centers, (3) 875 outpatient clinics or “CBOCs”, and (4) 136 nursing homes (Feeley, 4/9/08 @ 45).
In the plan overview (@ iv) it indicates that “at present the MHSP initiatives for suicide prevention are only partially implemented.” For example, on page 21 there is a chart summarizing the findings for six major objectives:
|A. Crisis intervention||24 hour mental health services in 94.5% of facilities|
|B. Screening||98% screen for depression, major suicide risk factor|
|C. Assessment||70% do not have tracking system|
|D. Interventions||61.8% do not target special groups|
|E. Databases||See SMITREC (data not available)|
|F. Education||61.4% of facilities did not make information on suicide risks mandatory|
The document (Cf., “Suicide Risk Assessment Guide, Reference Manual,” VA 001510 in Vets… v. Peake, 5/21/08, p. 1, no date) argues that suicide attempts are a major risk factor for suicide in vets (p. 1). The problem with this finding is that about 90% of older white males only make one suicide attempt (usually because they shoot themselves in the head; See Maris, 1981). Thus, for most vet suicides, a prior suicide attempt cannot be used to prevent their suicides. It is too late already.
Later (p. 16) the MHSP document argues that the “VA strategy for suicide prevention should include universal screening designed to activate the system for suicide prevention.” In fact (See “Suicide Template,” below) universal screening for vet suicide prevention includes asking only two questions (viz., “Have you felt depressed or hopeless in the last two weeks?”, and “Have you thought about hurting harming yourself in the last two week?” If the vet answers “No” to question # two, no further suicide screening is done (Cf., Marcus Nemuth deposition, 3/25/08, VA staff psychiatrist in Seattle area). Asking one or two suicide questions, which could easily be denied, misunderstood, misrepresented, etc., is not a suicide screen up the standard of care. Probably self-destruction is under-counted by the VA with such perfunctory screens.
Importantly, when the VA measures the crucial suicide risk factors of depression and hopeless, as far as I could determine, they just use self-reporting; not short, reliable and valid scales, like :
- The Hamilton Rating Scale for Depression (1960)
- The Beck Depression Inventory (1967; Cf., Maris et al., 2000: 84)
- Beck Hopelessness Scale (1974; Maris et al., 2000, Figure 3.5, p. 85)
- Beck Suicide Intent Scale (1990)
All of these scales are relatively short (17-20 questions), have the advantage of indirection (i.e., the vet is not sure what they measure), have known validity and reliability, and could be done in 15 to 30 minutes. Since hopelessness and depression are key suicide risk factors, they should be measured systematically, not by subjective self-reporting. Finally, some vets may not even know if they are depressed, hopeless, or suicidal.
On page 36 of the MHSP we are told “90.9% of the VA facilities do not have suicide case managers.” Why identify vets with suicide risk, if no one follows them? Recently, I have been told that in fact there are “suicide coordinators” in all 21 VA VISNs in the 154 medical centers (but none at the 875 CBOCs) . However, it is unclear (to me) who these people are, what their suicide prevention training is, what their exact job descriptions are, and how effective they are. There is also a question about the quality of staffing of CBOCs, most of which have LPNs, RNs, MSWs, and MA psychologists, and not psychiatrists.
We know that two psychiatric drugs have proven very effective in reducing suicidality in patient populations. One of these medications is lithium (See Baldessarini in Simon and Hales, 2006) for depressed and bipolar I patients even get lithium (@ p. 41). Likewise with suicidal schizophrenic patients, the drug Clozaril has been shown to be effective in clinical trials in reducing the suicide rate (See MHSP @ 42). In the vast majority of VA clinics (90.7%) fewer than 10% of their schizophrenic patients are on Clozaril.
Thus, most of the MHSP initiatives are only partially implemented after several years (about four years) and some of the operational definitions of key risk factors are below the standard of care.
Measuring Suicide Risk Factors and the Suicide Template. There is no reason why all veterans could not have all significant suicide risk factors measured at least at deployment, discharge, or at other crucial clinic visits (See my list of 15 suicide risk factors on page 1, above). The VA’s “Suicide Risk Screening and Comprehensive Suicide Risk Assessment” form (aka “Suicide Template” or “Suicide Risk Assessment Pocket Card”) is woefully inadequate to detect suicidality. As I said above, just asking if the vet felt (1) hopeless or depressed in the last two weeks or (2) thought about harming themselves in any way does not measure suicidality.
The vet could easily deny depression or suicide ideation (especially if they thought it might affect their promotions or military career, or were ashamed of their mental health issues) When I worked for the US Army in Berlin, Germany doing suicide prevention training, the staff psychiatrist there told me he had little to do, because especially male soldiers would not admit to any mental health problems for various career reasons. Many males do not seek mental health treatment. Other soldiers may not even realize they are depressed or self-destructive.
In short, all the questions on the suicide template need to be asked and answered and put in objective formats that do not make it obvious what is being measured. The suicide pocket assessment card has questions about (1) a suicide plan, (2)whether the plan includes firearms, (3) what psychiatric symptoms the vet is having, if any, (4) lack of social support, (5) the age, sex, race and family history of suicide of the vet, (6) whether or not there have been any prior suicide attempts, (7) levels of impulsivity, (8) past psychiatric diagnoses or treatment, (9) chronic pain, (10)protective factors like religion, (11) additional risk factors, (12) quantification of suicide risk level, and (13) immediate actions and treatment needed. Every vet should have every risk factor assessed, not just one or two of them, and asked in a manner that is effective.
Systematic Healthcare Deficiencies as Reflected in the VA Incident Briefs.
Although I was provided only 170 of the estimated 15,000 incident briefs in which VA patients’ suicides and suicide attempts were described, nonetheless they provide a sample of suggested systematic healthcare and treatment deficiencies identified by the VA itself. Below are some of the highlighted treatment failures of the VA in assessing and managing suicidal veterans (All documents were provided in the Vets v. Peake trial in San Francisco, California and were Bates-stamped for that trial; obviously, they have been redacted to protect individual patients; in each bullet item one could add “and the vet suicided or attempted suicide,” etc. Since these documents are “protected,” I have removed the VA Bates-stamped numbers):
- Treatment was delayed.
- Patient with suicide ideation not evaluated for suicide risk (violates template, criterion # 2).
- No coordination of patient’s care (even though there are s. coordinators).
- Vet should have been admitted but was not.
- Inadequate response to vet’s expressed wish-to-die.
- VA needs a suicide hotline (Note: VA now has a hotline, but research shows that a very small percentage of suicides [perhaps < 1%] even call the hotline; Feeley @ 51; I am not persuaded that male soldiers are likely to call a hotline).
- No referral for severe antisocial behavior of vet.
- No psychiatric evaluation of vet was done in the ER.
- Suicide assessment policies and procedures were not followed.
- Hopeless vet not identified as such.
- Vet not rescheduled for appointment within one week per policy.
- Suicide risk assessment was negative, but patient suicided anyway.
- Patient denied access to VA hospital and then suicided.
- Doctor at VA fired for inadequate treatment of soldier found dead.
- Inadequate healthcare for homeless vet with suicide ideation and threat.
- VA not meeting the needs of suicidal vet.
- Feeley says of this vet’s suicide: “VHA not meeting standard that we are after.”
- Vet actually shoots self on the grounds of the VA outpatient clinic.
These bulleted-items reflect the VA’s own admissions of healthcare problems or failures in treating suicidal vets. One can only imagine how much more investigators could have learned about assessment and treatment failures of suicidal vets, had they been given all of the redacted incident briefs and root cause analyses. Since this hearing is entitled “The Truth About Veterans’ Suicides,” it only makes sensethat all incidents be made public, after removing references to individual vets.
William Feeley, VA Deputy Under Secretary for Health Operations and Management (He reports to Dr. Kussman and Kussman reports to Secretary Peake; the following facts are reported in Mr. Feeley’s deposition of April 9, 2008 in the Vets v. Peake legal suit). Feeley said that although he was 3 rd in the chain of command, and when it came to vet healthcare, “the buck stops here” (although later on Feely tried to pass the buck to Dr. Katz and others at the VA).
- Feeley said (@ 19) that the 21 VISN directors all report to him at least once a week, but when asked about vet suicide rates, he said he did not talk to directors about their suicide rates (why not, if this is a “major problem”?). As Feeley put it (@ 35): “Suicide rates are not a metric we are measuring.”
- When asked about implementing the MHS Plan of 7/2004, his reply was (@ 64): “I did not read the plan from cover to cover.”
- When asked between 2004 and 2008 if there were a national systematic program for suicide prevention, Feeley answered “No.”
- One of the policies that have been supposedly fully implemented in the MHSP of 2007 was 24-hour VA healthcare. @ 97 Feeley was asked to name that policy. His answer: “I don’t know that policy.”
- @ 100 Feeley was asked, (well) “where are these policies? Answer: “I don’t know where they are.”
- Question @ 104: “Has the idea of screening every service person coming back from Iraq or Afghanistan for PTSD been a subject of discussion?” Answer: “I really could not give you an answer on that.”
- Question @ 105: “Is there a national screening program for every returning serviceman or woman to meet with a mental health professional?” Answer: “I don’t know the answer to that.”
- The MHSP (7/20/04) @ A-14 says that every military person…will meet individually with a mental health professional as part of post-deployment and separation. Question: “Has that happened?” Answer: “I don’t believe it has.”
- Question @ 141-142: “Have you read the national strategy for suicide prevention and the Institute of Medicine’s report Reducing Suicide (2002)?” Answer: “No.”
- Question @ 147: “What methods are there for tracking at-risk (for suicide) veterans?” Answer: “ I’m not sure, sorry.” What are suicide coordinators for?
- Question @ 171: “Is there any relationship between the number of times a vet is deployed and suicide?” Answer: “Don’t know.”
One could easily conclude that if the “suicidal buck” stops with Mr. Feeley, then the VA is in serious trouble when it comes to assessing and preventing veteran suicides. Mr. Feeley is singularly and dramatically uninformed about suicide. But maybe that is when Feeley passes the buck to Dr. Katz?
Leftovers and Loose-Ends. There are a few other important issues that at least deserve mention.
First, it is possible that soldiers become suicidal in part due to conditions pre-dating their military recruitment . If so, their baseline vulnerabilities (See the concept of “stress-diathesis” in Maris et al, 1992, Chapter 27) may interact with the stressors of combat to exacerbate their suicidality. One example on this might be the DSM diagnosis of antisocial personality disorder among young males (@ least 18 years old; DSM code 301.7). There is some evidence (See Vets v. Peake Complaint, 7/23/07 @ 8-24) that some soldiers may have been induced to accept a discharge diagnosis of antisocial personality disorder, rather than (say) PTSD. Importantly, a diagnosis of personality disorder precludes the veteran from receiving disability benefits, since the psychopathology was presumed to be present prior to the recruitment. Nevertheless, even if true, the Department of Defense needs to improve its recruitment screening procedures to keep such recruits out of the military in the first place.
Second, there is surprisingly little mention in the VA mental healthcare policies and procedures documents about treating the depressive disorders psycho-pharmacologically. It is axiomatic in suicide prevention that much of the treatment of suicidality requires prompt and precise diagnosis of depressive disorders, followed by appropriate specific pharmacological treatment of the patient with one or more of the SSRI antidepressants (e.g., Lexapro Prozac, Zoloft, Paxil, Louvox, Celexa, etc.), SNRIs (e.g., Cymbalta or Effexor, etc.), anxiolytics (such as the benzodiazepines like Xanax, Klonopin, Traxene, Ativan or non BZs, like Buspar, etc.), perhaps a major tranquilizer (like Risperdal or Zyprexa, etc.), and even electroconvulsive therapy in some cases. Note that many of the VA’s 875 outpatient clinics or “CBOCs” often do not even have a physician on staff, who can write critical prescriptions that suicidal vets may need. Since there are 875 CBOCs but only 154 VA hospitals or medical centers, structurally (given the VA healthcare system) a depressed vet is likely to get only psychotherapy, rather than both pharmacotherapy and psychotherapy.
Third, the VA takes pride that they now have “suicide coordinators” in their medical centers (See Feeley, 4/9/08 @ 88). However, serious questions remain about these suicide coordinators. Only the 154 medical center hospitals even have suicide coordinators; none of the 875 CBOCs do. Thus, the vast majority of VA facilities in fact do not have suicide coordinators. Several questions remain: (a) What do these coordinators do, exactly (job descriptions)? (b) How are they trained to do suicide assessment and prevention (Berman addressed this issue in Vets v. Peake)? (c) What are their professional credentials and licensing (LPN, RN, SW, MA psychologist, MH techs, etc)? (d) Who supervises these suicide coordinators? (e) Do suicide coordinators interact directly with suicidal vets in clinical care of the VA patients? (f) What exactly are they “coordinating” (data, people, policies and procedures, etc.)?
Finally, there is a whole set of issues concerning diagnosis, treatment, and benefit delays in VA mental healthcare, which I have not yet commented on (See Vets v. Peake, 4/21/08, federal trial in San Francisco). To even get mental health treatment for up to two years the veteran must fill out a 23-page application form (which can be very hard to do, if you in fact do have PTSD) and then receive a disability rate from 0 to 100% from a “Compensation and Pension” examination (Complaint, 25-98). If the disability is denied or too low, found not to be related to military service; then the appeal process can be long and drawn-out (some vets die during the appeal process), which can encourage a suicidal resolution of the vet’s problems. Note, too, that most of the VA suicide prevention initiatives (See OIG, MHSP, 5/10/07) have only been partially implemented after four years. Defense expert Alan Berman in the Vets v. Peake trial, testified that it could take up to ten years for the MHSP to be implemented. One wonders how many vets are going to die in the interim due to lack of assessment and treatment?
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