Thomas J. Berger, Ph.D.
Chairwoman Buerkle, Ranking Member Michaud, and Distinguished Members of the House Veterans Affairs Subcommittee on Health, Vietnam Veterans of America (VVA) thanks you for the opportunity to present our views on “Understanding and Preventing Veteran Suicide”. We should also like to thank you for your overall concern about the mental health care of our troops and veterans.
Consider the facts: earlier this spring, troubling data showed an average of 950 suicide attempts by veterans who are receiving some type of treatment from the VA. Seven percent of the attempts are successful, and eleven percent of those who don’t succeed on the first attempt try again within nine months. These numbers show about 18 veteran suicides a day and about five by vets receiving VA care. These numbers are simply unacceptable to both the veterans’ community and the American public.
Although statistics on suicide deaths are not as accurate as we would like because so many are not reported, as veterans of the Vietnam War and those who care for them, many of us have known someone who has committed suicide and others who have attempted it. VVA believes this to be a very real public health concern that needs solutions now.
To be fair, since media reports of suicide deaths and suicide attempts began to surface back in 2003, the VA has developed a number of strategies to reduce suicides and suicide behaviors that include: the establishment of the Veterans Crisis Hotline and Chatline (in partnership with the Substance Abuse and Mental Health Administration) and a social media campaign emphasizing VA crisis support services; the creation of suicide prevention coordinator (SPCs) positions at all VA medical facilities whose duties include education, training, and clinical quality improvement for VHA staff members; increased screening and monitoring of individuals who have been identified as being at high risk for suicide; and a few research efforts utilizing cognitive-behavioral interventions that target suicidal ideation and behaviors. While these efforts are laudable, VVA continues to believe they have not gone far enough.
So let’s cut to the chase: it is very challenging to determine an exact number of suicides. Some troops who return from deployment become stronger from having survived their experiences. Too many others are wracked by memories of what they have experienced. This translates into extreme issues and risk-taking behaviors when they return home, which is why veteran suicides have attracted so much attention in the media. Many times, suicides are not reported, and it can be very difficult to determine whether or not a particular individual's death was intentional. For a suicide to be recognized, examiners must be able to say that the deceased meant to die. Other factors that contribute to the difficulty are differences among states as to who is mandated to report a death, as well as changes over time in the coding of mortality data (1).
In addition, according to the American Foundation for Suicide Prevention, in more than 120 studies of a series of completed suicides, at least 90 percent of the individuals involved were suffering from a mental illness at the time of their death. The most important interventions are recognizing and treating these underlying illnesses, such as depression, alcohol and substance abuse, post-traumatic stress and traumatic brain injury. Many veterans (and active duty military) resist seeking help because of the stigma associated with mental illness, or they are unaware of the warning signs and treatment options. These barriers must be identified and overcome.
However, VVA has long believed in a link between PTSD and suicide, and in fact, studies suggest that suicide risk is higher in persons with PTSD. For example, research has found that trauma survivors with PTSD have a significantly higher risk of suicide than trauma survivors diagnosed with other psychiatric illness or with no mental pathology (1). There is also strong evidence that among veterans who experienced combat trauma, the highest relative suicide risk is observed in those who were wounded multiple times and/or hospitalized for a wound (2). This suggests that the intensity of the combat trauma, and the number of times it occurred, may indeed influence suicide risk in veterans, although this study assessed only combat trauma, not a diagnosis of PTSD, as a factor in the suicidal behavior.
Considerable debate exists about the reason for the heightened risk of suicide in trauma survivors. Whereas some studies suggest that suicide risk is higher due to the symptoms of PTSD (3,4,5), others claim that suicide risk is higher in these individuals because of related psychiatric conditions (6,7).However, a study analyzing data from the National Co-morbidity Survey, a nationally representative sample, showed that PTSD alone out of six anxiety diagnoses was significantly associated with suicidal ideation or attempts (8). While the study also found an association between suicidal behaviors and both mood disorders and antisocial personality disorder, the findings pointed to a robust relationship between PTSD and suicide after controlling for co-morbid disorders. A later study using the Canadian Community Health Survey data also found that respondents with PTSD were at higher risk for suicide attempts after controlling for physical illness and other mental disorders (9).
Some studies that point to PTSD as the cause of suicide suggest that high levels of intrusive memories can predict the relative risk of suicide (3). Anger and impulsivity have also been shown to predict suicide risk in those with PTSD (10). Further, some cognitive styles of coping such as using suppression to deal with stress may be additionally predictive of suicide risk in individuals with PTSD (3).
Other research looking specifically at combat-related PTSD suggests that the most significant predictor of both suicide attempts and preoccupation with suicide is combat-related guilt, especially amongst Vietnam veterans (11). Many veterans experience highly intrusive thoughts and extreme guilt about acts committed during times of war, and these thoughts can often overpower the emotional coping capacities of veterans.
Researchers have also examined exposure to suicide as a traumatic event. Studies show that trauma from exposure to suicide can contribute to PTSD. In particular, adults and adolescents are more likely to develop PTSD as a result of exposure to suicide if one or more of the following conditions are true: if they witness the suicide, if they are very connected with the person who dies, or if they have a history of psychiatric illness (12,13,14). Studies also show that traumatic grief is more likely to arise after exposure to traumatic death such as suicide (15,16). Traumatic grief refers to a syndrome in which individuals experience functional impairment, a decline in physical health, and suicidal ideation. These symptoms occur independent of other conditions such as depression and anxiety.
All of this brings us full circle to what VVA has been saying for years – if both DoD and VA were to use the PTSD assessment protocols and guidelines as strongly suggested by the Institutes of Medicine back in 2006 (http://iom.edu/Reports/2006/Posttraumatic-Stress-Disorder-Diagnosis-and-Assessment.aspx) (17), our veteran warriors would receive the accurate mental health diagnoses needed to assess their suicide risk status.
Once again, on behalf of VVA National President John Rowan and our National Officers and Board, I thank you for your leadership in holding this important hearing on this topic that is literally of vital interest to so many veterans, and should be of keen interest to all who care about our nation’s veterans. I also thank you for the opportunity to speak to this issue on behalf of America’s veterans.
I shall be glad to answer any questions you might have.
1. Knox, K.L. (2008). Epidemiology of the relationship between traumatic experience and suicidal behaviors. PTSD Research Quarterly, 19(4).