Running head: Veterans Suicide Article Reviews

Deeper Review on Most Recent Veterans Suicide Research

Daniel R. Gaita, MA
January 13th, 2017

Could the answer be as simple as:

Get an Honorable discharge and a College Degree? We think so.

Veterans Suicide Article Reviews

Veterans Suicide

Identification of Articles Importance

Recently released research by the herein reviewed 2016 Department of Veterans Affairs
(VA) and 2015 Journal of American Medicine (JAMA) studies on veterans suicide include data
sets of over 54 million veterans. This new information now supersedes the previous 2012 VA
Suicide Data Report. By converging the outcomes of each respective data set we appear to not
only garner a greater understanding of the veteran population segment most likely to kill
themselves, but may have also effectively pin-pointed the primary causes of and therefore
solutions to the ongoing tragic suicides of nearly 20 US military veterans every day.

Overview of Articles
This work will examine three articles specific to the most recent research on veterans
suicide. The first, Suicide Data Report (Kemp & Bossarte, 2012) is known as the study that
brought awareness to the 22 veterans suicides a day. Second, Suicide Among Veterans and Other
Americans (VA, 2016) relies upon a much larger data set. Third, Risk of Suicide Among US
Military Service Members Following Operation Enduring Freedom or Operation Iraqi Freedom
and Separation From the US Military (Reger, Smolenski, Skopp, Metzger-Abamukang, Kang,
Bullman, Perdue, & Gahm, 2015) looks deeper into the sub categories of service members and
suicide rates.

Article 1: Suicide Data Report, 2012

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This study (Kemp & Bossarte, 2012) began in 2007 following a Mental Health staffing
expansion through the Joshua Omvig Bill. It would also result in the development of data
systems used to increase understanding of suicide among veterans in order to develop and
improve suicide prevention programs. But for most of the US veteran Population it is known as
the 22 A Day study, which became a call to action at the VA and catalyzed veterans to look out
for one another and to reach out for help.
The final report, with a cumulative price tag of $46,771.29 contains a systematic
overview of data obtained from the State Mortality Project, Suicide Behavior Reports for fiscal
years 2009-2012 and sought to determine the number of veteran deaths from suicide between
1999-2009. The end result was clean data from twenty-one states containing information on over
147,000 suicides. The data was then drilled-down to conclude that an estimated 22 veterans had
died from suicide every day in 2010.
The study places emphasis on the significantly higher rate of male suicides. With the
highest risk factor for veterans with an average age 54.5 years. 79% of suicides aged 18 or older
were male and 44% of those suicides were among those aged 50 or older with 69% of all veteran
suicides among those aged 50 years or older. Veterans that were married, separated or divorced
had higher rates of suicide while those that were either widowed or single had the lowest rates.
Veterans with a High School diploma or less represented 45% of suicides, while those with at
least one year of college or more were far less likely.
Caution is advised not to make broad interpretations of the data based on proxy type
reports of military history from only 21 states. Moreover, the study demonstrated wide variability
across states with veteran suicides rates ranging from 7% to more than 26% of all suicides and
warned that such findings prevent conclusions. Furthermore, the report articulates that it is a first

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attempt to formulate a comprehensive review; that it was not a research-based analysis and did
have significant limitations specific to the data collected.
One detail of importance to note for future article analysis and discussion, is the studys
conclusion that the percentage of people who die by suicide in America that are veterans has
decreased slightly from 2009-2012. This is a vital observation as the report then makes the
inference that this finding provides preliminary evidence supporting the effectiveness of VA
programs outcome specific to suicide prevention and mental health treatments. However, keep in
mind that only those eligible to receive VA care are represented in that inference. This will be an
important consideration as we review the next two articles.

Article 2: Suicide Among Veterans and Other Americans 2001-2014

This joint Department of Defense & Department of Veterans Affairs, Office of Suicide
Prevention analyses (VA, 2016 & Thompson 2016) is inclusive of over 55 million Veteran
records from 1979 to 2014 from each of the 50 states in the nation. The data reduces the prior
2012 findings of 22 suicides per day down to an average of 20 Veterans a day in 2014. Of those,
only 30% were utilizing VA services.
This is a vital observation, as it again calls into awareness that utilization of VA services
is restricted to those eligible. Not all veterans are eligible for VA services. Those released
dishonorably are not eligible for care, service or programs. In the next article we will identify
how vital this observation may be in the future paradigm of veterans suicide prevention.
This 2016 VA report provides a brief summary of additional findings. Again, in this study
we see that the highest rate, 65%, of all 2014 suicides were committed by those aged 50 years or

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older. Further, that the two highest VA utilizing groups to commit suicide have either a 50% or
greater disability rating or are non-service connected and, non-compensable service-connected.
This is another key observation demonstrating that those who have the worst serviceconnected injuries are more likely to commit suicide along with those with injuries that are not
eligible for any type of compensation. For the 50% and higher rated disabled I would contend it
is a matter of suffering physically and or mentally regardless of economic compensation while
for the non-service connected, non-compensable it may very well be a combination of both pain
and suffering coupled with a lack of economic resources due to injury or disability, which often
worsen with age.
In addition, this study also demonstrated a substantial increase in rates of suicide for
younger veterans 18-29 and those aged 50-59. Also of interest to note, suicide rates of those aged
70-79 and 80+ represented the only veteran sub-groups with suicide rates lower than the civilian
rate. However, an 85.2% increase since 2001 in suicide rates amongst the female veteran
population was observed when compared to the 30.5% increase in the male veteran suicide rate
since 2001.
The report highlights enhancements to the VA 24/7 crisis line, improved mental health
services for females and the expansion of TeleMental Health Services. In addition, the report
describes new free mobile applications deployed to help both veterans and their families while
detailing the contributions of over 350 community and mobile based Vet Centers across all 50
states.
But again, while this report has shed light on who is committing suicide, little is provided
to answer the question of why. For that answer we look at the next article.

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Article 3: Risk of Suicide Among US Military Service Members Following Operation

Enduring Freedom or Operation Iraqi Freedom and Separation From the US Military
This final article which appeared in the June 2015 Journal of the American Medical
Association Psychiatry publication, (Reger, Smolenski & Skopp, et. al, 2015) may very well hold
the proverbial key to unlocking the primary causes of veterans suicide while offering us a
paradigm shifting insight on the solution to the problem.
The study sought to answer the question of whether or not deployment in support of
Operation Enduring (OEF) or Iraqi Freedom (OIF) related to suicide risks. To do so they
examined the records of all 3.9 million US military personnel between 2001- 2007 that served
during either OEF or OIF, including suicides that occurred after separation. The main conclusion
and finding was that Deployment was not associated with suicide but rather that separation status
of a less than an honorable discharge, and serving less than 4 years was. Further study data also
demonstrated that officers and senior enlisted members as well as those with more than 20 years
in service had significantly far lower rates of suicide. In addition, those with a four year college
degree or higher showed the lowest rate of suicide risk.
How does this tell us why veterans are killing themselves? To get to that answer we must
next assimilate the meaning behind the data in these studies.

Article Summary and Analysis

Prior to the release of the data in the third article (Reger, Smolenski & Skopp, et. al,
2015), the standard paradigm for veterans suicide had connected Combat to Post Traumatic
Stress (PTS) to suicide. Proof of such is measured in the enormous outlay of funds for these
investigations and resultant implementation of evidence based treatments for PTS and Mental

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Health treatment leading up to the publication of the first study (Kemp and Bossarte, 2012) to
present. Instead, what the convergence of article data suggest is the pathway for veterans suicide
is connected as follows: Dishonorable or less than honorable Discharge > Lack of access to
available service -> (education, healthcare, compensation) > Mental Health Crisis -> Suicide.
While the first two VA studies tell us who is committing suicide by way of age, gender
and population demographics it is the third study, which concludes who is not. It is not due to
deployment and thus not wholly due to combat. If it is not due to combat or deployment, how
can it be attributed to combat PTS? Its not, and here is why.
The third study data sets (Reger, Smolenski & Skopp, et. al, 2015) demonstrate that
service members who serve less than four years and do not receive an honorable discharge have
exponentially higher rates (3 or 4:1) of suicide than those serve at least four or more years and
earn an honorable discharge. Service members with less than a year of service have the highest
rate of suicide. Additionally, service members with an alternative high school diploma also have
a 3:1 rate of suicide when compared to those with a four-year degree or higher. Thus the
dilemma of veterans suicide is more a function of access to education and resources than a
function of combat trauma.
This determination effectively flips the current paradigm of suicide prevention though
mental health interventions on its head. In doing so it enables us to look at the real predictors
and address them before a mental health crisis emerges.
To better understand, the reader must comprehend the culture of the armed forces specific
to the Uniform Code of Military Justice as it pertains to how veterans are separated from service
and further understand how various separation codes (Honorable, Less Than Honorable, Bad
Conduct, Dishonorable etc) impact post service eligibility to VA programs and services.

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If a veteran serves less than four years, it is most likely due to some form of
administrative or other than honorable discharge determination. As a result the separated service
member may not eligible for many programs that include but are not limited to VA Disability
Compensation, Education and Healthcare benefits. Looking back at the first two studies, it was
observed that veterans that did not use the VA Healthcare System committed 70% of veterans
suicides. Perhaps lack of eligibility due to less than honorable discharge is a culprit? It is
certainly worth further investigation. That is the first argument.
The second is based on educational attainment. The next highest risk group for veterans
suicide in the third study was veterans with no high school or an alternative diploma. While the
lowest rate of risk of veterans suicide was observed by those with a 4-year degree or higher, and
again confirmed by the observation that Officers made up the group with the lowest risk for
suicide. In order to be an officer you must have a four-year degree.
Lack of access to post service education benefits or vocational rehabilitation
opportunities due to separation and discharge status determination may be a primary factor and
precursor to the later mental health challenges that result in suicide. It is certainly worth further
investigation.
Deductive reasoning lends us to better understanding of the actual simplicity of the
problem of veterans suicide which, when observed through the convergence of these data sets
can be summed up in these eight words: Get an Honorable Discharge and a College Degree.

Implications of Analysis
With the convergence of data from these three reports it appears possible the current
paradigm of federal funding targeting towards stopping veterans suicides may be misdirected

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towards the treatment of PTSD and Mental Health interventions. This is in no way meant to
diminish the value of the work being conducted in the fields of Mental Health, as they are
essential and the data supports the efficacy of that work. But rather as a means to enable further
consideration of other possible root causes of suicide that may better be addressed through
improved Officer and Staff Non-Commissioned Officer leadership training in order to help
correct the behavioral deficits that may be the primary cause of early separations from the armed
forces as a result of avoidable behavioral and disciplinary outcomes.
Perhaps less emphasis on non-judicial and court martial proceedings and more emphasis
on behavioral modification strategies that many in the Armed Forces leadership ranks have
argued have been recently replaced due to shifting political and social ideologies. This is not to
diminish the effectiveness of military type leadership, but rather re-embolden it to again be
effective at ensuring mission readiness through discipline and purpose. While at the same time
evolving it through a deeper understanding of human psychology via evidence-based
interventions at the Department of Defense level. This type of effort has the capability to shape a
potential suicide candidate into a respectable member of the armed forces worthy of the
programs, service and benefits that come with an honorable discharge. Such programs and
services, the data shows, are associated with far lower risk of suicide.

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Veterans Suicide Article Reviews

References:
Kemp, J., & Bossarte, R. (2012) Suicide Data Report, 2012. Department of Veterans
Affairs, Mental Health Services, Suicide Prevention Program. Retrieved from
http://www.va.gov/opa/docs/suicide-data-report-2012-final.pdf
Reger, M.A., Smolenski, D. J., Skopp, N. A., Metzger-Abamukang, M. J., Kang, H. K.,
Bullman, T. A., Perdue, S., & Gahm, G. A. (2015) Risk of Suicide Among US
Military Service Members Following Operation Enduring Freedom or Operation
Iraqi Freedom Deployment and Separation From the US Military. JAMA Psychiatry.
2015; 72(6):561-569. doi:10.1001/jamapsychiatry.2014.3195 Published online April
1, 2015.
Thompson, C. (2016) VA Suicide Prevention: Facts about Veterans Suicides. Suicide
Prevention and Community Engagement. Retrieved from
http://www.va.gov/opa/publications/factsheets/Suicide_Prevention_FactSheet_New_
VA_Stats_070616_1400.pdf
VA (2016) VA Office of Suicide Prevention. Suicide Among Veterans and Other
Americans. US Department of Veterans Affairs, Washington, DC. Available online:
http://www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf