The suicide rate among veterans is about twice that of the general population, and has been rising among younger veterans who served during the wars in Iraq and Afghanistan - Dave Philipps
image by: Earl Pike
“How has serving impacted you?” This simple question was posed to service members and veterans via Twitter by the US Army prior to the Memorial Day weekend. To date, the Twitter post has amassed more than 11,000 responses that collectively encapsulate the lived realities and consequences of military service—some positive, but most were overwhelmingly harrowing tales recounting post-traumatic stress, anxiety, depression, sexual assault, and suicide.
This blog post sheds light on the pervasiveness of suicide among veterans in the United States and the need for initiatives similar to a statewide community-based program in Arizona that has led the way in addressing this crisis. While federal, state, and local governments are all expected to align suicide prevention efforts, we hope to also galvanize health care stakeholders into acknowledging and actively participating in upstream interventions. In this way, we are able to offer our veterans and their families something far more meaningful than simply a passing thanks for their service.
National Landscape Of Veteran Suicide
Suicide among veterans in the United States has risen 35 percent since 2001, totaling 6,079 veteran deaths by suicide in 2016. According to Centers for Disease Control and Prevention population projections, each year there are roughly 55,000 veterans treated in hospital emergency departments for self-harm injuries and an estimated 164,000 suicide attempts by veterans (Note 1). The pressure to address veteran suicide comes at a time in which the Veterans Health Administration is facing criticism from numerous perspectives. In mid-April, three veterans who died by suicide at Veterans Affairs (VA) medical facilities resulted in another highly publicized call for action. As the tenth leading cause of death for all Americans, suicide has emerged as a leading public health crisis of our time and necessitates further discussion and action from stakeholders across the public and private sectors. This includes actively engaging the VA, other federal agencies, state and local governments, health care systems, community organizations, and advocates. While as a society we are often outspoken about our support of the military, the prevalence of veteran suicide belies this support: We are not able to reach those who have served during or before their time of greatest need.
Suicide As A Preventable Public Health Issue
Suicide is not a disease which simply manifests within the four walls of a clinical setting. We know that as many as 70 percent of veterans who died by suicide were not engaged with the VA in the two years prior to death. To address this gap, stakeholders must consider the confluence of social factors that impact the continuum of care for this population. Historically, suicide research has primarily focused on “downstream” crisis intervention and access to mental health services, such as therapy and medications. While these remedies are critical for individuals in crisis, thinking about suicide as a preventable public health issue requires reframing the conversation beyond the constraints of a health care setting. This includes “upstream” factors such as affordable and consistent housing, networks of social support, employment, education, and safe storage and use of firearms.
Veterans, service members, and their families all face unique challenges that increase their risk factors for suicide. Such challenges include: re-transitioning to civilian life, finding post-military employment, securing housing, re-adjusting to the isolation from the military unit and the independence associated with civilian life, challenges in joining supportive communities, restoration or renewal of prior relationships and the establishment of new ones, and many other risk factors. Additionally, veterans are at increased risk for experiencing a potential host of physical and mental health-related issues specific to their service, so that access to appropriate and coordinated care becomes even more vital. With the rates of death by suicide increasing nationally, it is clear that innovative solutions are necessary to properly serve the needs of this population.
Effective approaches to reducing veteran suicide demand casting a wider net and extending services beyond the walls of the hospitals and clinics and into the communities in which our veterans live. New initiatives at the federal and state levels seek to engage various community-based stakeholders in an effort to provide responsive solutions to this public health crisis.
Enacting Change At The Federal Level
In March 2019, President Donald Trump signed an executive order known as the President’s Roadmap to Empower Veterans and End a National Tragedy of Suicide, or PREVENTS. The PREVENTS initiative identifies ending veteran suicide as a national priority and calls for an, “aspirational, innovative, all-hands-on-deck approach to public health—not government as usual.” To support local communities seeking to bridge the gap between service delivery and resources for veterans, the PREVENTS initiative plans for a grantmaking program to be established by March 2020. The executive order is notable because it represents a commitment to this issue, as well as a recognition at the highest levels of leadership for collaborative and innovative interventions. Elsewhere in Washington, the US Senate Committee on Veterans’ Affairs has actively expressed its commitment to exploring the use of community-based suicide prevention initiatives as exhibited by the recent hearing titled, “Harnessing the Power of Community: Leveraging Veteran Networks to Tackle Suicide.” In addition, more localized efforts are also being developed to meet the needs of individual communities.
Be Connected Arizona
One such state-based intervention that is also serving as a national model is the Arizona “Be Connected” initiative, an upstream suicide prevention program for service members, veterans, and family members in Arizona. The initiative is led by the Arizona Coalition for Military Families (ACMF), a nationally recognized public/private partnership focused on building Arizona’s capacity to care for, serve, and support service members, veterans, their families, and communities.
In 2010, the Arizona National Guard was experiencing the highest rates of suicide in its recorded history. In collaboration with the Adjutant General and numerous stakeholders across the state, the ACMF led the development of a program specifically for the 8,000-member Arizona National Guard called “Be Resilient.” This initiative focused on reducing stigma and shifting military culture related to suicide and mental health through training provided to all Arizona National Guard members on resilience, suicide prevention, and recognizing stress levels. This comprehensive effort reduced suicide among Arizona National Guard members to zero during the three years of operation. Following passage of the Clay Hunt Suicide Prevention for American Veterans Act in 2015 and with the advocacy of the late Senator John McCain (R-AZ), Arizona would go on to be selected as a pilot site to test new approaches for preventing veteran suicide through VA and community partnership. Thanks largely to the success of Be Resilient, the Be Connected initiative was launched in 2017.
Be Connected is often described as a suicide prevention program that’s not focused only on suicide. The unique component of the Be Connected program, the upstream intervention model, focuses on providing resources across all social determinants of health before an individual reaches the point of a mental health crisis. Similar to a care coordination model, Be Connected helps its clients navigate the complex health and social services systems to connect them to the resources they need. Service members, veterans, and their families across Arizona can access Be Connected by meeting with a resource navigator in-person, calling a 24/7 support line, or matching to resources on a web platform. The program has partnered with hundreds of organizations statewide to vet more than 1,200 resources to provide a wide range of services through a single, centralized platform. Nationally recognized through the Mayors’ and Governors’ Challenge to Prevent Suicide among Service Members, Veterans and their Families, hosted by the Substance Abuse and Mental Health Services Administration and the VA, the Be Connected model is an exemplar for working toward health equity for the US military and veteran community.
Fulfilling Our Duty
Suicide among veterans is a pervasive public health emergency that necessitates immediate recognition and action from all health care stakeholders. To adequately address this crisis, the narrative and focus must shift from intervention at the point of crisis to upstream models that engage stakeholders and break through long-standing silos. That shift should be predicated on models that equip and empower our veteran communities to navigate and thrive, as well as provide available and potential resources needed to support their health and well-being.
We are encouraged by Congress’s interest in this issue and the White House’s action through the PREVENTS initiative. We hope that Congress continues to build upon this roadmap and explore legislation that supports and expands the capacity of developing initiatives such as Be Connected across the country through three main recommendations: capacity building at the state level to ensure states and communities are coordinated; funding for “backbone” organizations such as the Arizona Coalition for Military Families to engage and convene key stakeholders across each state to coordinate efforts; and support for initiatives using the upstream suicide prevention model, such as Be Connected.
Although suicide may frequently be touted as an insurmountable public health challenge, there is much more that we can do to address this very preventable crisis. We need coordinated, cross-sector efforts to leverage the existing resources and strengths of national, state, and community-based agencies to provide the right services at the right time. Reversing the current trajectory of suicide rates in our veterans necessitates that as a nation, we put our often-stated respect for their service into action by serving their social, emotional, and health needs—otherwise we do nothing but offer them empty rhetoric. This is our duty to this population—to serve those who have served.
According to the Centers for Disease Control and Prevention, during 2014, among adults ages 18 and older, for every one suicide there were nine adults treated in hospital emergency departments for self-harm injuries, 27 who reported making a suicide attempt, and more than 227 who reported seriously considering suicide. Using this logic yields 164,133 estimated veteran suicide attempts.
Source: Matthew Speer, Megan Anne Phillips, Thomas Winkel, Wanda Wright, Nicola Winkel, Swapna Reddy, Serving Those Who Serve: Upstream Intervention And The Uphill Battle Of Veteran Suicide Prevention In The US, Health Affairs, July 11, 2019.