Suicide Among Veterans Increasing

“If you are having thoughts of harming yourself, press 8.”

That message or a similar one is included in the welcome recording callers hear when they dial up most Veterans Administration healthcare facilities. That’s because the rate of suicide among veterans is twice as high as the general population. One in five suicides in America today is committed by a veteran. In fact, 18 veterans kill themselves every day, most using a firearm. Suicide also plagues active-duty military personnel. In 2009 and 2010, the military lost more troops to suicide than in combat in Iraq and Afghanistan.

Many soldiers who make it to their discharge date bring home with them mental-health challenges that have required a cadre of new VA psychiatrists and psychologists. Yet only 25 percent of America’s veterans are enrolled in the VA healthcare system, meaning physicians across the board must be vigilant for signs of mental health stress in their patients with a record of military service.

Bret A. Moore, PsyD, a former active-duty Army psychologist and two-tour veteran of Operation Iraqi Freedom, said general practitioners and even specialists should inquire about the mood of their patients who are veterans and should look for “a change from previous levels of functioning.” He noted that 50 percent of people who kill themselves, not just service members, had seen a primary care physician within the previous month and 75 percent within the last year. “Those numbers are staggering, but it shows that there’s an opportunity for the regular physician or nurse practitioner, whoever is on the front lines of medical care, to catch this stuff,” he said. “It’s very easy for primary care physicians to miss suicidal problems and depression if they don’t ask about it.”

An author of seven books including Wheels Down: Adjusting to Life After Deployment, Moore suggested some questions practitioners might ask their veteran patients:

• Have you been experiencing sadness or depression lately?
• Have you lost interest in things you used to enjoy?
• Have you been thinking about hurting yourself?
• Have you been exposed to any traumas?
• Are you having a hard time letting go of something that happened when you were deployed?

While Moore acknowledged that asking these questions and others isn’t a way to diagnose a psychiatric disorder, “it’s a good opportunity to determine if a referral to a mental health practitioner is warranted.”

Regina Austin, PhD, is a clinical psychologist who works with Iraq and Afghanistan veterans at the Alvin C. York VA Medical Center in Murfreesboro, Tenn. She said recent research points to an intimate relationship failure as the No. 1 catalyst for soldier and veteran suicides. She said a whopping 68 percent of U.S. soldiers in Iraq who committed suicide had had an intimate relationship failure. Research in 2008 found that the lengthy terms of deployment didn’t increase the suicide rate; however, deployments of a year or longer “served as a secondary factor in provoking marital disruption and loss of love relationships,” she said.

“One of the things that doctors can do when examining someone who is in the military or who has been deployed or recently returned is to ask them about their family life, about their relationships and whether there are any stressors there,” said Austin, who is spending much of her time offering marital and family counseling. She is in the process of becoming a Certified Gottman Specialist, meaning she will be trained in the couples therapy modality created by John and Julie Schwartz Gottman, founders of the Gottman Relationship Institute in Seattle, Wash. The institute has been contracted by the U.S. Army to help develop a comprehensive soldier fitness strategy aimed at better preparing troops to face the challenges of deployment and then their assimilation back to civilian life.

Current combat realities

War today is a different animal than when Allied forces rallied against a common and easily identifiable enemy nearly 70 years ago. “If you talk to the vets themselves, they will tell you that this war has a lot of similarities to what the Vietnam veteran faced,” Austin said. “You often don’t know who the enemy is. The threat could be anywhere, and hypervigilance and hyperarousal are great.” That means “everybody” faces an adjustment when they come back home, she said.

Moore echoed a similar sentiment. “These wars in Iraq and Afghanistan have been more of a nonlinear fight, where everybody is at risk,” he said. “There really is no front line. So, even the cook or the laundry specialist or the general service member is at risk for traumatic injury.”

Instant communication with home can also add to a deployed soldier’s stress levels. “Consider taking normal, everyday problems and then multiplying them by 10, because service members are thousands of miles away and can’t get to the school for the parents’ meeting or can’t fix the relationship because they are so far away. It takes its toll,” Moore said.

Thus, it’s no wonder that the incidents of post-traumatic stress disorder are soaring among America’s veteran population. According to the VA, research shows that the strong emotions caused by a traumatic event create changes in the brain. Austin said evidence-based, cognitive-behavioral therapies that are helping PTSD veterans include prolonged exposure therapy and cognitive processing therapy.

While CPT helps sufferers learn how to identify and control disturbing thought patterns, prolonged exposure therapy helps the service member re-experience the traumatic event in a safe, calm environment with a therapist. “The more you talk about it, the more used to it you become and the less impact it has on you,” said Moore, who uses the therapy often with his patients. The FDA has also approved a few medications, including Paxil and Zoloft, to treat PTSD. “But the data for medication is not as strong as it is for talk therapy,” Moore said.

Traumatic brain injury

More than ever before, veterans are suffering from traumatic brain injury, not necessarily considered a psychiatric disorder, but an injury with a number of psychological and mental health consequences.

Most TBIs are caused by improvised explosive devices, also known as roadside bombs, deployed by the enemy. So common are these IED blasts that traumatic brain injury is being dubbed the “signature injury” of the Iraq and Afghanistan conflicts. Such injuries can result in impaired physical, cognitive, emotional and behavioral functioning. Depression, angry outbursts, irritability, anxiety and personality changes are possible, taking a toll not only on the veterans, but their families as well. Moore said physicians treating veterans should take into account any possibility of a traumatic brain injury and follow up accordingly.

Moore writes a column for ArmyTimes called “Kevlar for the Mind.” In the inaugural column two years ago, he wrote, “Being a service member has many challenges and problems that would psychologically immobilize the average civilian.”

Indeed, that’s true. That’s why physicians treating today’s veterans must consider it a civic duty to ensure that America’s troops, present and past, have access to the mental health help they need.