Suicide among veterans: Identifying risk factors and prevention strategies

Military veterans in the United States face a significantly higher risk of suicide compared to the general population—a crisis that raises alarm among families, communities, health care providers, researchers, and policymakers alike.

In response, experts from the University of Michigan Medical School and VA Center for Clinical Management Research, who are also members of the U-M Institute for Healthcare Policy & Innovation (IHPI), have been examining the complex web of factors contributing to this heightened risk. Their research aims to inform and strengthen suicide prevention efforts for veterans through early intervention, expanded access to mental health care, and stronger social supports.

Recent studies by these researchers offer valuable insights into the dynamics of suicide among veterans and highlight opportunities to improve prevention programs, including those provided through the Veterans Health Administration (VHA): 

Starting PTSD therapy linked to lower suicide risk for veterans  

Veterans who begin treatment for post-traumatic stress disorder, or PTSD, are significantly less likely to die by suicide, even if they do not complete a full course of therapy, according to a study published in JAMA Network Open by a team led by Kevin Saulnier, Ph.D., assistant professor of psychiatry, and Rebecca Sripada, Ph.D., ABPP, associate professor of psychiatry.  

The research followed over 847,000 veterans in the VHA who were newly diagnosed with PTSD between 2016 and 2019, tracking suicide outcomes through 2020. Veterans who initiated either form of evidence-based therapy for PTSD —cognitive processing therapy or prolonged exposure — had a 23% lower risk of suicide compared to those who did not begin these treatments. Interestingly, getting a full course of treatment (defined as eight or more sessions) did not seem to lower suicide risk beyond what was seen from simply starting therapy. 

In all, the results highlight the critical role of helping veterans take the first step into therapy and could inform VHA efforts to expand access to treatment for PTSD.  

988 Veterans Crisis Line: Assessing the impact of a lifeline for those who served

For veterans facing mental health challenges, the 988 Veterans Crisis Line offers immediate, confidential support from trained responders—many of them fellow veterans. A series of studies involving Mark Ilgen, Ph.D., professor of psychiatry, and colleagues look at the impact of this lifesaving service.  

A recent study published in Psychiatric Services finds that most veterans who receive an emergency dispatch (an in-person response from emergency personnel) through the Veterans Crisis Line went on to access VHA behavioral health services within a month of the call—86% of those who had previously received VA care and 62% of those who had not. Veterans with prior VA use had greater odds of connecting with in-person and telehealth outpatient VA behavioral health services after an emergency dispatch, while veterans without prior use did not. The study’s findings suggest a need to improve strategies for connecting with crisis line callers who are first-time users of VA behavioral health services.  

In a similar study published in the Journal of Psychiatric Research, llgen and colleagues found that of nearly 250,000 calls to the Veteran Crisis Line, about 11% led to emergency dispatches. The research showed that veterans with more health problems—especially those with multiple mental or physical diagnoses—were much more likely to trigger a dispatch.  

A Preventative Medicine study showed that Veterans Crisis Line callers mentioning suicidal thoughts were over nine times more likely to trigger a 911 dispatch than other calls, with other factors that also significantly boosted the odds of emergency response including homicidal thoughts, worried friends or family, substance use crises, violence or abuse, and serious health issues.  

Another study authored by Ilgen and team looked at the timing of emergency dispatches initiated by calls to the Veterans Crisis Line, finding that emergency dispatches were more likely during certain days and times—especially on holidays like Labor Day and Independence Day, on weekends (particularly Saturdays), and during evening hours.

Employment linked to lower suicide and overall death risk among veterans in VA job program

A long-term study indicates that employment significantly reduces the risk of death—especially by suicide—among veterans who participated in VA Vocational Rehabilitation and Employment (VR&E) programs.  

Published in Psychiatric Services by a team including Kara Zivin, Ph.D., M.S., M.A., M.F.A., professor of psychiatry, the study followed more than 78,000 veterans who received VR&E services between 2005 and 2014 and looked at mortality causes within one to five years after their discharge from the VR&E program through 2019. Veterans who were employed at the time of VR&E discharge had almost half the risk of dying by suicide within one year compared to those who were unemployed. This association between employment and lower suicide death risk appeared strongest in the first year after discharge, while the reduced risk of death from other causes—overdose, accidents, or natural causes—continued for up to five years post-discharge.

The researchers believe that employment may help reduce death risks by providing stability, income, social connection, and improved well-being. They suggest that increasing access to employment services like VR&E could be a vital part of preventing suicide among veterans. 

Understanding which veterans have the highest risk of dying by suicide

Firearm access, suicidal thinking and suicide planning are major predictors of suicide death among veterans, according to an analysis of data from the Comprehensive Suicide Risk Evaluations (CSRE) implemented at VA medical centers nationwide. These evaluations use a standardized checklist to assess a veteran’s suicide risk and protective factors, often leading to mental health referrals and personalized support plans.

The study, published in JAMA Network Open by a team led by Kevin Saulnier, Ph.D., assistant professor of psychiatry, examined 269,374 CSREs that were completed for VA patients between 2019 and 2020. Among those evaluated, 791 veterans died by suicide—144 within 30 days and 647 within one year of the assessment. Even after going through the CSRE process, veterans who were actively experiencing suicidal thoughts, had made suicide plans, had access to firearms, or had a history of mental health inpatient stays were more likely to die by suicide, compared with others who had been through the evaluation but did not have these risk factors.  

These findings could help clinicians tailor interventions for veterans at the highest risk of suicide.  

Veterans at lower predicted suicide risk are more likely to die from firearms

Veterans who are not flagged as high-risk for suicide are actually more likely to die by using a firearm, according to a study published in Psychiatry Research Communications by John McCarthy, Ph.D., M.P.H., research associate professor of psychiatry, and colleagues. The study, conducted using data from over 5,000 veterans who died by suicide between 2017 and 2019, revealed surprising patterns about how suicide methods vary by predicted risk.  

Using the VA’s REACH VET algorithm, which predicts veterans' level of risk for suicide based on electronic health records, the researchers found that 79% of veterans in the lower half of predicted suicide risk groups died using a firearm compared to only 35% of those in the highest risk group. Instead, highest-risk veterans were more likely to die by methods like poisoning or suffocation. The study also showed that veterans without a recent history of suicide attempts were far more likely to use firearms.  

These findings indicate a need for suicide prevention programs to offer firearm safety counseling to all veterans, not just those labeled as high risk, and address other methods of suicide, such as poisoning and suffocation, especially for those already receiving mental health support.