Veterans suicide

THOSE WHO SERVE ADDRESSING FIREARM SUICIDE AMONG MILITARY VETERANS INTRODUCTION During a five-day period in April 2019, three veterans died by suicide at Veterans Affairs facilities. In Dublin, Georgia, a 28-year-old veteran died inside his car in the parking lot of a VA medical center.1 The next day, at a VA hospital less than 200 miles away in Decatur, Georgia, a 68-year-old veteran died outside the main entrance of the hospital.2 And shortly after that, a veteran died by suicide inside the waiting room of a VA clinic in Austin, Texas.3 Guns were used in all three suicides. In June, the US Senate Committee on Veterans’ Affairs convened to discuss “the power of community” in addressing the challenges often faced by those who have served in the military. Moving testimony was given by members of this community, which included veterans, the leaders of veteran service organizations, and military family members. But in the more than 20 pages of testimony submitted to the committee, the risk that firearms pose was mentioned only once.4 Gun ownership and training among those who serve in our nation’s military has long been a fundamental component of our armed forces, but we cannot address veteran suicide without talking about guns. FINDINGS 4,200 VETERANS DIE BY FIREARM SUICIDE EVERY YEAR—ABOUT 11 DEATHS A DAY. THE VETERAN FIREARM SUICIDE RATE HAS INCREASED 33 PERCENT SINCE 2005. 25 Firearm Suicide Rate (per 1000,000 people) AN AVERAGE Veteran firearm suicide is a virulent strain of a larger crisis. Firearm suicide is a significant public health crisis in the United States, claiming the lives of over 22,000 Americans every year.5 The problem is not getting better: The firearm suicide rate has increased 19 percent over the past decade.6 Approximately one in five of these firearm suicides are by veterans.7 An average of 4,200 veterans die by firearm suicide every year—about 11 deaths a day.8 Over the past decade, the veteran firearm suicide rate has increased dramatically. Between 2005 (the earliest year for which veteran suicide data are available) and 2017, the rate increased nearly every year, from 16.2 veteran firearm suicides per 100,000 people in 2005 to 21.5 per 100,000 in 2017—a roughly 33 percent increase. During the same time period, the rate of firearm suicide among non-veterans increased 23 percent (from 6.7 to 8.2 per 100,000 people).9 20 Veterans 15 Non-Veterans 10 5 0 2005 2007 2009 2011 2013 2015 2017 Year Veteran and non-veteran firearm suicide rates exclude suicides among people age 17 years old and under. everytownresearch.org October 2019 1 Gun ownership increases the likelihood of firearm suicide, and suicide attempts are nearly always lethal. The dynamics of suicide are complex, involving factors like poverty, unemployment, substance abuse, and mental illness.10 But one thing is clear: Easy access to firearms during a moment of crisis can mean the difference between life and death. Personal or household gun ownership increases the risk of suicide by three times.11 Firearms are a particularly lethal means of self-harm, with a fatality rate of approximately 85 percent.12 By comparison, less than 5 percent of people who attempt suicide using other methods die.13 Most people who survive a suicide attempt do not go on to die by suicide.14 Limiting gun access in even one moment can ensure veterans live on as valued and valuable members of American communities. FIREARM SUICIDES MAKE UP... OF ALL GUN DEATHS. OF ALL SUICIDES. Veterans are more likely to own guns than non-veterans and are more likely to die by firearm suicide. Nearly 45 percent of veterans (44.9 percent) report owning guns (compared to 20 percent of non-veterans),15 and in 2017, the most recent year of available data, veterans were 1.5 times more likely than non-veterans to die by suicide.16 Our country’s veterans are at a heightened risk of suicide, and firearms—the most lethal among commonly used methods of self-harm—are the prevailing method of suicide among veterans.17 On average, two-thirds (68.2 percent) of suicides among veterans are by firearm,18 compared to non-veteran adults, where about half of all suicides are with a firearm.19 In fact, the use of guns in veteran suicide is becoming more and more frequent; in 2017, 69.4 percent of veteran suicides were by gun—the highest it has been in the last decade.20 VETERANS NON-VETERANS everytownresearch.org 68.2% 48.1% October 2019 Nonfirearm Firearm FIREARMS ARE THE PREVAILING METHOD OF SUICIDE AMONG VETERANS. 2 Firearms are increasingly used in suicides among female veterans. The proportion of firearm suicide among female veterans is lower than among males (43.2 and 70.7 percent, respectively).21 Compared to other methods, suicide by firearm has also increased over time among female veterans. From 2005 to 2017, the proportion of suicide deaths by firearms increased nearly 26 percent among female veterans (from 34.3 to 43.2 percent), whereas the proportion of suicide deaths by firearms among male veterans increased 2.8 percent in the same period (from 68.8 to 70.7 percent).22 Female veterans are more likely than civilian women to use a gun to die by suicide—43.2 percent compared to 31.3 percent for female non-veterans.23 Women are the fastest-growing veteran group, currently comprising about 9 percent of the US veteran population.24 As this population grows, gun suicide prevention among female veterans will become more urgent.25 MORE SUICIDES BY FEMALE VETERANS ARE BY GUN THAN EVER BEFORE—A NEARLY 26 PERCENT INCREASE SINCE 2005. 68.8% 70.7% 34.3% 2005 43.2% 2017 Female Veterans Male Veterans 2005 2017 The West has the highest rate of veteran firearm suicides of any region. The West has the highest rate of veteran firearm suicides, followed closely by the South (23.6 and 22.6 veteran firearm deaths per 100,000 people, respectively).26 The Northeast has the lowest rate of veteran firearm suicide, and the Midwest has the second lowest (19.0 and 13.9 veteran firearm deaths per 100,000 people, respectively).27 The gap between rates of veteran suicide by gun is quite large; the region where this phenomenon is the worst—the West—has rates roughly 70 percent higher than the region where veteran gun suicide occurs at the lowest rate—the Northeast.28
 RECOMMENDATIONS Nationwide, 53,230 military veterans died by gun suicide in the period between 2005 and 2017—more than 13 times the number of service members who were killed in action during the United States engagements in Afghanistan, Iraq, and Syria combined (4,076).29 Veterans faced unique challenges during their service and face unique challenges when they come home. And because they are more likely than the general population to own firearms, veterans are now facing a uniquely deadly firearm suicide crisis. Addressing the unique role guns play is an integral part of efforts to end veteran suicide. The following are evidence-backed recommendations to address today’s high and rising rates of veteran firearm suicide: 4,076 service members were killed in action during US engagements in Afghanistan, Iraq, and Syria combined. everytownresearch.org October 2019 53,230 military veterans died by gun suicide in the period between 2005 and 2017. 3 We need to identify veterans in crisis and temporarily remove access to firearms. Extreme Risk laws, which allow for temporary firearm removal during times of crisis and are sometimes referred to as “red flag” laws, have been shown to reduce suicide in states where they have been implemented.30 Risk-mitigation planning is critical to preventing suicide. For families and friends of veterans, this plan can include steps to intervene by utilizing these laws, which allow immediate family members and law enforcement to petition a court for an order to temporarily remove guns from dangerous situations. If a court finds that a person poses a serious risk of injuring themselves with a firearm, that person is temporarily prohibited from purchasing and possessing guns, and any guns they already own are held by law enforcement or another authorized party while the order is in effect. While not all veterans seek the services of the Veterans Health Administration (VHA), the agency’s prominence suggests that it can, when not in conflict with patient confidentiality, work within established Extreme Risk laws to protect at-risk veterans by temporarily preventing their access to firearms. Extreme Risk laws, currently in place in 17 states and DC,31 have been proven to reduce firearm suicides. Following Connecticut’s increased enforcement of its Extreme Risk law, one study found the law to be associated with a 14 percent reduction in the state’s firearm suicide rate. And in Indiana, in the 10 years after the state passed its Extreme Risk law in 2005, the state’s firearm suicide rate decreased by 7.5 percent.32 Warning signs that someone is suicidal are often most apparent to household or family members, and while it can sometimes feel like there is nothing that can be done, requesting an Extreme Risk Protection Order is one thing people can do. ONE IN THREE VETERAN GUN OWNERS STORE AT LEAST ONE OF THEIR FIREARMS LOADED AND UNLOCKED. We need to promote secure storage practices in order to put time and distance between those contemplating suicide and their guns. Secure firearm storage is yet another way to disrupt access to lethal means for suicide. And experts agree: In order to prevent access at critical moments, firearm storage should include three best practices—unloading the ammunition, locking the firearm, and storing the firearm and ammunition in separate locations. Veterans are more likely to own firearms—six, on average—than non-veterans.33 Secure storage practices are likely familiar to military service members and veterans as militaryissued guns have storage specifications. However, personal weapons may be treated differently: A 2018 survey found that one in three veteran gun owners store at least one of their firearms loaded and unlocked.34 Encouraging veterans to treat personal weapons with the same focus on safety expected of the storage of their military-issued weapon is just one way we can fight gun suicides in military communities. We need more public and veteran awareness about the inherent risks of firearm access. Many Americans are unaware of the threat firearms in the home can pose with respect to suicide. Access to a firearm increases the risk of suicide three-fold for all family members.35 Veterans are more likely to own firearms than non-veterans (44.9 percent and 20.0 percent, respectively), and a majority (63.1 percent) cite protection as a primary reason for firearm ownership.36 But when asked, only 6 percent of veterans agree that having a gun in the home is a suicide risk factor.37 Building public awareness about the inherent risk of firearm access may empower gun-owning veterans or their families to mitigate risks. We need to empower veteran gun owners who know they are at risk. Sometimes, a person at risk of suicide knows it. Veterans with firearms in their homes can work with friends, family members, or physicians to put a plan in place to temporarily store their firearms with a friend or relative or in a storage facility, and/or limit their own everytownresearch.org October 2019 4 ability to acquire new guns in times of crisis. Voluntary Do Not Buy lists (sometimes called Voluntary Prohibition lists), currently being piloted in Washington state, empower people to put themselves on a list that prevents them from purchasing guns.38 Like Extreme Risk laws, discussed above, these laws are intended to temporarily disrupt gun access. In Washington, for example, voluntary waivers of firearm rights prohibit the person from purchasing or receiving a firearm through a gift or transfer. The person may file a revocation of the voluntary waiver at any time after 7 calendar days have passed. Further public awareness and comprehensive implementation through relevant state-based agencies are necessary to give power to those who know they are at risk by enabling them to take potentially life-saving action. ROUGHLY TWO IN THREE AMERICANS WHO ATTEMPT SUICIDE WILL VISIT A HEALTHCARE PROFESSIONAL IN THE MONTH BEFORE THE ATTEMPT. THE DYNAMICS AFFECTING VETERAN SUICIDE ARE COMPLEX, BUT FOR THE MORE THAN 9 MILLION VETERANS WHO USE THE AGENCY’S SERVICES EACH YEAR, THE VHA COULD PLAY A MEANINGFUL ROLE IN PREVENTING SUICIDE. We need healthcare professionals to have conversations about gun access and suicide risk. The responsibility to identify suicide risks should not fall just to veterans. Roughly two in three Americans who attempt suicide will visit a healthcare professional in the month before the attempt.39 One survey of veterans already receiving mental health care found that more than half (55.6 percent) of patients with a suicide plan had guns in the household.40 Medical professionals have an important role to play in discussing behavioral risks with their patients. Counseling for Access to Lethal Means (CALM) is one program designed to equip medical professionals with language for discussing this risk with their patients, and it has already been piloted by some VHA facilities. Providers who have received this training are more likely to counsel clients on the importance of restricting access to lethal means.41 And while these conversations may be challenging, a majority of US gun owners, including veterans, agree that it is appropriate for clinicians to talk about firearm safety with their patients.42 These conversations could save lives. We need more research on the effectiveness of existing initiatives to combat suicide. There are a number of innovative programs across the country with the objective of bringing suicide prevention information directly to gun owners. These include a partnership between suicide prevention and firearm safety organizations to bring mandatory training sessions to those seeking concealed-carry permits in Utah.43 Likewise, the Gun Shop Project in New Hampshire, which provides suicide prevention literature at firearm retailers, has been adopted in 10 other states.44 Although some research demonstrates the impact of the Gun Shop Project in New Hampshire, rigorous evaluation of training programs for firearm purchasers and public awareness campaigns is needed in order to provide further information on their efficacy in reducing gun suicide throughout the country, particularly among veterans. We need to understand how VHA services affect veteran gun suicide. Between 2005 and 2017, the increase in suicide rates among veterans not using VHA services was more than twice that of veterans who used VHA services (31.9 percent and 13.7 percent increase, respectively).45 As the country’s leading veteran health institution, the VHA is uniquely positioned to establish self-harm intervention programs, promote secure firearm storage, intervene when a veteran is in crisis, and evaluate the best programs for saving veterans’ lives. The dynamics affecting veteran suicide are complex, but for the more than 9 million veterans who use the agency’s services each year, the VHA could play a meaningful role in preventing suicide.46 everytownresearch.org October 2019 5 CONCLUSION: BETTER SUPPORTING THOSE WHO SERVE The US Government Accountability Office found that, in 2018, of the $6.2 million that the VA set aside for suicide prevention media outreach, only $57,000—less than 1 percent— was actually spent. An average of 4,200 veterans die by firearm suicide every year— about 11 deaths a day. To truly honor those who serve, we must fully support the strategies and additional research necessary to prevent veteran firearm suicide. Veterans deserve the best resources our country can offer. The recommendations outlined above are just the start of a larger dialogue on effective strategies to give back to those who serve. If you are a veteran in crisis—or you’re concerned about one—free, confidential support is available 24/7. Call the Veterans Crisis Line at 1-800-273-8255 and press 1, send a text message to 838255, or chat online. For support for the deaf and hard-of-hearing, call 1-800-799-4889. veteranscrisisline.net everytownresearch.org October 2019 If you or someone you know is in crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255), or text HOME to 741741 to reach the Crisis Text Line for free from anywhere in the US. 6 Everytown for Gun Safety would like to acknowledge and thank Michael Anestis, PhD at University of Southern Mississippi for advising on this report. 1. Alex Sundby, “Three Veterans Kill Themselves at Veterans Affairs Facilities within Five Days,” CBS News, April 15, 2019, https://cbsn. ws/2XaGhzu. 2. Jeremy Redmon, “Veteran Who Killed Himself Outside of VA Center in Decatur Identified,” The Atlanta Journal-Constitution, April 9, 2019, https://on-ajc.com/2Q29FWD. 3. Tom Miller, “Austin Veterans Affairs Clinic to Reopen Wednesday After Suicide Shut Down Building,” KXAN, April 10, 2019, https://bit. ly/2WGUXXs. 4. US Senate Committee on Veterans’ Affairs, “Harnessing the Power of Community: Leveraging Veteran Networks to Tackle Suicide,” June 19, 2019, https://bit.ly/2WLIuko. 5. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Webbased Injury Statistics Query and Reporting System (WISQARS) Fatal Injury Reports. A yearly average was developed using five years of most recent available data: 2013 to 2017. 6. Ibid. A percent change was developed using 2008 to 2017 ageadjusted rates for all ages. 7. US Department of Veterans Affairs, Office of Mental Health and Suicide Prevention, “2005-2017 State Data Appendix,” September 2019, https://bit.ly/2Qblicx. A yearly average was developed using five years of most recent available data: 2013 to 2017. 8. Ibid. A yearly average was developed using five years of most recent available data: 2013 to 2017. 9. U.S. Department of Veterans Affairs, Office of Mental Health and Suicide Prevention. 2005 - 2017 state data appendix. https://bit.ly/2Qblicx. September 2019. Veteran firearm suicide crude rates were calculated using veteran population estimates provided by the VA in the 2017 National Data Appendix: https://bit. ly/2IENqn0. 10. American Foundation for Suicide Prevention, “Risk Factors and Warning Signs,” https://bit. ly/2bmWnQx. 11. Anglemyer A, Horvath T, Rutherford G. The accessibility of firearms and risk for suicide and homicide victimization among household members: a systematic review and meta-analysis. Annals of Internal Medicine. 2014;160:101–110. everytownresearch.org 12. Vyrostek SB, Annest JL, Ryan GW. Surveillance for fatal and nonfatal injuries—United States, 2001. Morbidity and Mortality Weekly Report. Surveillance Summaries. 2004; 53(7): 1–57; Miller M, Azrael D, Barber C. Suicide mortality in the United States: The importance of attending to method in understanding population-level disparities in the burden of suicide. Annual Review of Public Health. 2012; 33: 393–408. 13. Ibid. 14. David Owens, Judith Horrocks, and Allan House, “Fatal and Non-fatal Repetition of Self-Harm: Systematic Review,” British Journal of Psychiatry 181, no. 3 (September 2002): 193-199. 15. Deborah Azrael et al., “The Stock and Flow of US Firearms: Results from the 2015 National Firearms Survey,” RSF: The Russell Sage Found Journal of the Social Sciences 3, no. 5 (October 2017): 38–57. 16. US Department of Veterans Affairs, Office of Mental Health and Suicide Prevention, “2019 National Suicide Prevention Annual Report,” September 2019, https://bit. ly/2Qblicx. 17. US Department of Veterans Affairs, Office of Mental Health and Suicide Prevention, “2005-2017 State Data Appendix,” September 2019, https://bit.ly/2Qblicx. 18. Ibid. The average percent of veteran suicide deaths by firearms was developed using five years of most recent available data: 2013 to 2017. 19. Ibid. The proportion of suicides by gun in the general population was developed using five years of most recent available data: 2013 to 2017. 20. Ibid. 21. US Department of Veterans Affairs, Office of Mental Health and Suicide Prevention, “2019 National Suicide Prevention Annual Report,”September 2019, https://bit. ly/2Qblicx. 25. US Department of Veterans Affairs, National Center for Veterans Analysis and Statistics, “America’s Women Veterans: Military Service History and VA Benefit Utilization Statistics,” November 23, 2011, https://bit.ly/2QD1a2B. 26. U.S. Department of Veterans Affairs, Office of Mental Health and Suicide Prevention. 2005 - 2017 state data appendix. https://bit. ly/2Qblicx. September 2019. Rates of veteran suicide deaths by region were developed using three years of most recent available data: 2015 to 2017. 27. Ibid. 28. Ibid. 29. Ibid.; Nese F. DeBruyne, “American War and Military Operations Casualties: Lists and Statistics,” Congressional Research Service (September 24, 2019), https://bit. ly/2qOCavj. This reflects the sum of deaths where casualty type was classified as “killed in action” for Operation Enduring Freedom, Operation Iraqi Freedom, Operation New Dawn, and Operation Inherent Resolve: 4,076. 30. Aaron J. Kivisto and Peter Lee Phalen, “Effects of Risk-Based Firearm Seizure Laws in Connecticut and Indiana on Suicide Rates, 1981-2015,” Psychiatric Services 69, no. 8 (June 2018): 855–862; Jeffrey W. Swanson et al., “Implementation and Effectiveness of Connecticut's Risk-Based Gun Removal Law: Does It Prevent Suicides? Law and Contemporary Problems 80, no. 2 (2017): 179–208; Jeffrey W. Swanson et al., “Criminal Justice and Suicide Outcomes with Indiana’s Risk-Based Gun Seizure Law,” Journal of the American Academy of Psychiatry and the Law 47, no. 3 (April 2019), pii: JAAPL.003835-19. 22. Ibid. US Department of Veterans Affairs, Office of Mental Health and Suicide Prevention, “VA National Suicide Data Report 2005-2015, ”June 2018, https://bit.ly/2Qblicx. 23. Ibid. 24. US Department of Veterans Affairs, Office of Mental Health and Suicide Prevention, “2019 National Suicide Prevention Annual Report,” September 2019, https://bit. ly/2Qblicx. October 2019 7 31. Cal. Penal Code § 18125; Cal. Penal Code § 18150; Cal. Penal Code § 18175; CO HB 1177 (2019); Conn. Gen. Stat. § 29-38c; 10 Del. C. 7701, et seq.; 2018 D.C. Act 22-629; Fla. Stat. § 790.401; 430 ILCS 67/1, et seq.; HI SB 1466 (2019); Ind. Code § 35-47-14-1; Ind. Code § 35-47-14-2; Ind. Code § 35-47-14-5; Ind. Code § 35-47-14-6; Ind. Code § 35-47-148; Md Public Safety Code 5-601, et seq; Mass. Gen. Laws ch. 140, § 121; Mass. Gen. Laws ch. 140, § 129B(C); Mass. Gen. Laws ch. 140, § 131(C); Mass. Gen. Laws ch. 140, §131R-Z; Nev. AB 291 (2019); NY SB 2451 (2019); NJ A 1217 (2018); ORS 166.525, et seq.; 13 VSA 4051, et seq.; RI Gen Laws 8-8.3-1, et seq.; Wash. Rev. Code § 7.94.030; Wash. Rev. Code § 7.94.040; Wash. Rev. Code § 7.94.050; Wash. Rev. Code § 7.94.080. 36. Emily C. Cleveland et al., “Firearm Ownership among American Veterans: Findings from the 2015 National Firearm Survey,” Injury Epidemiology 4, no. 33 (December 2017) doi: 10.1186/s40621-0170130-y); Andrew Anglemyer, Tara Horvath, and George Rutherford, “The Accessibility of Firearms and Risk for Suicide and Homicide Victimization among Household Members: A Systematic Review and Meta-analysis,” Annals of Internal Medicine 160, no. 2 (January 2014): 101–110. 32. Aaron J. Kivisto and Peter Lee Phalen, “Effects of Risk-Based Firearm Seizure Laws in Connecticut and Indiana on Suicide Rates, 19812015,” Psychiatric Services 69, no. 8 (June 2018): 855–862. 39. Brian Ahmedani et al., “Racial/ Ethnic Differences in Health Care Visits Made before Suicide Attempt across the United States,” Medical Care 53, no. 5 (May 2015): 430-435. 33. Emily C. Cleveland et al., “Firearm Ownership among American Veterans: Findings from the 2015 National Firearm Survey,” Injury Epidemiology 4, no. 33 (December 2017) doi: 10.1186/s40621-0170130-y). 34. Joseph A. Simonetti et al., “Firearm Storage Practices among American Veterans,” American Journal of Preventive Medicine 55, no. 4 (October 2018): 445-454. 35. Andrew Anglemyer, Tara Horvath, and George Rutherford, “The Accessibility of Firearms and Risk for Suicide and Homicide Victimization among Household Members: A Systematic Review and Metaanalysis,” Annals of Internal Medicine 160, no. 2 (January 2014): 101–110. everytownresearch.org 37. Joseph A. Simonetti et al., “Firearm Storage Practices among American Veterans,” American Journal of Preventive Medicine 55, no. 4 (October 2018): 445-454. 38. 2017 WA S 5553 (enacted March 2018, effective January 1, 2019). 40. Marcia Valenstein et al., “Possession of Household Firearms and Firearm-Related Discussions with Clinicians among Veterans Receiving VA Mental Health Care,” Archives of Suicide Research (February 2019) doi: 10.1080/13811118.2019.1572555. 43. Utah Suicide Prevention Coalition, “Is Your Safety On? Firearm Suicide Prevention: A Brief Module for Utah Concealed Carry Classes” (2016), https://bit.ly/2m2QGQy. 44. New Hampshire Firearm Safety Coalition, “Suicide Prevention: A Role for Firearm Dealers and Ranges,” https://bit.ly/2kaITQh; Harvard T.H. Chan School of Public Health, “Means Matter: Gun Shop Project,” https://bit.ly/2c4QKah. 45. US Department of Veterans Affairs, Office of Mental Health and Suicide Prevention, “2017 National Data Appendix,” September 2019, https://bit.ly/2Qblicx. 46. US Department of Veterans Affairs, Veterans Health Administration, September 2019, https://bit. ly/2FyLGrv. 47. US Government Accountability Office, “Report to the Ranking Member Committee on Veterans Affairs, House of Representatives: Improvements Needed in Suicide Prevention Media Outreach Campaign Oversight and Evaluation,” November 2018. 41. Renee M. Johnson et al., “Training Mental Healthcare Providers to Reduce At-Risk Patients' Access to Lethal Means of Suicide: Evaluation of the CALM Project,” Archives of Suicide Research 15, no. 3 (August 2011): 259-264. 42. Marian E. Betz et al., “Public Opinion Regarding Whether Speaking with Patients about Firearms Is Appropriate: Results of a National Survey,” Annals of Internal Medicine 165, no. 8 (October 2016): 543-550. October 2019 8