In one key study, only 24% of patients who completed suicide had been screened for suicidal intent, despite being seen by a primary care provider within 28 days of their death.13 Many veterans seek primary care outside the VA system,14 yet primary care providers are often unprepared to navigate the healthcare needs of military personnel and veterans. This is especially true of members of the Reserve and National Guard, who typically receive care outside the VA system.
In this article, using the American Academy of Nursing initiative “Have you ever served in the military?” as a basis for patient evaluation,15 we offer tools to help guide conversations with military and veteran patients. Risk factors for veteran suicide are discussed to educate nurse practitioners and physician assistants about the unique healthcare needs of veterans and soldiers serving since September 11, 2001.
Gender differences in the rates of veteran suicides have been explored, and the rate of suicide in female veterans is markedly increased compared with the rate in their nonveteran peers.16 The female veteran suicide rate was found to be more than 300% higher than projected for the year 2000. This is a consequence, in part, of the greater number of female soldiers involved in combat, and of the significant number of female soldiers experiencing sexual abuse. The top overall causes of death in veteran suicides are firearms and alcohol. Veterans are 58% more likely than nonveterans to use a firearm to commit suicide.17 Other risk factors for veteran suicide are summarized in Table 2. These risk factors should guide the provider while he or she is taking the history and performing the physical examination. In addition to assessing patients for the risk factors listed in Table 2, the provider should consider asking for a detailed history, as outlined in Table 3.
Sexual trauma, specifically military sexual trauma, is a risk factor for suicide.18 The term military sexual trauma (MST) is used by the VA to refer to any sexual assault or harassment that occurs while a person is serving in the military.19 Table 4 further defines MST and sexual harassment. The VA reports that about 1 in 4 women and 1 in 100 men answer yes when screened by a VA provider for MST. MST is associated with an increased risk for mental disorder diagnoses, including PTSD, anxiety, and depression.18 Although rates of MST are higher among women, because of the potential stigma attached to reporting MST, it is estimated that many men underreport it.
Veterans 18 to 29 years of age are at the highest risk for completing suicide.16 According to the National Institute of Mental Health,20 the young adult brain is still developing in people in their twenties. Specifically, the volume of gray matter, the outer layer of the cortex of the brain, is still fluctuating. Changes in this area of the brain reflect the maturation of the emotional centers of the brain. Although the intellectual centers of the brain are fully formed in young adults, fluctuations in the volume of gray matter can be associated with unstable emotions and impulsive behavior.20