Data indicate that a mental health or behavioral disorder has been diagnosed in more than 41% of veterans currently living in the United States.21 Common issues within the veteran population include mood disorders such as depression and manic-depressive disorders, as well as disorders associated with binge drinking and substance abuse, both of which increase the risk for suicide.21
As noted by Olenick and colleagues, “Military culture includes, but is not limited to, values, customs, traditions, philosophical principles, ethos, standards of behavior, standards of discipline, teamwork, loyalty, selfless duty, rank, identity, hierarchy, ceremony and etiquette, cohesion, order and procedure, codes of conduct, implicit patterns of communication, and obedience to command.”21
This type of life is very different from civilian life and needs to be treated as such to avoid complications resulting from separation from military service and issues related to complex multiple deployments. Veterans have identified these issues specifically as problem areas during adjustment to civilian life.21
Physical and environmental stressors that influence the mental health status of veterans and active duty personnel must also be considered: chronic pain, amputations, homelessness, hazardous exposures, and the difficulties of civilian reintegration. A key to suicide prevention is helping veterans reintegrate into civilian life by “providing veterans with training that builds on their military knowledge and skill, employment post-separation from service, homelessness prevention, and mental health programs that promote civilian transition.”21 Primary care clinicians must be aware of the risks and stressors common to civilian re-entry, and they must be prepared to help patients who are veterans undergo this key transition with both compassion and appropriate referrals.
Studies show that communal and familial support is protective against veteran suicide.22,23 According to one hypothesis, an increased awareness of veteran suicide among a population decreases the risk for veteran suicide (the “yellow ribbon” effect).22 This effect is attributed to the change in the “public’s view of military service and of veterans, and, probably, the way it led to changes in veterans’ perceptions of the way America valued their history of service.”22 Other protective factors include self-reported feelings of control over one’s life, hardiness, and resilience.23 For Operation Iraqi Freedom and Enduring Freedom veterans, increased social support and an increased sense of worth within the community are protective factors against suicide completion.23
There is a common misconception among primary care providers that veterans use the VA for their care. The current estimate is that only 40% of eligible new veterans use VA care.24 As of 2000, 45% of suicide victims had contact with a primary care clinician within 1 month of their suicide. Only a small portion of these patients had contact with a mental health practitioner. For most of them, primary care clinicians were the first and only line of defense against veteran suicide.11 Nonetheless, there is little available literature to help primary care clinicians describe the characteristics of veterans who have committed suicide after seeing a primary care provider.11
The American Association of Nurses in 2013 began a campaign entitled “Have you ever served in the military?”15 This simple question can initiate what may be a difficult conversation for both clinician and patient. A review of symptoms and questions to ask during the social, medical, and family history that can help identify symptoms and risk factors for veteran suicide are outlined in Table 3.