Suicide in Military and Veteran Populations: A View Across the Five Eyes Nations

Abstract

Objective

This commentary highlights challenges and opportunities in suicide prevention across the military and veteran populations of the Five Eyes nations.

Methods

Trends in suicides and suicidality in military and veteran populations are outlined, as well as identified risk and protective factors, and approaches to suicide prevention.

Results

Suicide risk is higher in veterans compared to current serving and community samples. Despite extensive research, the causation, prediction, and prevention of suicide, is still not well understood. We propose areas for further attention in prevention strategies.

Conclusion

Suicide and suicidality are issues of concern in military and veteran populations. Suicide prevention requires commitment to continuous improvement through research, analysis, and incorporation of evolving best practice.

Suicide and suicidality (ideation, plans, and attempts) are issues of significant concern among military and veteran populations, with devastating human costs and impacts on family members, units, colleagues, and operational readiness.

Defence forces in most developed countries, including the Five Eyes nations, collect data on suicides, with recent rates in current serving male members ranging from slightly lower to slightly higher than matched community samples. Available evidence suggests males are at higher risk for death by suicide, while females are at higher risk for suicidal thoughts and behaviors (Australian Institute of Health and Welfare, 2022; Defense Suicide Prevention Office, 2022). Analysis of data on suicides in female members had been limited by the smaller number of women serving, although this is changing. Recent increases in suicide rates, especially in army members over the past decade, indicate risk levels that now approach those of the general population (Ministry of Defence, 2022). Furthermore, suicide risk increases as individuals transition out of active military service (US Department of Veterans Affairs, 2022) with available evidence suggesting higher levels of death by suicide and suicidality in veterans compared to both current serving and community samples. These highlight the need to better understand the drivers and patterns of suicidal behaviour.

Although many risk indicators and factors have been identified, they have limited predictive power: it remains difficult to accurately predict who will attempt suicide. Importantly, different risk factors may exist for suicidality versus death by suicide (Ursano et al., 2016) and there is evidence of diverse trajectories of suicidality (Bryan et al., 2023). Risk indicators are characteristics of subgroups in whom suicide is more common but do not necessarily confer causal risk. In military and veteran populations, these include male gender, younger age, and lower rank. Conversely, risk factors have a demonstrable causal effect and are potentially modifiable or manageable. In veteran and military populations, these include the presence of mental or physical health problems, cumulative trauma exposure (including military sexual trauma), and medical or involuntary discharge from the military. Research is underway to understand the risk profile for the progression from ideation to suicide attempts since these are obvious targets for intervention. Protective factors may include healthy social connections, good leadership, good physical health, secure employment and housing, and personal resilience.

Clearly, the key challenge in suicide is that of prevention. Most developed countries have suicide prevention strategies for military and veteran populations and/or suicide prevention is central to a broader mental health strategy (Department of Defense, 2023; Department of Veterans Affairs, 2020; Government of Canada, 2017; Veterans Affairs New Zealand, 2022). Military and veteran policies may operate best when explicitly linked to national community mental health and suicide prevention strategies—a “whole community approach.” Similarly, a core component of effective suicide prevention is “whole-of-life” strategies to maintaining good mental, physical, and social health, with effective alignment of related policies and procedures. This includes strong attention to “upstream” factors—the social determinants of health—that may contribute to suicidality such as adverse childhood experiences, job and financial security, healthy relationships, and substance use.

Suicide prevention strategies should pay strong attention to early identification of mental health problems and suicidality, starting from enlistment, with interventions throughout the career lifecycle designed to mitigate the potential risks. Easy access to evidence-based care tailored to individual need, addressing stigma and other barriers to help-seeking, effective engagement, and education for individuals, peers, leaders, families, and communities are essential. Strategies should seek to optimise leadership around behavioral health support and team cohesion. Postvention follow-up and support is required following a suicide, including sensitivity to the risk of suicide clusters within teams due either to similar stressors and adversities or contagion. Building on the above, veteran suicide prevention strategies should include particular attention to additional support during and following transition from military to civilian life. Given the increased risk of suicide following discharge, greater consideration of the circumstances and environment into which veterans are transitioning is essential, along with enhanced support for families and ensuring skills to support transition. Working with the media to facilitate sensitive reporting of military and veteran suicides may also decrease the risk of suicide contagion. Importantly, reducing or restricting access to lethal means (e.g., the safe storage of firearms) is an obvious practical step.

Despite decades of research, the causation, prediction, and prevention of suicide in military and veteran populations are not well understood. More longitudinal and integrated research is required from pre-enlistment through service and post-service years, with stronger international collaborations, to identify pathways or algorithms (and the underlying mechanisms) of suicidality, rather than simply generating lists of indicator and risk factors. While suicide is a particular challenge in military and veteran populations, the issue of effective suicide prevention has much broader implications across the whole of society. Suicide prevention requires commitment from the highest levels to continuous improvement through research, analysis, and incorporation of evolving best practice.

DISCLAIMER

The opinions and assertions expressed herein are those of the author(s) and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences or the Department of Defense.

Acknowledgments

The Mental Health Research and Innovation Collaborative in military and veteran mental health across the Five Eyes nations (Australia, Canada, United Kingdom, United States and New Zealand) includes Amy B. Adler, Clare Bennett, Richard Bryant, Walter Busuttil, John Cooper, Stephen Cozza, Mark Creamer, Heidi Cramm, Nicola Fear, Deniz Fikretoglu, David Forbes (Co-Chair), Neil Greenberg, Alexandra Heber, Charles W. Hoge, Fardous Hosseiny, Rakesh Jetly, Stephen Kearney, Alexander McFarlane, Joshua Morganstein, Dominic Murphy, Anthony Nazarov, MaryAnn Notarianni, Meaghan O’Donnell, David Pedlar (Co-Chair), Andrea Phelps, Don J. Richardson, Nicole Sadler, Paula P. Schnurr, Marie-Louise Sharp, Robert Ursano, Miranda Van Hooff & Simon Wessely.

DISCLOSURE STATEMENT

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Nicole Sadler

Nicole L. Sadler, MPsych (Clin), Enterprise Professor and Director of Policy and Practice, Phoenix Australia—Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Victoria, Australia.

David Pedlar

David Pedlar, PhD, Scientific Director of the Canadian Institute of Military and Veteran Health Research and Professor in the School of Rehabilitation Therapy, Queen’s University, Kingston, Ontario, Canada.

Robert Ursano

Robert J. Ursano, MD, Professor Psychiatry and Neuroscience, Director Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University, Bethesda, United States.