2023 National Veteran Suicide Prevention Annual Report

2023

National Veteran

Suicide Prevention

Annual Report

VA Suicide Prevention

Oce of Mental Health and Suicide Prevention

November 2023

Contents

Introduction 5

Anchors of Hope 5

A Call to Action for Each of You 6

Reviewing Veteran Suicide Within the Context of 2021 6

Key Findings 8

Need for a Whole-of-Nation Public Health Approach to Veteran Suicide Prevention: Themes for Action 10

Organization of Report 13

Part 1: Suicide Among Veterans, 2001–2021 14

Suicide Deaths 14

Average Number of Suicides Per Day 15

Suicide Rates 16

Suicide Rates, by Sex 17

Suicide Rates, by Age 18

Suicide Rates, by Sex and Age 19

Suicide Rates, by Race and Ethnicity 20

Suicide Rates in Year Following Military Separation 22

Method-Specific Suicide Rates 24

Method-Specific Suicide Rates, by Veteran Status and Sex 26

Method-Specific Suicide Rates, by Sex and Veteran status 26

Lethal Means Involved in Suicide Deaths 27

Comparing Suicide Mortality Among Veterans and Non-Veteran U.S. Adults 30

Veteran Leading Causes of Death 34

Years of Potential Life Lost 37

COVID-19 Pandemic: Suicide Surveillance 37

Review of Overall Veteran Suicide Data 37

Reflecting Back, Looking Forward: Laying the Foundation for Future

Courses of Action for Suicide Prevention for All Veterans 38

Promote Secure Firearm Storage for Veteran Suicide Prevention 38

Implement and Sustain Community Collaborations Focused Upon Community-Specific

Veteran Suicide Prevention Plans 40

Continue Expansion of Readily Accessible Crisis Intervention Services 42

Improve Tailoring of Prevention and Intervention Services to the Needs,

Issues, and Resources Unique to Veteran Subpopulations 44

Communication and Outreach 44

Community Prevention 44

Research and Innovation 45

Clinical Innovation 46

Part 2: Veterans with VHA or VBA Contact 47

Veterans Health Administration (VHA) Health Care 47

VHA Health Care Engagement, 2001–2021 47

Suicide Deaths 48

Suicide Rates 49

Marital Status 52

Mental Health and Substance Use Disorder Diagnoses 52

Homelessness 55

Veterans Justice Programs 55

Rurality 57

Gender Identity 57

VHA Priority Eligibility Groups 58

Veteran All-Cause Mortality, Overall and by VHA Engagement 61

Leading Causes of Death, for Recent Veteran VHA Users and Other Veterans 62

Recent Veteran VHA Users 62

Other Veterans 63

VA Community Care 64

Veterans, by Receipt of VHA and VBA Services 66

VBA Benefit Types Received, Percentage, Among Veterans with VBA Benefits, 2019–2021 68

Suicide Rates Among Veterans by Receipt of VBA or VHA Services 69

Suicide Decedents in 2021: Contacts with VHA and VBA 71

Suicide Decedents, VBA Contact 72

Suicide Decedents with Recent VBA Contact, VBA Services Received 72

Suicide Decedents, Recent Veteran VHA Users with Behavioral Health Autopsy Program Reviews 73

Reflecting Back, Looking Forward: Laying the Foundation for Future

Courses of Action for Suicide Prevention for VHA- and VBA-Engaged Veterans 74

Advance Suicide Prevention Meaningfully into Non-Clinical Support and

Intervention Services, Including Financial, Occupational, Legal and Social Domains 74

Increase Access to and Utilization of Mental Health Services Across a Full Continuum of Care 76

Integrate Suicide Prevention Within Medical Settings to Reach All Veterans 78

Conclusion 81

Appendix A: Brief Summary of 2021 VA Suicide Prevention Initiatives 83

Appendix B: Suicide Prevention Demonstration (Pilot) Projects, FY 2024 86

Introduction

This Department of Veterans Affairs (VA) “2023 National Veteran Suicide Prevention Annual Report” provides new

information regarding suicide mortality among Veterans and non-Veteran U.S. adults, from 2001 through 2021,

including the first full year of information since the onset of the COVID-19 pandemic, in March 2020. This annual report

of Veteran suicide mortality over time is a critical part of our public health approach to inform next steps in suicide

prevention across the Nation, reflecting on the lives lost and reviewing themes of action to move forward to prevent

suicide. In alignment with prior concerns about the potential for increases in suicide rates with the worldwide COVID-19

pandemic,

1,2

and consistent with trends for the overall U.S. population,

this report documents increases in suicide rates in

2021 for Veterans and non-Veteran U.S. adults. Overall reductions in suicide rates among U.S. adults in 2019 and 2020 were

not repeated in 2021. This may reflect a trend in which suicide rates are seen to initially remain stable or diminish during

emergencies and natural disasters, due to a collective “coming together,”

followed by increases in rates in ensuing years.

5,6

In 2021, 6,392 Veterans died by suicide, an increase of 114 suicides from 2020. When looking at increases in rates from

2020 to 2021, the age- and sex-adjusted suicide rate among Veterans increased by 11.6%, while the age- and sex-adjusted

suicide rate among non-Veteran U.S. adults increased by 4.5%. Veterans remain at elevated risk for suicide. These

numbers are more than statistics — they reflect Veterans’ lives prematurely ended, which continue to be grieved by

family members, loved ones and the Nation. One Veteran suicide is 1 too many. In this report we reflect on the context

of 2021 and the themes of data which will drive us towards further action for our work together in the mission of suicide

prevention. Our actions are built upon a foundation of hope, and we begin our review reflecting first upon these anchors

for our future work together.

Anchors of Hope

Hope is essential to life and hope serves an important role within suicide prevention efforts. Within the challenges faced

in 2021, key areas of hope emerged, including:

• From 2020 to 2021:

• Suicide rates fell by 8.1% for Veteran men aged 75-years-old and older.

• Among Recent Veteran Veterans Health Administration (VHA) Users

between ages 55- and 74-years-old, the

suicide rate fell by 2.2% overall (-0.6% for men, -24.9% for women).

• Among male Recent Veteran VHA Users, suicide rates fell by 1.9% for those aged 18- to 34-years-old.

Reger MA, Stanley IH, Joiner TE. 2020. Suicide Mortality and Coronavirus Disease 2019—A Perfect Storm? JAMA Psychiatry. 77(11), 1093-1094.

Banerjee D, Kosagisharaf JR, Rao TSS. 2021. ‘The Dual Pandemic’ of Suicide and COVID-19: A Biopsychosocial Narrative of Risks and Prevention.

Psychiatry Research. 295. https://doi.org/10.1016/j.psychres.2020.113577

Garnet MF, Curtin SC. 2023. Suicide Mortality in the U.S., 2001–2021. CDC National Center for Health Statistics, Data Brief 464.

These may have fragmented protective feelings of social integration that commonly follow elections. See: Classen TJ, Dunn RA. 2010. The Politics of

Hope and Despair: The Effect of Presidential Election Outcomes on Suicide Rates. Soc Sci Q. 91(3): 593–612.

Horney JA, Karaye IM, Abuabara A, Gearhart S, Grabich S, Perez-Patron M. 2020. The Impact of Natural Disasters on Suicide in the United States,

2003–2015. 42(5):328-334. doi: 10.1027/0227-5910/a000723.

Kolves K, Kolves KE, De Leo D. 2013. Natural Disasters and Suicidal Behaviours: A Systematic Literature Review. 146(1):1-14.

Recent Veteran VHA Users are defined as Veterans who were alive at the start of the year and who received inpatient or outpatient care from VHA

providers in the year or prior year.

• Among male Recent Veteran VHA Users, suicide rates fell by 8.6% for those aged 75-years-old and older.

• Among male Veterans not in VHA care who were aged 75-years-old and older, the suicide rate fell by 7.8%.

• From 2001 to 2021:

• The suicide rate among Recent Veteran VHA Users with mental health or substance use disorder diagnoses

fell from 77.8 per 100,000 to 58.2 per 100,000 in 2021.

• Suicide rates fell for Recent Veteran VHA Users with diagnoses of sedative use disorder (-40.4%), depression

(-32.9%), posttraumatic stress disorder (-27.6%) and anxiety (-26.9%).

• Recent Veteran VHA Users rates grew more slowly across 20 years when compared to rates of Veterans

without Recent VHA use. From 2001 to 2021, age-adjusted suicide rates rose 24.5% for male Veterans with

Recent VHA use and 62.6% for male Veterans without Recent VHA use. Age-adjusted suicide rates rose 87.1%

for female Veterans with recent VHA use and 93.7% for female Veterans without Recent VHA use.

• From 2011–2012 to 2020–2021, the suicide rate among Veterans in VHA care with diagnoses related to gender

identity fell from 267.9 per 100,000 person-years to 84.6 per 100,000 person-years.

Hope is the foundation for action in suicide prevention. As we reflect on these anchors of hope, we move to review the

larger context of 2021, laying out a pathway for our course of action for Veteran suicide prevention.

A Call to Action for Each of You

Reviewing Veteran Suicide Within the Context of 2021

This report reflects the complexity of suicide inherent in the Veteran population, and the United States as a whole, in the

context of 2021. Suicide prevention entails numerous and complex risks and protective factors across individual,

relational, community and societal levels.

Within 2021, Veterans and the entire U.S. population directly faced health and

mortality effects of the COVID-19 pandemic.

Weekly U.S. COVID-19 deaths peaked, ebbed, and climbed anew across

2021. By year’s end, over 837,000 Americans had died from COVID-19 since the pandemic began, including over 469,000

Americans who perished from COVID-19 in 2021 alone.

In 2020 and 2021, COVID-19 was the third leading cause of death

in the U.S., both overall

11,12

and for Veterans. There were 52,538 Veteran deaths from COVID-19 in 2020, and 60,356 in 2021.

Veteran age- and sex-adjusted all-cause mortality rates were 13.7% higher in 2020–2021 than in 2017–2019.

In addition

Reed J, Quinlan K, Labre M, Brummett S, Caine ED. 2021. The Colorado National Collaborative: A Public Health Approach to Suicide Prevention. Prev

Med. 152(Pt 1):106501.

In September 2021, COVID-19 became the deadliest respiratory pandemic in U.S. history. Lovelace B. CNBC. Covid is Officially America’s Deadliest

Pandemic as U.S. Fatalities Surpass 1918 Flu Estimates. 9/20/2021. https://www.cnbc.com/2021/09/20/covid-is-americas-deadliest-pandemic-as-us-

fatalities-near-1918-flu-estimates.html (Accessed 7/2/2023).

https://covid.cdc.gov/covid-data-tracker/#trends_weeklydeaths_select_00 (Accessed 7/7/2023). Also, in 2021 alone, there were over 2.5 million

COVID-19 hospitalizations in the United States, reaching over 3.6 million from the start of the pandemic through 12/31/2021. https://covid.cdc.gov/

covid-data-tracker/#trends_cumulativehospitalizations_select_00. Despite having substantial prevention resources, U.S. mortality outcomes were

poor relative to other countries. See: Ledesma JR, Isaac CR, Dowell SF, Blazes DL, Essix GV, Budeski K, Bell J, Nuzzo JB. 2023. Evaluation of the Global

Health Security Index as a Predictor of COVID-19 Excess Mortality Standardised for Under-Reporting and Age Structure. BMJ Global Health. doi:

10.1136/bmjgh-2023-012203.

Murphy SL, Kochanek KD, Xu J, Arias E. Mortality in the United States, 2020. NCHS Data Brief, 427. Hyattsville, MD: National Center for Health

Statistics. 2021. https://stacks.cdc.gov/view/cdc/112079/cdc_112079_DS2.pdf (Accessed 6/25/2023).

Xu J, Murphy SL, Kochanek KD, Arias E. Mortality in the United States, 2021. NCHS Data Brief, 456. Hyattsville, MD: National Center for Health

Statistics. 2022. https://www.cdc.gov/nchs/data/databriefs/db456.pdf (Accessed 6/25/2023).

Assessed by comparing the average of the annual rates.

to these losses, the Nation faced greater financial strain,

housing

instability,

anxiety and depression levels,

barriers to health care and

increased firearms availability, all of which are associated with heightened

suicide risk.

17,18

With the increased purchasing of firearms noted in 2020

and 2021, those who purchased and owned firearms were more likely than

non-firearm owners to report experiencing thoughts of suicide,

and

first-time firearm purchasers were more likely to report suicidal ideation.

In 2021, potential further distress was experienced by many as a result of

social conflict and political violence.

Veteran distress increased from fall

2019 to fall and winter 2020, with evidence of the highest increases in

distress among Veterans aged 18- to- 44-years-old and among women

Veterans. These increases in reported distress were associated with

increasing socioeconomic concerns, greater problematic alcohol use and

decreased community integration.

During the COVID-19 pandemic, Veterans were found to experience more mental

health concerns than non-Veterans. A systematic review of 23 studies found increases in the prevalence rates of alcohol

use, anxiety, depression, posttraumatic stress disorder, stress, loneliness and suicidal ideation. The results of this

systematic review found key risk factors to include pandemic-related stress, family relationship strain, lack of social

support, financial concerns and preexisting mental health disorders.

Data from the 2021 Survey of Household Economics and Decisionmaking indicate that: 1) for both Veterans and non-Veteran U.S. adults,

financial hardships (e.g., lower income, greater debt, residence in economically challenged areas, lack of a rainy day fund) were associated with

poorer physical health, and 2) Veterans more commonly reported financial challenges involving credit card debt and overdraft fees. Personal

communication. 8/7/2023. E. Elbogen, VA National Veterans Financial Resource Center.

Elbogen EB, Lanier M, Blakey SM, Wagner HR, Tsai J. 2021. Suicidal Ideation and Thoughts of Self-Harm During the COVID-19 Pandemic: The Role of

COVID-19-Related Stress, Social Isolation, and Financial Strain. Depression Anxiety. 38:739-748.

Fischer IC, Na PJ, Harpaz-Rotem I, Krystal JH, Pietrzak RH. 2023. Characterization of Mental Health in US Veterans Before, During, and 2 Years After

the Onset of the COVID-19 Pandemic. JAMA Network Open. 6(2):e230463.

Monteith LL, Miller CN, Polzer E, Holliday R, Hoffmire CA, Iglesias CD, Schneider AL, Brenner LA, Simonetti JA. 2023. “Feel the need to prepare

for Armageddon even though I do not believe it will happen”: Women Veterans’ Firearm Beliefs and Behaviors During the COVID-19 Pandemic,

Associations with Military Sexual Assault and Posttraumatic Stress Disorder Symptoms. PLOS ONE. 18(2):e0280431. As noted by Monteith and

colleagues, “… it is unclear how women Veterans’ firearm beliefs and behaviors might have changed following 2020, nor whether the pandemic

itself or other relevant societal events (e.g., racial justice protests, political violence) were the predominant drivers of perceptions among any

individual participant.”

Miller M, Zhang W, Azrael D. 2022. Firearm Purchasing During the COVID-19 Pandemic: Results From the 2021 National Firearms Survey. Annals of

Internal Medicine. 175(2):219-225.

Also referred to as suicidal ideation.

Anestis MD, Bandel SL, Bond AE. 2021. The Association of Suicidal Ideation with Firearm Purchasing During a Firearm Purchasing Surge. JAMA

Network Open. 4(10):e2132111. doi: 10.1001/jamanetworkopen.2021.32111.

Of note, January 2021 included a single week with the most U.S. COVID-19 deaths of the entire pandemic (25,974 deaths in the week of 1/9/2021

https://covid.cdc.gov/covid-data-tracker/#trends_weeklydeaths_select_00); the invasion and looting of the U.S. Capitol by over 2,000 individuals;

impeachment of the former president for inciting insurrection; and the largest increase in the number of firearm purchases in the period from

1/1/2020-4/26/2021 (Miller M, Zhang W, Azrael D. 2022. Firearm Purchasing During the COVID-19 Pandemic: Results From the 2021 National

Firearms Survey. Annals of Internal Medicine. 175(2):149-304.) In summer 2021, the U.S. withdrawal from Afghanistan raised additional concerns

as a potential stressor for Veterans. In 2021, conflicting perspectives regarding pandemic responses, social justice, election integrity, and political

violence were in plain view.

Fischer IC, Na PJ, Harpaz-Rotem I, Krystal JH, Pietrzak RH. 2023. Characterization of Mental Health in US Veterans Before, During, and 2 Years After

the Onset of the COVID-19 Pandemic. JAMA Network Open. 6(2):e230463.

Li S, Huang S, Hu S, Lai J. Psychological Consequences Among Veterans During the COVID-19 Pandemic: A Scoping Review. Psychiatry Research.

2023 Jun;324:115229.

Heavily Impacted Groups in 2021

• Women Veterans

• American Indian or Alaska Native

Veterans

• VHA Veterans

• Homeless Veterans

• Justice-Involved Veterans

Simultaneously, VA was moving forward key suicide prevention initiatives in collaboration with other federal agencies,

Veterans Service Organizations (VSO), community partners, non-profit organizations, and others across the Nation

to address the rising needs outlined in 2021. These included the following: Veterans Crisis Line (VCL) 988 preparation;

Suicide Prevention 2.0 (SP 2.0) clinical telehealth expansion; SP 2.0’s Community-Based Intervention for Suicide

Prevention (CBI-SP) growth; Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program (SSG Fox SPGP) and

Mission Daybreak development; expansion of special population suicide prevention efforts; and firearm lethal means

safety (LMS) efforts (see Appendix A for a summary). Yet, more work remained for full implementation to occur in each of

the areas.

The context of 2021 challenges for the Nation, and for Veterans specifically, is critical to consider as we review highlights

of this year’s data and outline key courses of action moving forward. Veteran suicide deaths increased by 114 from 2020,

with 6,392 individual Veteran lives lost to suicide in 2021. It is also important to reflect on the subpopulations of Veterans

to identify the unique impacts and potential courses of action to address suicide prevention moving forward. From 2020

to 2021, suicide rates fell by 8.1% for Veteran men aged 75-years-old and older, which may reflect a Nation more fully

focused on connection and support for its more vulnerable individuals during the pandemic. Unfortunately, Veteran

suicide rates increased for other age groups. The increase in Veteran suicides seen in 2021, compared to 2020, was

particularly seen in women Veterans, for whom there was a 24.1% increase in the age-adjusted suicide rate, compared to

an increase of 6.3% among male Veterans. Similarly, when looking at race/ethnicity, we saw the largest increase in rate

among American Indian or Alaska Native Veterans. Among Veterans in VHA care, those with legal system involvement

were at increased risk of suicide-related behavior.

The suicide rate for recipients of VA Justice Program services was

10.2% higher in 2021 than in 2020. Additionally, in 2021, the unadjusted suicide rate among Recent Veteran VHA Users

with indications of homelessness was 38.2% higher than in 2020. Finally, 48.7% of all 6,392 Veterans who died by suicide

in 2021 had received either VHA or Veterans Benefits Administration (VBA) services in 2020 or 2021,

while 51.3%

had received neither VHA nor VBA services. This underscores the need to continue to reach outside of VA into local

communities and neighborhoods to connect with all Veterans as part of our national approach to end Veteran suicide.

Key Findings

• In 2021, suicide was the 13th-leading cause of death for Veterans overall, and the second-leading cause of death

among Veterans under age 45-years-old.

• There were 6,392 Veteran suicide deaths in 2021. This was 114 more than in 2020.

• In 2021, there were 6,042 suicide deaths among Veteran men and 350 suicide deaths among Veteran women.

• The unadjusted rate of suicide in 2021 among U.S. Veterans was 33.9 per 100,000, up from 32.6 per 100,000 in 2020.

• In 2021, unadjusted suicide rates were highest among Veterans between ages 18- and 34-years-old, followed by

those aged 35- to 54-years-old.

• In 2021, the unadjusted suicide rate was 46.3 per 100,000 for American Indian or Alaska Native Veterans; 36.3 per

100,000 for White Veterans; 31.6 per 100,000 for Asian, Native Hawaiian or Pacific Islander Veterans; 17.4 per 100,000

for Black or African American Veterans; and 6.7 per 100,000 for Veterans of multiple races.

• In 2021, the unadjusted suicide rate was 19.7 per 100,000 for Veterans with Hispanic ethnicity, and it was 33.4 per

100,000 for other Veterans.

Palframan KM, Blue-Howells, J, Clark SC, McCarthy JF. 2020. Veterans Justice Programs: Assessing Population Risks for Suicide Deaths and

Attempts. Suicide and Life-Threatening Behavior. 50(4):792-804.

Of the 6,392 Veterans who died from suicide in 2021, 38.1% received VHA services in 2020 or 2021 and 34.0% received VBA services in 2020 or 2021.

• Suicide was the fourth-leading cause of years of potential life lost (YPLL)

in 2019, prior to the COVID-19 pandemic;

in 2020 and 2021, suicide was the fifth-leading cause of YPLL.

• Among U.S. adults who died from suicide in 2021, firearms were more commonly involved among Veteran deaths

(72.2%) than among non-Veteran deaths (52.2%).

• Within the overall unadjusted suicide rate for Veterans in 2021 (33.9 per 100,000), its largest component was firearm

suicide mortality (24.5 per 100,000), followed by suffocation suicide mortality (5.0 per 100,000), poisoning suicide

mortality (2.7 per 100,000) and suicide involving other methods (1.8 per 100,000).

• Among Veterans, in each year, firearm suicide and suffocation suicide mortality rates were greater for men than for

women, while the poisoning suicide mortality rate was lower for men than for women.

• Among U.S. adult men and women, rates of firearm and of poisoning suicide mortality were greater for Veterans

than for non-Veterans, and differentials in rates by Veteran status were particularly high among women (e.g., the

firearm suicide rate among Veteran women was 281.1% higher than that of non-Veteran women, while the firearm

suicide rate among Veteran men was 62.4% higher than for non-Veteran men).

• Consistent with higher-complexity medical and psychosocial needs among Veterans who seek VHA care, rates in

2021 were higher among Recent Veteran VHA Users than for Other Veterans for all-cause mortality and for leading

causes of death, including heart disease, cancer, COVID-19, unintentional injury, and suicide.

• Age- and sex-adjusted suicide rates were higher among Recent Veteran VHA Users than for Other Veterans. In

comparison with Veterans not receiving VHA care, Veterans receiving VHA care have a higher risk with being more

likely to have lower annual incomes; poorer self-reported health status;

more chronic medical conditions

and

self-reported disability due to physical or mental health factors;

greater depression and anxiety;

and greater

reporting of trauma, lifetime psychopathology and current suicidality.

These differences may help to explain the

greater suicide rates among Recent Veteran VHA Users compared to Other Veterans.

• However, Recent Veteran VHA Users rates grew more slowly across 20 years when compared to rates of Veterans

without Recent VHA use. From 2001 to 2021, age-adjusted suicide rates rose 24.5% for male Veterans with Recent

VHA use and 62.6% for male Veterans without Recent VHA use. Age-adjusted suicide rates rose 87.1% for female

Veterans with recent VHA use and 93.7% for female Veterans without Recent VHA use.

• Among Recent Veteran VHA Users experiencing homelessness, the suicide rate in 2021 (112.9 per 100,000) was the

highest observed over the period 2001–2021, after increasing 38.2% since 2020.

• The suicide rate in 2021 among Recent Veteran VHA Users who received Justice Program services was also the

highest over this period (151.0 per 100,000) after a 10.2% increase since 2020.

Years of potential life lost is a measure of premature death which expresses the number of years that would have been lived if premature death

had not occurred. It is calculated as the difference between age at death and 75 (approximate life expectancy). If individuals live to or beyond age

75, YPLL is equal to 0. See: CDC. 1986. Premature Mortality in the United States: Public Health Issues in the Use of Years of Potential Life Lost. MMWR,

12/19/1986, 35(2S):1s-11s. https://www.cdc.gov/mmwr/preview/mmwrhtml/00001773.htm (Accessed 7/4/2023).

Agha Z, Lofgren RP, VanRuiswyk JV, Layde PM. 2000. Are Patients at Veterans Affairs Medical Centers Sicker? A Comparative Analysis of Health

Status and Medical Resource Use. Arch Intern Med. 160:3252-3257.

Dursa EK, Barth SK, Bossarte RM, Schneiderman AI. 2016. Demographic, Military, and Health Characteristics of VA Health Care Users and Nonusers

Who Served in or During Operation Enduring Freedom or Operation Iraqi Freedom, 2009–2011. Public Health Reports. 131(6):839-843.

Nelson KM, Starkebaum GA, Reiber GE. 2007. Veterans Using and Uninsured Veterans Not Using Veterans Affairs (VA)

Health Care. Public Health Rep. 122:934-100.

Fink DS, Stohl M, Mannes ZL, Shmulewitz D, Wall M, Gutkind S, Olfson M, Gradus J, Keyhani S, Maynard C, Keyes KM, Sherman S, Martins S, Saxon

AJ, Hasin DS. 2022. Comparing Mental and Physical Health of U.S. Veterans by VA Healthcare Use: Implications for Generalizability of Research in the

VA Electronic Health Records. BMC Health Services Research. 22:1500 https://doi.org/10.1186/s12913-022-08899-y

Meffert BN, Morabito DM, Sawicki DA, Hausman C, Southwick SM, Pietrzak RH, Heinz AJ. 2019. U.S. Veterans Who Do and Do Not Utilize VA Health

Care Services: Demographic, Military, Medical, and Psychosocial Characteristics. Primary Care Companion CNS Disorders. 21(1):doi:10.4088/

PCC.18m02350.

• Among VHA-enrolled Recent Veteran VHA Users in 2021, the suicide rate was highest for those in Priority Eligibility

Group 5, which includes income-based eligibility (57.1 per 100,000).

• In 2020 and 2021, suicide rates were highest for Veterans who received any Community Care services, followed by

Veterans who received any VHA direct care, and suicide rates were lowest among Veterans who did not receive

either Community Care or VHA direct care.

• In 2020 and 2021, suicide rates were greater among Veterans who received VA Community Care services and did not

receive VHA direct care services than among Veterans who received VHA direct care services and did not receive VA

Community Care services.

• Overall, 48.7% of Veterans who died from suicide in 2021 had received VHA or VBA services in 2020 or 2021, while

51.3% of Veterans in 2021 did not.

• For the overall Veteran population in 2021, 47.2% received some VHA or VBA services in 2020 or 2021, while 52.8% of

the overall Veteran population in 2021 did not.

• In 2021, suicide rates were highest among Veterans who only received VHA services, followed by those who

received both VHA and VBA services, then those who received neither VHA nor VBA services. Suicide rates were

lowest among Veterans who received VBA services and did not receive VHA services.

• Among Recent Veteran VHA Users whose suicide deaths occurred in 2019–2021 and were reported to VHA Suicide

Prevention teams, VA Behavioral Health Autopsy Program data indicated that the most frequently identified risk

factors were: pain (55.9%), sleep problems (51.7%), increased health problems (40.7%), relationship problems (33.7%),

recent declines in physical ability (33.0%), hopelessness (30.6%) and unsecured firearms in the home (28.8%).

Need for a Whole-of-Nation Public Health Approach to Veteran Suicide Prevention:

Themes for Action

The significant and unprecedented challenges this country faced in 2021 fuel this report’s continued call to action related

to a whole-of-government and whole-of-Nation approach to suicide prevention. Suicide is a complex problem requiring

a full public health approach involving community prevention and clinical intervention. VA services are a critical part

of this public health approach, as the data from this report highlights. The data across 20 years reveals that Veterans

engaged in VHA care have shown a less sharp rise in suicide rates, underscoring the importance of VHA care. Over 20

years of Veteran suicide data also reveal a substantial reduction in suicide rates, specifically for Recent Veteran VHA Users

with mental health or substance use disorder diagnoses (77.8 per 100,000 in 2001 to 58.2 per 100,000 in 2021), falling

32.9% for Veterans with depression, 27.6% for those with posttraumatic stress disorder, 26.9% for those with anxiety and

40.4% for those with sedative use disorder. Comparing Veterans with Recent VHA use to other Veterans, we also find

notable trends. While overall rates of Veteran suicide rose across the 20 years, age-adjusted suicide rates rose 24.5% for

male Veterans with Recent VHA use compared to 62.6% for male Veterans without Recent VHA use. While less notable

for women Veterans, the age-adjusted suicide rates rose 87.1% for female Veterans with Recent VHA use and 93.7% for

female Veterans without Recent VHA use. Likewise, when looking more specifically across 2020 and 2021, we find the

greatest increase in unadjusted rates for Veterans who were neither engaged with VHA nor with VBA. From 2020 to

2021, there were also notable decreases for particular subpopulations of Veterans with Recent VHA use, including those

between ages 55- and 74-years-old (overall suicide rate -2.2%, -0.6% for men, -24.9% for women), males between ages

18- and 34-years-old (overall suicide rate -1.9%) and males aged 75-years-old and older (overall suicide rate -8.6%). These

findings underscore the importance of continuing to expand access to and engagement of Veterans in VHA and VBA

services, as over 50% of Veterans who died by suicide in 2021 had not been engaged in either service.

Yet, in order to address the complex interweaving of individual, relational, community and societal risks, VA must

continue to fully engage with other federal agencies; public-private partnerships; government at the local, state and

As noted above, Veterans receiving VHA care show evidence of higher risk with being more likely to have lower annual incomes, poorer self-

reported health status, more chronic medical conditions, and self-reported disability due to physical or mental health factors, greater depression

and anxiety, and greater reporting of trauma, lifetime psychopathology, and current suicidality.

national levels; VSOs; and local communities to reach all Veterans to support the implementation of a full public health

approach, as outlined in the White House Strategy Reducing Military and Veteran Suicide (2021)

and VA’s National

Strategy for Preventing Veteran Suicide (2018).

These guiding documents have been operationalized through SP 2.0;

Suicide Prevention Now initiative (SP Now); new laws, including the 2020 Commander John Scott Hannon Veterans Mental

Health Care Improvement Act; the Veterans Comprehensive Prevention, Access to Care and Treatment Act (COMPACT)

of 2020; the National Suicide Hotline Designation Act of 2020; and emerging innovations combined with research and

program evaluation. As 2021 has again shown, this public health approach must include both community-based prevention

and clinical interventions to reduce suicide in the Veteran population. As we reflect on the core of what we learned about

Veteran suicide in 2021, 7 themes emerge for our call to action (see summary listing and description below).

While no one solution can address the complexity of all factors involved in suicide, the data clearly outlines that significant

reductions in Veteran suicide will not occur without meaningful focused effort to address Veteran firearm suicide. While

we vigorously pursue enhanced policies, research, and programs to effectively address the broader socioecological and

individual risk and protective factors which speak to “why” a Veteran may consider suicide, we must address directly the

“how” of Veteran suicide. It is inescapable that the “how” in 72% of Veteran suicide deaths is firearm compared to 52% of

non-Veteran U.S. adult suicides. We therefore begin our call to action with a focus on secure firearm storage.

1. Promote secure firearm storage for Veteran suicide prevention. Firearm ownership and storage practices vary

among Veterans.

One in 3 Veteran firearm owners store at least 1 firearm unlocked and loaded. This unsafe storage

practice is more frequent among Veteran firearm owners who seek VHA care (38.0%) than among other Veterans

who own firearms (31.9%).

As seen across years of Veteran suicide data, Veteran suicide deaths disproportionately

involve firearms; Veteran suicide rates exceed those of non-Veterans; and differentials in suicide rates by Veteran

status are greater for women than for men. Promoting secure storage of firearms has been found to reduce suicide

— this is not about taking away firearms but about promoting time and space during a time of crisis.

2. Implement and sustain community collaborations focused upon community-specific Veteran suicide

prevention plans. Over 60% of Veterans who died by suicide in 2021 were not seen in VHA in 2020 or 2021, and

over 50% had received neither VHA nor VBA services. In order to reach all Veterans, we must continue to expand

our work in the community through the SP 2.0 Community Based Intervention (CBI) Program. This includes the joint

VA and Substance Abuse and Mental Health Services Administration (SAMHSA) Governor’s Challenge to Prevent

Suicide Among Service members, Veterans, and their Families, which encompasses all 50 states, 5 territories and

work in over 1,700 local community coalitions. This also includes the SSG Fox SPGP awarding $52.5 million to 80

community-based organizations in 43 states, the District of Columbia and American Samoa in fiscal year (FY) 2023.

White House: Reducing Military and Veteran Suicide: Advancing a Comprehensive, Cross-Sector, Evidence-Informed Public Health Strategy. 2021.

https://www.whitehouse.gov/wp-content/uploads/2021/11/Military-and-Veteran-Suicide-Prevention-Strategy.pdf

Department of Veterans Affairs (2018). National Strategy for Preventing Veteran Suicide.

https://www.mentalhealth.va.gov/suicide_prevention/docs/Office-of-Mental-Health-and-Suicide-Prevention-National-Strategy-for-Preventing-

Veterans-Suicide.pdf

Combining reports from Azrael et al., 2017, and Cleveland et al., 2017, and VetPop estimates of the 2015 populations of Veteran men and women,

we estimate that in 2015 household firearm ownership among Veteran men was 62.3% higher than for non-Veteran men, and household firearm

ownership among Veteran women was 106.6% higher than for non-Veteran women.

Simonetti JA, Azrael D, Rowhani-Rahbar A, Miller M. 2018. Firearm Storage Practices Among American Veterans. American Journal of Preventative

Medicine. 55(4):445-454.

Mann JJ, Michel CA, Auerbach RP. 2021. Improving Suicide Prevention Through Evidence-Based Strategies: A Systematic Review. American Journal

of Psychiatry. 178(7):611-624.

3. Continue expansion of readily accessible crisis

intervention services. The Nation saw a reduction of

access to mental health services initially during the

COVID-19 pandemic.

38,39

Veterans desired access that was

not in-person and available whenever they needed it

and VHA care rapidly expanded remote care services

delivery.

Continued expansion of access to 24/7/365

services through the VCL 988 expansion and through

COMPACT Act implementation paved the way for more

emergency services for Veterans in acute suicidal crisis to

be provided at no cost, whether enrolled in VA or not.

4. Improve tailoring of prevention and intervention

services to the needs, issues, and resources unique

to Veteran subpopulations. Creating culturally

sensitive and responsive interventions to meet each

population’s needs will be required to address what 2021

revealed to us, with growing rates in American Indian/

Alaska Native Veteran populations, younger Veterans,

transitioning Service member populations, women

Veterans and more, as seen in the data for 2021.A

one-size-fits-all Veteran suicide prevention strategy will

not be effective in meeting the needs of the diverse

population of Veterans.

5. Advance suicide prevention meaningfully into

non-clinical support and intervention services,

including financial, occupational, legal, and social

domains. Suicide risk factors include issues outside

of mental health and require meaningful upstream

interventions across the Nation, as denoted in the White

House Strategy Reducing Military and Veteran Suicide

(2021).

Impacts related to homelessness and legal issues

were seen for Veterans in 2021, as outlined above. A

whole-of-Nation approach for upstream interventions in

employment, housing, legal support, and financial strain

is needed to address Veteran suicide prevention.

Zhang J, Boden M, Trafton J. 2022. Mental Health Treatment and the Role of Tele-Mental Health at the Veterans Health Administration During the

COVID-19 Pandemic.Psychological Services. 19(2):375-385.https://doi.org/10.1037/ser0000530

Behavioral Health: Patient Access, Provider Claims Payment, and the Effects of the COVID-19 Pandemic. GAO-21-437R. Mar 31, 2021.

Goetter EM, Iaccarino MA, Tanev KS, Furbish KE, Xu B, Faust KA. 2022. Telemental Health Uptake in an Outpatient Clinic for Veterans During the

COVID-19 Pandemic and Assessment of Patient and Provider Attitudes.Professional Psychology: Research and Practice. 53(2):151-159.https://doi.

org/10.1037/pro0000437

Cornwell B, Szymanski BR, McCarthy JF. 2021. Impact of the COVID-19 Pandemic on Primary Care-Mental Health Integration Services in the VA

Health System. Psychiatric Services. 72(8):972-973.

The calls for action encompass work that has been ongoing since 2021 and needs for ongoing development. Thus, COMPACT and 988 are included

here, both of which had work underway in 2021.

White House: Reducing Military and Veteran Suicide: Advancing a Comprehensive, Cross-Sector, Evidence- informed Public Health Strategy. 2021.

https://www.whitehouse.gov/wp-content/uploads/2021/11/Military-and-Veteran-Suicide-Prevention-Strategy.pdf

Call to Action: 7 Themes

Promote rearm secure storage for

Veteran suicide prevention.

Implement and sustain community

collaborations focused upon community-specic

Veteran suicide prevention plans.

Continue expansion of readily accessible

crisis intervention services.

Improve tailoring of prevention and intervention

services to the needs, issues, and resources

unique to Veteran subpopulations.

Advance suicide prevention meaningfully into

non-clinical support and intervention services,

including nancial, occupational, legal,

and social domains.

Increase access to and utilization of mental

health across a full continuum of care.

Integrate suicide prevention within medical

settings to reach all Veterans.

6. Increase access to and utilization of mental health services across a full continuum of care. The COVID-19

pandemic saw increased distress in the Veteran population

with initial decreases in utilization of mental health

services, while telemental health services expanded. During the pandemic, weekly patient encounters at VHA

decreased by 3% for ongoing suicide attempt care, while new treatment initiation for suicide attempts decreased

30%.

Making access as easy as possible to a continuum of evidence-based mental health treatments is an

important part of the public health approach to suicide prevention.

7. Integrate suicide prevention within medical settings to reach all Veterans. Our data again showed that a

significant percentage of VHA Veterans who died by suicide did not have a VHA mental health or substance use

disorder diagnosis. We need to creatively address the needs of those at risk who may never seek mental health

services and who may have other risk factors outside of mental health (e.g., pain, cancer, sleep disturbance) through

expansion of suicide screening, assessment, and safety planning into all medical settings, within VHA and within

community care.

Organization of Report

This year’s report is organized in alignment with the call to action, as Veteran suicide prevention will take all of us.

After an initial summary of key findings, the report is organized into two overarching sections:

1) The overall Veteran population; and

2) Veterans with Recent VHA or VBA engagement.

Specifically, the data is broken out in the following manner to assist ongoing efforts, together with you, to

reduce Veteran suicide:

• Suicide among Veterans, overall and compared to non-Veteran U.S. adults, including patterns of Veteran mortality,

including the initial 2 calendar years of the COVID-19 pandemic.

• Suicide among Veteran subpopulations, including:

• By VHA engagement, including:

- Veterans who received VHA health care

in the year or prior year, who in this report are described as

“Recent Veteran VHA Users.”

- Veterans who were not Recent Veteran VHA Users, who in this report are described as “Other Veterans.”

• By VBA engagement

- Overall and by receipt of categories of VBA benefits.

After each of these sections, the report will reflect on relevant research that has served to inform next steps, where VA

is moving next steps forward, and specific actions that VA and each of us across the Nation can take to join together in

Veteran suicide prevention. The detailed analyses of suicide mortality over time and across Veteran subgroups can help

us together to advance suicide prevention initiatives across both the individual and societal levels.

Fischer IC, Na PJ, Harpaz-Rotem I, Krystal JH, Pietrzak RH. 2023. Characterization of Mental Health in US Veterans Before, During, and 2 Years After

the Onset of the COVID-19 Pandemic. JAMA Network Open. 6(2):e230463.

Zhang J, Boden M, Trafton J. 2022. Mental Health Treatment and the Role of Tele-Mental Health at the Veterans Health Administration During the

COVID-19 Pandemic. Psychological Services. 19(2):375-385.

VHA health care receipt is here defined as having at least 1 VHA inpatient or outpatient utilization record.

Part 1: Suicide Among Veterans, 2001–2021

Suicide Deaths

• In 2021, there were 46,412 suicides among U.S. adults. These included 6,392 suicides among Veterans

(114 more

than in 2020) and 40,020 among non-Veterans (2,000 more than in 2020).

• Among Veterans, non-Veteran adults, and U.S. adults overall, the number and rate of suicide deaths increased from

2020 to 2021 (Figure 1 and Figure 3).

Figure 1: Suicide Deaths Among Veterans and Non-Veteran U.S. Adults, by Year, 2001–2021

For this report, Veterans were defined as persons who had been activated for federal military service and were not currently serving at the time of

death. For more information see the accompanying 2023 National Veteran Suicide Prevention Annual Report Methods Summary.

Veterans Non-Veteran Adults

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

45,000

40,000

35,000

30,000

25,000

20,000

15,000

10,000

5,000

2020 2021

6,000

6,392

23,580

40,020

Number of Suicides

Figure 2 details variation in the number of Veteran suicides, by year from 2001 to 2021.

Figure 2: Veteran Suicide Deaths, 2001–2021

Average Number of Suicides Per Day

• In 2021, there were on average 127.2 suicides per day among U.S. adults, including 17.5 per day among Veterans and

109.6 per day among non-Veteran adults.

• Among all U.S. adults, including Veterans, the average number of suicides per day rose from 81.0 per day in 2001 to

127.2 in 2021. The average number per day among U.S. adults was highest in 2018 (127.4 per day).

• The average number of Veteran suicides per day rose from 16.4 in 2001 to 17.5 in 2021. For U.S. adults, the average

number of suicides per day was highest in 2018 for Veterans (18.4 per day). Of the on-average 17.5 Veteran suicides

per day in 2021, approximately 38.1% (6.7 per day) were among Recent Veteran VHA Users

and 61.9% (10.8 per day)

were among Other Veterans.

Decreases in the size of the Veteran population and increases in the size of the U.S. population over this period limit interpretation of these

statistics. Rates of suicide, stratified by group, are the appropriate for understanding changes in Veteran and non-Veteran populations. These are

included elsewhere in this report and in the accompanying data appendix.

Consistent with prior reports, Recent Veteran VHA Users were defined as Veterans who received inpatient or outpatient care health care (in person

or via telehealth) at a VHA facility in the year of interest or the prior year (here, 2021 or 2020). Health care received from non-VHA facilities, including

such care that was funded by VA (i.e., community care) was not included.

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

7,000

6,800

6,600

6,400

6,200

6,000

5,800

5,600

2020 2021

6,000

6,142

6,008 6,004

6,035

6,126

6,249

6,567 6,545

6,519

6,447

6,441

6,501

6,645

6,467

6,481

6,616

6,686

6,392

6,278

6,718

Number of Suicides

Suicide Rates

From 2001 to 2021, the Veteran population decreased by 27.0%, from 25.8 million to 18.8 million. During this same

timeframe, the non-Veteran U.S. adult population increased by 28.4%, from 186.5 million to 239.5 million. In this context, it is

important to assess suicide mortality rates, which convey the incidence of suicide relative to the size of the population.

Unadjusted suicide rates represent the number of suicide deaths relative to the population’s time at risk of being

observed with a suicide death.

Rates are reported as suicides per 100,000.

Direct adjusted rates are used for

comparisons while adjusting for population differences, such as age and sex distributions.

To describe the burden of

suicide in a given population and period, we use unadjusted rates. To compare rates across populations or periods, we

use direct adjusted rates.

• The unadjusted suicide rate for Veterans was 23.3 per 100,000 in 2001 and 33.9 per 100,000 in 2021. For non-Veteran

U.S. adults, the suicide rate was 12.6 per 100,000 in 2001 and 16.7 per 100,000 in 2021.

• In 2021, Veterans between ages 18- and 34-years old had an unadjusted suicide rate of 49.6 per 100,000, while the

rate was 35.5 per 100,000 for those between ages 35- and 54-years old; 29.9 per 100,000 for those between ages 55-

and 74-years old; and 32.1 per 100,000 for those aged 75-years-old and older.

• In 2021, the unadjusted suicide rate of Veteran men was 35.9 per 100,000 (3.5% higher than in 2020) and it was 17.5

per 100,000 for Veteran women (23.7% higher than in 2020).

• Age- and sex-adjusted suicide rates from 2001 to 2021 are presented in Figure 3 for Veterans and non-Veteran U.S.

adults, by year. The difference in age- and sex-adjusted rates was greatest in 2021, when the age- and sex-adjusted

rate for Veterans was 71.8% greater than that of non-Veteran adults.

• Bivariate comparisons indicated that Veteran age- and sex-adjusted suicide rates were significantly greater in 2021

than in 2019 or 2020.

Risk time is measured using mid-year population estimates when individuals’ exact risk times were unavailable. It was calculated exactly for

analyses of subgroups of Veterans with recent VHA care.

For the Veteran population, risk time was assessed using the mid-year population estimate, as detailed in the accompanying methods summary.

When risk time was assessed per individual level risk-time information, we included “per 100,000 person-years.”

Unadjusted rates communicate the magnitude of suicide mortality in a given population in a time period. Suicide risks differ across age and sex

categories. Consequently, if groups differ in these characteristics, then that variation may account for some of the differences in unadjusted rates.

Adjusted rates translate the unadjusted rate for a population into a measure of what the rate would be if the compared populations had the same

distributions of the demographic factors that are adjusted for. Per standard practice, adjusted rates are calibrated to the demographic distribution

of the U.S. adult population in 2000. Calculating adjusted rates (e.g., age-adjusted or age- and sex-adjusted rates) enhances rate comparisons by

adjusting for population demographic differences. Notably, the Veteran and non-Veteran adult populations differ by age and sex, with Veterans

being on average older and more male.

The interpretation of adjusted rates is somewhat technical. They represent the level of suicide mortality that we would see in the population and

time period if the population had the same demographic distribution of a standard population, at least in terms of the adjustment variable(s).

Consistent with current practice, in this report adjusted rates use the U.S. adult population in 2000 as the standard population. Unadjusted rates

are presented when adjustment was not possible due to small numbers within strata. Use of the direct method and the standard U.S. population of

2000 for adjustment are consistent with CDC reporting (Garnet MF, Curtin SC. 2023. Suicide Mortality in the United States, 2001–2021. CDC NCHS,

Data Brief 464. Klein RJ, Schoenborn CA. Age Adjustment Using the 2000 Projected U.S. population. Healthy People 2000 Statistical Notes, no. 20.

Hyattsville, Maryland: NCHS. January 2001).

Figure 3: Age- and Sex-Adjusted Suicide Rate, Veterans and Non-Veteran U.S. Adults, 2001–2021

Suicide Rates, by Sex

• Figure 4 presents age-adjusted suicide rates for Veteran men and for Veteran women, by year, 2001–2021. For

Veteran men and Veteran women, rates were highest in 2021.

• From 2020 to 2021, the age-adjusted suicide rate increased 6.3% among Veteran men and 24.1% among Veteran

women. From 2020 to 2021, the age-adjusted suicide rate increased 4.9% among non-Veteran men and 2.6% among

non-Veteran women.

• In 2021, the age-adjusted suicide rate of Veteran men was 43.4% greater than that of non-Veteran U.S. adult

men, and the age-adjusted suicide rate of Veteran women was 166.1% higher than that of non-Veteran U.S.

adult women.

For men and for women, differentials in adjusted rates by Veteran status were highest in 2021.

Veterans Non-Veteran Adults

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

2020 2021

Age- and Sex-Adjusted Rate per 100,000

Figure 4: Age-Adjusted Suicide Rate, Male and Female Veterans, 2001–2021

Suicide Rates, by Age

Figure 5 presents unadjusted suicide rates for Veterans, by age categories and year, 2001–2021.

From 2020 to 2021, the suicide rate among Veterans aged 18- to 34-years-old increased by 7.1%; the rate for Veterans

aged 35- to 54-years-old rose by 10.7%; the rate for Veterans aged 55- to 74-years old rose by 7.4%; and for Veterans aged

75-years-old and older, the suicide rate fell by 8.0%.

Figure 5: Unadjusted Suicide Rate, Veterans, by Age Group, 2001–2021

Male Veterans Female Veterans

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

2020 2021

Age-Adjusted Rate per 100,000

18-34 35-54 55-74 75+

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

2020 2021

Rate per 100,000

Suicide Rates, by Sex and Age

Figures 6 and 7 present suicide rates

for Veteran men and women, by age categories and year, 2001–2021.

• In 2021, suicide rates were highest among Veterans between ages 18- and 34-years-old (55.4 per 100,000 among

Veteran men aged 18- to 34-years-old, and 24.8 per 100,000 among Veteran women aged 18- to 34-years-old).

• Suicide rates among male Veterans aged 75-years-old and older decreased by 8.1% from 2020 to 2021, while rates

for all other groups increased.

Figure 6: Unadjusted Suicide Rate, Male Veterans, by Age Group, 2001–2021

Figure 7: Unadjusted Suicide Rate, Female Veterans, by Age Group,

2001–2021

As rates are specific to age- and sex-subgroups, adjustment was not applicable.

Due to the small number of deaths among older age groups of female Veterans, the 55- to 74-years-old and 75-years-old and older age groups are

combined, for reporting purposes.

18-34 35-54 55-74 75+

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

2020 2021

Rate per 100,000

18-34 35-54 55+

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

2020 2021

Rate per 100,000

Suicide Rates, by Race and Ethnicity

Figure 8 presents unadjusted Veteran suicide rates, by race.

• In 2021, the suicide rate was 36.3 per 100,000 for White Veterans; 31.6 per 100,000 for Asian, Native Hawaiian or

Pacific Islander Veterans; 46.3 per 100,000 for American Indian or Alaska Native Veterans; 17.4 per 100,000 for Black

or African American Veterans; and 6.7 per 100,000 for Veterans of multiple races.

• In 2021, the highest suicide rate was among American Indian or Alaska Native Veterans and the lowest rate was

among Veterans of multiple races.

• Among the U.S. adult general population in 2021, which includes Veteran and non-Veteran adults and uses more

detailed race categories, unadjusted suicide rates were also highest among those who were American Indian or

Alaska Native, followed by those who were White, Native Hawaiian or other Pacific Islander, multiple races, Black or

African American and Asian.

Figure 8: Unadjusted Suicide Rate, Veterans, by Race,

2001–2021

It was not possible to generate adjusted rates, due to data constraints. Consequently, differences in rates may in part be due to population

differences in demographic factors that are independently associated with suicide risk.

Note that the U.S. adult population includes both Veteran and non-Veteran U.S. adults. Suicide rates for adults in the U.S. general population are

derived from CDC WONDER. For more information on CDC WONDER, see: https://wonder.cdc.gov/ucd-icd10-expanded.html. Unadjusted suicide

rates among U.S. adults in 2021 were as follows: American Indian or Alaska Native: 21.7 per 100,000; White: 20.1 per 100,000; Native Hawaiian or

other Pacific Islander: 14.0 per 100,000; multiple races: 12.0 per 100,000; Black or African American: 10.6 per 100,000; and Asian: 8.3 per 100,000.

Categories presented are mutually exclusive. The availability of information regarding race demographics for the overall Veteran population

is limited, sometimes combining the Asian, Native Hawaiian, and Pacific Islander race categories. To provide the most complete information

available, we present information using this combined category. The percentage of Veteran suicide deaths missing race information was 7.8% in

2001, 7.7% in 2002, 7.7% in 2003, 8.0% in 2004, 7.5% in 2005, 6.9% in 2006, 7.4% in 2007, 11.0% in 2008, 13.7% in 2009, 2.9% in 2010, 2.3% in 2011,

2.5% in 2012, 2.6% in 2013, 3.0% in 2014, 2.7% in 2015, 2.9% in 2016, 2.5% in 2017, 2.8% in 2018, 3.4% in 2019, 4.7% in 2020 and 4.2% in 2021.

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

2020 2021

Rate per 100,000

White

Black or African

American

American Indian

or Alaska Native

Asian, Native Hawaiian,

or Pacific Islander

Multiple Race

Figure 9 presents unadjusted suicide rates for Veterans, by Hispanic ethnicity.

• From 2020 to 2021, suicide rates increased 0.5% for Hispanic Veterans and 4.7% for non-Hispanic Veterans. By

comparison, in the U.S. adult general population, suicide rates increased by 6.1% among individuals with Hispanic

ethnicity and by 3.7% among other adults.

Figure 9: Unadjusted Suicide Rate, Veterans, by Hispanic Ethnicity, 2001–2021

It was not possible to generate adjusted rates, due to data constraints. Consequently, differences in rates may in part be due to population

differences in demographic factors that are independently associated with suicide risk.

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

2020 2021

Rate per 100,000

Hispanic Non-Hispanic

13.3

19.7

20.4

33.4

Suicide Rates in Year Following Military Separation

Figure 10 presents the unadjusted suicide rate per 100,000 over 12 months following Veterans’ separation from active

military service, by year of separation, 2010–2020.

61,62

Suicide rates in the 12 months following separations ranged from 34.8 per 100,000, for Veterans who separated in 2010,

to 48.9 per 100,000, for Veterans who separated in 2019.

Figure 10: Unadjusted Suicide Rate, 12 Months Following Separation from Active Military Service, by Year

of Separation, 2010–2020

Twelve-month suicide mortality rates are reported for cohorts of Veterans who separated from military service in the years 2010 through 2020.

Separations were identified using VA/Department of Defense Identity Repository (VADIR) data. Reporting is not included for years prior to 2010

due to data constraints. Given small cell sizes, it was not possible to calculate adjusted rates. The 12-month observation period for the most recent

cohort (separations in calendar year 2020) extended into 2021, using the most current available mortality data. Review of 95% confidence intervals

(not shown) indicated that these were overlapping for each year, indicating no statistical differences in rates over this period.

In 2010, there were 226,928 Veterans with most recent separations from active military service, and there were 195,385 in 2020. For Veterans who

separated in 2010, 16.8% were female and the median age at separation was 26. For those who separated in 2020, 17.4% were female and the

median age at separation was 27. There were 79 and 93 Veteran suicides within 12 months of military separations in 2010 and 2020, respectively.

2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

2020

Rate per 100,000 Person-Years

Year of Separation

34.8

42.8

39.4

42.1

41.7

35.6

35.8

46.7

48.1

48.9

47.6

Figure 11 presents unadjusted suicide rates in the 12 months following separation, by year of separation and service branch.

For the most recent separation cohort, who separated from active military service in 2020, suicide rates over the

following 12 months were highest among those who separated from the Marines Corps (80.9 per 100,000), followed by

the Navy (50.1 per 100,000) and Army (46.1 per 100,000).

Figure 11: Unadjusted Suicide Rate, 12 Months Following Separation from Active Military Service, by

Branch of Service and Year of Separation, 2010–2020

Not presented for Veterans who separated from the Air Force in 2020, as there were fewer than 10 suicide deaths.

Rates are suppressed if there were fewer than 10 suicide deaths, with dotted lines connecting non-suppressed data points. The dotted lines

represent suppressed rates and should not be interpreted as estimated rates.

2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

2020

Rate per 100,000

Year of Separation

Army Air Force Navy Marines

Method-Specific Suicide Rates

Figure 12 presents method-specific

suicide rates among Veterans, by year, 2001–2021, and the percentage change in

rates from 2001 to 2021.

• In each year, Veteran firearm suicide rates exceeded those of all other categories.

• Changes in Veteran method-specific suicide rates are listed below:

2001 to 2021 2019 to 2020 2020 to 2021

Firearm suicide rate +58.3% +1.4% +5.5%

Poisoning suicide rate (-13.4%) +0.4% (-1.1%)

Suocation suicide rate +55.6% (-10.8%) +5.0%

Other methods suicide rate +18.2% +6.3% (-5.9%)

Figure 12: Unadjusted Method-Specific Suicide Rate, Veterans, 2001–2021, and Change from 2001 to 2021

Similar to patterns for Veterans, among non-Veteran U.S. adults firearm suicide mortality rates exceeded all other

method-specific suicide rates in each year.

For non-Veteran U.S. adults, there was also a decrease from 2001 to 2021 in

poisoning suicide mortality rates (-11.2%) and increases in rates of firearm suicide mortality (+30.9%), suffocation suicide

mortality (+70.7%) and suicide involving other methods (+39.8%).

Methods were assessed from death certificate data per ICD-10 codes X72-X74 for firearm, X60-X69 for poisoning (including intentional overdose)

and X70 for suffocation (including strangulation). “Other Means” (U03, X71, X75-X84, Y87.0) included cutting/ piercing, drowning, falls, fire/flame,

other land transport, being struck by/against and other specified or unspecified injury.

Results not shown.

Firearm suicide mortality accounted for a larger portion of the overall Veteran suicide rate in 2001 and 2021 (66.5% and 72.2%, respectively) than

for non-Veterans (52.7% and 52.2%, respectively).

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

2020 2021

Rate per 100,000

+58.3

-13.4

+55.6

+18.2

Percentage Change,

2001 to 2021

Firearm Poisoning Suffocation Other

Figures 13 and 14 show method-specific suicide rates for male Veterans and female Veterans, respectively.

Figure 13: Unadjusted Method-Specific Suicide Rate, Male Veterans, 2001–2021, and Change from 2001 to 2021

Figure 14: Unadjusted Method-Specific Suicide Rate, Female Veterans, 2001–2021, and Change from 2001

to 2021

Rates are suppressed for female Veterans, Other Means, for 2002 and 2013. Dashed lines are for presentation purposes and do not represent

estimated rates.

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

2020 2021

Rate per 100,000

+61.8

-17.6

+54.0

+21.7

Percentage Change,

2001 to 2021

Firearm Poisoning Suffocation Other

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

2020 2021

Rate per 100,000

+157.7

+249.5

+2.2

-8.6

Percentage Change,

2001 to 2021

Firearm Poisoning Suffocation Other

Method-Specific Suicide Rates, by Veteran Status and Sex

Here we compare method-specific rates of Veteran men and women, and we compare rates of non-Veteran men and

women.

As indicated below, method-specific suicide rates varied by sex for Veterans and non-Veterans. The magnitude

of this variation differed by Veteran status.

• Among Veterans, in each year, firearm suicide and suffocation suicide mortality rates were higher for men than for

women, while poisoning suicide mortality rates were lower for men than for women. In 2021:

• Firearm suicide rate: 190.1% higher for Veteran men than for Veteran women

• Suffocation suicide rate: 50.9% higher for Veteran men than for Veteran women

• Poisoning suicide rate: 40.4% lower for Veteran men than for Veteran women

• Among non-Veteran U.S. adults, in each year, all method-specific suicide rates were greater for men than for

women. In 2021:

• Firearm suicide rate: 580.7% higher for non-Veteran men than for non-Veteran women

• Suffocation suicide rate: 313.0% higher for non-Veteran men than for non-Veteran women

• Poisoning suicide rate: 9.6% higher for non-Veteran men than for non-Veteran women

• Poisoning suicide mortality rates were lower for Veteran men than for Veteran women, and they were higher for

non-Veteran men than for non-Veteran women.

Method-Specific Suicide Rates, by Sex and Veteran status

Here we compare method-specific rates of male Veterans to those of male non-Veterans, and we compare method-

specific rates of female Veterans to those of female non-Veterans.

70,71

As indicated below, method-specific suicide rates

varied by Veteran status, for both men and women. The magnitude of this variation differed by sex.

• Among men, in each year, 2001–2021, firearm suicide mortality and poisoning suicide mortality rates were higher,

and suffocation mortality rates were lower, for Veteran men than for non-Veteran men. In 2021:

• Firearm suicide rate: 62.4% higher for Veteran men than for non-Veteran men

• Poisoning suicide rate: 14.3% higher for Veteran men than for non-Veteran men

• Suffocation suicide rate: 31.3% lower for Veteran men than for non-Veteran men

• Among women, in each year, 2001–2021, firearm suicide mortality and poisoning suicide mortality rates were higher

for Veteran women than for non-Veteran women. In 2021:

• Firearm suicide rate: 281.1% higher for Veteran women than for non-Veteran women

• Poisoning suicide rate: 110.1% higher for Veteran women than for non-Veteran women

• Among women, the suffocation suicide rate in 2021 was 88.0% higher for Veteran women than for non-

Veteran women.

Due to small cell sizes, it was not possible to provide age-adjusted method-specific rates.

Compared to non-Veteran adults, Veterans are more likely to own firearms. Estimates derived from 2015 National Firearm Survey reports and

VetPop data suggest that in 2015 firearm ownership was approximately 62% higher for Veteran men than for non-Veteran men, and it was

approximately 107% higher for Veteran women than for non-Veteran women.

This direction and scale of this differential ranged from 2006, when Veteran women had a 13.7% lower rate of suffocation suicide than non-Veteran

women, to 2021, when Veteran women had an 88.0% higher suffocation suicide rate than non-Veteran women.

Lethal Means Involved in Suicide Deaths

Table 1 provides information on lethal means, or methods, involved in suicide deaths of Veterans and non-Veteran U.S.

adults in 2021 and a measure of change compared to suicides in 2001.

• Overall and by sex, suicide deaths among Veterans were more likely to involve firearms than suicide deaths among

non-Veteran U.S. adults. For example, firearms were involved in 73.4% of suicide deaths in 2021 among Veteran

men, compared to 57.2% of suicide deaths among non-Veteran men; and firearms were involved in 51.7% of suicides

by Veteran women in 2021, compared to 34.6% of non-Veteran women.

• Among Veteran suicide deaths in 2021, relative to those in 2001, there were increases in the percentage involving

firearms (+5.7%) and suffocation (+0.9%) and decreases for poisoning (-5.4%) and other means (-1.2%).

• For suicide deaths of non-Veteran U.S. adults, there were increases from 2001 to 2021 in the percentage involving

suffocation (+6.1%) and other means (+0.5%) and decreases in the percentage involving firearms (-0.5%) and

poisoning (-6.0%).

72%

Firearm

Suicide

5.7%

1 in 3

of Veteran suicides

were by firearm in 2021.

Veteran firearm suicides

from 2001 to 2021

increased by

Firearm suicide rate among

Veteran men was

62.4% higher

than for non-Veteran

men in 2021.

Firearm suicide rate among

Veteran women was

281.1%

higher

than non-Veteran

women in 2021. There was a

14.7% increase in Veteran

women firearm suicide deaths

from 2001

–

2021.

Firearm ownership is

more prevalent

among Veterans (45%)

than non-Veterans (19%).

Veteran firearm owners store

at least one firearm

unlocked and loaded.

Table 1: Suicide Deaths, Methods Involved, 2021 and Difference From 2001, by Veteran Status, Sex and

Age Groups

Veterans

Non-Veteran

U.S. Adults

Veteran

Men

Non-Veteran

Men

Veteran

Women

Non-Veteran

Women

2021 Change 2021 Change 2021 Change 2021 Change 2021 Change 2021 Change

All Ages

Firearms 72.2% +5.7% 52.2% -0.5% 73.4% +6.1% 57.2% -0.8% 51.7% +14.7% 34.6% -0.9%

Poisoning 7.8% -5.4% 12.4% -6.0% 6.9% -5.5% 7.7% -4.7% 23.7% -19.2% 28.8% -9.2%

Suocation 14.9% +0.9% 26.8% +6.1% 14.6% +0.5% 26.9% +4.5% 19.7% +9.3% 26.8% +11.1%

Other 5.2% -1.2% 8.6% +0.5% 5.2% -1.1% 8.3% +1.0% 4.9% -4.9% 9.8% -1.0%

Ages 18–34

Firearms 66.2% +5.3% 49.7% -1.9% 68.0% +5.9% 53.9% -0.8% 49.4% +12.7% 31.9% -3.9%

Poisoning 5.9% -5.4% 8.9% -3.8% 4.6% -5.5% 6.2% -3.1% 18.8% -17.9% 20.9% -9.5%

Suocation 22.7% +0.6% 32.5% +4.0% 22.0% -0.5% 31.4% +2.2% 29.4% -- 36.8% +12.7%

Other 5.2% -0.5% 8.9% +1.6% 5.4% +0.2% 8.6% +1.7% -- -- 10.4% +0.7%

Ages 35–54

Firearms 62.1% +7.7% 46.5% -0.1% 63.3% +8.2% 50.1% -1.8% 49.7% +10.4% 34.9% +2.3%

Poisoning 9.0% -10.0% 13.4% -11.4% 7.7% -10.2% 8.7% -8.8% 23.5% -22.3% 28.5% -15.6%

Suocation 23.2% +3.8% 31.5% +11.6% 23.3% +3.5% 32.6% +10.1% 21.5% -- 28.0% +14.9%

Other 5.7% -1.4% 8.6% -0.1% 5.7% -1.4% 8.6% +0.5% -- -- 8.7% -1.5%

Ages 55–74

Firearms 72.7% -3.2% 56.8% -6.2% 73.5% -2.8% 63.8% -7.4% 55.3% -- 36.5% -5.4%

Poisoning 8.9% -1.1% 15.6% -1.1% 7.9% -1.8% 9.0% -0.5% 30.1% -- 34.9% -0.5%

Suocation 12.4% +4.0% 18.6% +6.6% 12.6% +4.2% 18.7% +6.4% -- -- 18.3% +6.8%

Other 6.0% +0.3% 9.0% +0.8% 6.0% +0.4% 8.5% +1.5% -- -- 10.3% -0.9%

Ages 75+

Firearms 86.5% +5.1% 73.5% +4.8% 86.6% +4.9% 81.8% +3.3% -- -- 36.4% +0.4%

Poisoning 6.1% -0.3% 11.8% +1.6% 6.1% -0.4% 6.0% +0.7% -- -- 38.4% +11.1%

Suocation 4.0% -2.0% 9.1% -4.0% 4.1% -1.8% 7.8% -3.2% -- -- 14.9% -5.6%

Other 3.3% -2.8% 5.6% -2.3% 3.3% -2.7% 4.5% -0.9% -- -- 10.3% -5.9%

“Change” is the absolute difference comparing the percentage of suicide deaths in 2021 to the percentage of suicide deaths in 2001. Percentages

and differences are not presented when based on fewer than 10 deaths, indicated by “--”.

Figure 15 presents the distribution of methods involved in Veteran suicide deaths, from 2001–2021.

Figure 15: Methods Involved, Percentage, Veteran Suicide Deaths, 2001–2021

• From 2020 to 2021, among Veteran suicide deaths, the involvement of firearms and suffocation increased from

71.3% to 72.2% and 14.8% to 14.9%, respectively, while the involvement of poisoning and other methods decreased,

from 8.3% to 7.8% and from 5.7% to 5.2%, respectively.

• In 2021, firearms were involved in 73.4% of suicides by male Veterans, up from 72.3% in 2020, and in 51.7% of

suicides by female Veterans, up from 48.6% in 2020.

• The distribution of methods involved in suicides by non-Veteran U.S. adults changed from 2020 to 2021.

Involvement of firearms increased from 50.2% to 52.2%, while poisoning and suffocation decreased, from 12.9% to

12.4% and from 28.5% to 26.8%, respectively.

• Considering trends from 2019, prior to the first year of the COVID-19 pandemic, from 2019 to 2021, among Veteran

suicide deaths, the involvement of firearms increased from 70.0% to 72.2%, while the involvement of poisoning,

suffocation and other methods decreased, from 8.2% to 7.8%, 16.5% to 14.9% and 5.4% to 5.2%, respectively. Among

non-Veteran U.S. adults from 2019 to 2021, involvement of firearms increased from 47.6% to 52.2%, while poisoning,

suffocation, and other methods decreased, from 13.9% to 12.4%, 29.7% to 26.8% and 8.7% to 8.6%, respectively.

Firearm Poisoning Suffocation Other

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021

Percent

6.4

5.9

5.2

5.7

5.4

5.2

5.0

5.2

5.6

4.8

5.55.6

5.4

5.0

5.6

5.3

5.75.8

5.5

5.9

6.2

13.9

13.6

14.9

14.8

16.5

16.6

15.5

14.8

16.0

16.7

15.4

14.5

14.7

15.9

15.2

14.5

13.7

13.8

13.5

13.2

13.3

7.8

8.3

8.2

9.3

9.7

10.5

11.4

11.6

11.1

11.9

12.2

13.0

12.6

13.4

12.9

12.4

13.1

14.0

13.1

66.5

67.3

72.2

71.3

70.0

68.9

69.9

69.6

67.1

66.9

68.0

67.267.1

67.5

67.2

65.4

66.1

67.2

67.7

66.3

67.3

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Comparing Suicide Mortality Among Veterans and Non-Veteran U.S. Adults

Efforts to understand Veteran suicide include comparisons of suicide statistics for Veterans and non-Veteran U.S. adults.

Here, we consider suicide measures as resources for comparisons, and we discuss findings.

• Counts of suicide deaths. In 2021, there were 6,392 suicides among Veterans and 40,020 among non-Veteran

U.S. adults.

• Limitation: These data points tell us the actual number of suicides that occurred; however, they are not

comparable because they do not account for the size of the populations, which differed substantially. In 2021,

there were 18.8 million Veterans and 239.5 million non-Veteran U.S. adults.

• Unadjusted suicide rates. Also known as crude rates, these measure the annual number of suicide deaths per

100,000 people in the population of interest. In 2021, the unadjusted suicide rate for Veterans was 33.9 per 100,000,

and for non-Veteran U.S. adults, 16.7 per 100,000. Unadjusted suicide rates summarize the number of suicides

relative to the size of the population, for the year specified.

• Limitation: They do not account for population differences in factors that may be related to suicide risk, such

as sex and age. The sex and age distributions of the Veteran and non-Veteran U.S. adult populations differ

substantially. For example, in 2021, the Veteran population included a higher proportion of men (89.4%) than

the non-Veteran adult population (45.9%). This difference matters for comparisons because, for example,

among U.S. adults, suicide rates in 2021 were 4 times greater for men than for women. To better understand

suicide patterns related to Veteran status, rather than the demographic characteristics of individuals who

become Veterans,

it is important to account for population differences.

This report employs two approaches for comparing suicide rates across populations and time periods.

• Compare unadjusted rates for subgroups. The first and most informative approach

is to compare unadjusted

suicide rates for Veterans and non-Veterans in specific demographic subgroups (or strata), such as men aged 18- to

34-years-old. The Data Appendix that accompanies this report

provides rate information stratified by age and sex

for Veterans and non-Veteran U.S. adults.

• Note: This approach offers as many comparisons as the number of subgroups and time periods examined; it

does not yield a single overall comparison measure.

• Compare adjusted rates for Veterans and non-Veterans. The second approach is to generate a summary

measure of rate differences that adjusts for population demographic differences. For example, Figure 3 presents

age- and sex-adjusted suicide rates for Veterans and non-Veteran U.S. adults. These were generated using direct

adjustment.

Specifically, we calculated what the overall suicide rates would be for Veterans and for non-Veteran

U.S. adults in each year if their age- and sex-specific suicide rates occurred in a population with the distribution of

a standard reference population. Following scientific recommendations and Department of Health and Human

Griffin BA, Grimm GE, Smart R, Ramchand R, Jaycox LH, Ayer L, Leidy EN, Davenport S, Schell TL, Morral AR. Comparing the Army’s Suicide Rate to

the General U.S. Population: Identifying Suitable Characteristics, Data Sources, and Analytic Approaches. Santa Monica, CA: RAND Corporation,

2020. https://www.rand.org/pubs/research_reports/RR3025.html

Even within a defined population, population characteristics may change over time. For example, from 2001 to 2021 the percentage of Veterans

who were male decreased from 93.7% to 89.4%.

Anderson RN, Rosenberg HM. 1998. Age Standardization of Death Rates: Implementation of the Year 2000 Standard. CDC National Vital Statistics

Reports. 47(3):1-17.

The Data Appendix is available here: https://www.mentalhealth.va.gov/about/data-reporting/suicide-prevention-data.asp

Curtin LR, Klein RJ. 1995. Direct Standardization (Age-Adjusted Death Rates). CDC/National Center for Health Statistics. DHHS Publication No. (PHS)

95-1237. https://www.cdc.gov/nchs/data/statnt/statnt06rv.pdf

Services policy,

this report uses the standard 2000 U.S. adult population as the reference population.

then created overall adjusted rates for the two populations, with each standardized to the same demographic

distribution. The adjusted rates can then be compared. For example, in 2021, the age- and sex-adjusted rate for

Veterans was 71.8% greater than that of non-Veteran adults.

• Note: Use of direct adjusted rates aligns with reporting by other federal agencies and facilitates comparisons

with other populations. They provide a consistent metric for comparisons; however, their interpretation is not

as straightforward as for unadjusted rates. Essentially, they enable consistent “what if” comparisons across

populations and time periods. For each, they tell us what the overall suicide rate would be if the population

of interest had the demographic distribution of the standard 2000 U.S. adult population. They are useful only

for comparisons and not for measuring absolute magnitude.

81,82

Indirect adjustment offers yet another method for comparing suicide mortality.

• Compare the number of Veteran suicide deaths to the number that would have occurred if the Veteran

population had the same age- and sex-subgroup-specific suicide rates as the non-Veteran population.

Indirect adjustment involves applying the subgroup-specific suicide rates of one population (e.g., non-Veteran U.S.

adults) to the demographic distribution of the population of interest (e.g., Veterans) in order to estimate the ratio of

the number of deaths that would occur if the strata-specific rates of the first population occurred in a population

with the demographic distribution of the second. The ratio of the number of deaths that were actually observed

in the second population (e.g., Veterans) to the number that would be expected if the second population had the

subgroup-specific rates of the first population is called a Standardized Mortality Ratio (SMR). Ratios greater than 1.0

indicate increased mortality in the second population; ratios less than 1.0 indicate decreased mortality.

• Note: Applying indirect adjustment, analyses evaluated the observed number of Veteran suicides in 2021

relative to the number that would have been observed if the Veteran population had the age- and sex-

specific suicide rates of the non-Veteran U.S. adult population. The resulting SMR was 1.124.

This indicates

that the number of Veteran suicide deaths in 2021 was 12.4% higher than what would be observed if the

Veteran population had the age- and sex-specific suicide rates of the non-Veteran U.S. adult population.

Anderson RN, Rosenberg HM. 1998. Age Standardization of Death Rates: Implementation of the Year 2000 Standard. CDC National Vital Statistics

Reports. 47(3):1-17. Use of the 2000 standard was recommended by a national workshop including representatives from CDC, the National Academy

of Sciences, the National Institutes of Health, State health departments, and academia. The authors note, “the choice (of a standard population) can

make a difference in some cases, when age-specific rates trace divergent trends, or when the age structure of the alternative standard populations

differ.” Further, they note that “standardization is an important and useful tool, (yet) some of its limitations become apparent when changing the

population standard.”

Klein RJ, Schoenborn CA. 2001. Age Adjustment Using the 2000 Projected U.S. Population. Healthy People Statistical Notes, no. 20. Hyattsville,

Maryland: National Center for Health Statistics.

Curtin LR, Klein RJ. 1995. Direct Standardization (Age-Adjusted Death Rates). CDC/National Center for Health Statistics. DHHS Publication No. (PHS)

95-1237. https://www.cdc.gov/nchs/data/statnt/statnt06rv.pdf

Population alignment is specific to the measures used for adjustment. Of note, the approach applies to suicide rates of strata-specific subgroups to

their demographic distribution in the U.S. standard 2000 adult population. Consequently, this increases the relative influence of underrepresented

subpopulations (relative to their distribution in the U.S. standard 2000 adult population) in terms of the overall adjusted suicide mortality rate.

Notably, the Veteran population includes proportionally fewer women and younger adults than did the 2000 U.S. adult population. See: Morral

AR, Schell TL, Smart R. 2023. Comparison of Suicide Rates Among US Veteran and Nonveteran Populations. JAMA Network Open. 6(7):e2324191.

doi:10.1001/jamanetworkopen.2023.24191.

The 95 % confidence interval was from 1.096 to 1.152.

The direct and indirect adjustment methods indicated that Veterans were at increased risk of suicide in 2021, accounting

for differences in age and sex distributions. Each approach addresses a distinct question.

• Comparison of direct adjusted rates tells us that if the Veteran and non-Veteran U.S. adult populations in 2021 had

the demographic profile of the standard 2000 U.S. adult population, then the Veteran suicide rate would be 71.8%

higher than the rate among non-Veteran adults.

• Indirect adjustment tells us that in 2021 the Veteran population experienced 12.4% more suicide deaths than if the

Veteran population had the strata-specific suicide rates of non-Veteran U.S. adults.

Each approach is valid, and each indicates greater suicide among Veterans in 2021 compared to non-Veteran adults. The

variation between these summary measures relates to differences in population distributions and subgroup-specific

suicide risk differentials.

Both approaches have limitations.

• Direct adjustment is best suited for comparing populations with distributions similar to that of the

standard population.

• A limitation of indirect adjustment is that SMRs may not be comparable over time if the demographic distribution

of the target population varies over time. Note: The age and sex distributions of the Veteran population changed

substantially from 2001 to 2021.

To address this concern, we examined SMRs standardized to the distribution of the Veteran population of 2021.

These

analyses documented elevated suicide mortality among Veterans in 2009 and 2010 and 2014–2021, and lower suicide

mortality among Veterans 2001–2008, relative to non-Veteran U.S. adults. Also, we conducted analyses stratified by sex,

with standardization by age. These analyses indicated that among women, Veteran status was associated with elevated

suicide mortality in each year, and among men, Veteran status was associated with reduced suicide mortality 2001–2008

and 2011–2013 and with increased suicide mortality 2017–2021.

As noted, the variation in trends for the composite adjusted suicide measures is related to heterogeneity in the

populations and strata-specific suicide risks. It is thus important to examine the ratios of strata-specific unadjusted

suicide rates for Veterans relative to non-Veteran U.S. adults. As noted previously, this is the “most informative method of

making comparisons of mortality risk between groups.”

Figure 16 shows for U.S. men and women, by age groups, the ratio of the Veteran unadjusted suicide rate and the

unadjusted suicide rate for non-Veteran U.S. adults, 2001–2021.These are rate ratios, rather than rates. Values greater than

1.0 indicate increased risk among Veterans in the age and sex group, and values less than 1.0 indicate decreased suicide

risk among Veterans in the age and sex group.

For example, direct adjustment’s weighting of strata-specific suicide rates to the distributions of the Standard U.S. population results in a

reweighting of the differentials in strata-specific rates by Veteran status. Of note, the Standard U.S. population includes proportionally more

women and younger adults than the Veteran population, and for both women and younger adults, the differential in rates by Veteran status is

particularly elevated. As a result, the differential in suicide patterns appears greater using direct adjustment than when using indirect adjustment.

Curtin LR, Klein RJ. 1995. Direct Standardization (Age-Adjusted Death Rates). CDC/National Center for Health Statistics. DHHS Publication No. (PHS)

95-1237. https://www.cdc.gov/nchs/data/statnt/statnt06rv.pdf

This was calculated as: (Number of suicides that would have occurred if Veteran age- and sex-strata-specific rates in the year occurred in a

population with the distribution of the Veteran population in 2021) / (Number of suicides that would have occurred if non-Veteran U.S. adult

population’s age- and sex-strata-specific rates occurred in a population with the distribution of the Veteran population in 2021).

Anderson RN, Rosenberg HM. 1998. Age Standardization of Death Rates: Implementation of the Year 2000 Standard. CDC National Vital Statistics

Reports. 47(3):1-17.

Figure 16: Veterans to Non-Veteran U.S. Adults, Age-Group-Specific Suicide Rate Ratios, 2001–2021, Male

and Female

18-34

Male

35-54 55-74 75+

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

2020 2021

Rate Ratio

18-34

Female

35-54 55

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

2020 2021

Rate Ratio

The suicide rate ratios provide the clearest information regarding differentials in suicide risks by Veteran status and how

these vary by sex and age. In all years from 2001–2021, Veterans had greater suicide rates than non-Veterans among men

and women under age 55-years-old (rate ratio greater than 1.0). In all years, Veteran men aged 75-years-old and older had

lower suicide rates than non-Veteran men in the same age group (rate ratio less than 1.0). For men and women, from 2003

through 2021, the highest rate ratios were among those aged 18- to 34-years-old, indicating that for those aged 18- to

34-years-old, increased rates for Veterans were most pronounced, relative to those of non-Veteran men and women.

Veteran Leading Causes of Death

This section provides information on suicide as a leading cause of death among Veterans in 2021. For each leading cause,

we also report age-adjusted cause-specific mortality rates for 2019, 2020 and 2021. In 2021, suicide was the 13th leading

cause of death among Veterans.

There were 481,718 Veteran deaths in 2019, 529,156 in 2020 and 514,845 in 2021. The unadjusted all-cause Veteran mortality rate in 2019 was 2,430.8

per 100,000, 2,745.0 per 100,000 in 2020 and 2,732.6 in 2021.Thirteen leading causes were presented to be inclusive of suicide, the 13th leading

cause among Veterans in 2021, overall. Causes of death are classified based on the underlying cause of death; leading causes are ranked based on

the number of deaths, by cause.

Figure 17 presents leading causes of death, based on counts of deaths, and the age-adjusted mortality rate per 100,000,

for each cause, in 2019–2021.

Figure 17: Leading Causes of Death in 2021, Veterans, and Associated Age-Adjusted Mortality Rates,

2019–2021

There is no comparison rate for 2019. COVID-19 deaths were identified based on underlying cause of death ICD-10 code U07.1, which was added as

a cause of death code in 2020.

0 50 100 200 250 300150

(1) Heart Disease

(2) Cancer

(3) COVID-19

(5) Stroke

(6) Unintentional Injuries

(7) Diabetes

(8) Alzheimer’s Disease

(9) Kidney Disease

(10) Parkinson’s Disease

(12) Influenza and Pneumonia

(13) Suicide

(11) Chronic Liver Disease and

Cirrhosis

(4) Chronic Lower Respiratory

Disease

Rate per 100,000

241.8

249.7

246.9

218.1

213.7

212.1

100.8

56.5

54.6

50.5

42.2

43.7

44.2

74.0

83.5

90.8

31.2

34.9

35.3

27.7

29.4

25.4

16.7

16.4

17.0

15.2

16.6

14.9

17.7

20.4

22.5

15.5

16.1

13.0

35.8

36.2

38.7

142.8

2019

2021

2020

The relative rank of suicide as a leading cause of death was higher among younger Veterans (Table 2).

Table 2: First and Second Leading Causes of Death and Suicide Ranking, Veterans, by Age and Sex, 2021

First Leading Cause of Death Second Leading Cause of Death

Rank of Suicide as a

Leading Cause of Death

All Veterans

All Ages Heart Disease Cancer 13th

18 to 34 Accident (Unintentional Injury) Suicide 2nd

35 to 44 Accident (Unintentional Injury) Suicide 2nd

45 to 54 COVID-19 Heart Disease 5th

55 to 64 Heart Disease Cancer 9th

65 to 74 Cancer Heart Disease 14th

75 to 84 Heart Disease Cancer 17th

85 and older Heart Disease Cancer 17th

Male Veterans

All Ages Heart Disease Cancer 13th

18 to 34 Accident (Unintentional Injury) Suicide 2nd

35 to 44 Accident (Unintentional Injury) Suicide 2nd

45 to 54 COVID-19 Heart Disease 5th

55 to 64 Heart Disease Cancer 9th

65 to 74 Cancer Heart Disease 14th

75 to 84 Heart Disease Cancer 17th

85 and older Heart Disease Cancer 17th

Female Veterans

All Ages Cancer Heart Disease 9th

18 to 34 Accident (Unintentional Injury) Suicide 2nd

35 to 44 Accident (Unintentional Injury) Cancer 4th

45 to 54 Cancer COVID-19 6th

55 to 64 Cancer Heart Disease 9th

65 to 74 Cancer Heart Disease 13th

75 to 84 Heart Disease Cancer --

85 and older Heart Disease Alzheimer's disease --

Ranking is not reported when based on fewer than 10 deaths, indicated by “--.”

Years of Potential Life Lost

One measure of the relative impact of different causes of death is their contributions to premature mortality, measured in

terms of Years of Potential Life Lost (YPLL).

Analyses for 2019–2021 that are not detailed in this report indicate that suicide was the fourth leading cause of premature

mortality among Veterans in 2019, and it ranked fifth in 2020 and 2021.

COVID-19 Pandemic: Suicide Surveillance

Figure 18 shows the number of Veteran suicide deaths, by week, from 12 months prior to the declaration of the COVID-19

pandemic through 2021.

Figure 18: Veteran Suicide Deaths, By Week, 12 Months Prior to Onset of the COVID-19 Pandemic through 2021

• Trend analyses did not identify a change in Veteran suicide mortality trends at onset of the pandemic in 2020.

Review of Overall Veteran Suicide Data

In the U.S. adult population as a whole, including Veterans and non-Veteran adults, there were substantial increases

in suicide deaths in 2021. Among Veterans, despite a 2.3% decrease in the Veteran population from 2020 to 2021, the

number of suicide deaths increased, from 6,278 to 6,392. Among non-Veteran U.S. adults, the population increased by

YPLL for individuals who died before age 75 are calculated as (75 minus age at death). YPLL are set to zero for individuals who died at age 75 or older.

The average number of years of premature mortality per Veteran suicide rose from 17.4 in both 2019 and 2020 to 18.1 in 2021. In 2021, the 6,392

Veteran suicide deaths resulted in an estimated 115,626 years of potential life lost, 5.8% of all YPLL for Veterans who died in 2021. Also, COVID-19

emerged in 2020 as the fourth-leading cause of premature mortality. In 2021, COVID-19 ranked third, with 272,736 estimated YPLL, or 13.7% of all

YPLL for Veterans who died in 2021.

Comparing 2019 and 2020, trend analyses using Joinpoint did not identify changes in suicide mortality rates for Veterans or for non-Veteran U.S.

adults, or for Recent Veteran VHA Users or for Other Veterans.

180

160

140

120

100

3/14/2019

3/28/2019

4/11/2019

4/25/2019

5/9/2019

5/23/2019

6/6/2019

6/20/2019

7/4/2019

7/18/2019

8/1/2019

8/15/2019

8/29/2019

9/12/2019

9/26/2019

10/10/2019

10/24/2019

11/7/2019

11/21/2019

12/5/2019

12/19/2019

1/2/2020

1/16/2020

1/30/2020

2/13/2020

2/27/2020

3/12/2020

3/26/2020

4/9/2020

4/23/2020

5/7/2020

5/21/2020

6/4/2020

6/18/2020

7/2/2020

7/16/2020

7/30/2020

8/13/2020

8/27/2020

9/10/2020

9/24/2020

10/8/2020

10/22/2020

11/5/2020

11/19/2020

12/3/2020

12/17/2020

12/31/2020

1/14/2021

1/28/2021

2/11/2021

2/25/2021

3/11/2021

3/25/2021

4/8/2021

4/22/2021

5/6/2021

5/20/2021

6/3/2021

6/17/2021

7/1/2021

7/15/2021

7/29/2921

8/12/2021

8/26/2021

9/9/2021

9/23/2021

10/7/2021

10/21/2021

11/4/2021

11/18/2021

12/2/2021

12/16/2021

1 2/30/2021

Week Ending

0.6% from 2020 to 2021 and the number of suicide deaths increased from 38,020 to 40,020. When looking at increases in

rates over 2020 to 2021, the age- and sex-adjusted suicide rate among Veterans increased by 11.6%, while the age- and

sex-adjusted suicide rate among non-Veteran U.S. adults increased by 4.5%. We also observed that from 2001–2021,

age- and sex-adjusted rates rose significantly faster for Veterans than for non-Veteran U.S. adults. In 2021, the age- and

sex-adjusted suicide rate for Veterans was 71.8% greater than for non-Veteran adults. It is clear from these findings that

Veterans remain at elevated risk for suicide.

Certain sub-populations in 2021 were found to have substantial increases in suicide rates from 2020 to 2021, including

Veterans aged 35- to 54-years-old with an increase of 10.7% in the age-specific suicide rate, women Veterans with an

increase of 24.1% in the age-adjusted suicide rate and American Indian and Alaska Native Veterans with an increase of

51.8% in the unadjusted suicide rate. Further, the prevalence of firearm involvement in Veteran suicide deaths rose from

71.3% to 72.2%, the highest percentage recorded for Veterans over the last 20 years, continuing to be significantly higher

than the non-Veteran U.S. adult population at 52.2%.

Reflecting Back, Looking Forward: Laying the Foundation for Future Courses of

Action for Suicide Prevention for All Veterans

Promote Secure Firearm Storage for Veteran Suicide Prevention

Suicide attempts involving firearms are particularly lethal

with an 85–90% likelihood of death compared to 5–10% for

other methods of suicide.

Additionally, firearm ownership is more prevalent among Veterans (45%) than non-Veterans

(19%), and the differential in firearm ownership is particularly high among women.

96,97,98,99,100

Veteran suicide deaths

continue to disproportionately involve firearms and Veteran suicide rates exceed those of U.S. non-Veteran adults. One in

3 Veteran firearm owners store at least 1 firearm unlocked and loaded.

101

Building in time and space between a suicidal

impulse and taking action may offer enough time for crisis to pass. Veteran suicide rates will likely not significantly

improve until there is increased collective engagement regarding the relationship between Veteran suicide and firearms.

As such, VA has focused on the secure storage of firearms as a method for reducing Veteran suicide.

Spicer RS, Miller TR. 2000. Suicide Acts in 8 States: Incidence and Case Fatality Rates by Demographics and Method. American Journal of Public

Health. 90:1885-1891.

Centers for Disease Control and Prevention (2016). Web-based Injury Statistics and Query and Reporting System. Retrieved from http://www.cdc.

gov/injury/wisqars/index.html

Combining reports from Azrael et al., 2017, and Cleveland et al., 2017, and VetPop estimates of the 2015 populations of Veteran men and women,

we estimate that in 2015 household firearm ownership among Veteran men was 62.3% higher than for non-Veteran men, and household firearm

ownership among Veteran women was 106.6% higher than for non-Veteran women.

Cleveland EC, Azrael D, Simonetti J, Miller M. 2017. Firearm Ownership Among American Veterans: Findings from the 2015 National Firearm Survey.

Injury Epidemiology. 4(1). doi:10.1186/s40621-017-0130-y.

Azrael D, Hepburn L, Hemenway D, Miller M. 2017. The Stock and Flow of U.S. Firearms: Results from the 2015 National Firearms Survey. The Russell

Sage Foundation Journal of the Social Sciences. 3(5):38-57.

Data from the 2015 National Firearm Survey indicate that 22% of U.S. adults (including Veterans) owned firearms (32% of men, 12% of women). 19%

of non-Veteran adults owned firearms, while 44.9% of Veterans reported firearm ownership (47.2% of Veteran men, 24.4% of Veteran women).

100

Among Veterans receiving VHA mental health care in 2015, 45.3% had firearms in their households, as did 46.9% of those with thoughts of suicide

and 55.6% of those who reported having a plan for suicide. Also, of those respondents who reported household firearms, 83.1% had at least 1

handgun and 38.5% reported having a firearm at home that was both unlocked and loaded. See: Valenstein M, Walters H, Pfeiffer PN, Ganoczy

D, Ilgen MA, Miller MJ, Fiorillo M, Bossarte RM. 2020. Possession of Household Firearms and Firearm-Related Discussions with Clinicians Among

Veterans Receiving VA Mental Health Care. Archives Suicide Research. 24:S260-S279.

101

Simonetti JA, Azrael D, Rowhani-Rahbar A, Miller M. 2018. Firearm Storage Practices Among American Veterans. American Journal of Preventive

Medicine. 55(4):445-454.

In 2023, VA continued expansion of secure firearm storage initiatives in training, gun lock distribution, collaboration

efforts and communication and outreach efforts. VA launched an updated VA S.A.V.E.

102

refresher training, required for all

non-clinicians, that includes a larger focus on LMS and secure firearm storage. VA suicide prevention is also collaborating

with the Caregiver Support Program to provide trainings to assist caregiver support personnel in discussing LMS

(firearms and medication) with Veterans/caregivers. VA is on target to reach its agency priority goal of a 10-fold increase

in training of community providers in LMS. VA is actively marketing two LMS trainings to community providers, including

the Community Care Network providers, SSG Fox SPGP grantees and other community providers via a communications

toolkit. This toolkit has been shared with community health care systems (e.g., Kaiser, Cigna, Wounded Warrior Project,

Cohen Veterans Network, Bush Institute) and professional provider organizations and associations (e.g., American

Medical Association, American Psychological Association, American Psychiatric Association and National Association

of Social Workers) and includes an hour-long version and a shorter 25-minute version, provided in collaboration with

PsychArmor. VA also exceeded its agency priority goal to exceed its gun lock distribution to external partners by tenfold

by the end of FY 2023. In FY 2023, from October 2022 through June 2023, VA provided more than 409,000 gun locks

to VHA staff for distribution and more than 245,000 to entities outside VA for distribution. VA Suicide Prevention also

collaborated with the National Cemetery Administration (NCA) to provide gun locks and lethal means safety resources

at all NCA sites. VA continues to expand suicide prevention collaboration across the Nation, including relationships that

are established to amplify lethal means safety messaging across industries. To follow up on a successful initial Firearm

Industry Veteran Suicide Prevention Roundtable in July 2022, co-hosted with the National Shooting Sports Foundation

(NSSF), VA coordinated a follow-up meeting in September 2023, during Suicide Prevention Month, with firearm industry

and trade advocates, manufacturers, retailers and range owners/operators to advance joint efforts to promote secure

firearm storage as part of suicide prevention.

The Keep It Secure campaign has more than 326 million impressions and approximately 100 million video views and

7.8 million LMS website resource visits in FY 2023, to date. Future phases of the secure firearm storage campaign are

underway, including the development of a new national call to action campaign, including industry toolkits, technical

assistance, training, and public service assets. This encompasses the development of a national suicide prevention LMS

resource repository website; the development and dissemination of multi-state maps for out-of-home and secure storage

options; and education training materials in various formats for dissemination. VA also initiated a full Keep It Secure LMS

campaign evaluation to inform impacts, targeting of messaging to diverse populations and efficacy of messaging.

102

The acronym S.A.V.E. helps one remember the important steps involved in suicide prevention: S=Signs of suicidal thinking should be recognized;

A=Ask the most important question of all—“Are you thinking of killing yourself?”; V=Validate the Veteran’s experience; E=Encourage treatment and

Expedite getting help.

Reection: Secure Firearm Storage

Summary: The majority of Veterans who die by suicide die by rearm. As many as 9 in 10 suicide attempts that

involve rearms prove lethal. People who attempt suicide by less lethal means are more likely to survive. Storing

your rearm in a locked location and with the ammunition stored separately can allow time and space for reection,

which can save a life.

What You Can Do: Normalize the discussion. It’s okay to ask if someone is having thoughts about suicide. And it

is okay to ask about how they are storing their rearms too. This brochure provides a guide in how to have these

discussions with loved ones. Work within your local communities to promote secure rearm storage, utilizing this

community toolkit and messaging to help Veterans, families and communities learn about putting “time and space”

between a Veteran in crisis and a rearm. Obtain a free gun lock from your local VA and ensure your loved ones

have access to one. Placing objects that have personal meaning, such as pictures of loved ones or personal notes,

by your gun lock or safe, along with a reminder of the Veterans Crisis Line’s number (Dial 988 then Press 1) can serve

as reminders of hope during a time of crisis. All community care providers can assist with reducing rearm Veteran

suicide by taking this training about how to incorporate discussions about secure storage within their clinical care.

Implement and Sustain Community Collaborations Focused Upon Community-

Specific Veteran Suicide Prevention Plans

VA’s SP 2.0 CBI model is grounded in evidence-based practices of community-based prevention and community

implementation science paired with a focus on disseminating suicide prevention strategies within communities across

the country.

103,104

This work is informed by prior community-based and public health suicide prevention approaches

which have been shown to effectively reduce suicide rates in diverse communities.

105

VA’s efforts include effective

community-based suicide prevention programs that focus on both health promotion and “upstream” strategies,

as well as efforts to improve the delivery of clinical and crisis services throughout the community and across other

organizations.

106,107,108

The Governor’s Challenge has now expanded to include all 50 states and 5 U.S. territories. VA’s community-based

interventions support more than 1,700 local community suicide prevention coalitions, an 815% increase from 2021.

These efforts in SP 2.0 CBI-SP are continuing to work across federal, state and community collaborations to reduce

Veteran suicide. The coalitions provide a unifying model to coordinate shared messaging on lethal means safety, suicide

prevention outreach, education, intervention, and the distribution of secure storage resources. To date, almost 40% of the

1,700 coalitions have moved through forming and planning stages to implementation of strategies, meaning more than

7,150,000 Veterans are starting to see efforts locally to prevent suicide. These efforts, which were established to further

the reach of VA’s Public Health Model for Suicide Prevention, now extend to more than 11 million Veterans nationwide.

While this is a major accomplishment, perhaps most important is that this work reflects a deep commitment from states

and communities to work toward ending Veteran suicide.

103

Frieden TR. 2014. Six components necessary for effective public health program implementation. Am J Public Health. 104(1):17-22.

104

Lai C, Law YW, Shum AK, Ip FW, Yip PS. 2019. A Community-Based Response to a Suicide Cluster: A Hong Kong Experience. Crisis: The Journal of

Crisis Intervention and Suicide Prevention. 41(3):163-171.

105

Hegerl U, Althaus D, Schmidtke A, Niklewski G. 2006. The Alliance Against Depression: 2-Year Evaluation of a Community-Based Intervention to

Reduce Suicidality. Psychological Medicine. 36(9):1225-1233.

106

Caine, E. D. (2013, May). Forging an agenda for suicide prevention in the United States. American Journal of Public Health. 103(5), 822-9.

107

Lai C, Law YW, Shum AK, Ip FW, Yip PS. 2019. A Community-Based Response to a Suicide Cluster: A Hong Kong Experience. Crisis: The Journal of

Crisis Intervention and Suicide Prevention. 41(3):163-171.

108

Oyama H, Watanabe N, Ono Y, Sakashita T, Takenoshita Y, Taguchi M, Takizawa T, Miura R, Kumagai K. 2005. Community‐Based Suicide Prevention

Through Group Activity for the Elderly Successfully Reduced the High Suicide Rate for Females. Psychiatry and Clinical Neurosciences. 59(3):337-344.

VA has also continued to expand the work with the Ad Council. Since launching “Don’t wait. Reach out.” in October of

2021, the campaign has garnered over $40 million in donated media support, across broadcast, digital, and out-of-home

mediums, resulting in more than 3.5 million visits to VA.gov/REACH. The campaign has worked with several high-profile

media organizations, including Fox Sports, Meta, Twitch, Reddit, We Are the Mighty, Yahoo and YouTube, to reach

Veterans. The campaign has reached 7.9 million Veterans, according to Ad Council campaign tracking studies. This is

approximately 44% of Veterans in the U.S. In FY 2023 through August 31, 2023, there were nearly 2 billion donated media

impressions (opportunities to view the campaign’s PSA), 142,229 donated media detections (times the PSA was shown)

and 3.5 million website visits. In September 2023, VA launched new PSAs for Suicide Prevention Month, continuing the

work of this successful effort.

In addition to expansion of SP 2.0 CBI-SP and communication campaigns to reach all Veterans, VA expanded its reach

to Veterans through a new grant effort. The Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program (SSG

Fox SPGP), authorized as part of the Commander John Scott Hannon Veterans Mental Health Care Improvement Act of

2019, has awarded $52.5 million to 80 awardees in 43 states, the District of Columbia and American Samoa for services in

FY 2023. The mission of SSG Fox SPGP is to reduce Veteran suicide through awarding grants to eligible entities providing or

coordinating suicide prevention services to eligible individuals and their families. Through June 2023, grantee organizations

have reached more than 10,000 Veterans and families in need and completed assessments that resulted in the identification

of approximately 130 imminent-risk Veterans, 800 non-emergency referrals and approximately 1,800 social service referrals

to address drivers of risk (including homelessness, employment, income supports, legal services and other resources).

Ongoing program evaluation is underway to continue to assess the impact of these services in the community.

SSG Fox SPGP Grantee:

Oneida County and Utica Center for Development

“The Neighborhood Center is honored to be involved in developing and assisting with suicide prevention services for

Veterans alongside Oneida County and Utica Center for Development,” said Sandra Soroka, Executive Director of The

Neighborhood Center.

“The diculties often facing many Veterans can feel overwhelming, especially if they don’t receive help. Society sees

Veterans as heroes, which they are,” she continued.

“They have made sacrices for our country and in return we have an obligation to ensure they receive meaningful

services to help deal with the complexities of emotions, life changes, diculties in resuming their pre-service jobs

and relationships, as well as treatment for Posttraumatic Stress Disorder.”

Reection: Community Prevention

Summary: The majority of Veterans who die by suicide are not engaged in VHA care. We must continue to ensure

methods of outreach and engagement for all Veterans, reminding them of resources and support, both in VA, but

also in their local communities. Connection saves lives.

What You Can Do: Consider joining your Governor’s Challenge state partners to identify ways to support your

local communities in Veteran suicide prevention. Promote the “Don’t wait. Reach out.” campaign messages of hope

through your social media connections and local community networks, using the “Spread the Word” materials

available. Encourage local community organizations that provide or coordinate suicide prevention services to

consider applying for the Sta Sergeant Parker Gordon Fox Suicide Prevention Grant Program.

Continue Expansion of Readily Accessible Crisis Intervention Services

The passing of the National Suicide Hotline Designation Act of 2020 provided a critical pathway forward for expanding

ease of access to the National Suicide Prevention Lifeline, now the 988 Suicide & Crisis Lifeline, and VCL with a 3-digit

number (Dial 988 then Press 1 for VCL). VCL is an important part of VA’s public health approach to address Veteran

suicide as it is for all Veterans, not only those engaged in VHA services. VCL is also 1 of the few crisis lines in the country

integrated within an existing health system, as noted by a recent RAND evaluation.

109

Below, we discuss VCL’s growth in

preparation for 988 and its expansion of services after the launch of 988.

From 2021 to 2023, VCL continued preparing for the implementation of 988, hiring over 900 individuals. From the

launch of 988 on July 16, 2022, through June 30, 2023, VCL fielded nearly 1 million contacts, including over 750,000

calls — an increase of 12.5% compared to the same timeframe from the previous year and with an average speed to

answer of 9.4 seconds. In addition, there was a year-over-year increase in text messages (45%) and online chats received

(8.6%). This increase in contacts reflects the work of the VCL campaign to share the message of the easier way to reach

VCL through 988, then Press 1. The VCL communications campaign provided specific resources for connecting to

care as well as nationwide messaging resources through the VeteransCrisisLine.net/Spread-the-Word site. More than

2.1 billion impressions, 575 million completed video views, and more than 100,000 resource locator uses, and self-

check quiz completions reflect that this outreach is working. The growth of VCL’s reach is also supported by extensive

collaboration with SAMHSA, National Action Alliance for Suicide Prevention, Federal Communications Commission,

Cellular Telecommunications Industry Association, Department of Defense, Veterans Service Organizations, community

organizations and more who raised awareness of 988 and VCL. In alignment with ongoing expansion of peer specialist

services into suicide prevention efforts,

110

VCL also expanded its services in 2021 with the establishment of its Peer

Support Outreach Center (PSOC) to provide support, hope, and recovery-oriented services to Veterans beyond their

initial VCL call.

Veterans Crisis Line Services Matter

109

Ramchand R, Jaycox LH, Ebener PA. 2017. Suicide Prevention Hotlines in California: Diversity in Services, Structure, and Organization and the

Potential Challenges Ahead. Rand Health Q. 19;6(3):8. PMID: 28845360; PMCID: PMC5568153.

110

Pfeiffer PN, King C, Ilgen M, Ganoczy D, Clive R, Garlick J, Abraham K, Kim HM, Vega E, Ahmedani B, Valenstein M. 2019. Development and Pilot

Study of a Suicide Prevention Intervention Delivered by Peer Support Specialists. Psychological Services, 16(3), 360-371. https://doi.org/10.1037/

ser0000257

111

Britton PC, Karras E, Stecker T, Klein J, Crasta D, Brenner LA, Pigeon WR. 2022. Veterans Crisis Line Call Outcomes: Distress, Suicidal Ideation, and

Suicidal Urgency. American Journal of Preventive Medicine, 62(5), 745-751. https://doi.org/10.1016/j.amepre.2021.11.013

112

Johnson LL, Muehler T, Stacy MA. 2021. Veterans’ Satisfaction and Perspectives on Helpfulness of the Veterans Crisis Line. Suicide and Life-

Threatening Behavior, 51(2), 263-273. ht t ps://do i.org /10.1111/sl tb.12702

• Over 5 times more likely to have less distress

at the end of the call than at the beginning

• Almost 5 times more likely to have less

suicidal ideation at the end of the call than

at the beginning

• 11 times more likely to have a less suicidal urgency

at end of call than beginning

111

• 82.6% reported that using the Veterans Crisis Line

played a role in stopping them from acting on

suicidal thoughts

112

While VCL operations continued to expand, so did the program evaluation efforts to assess VCL effectiveness and impact

on VCL services during the COVID-19 pandemic. During the initial period of the pandemic, “suicidal thoughts or crisis”

were reported by approximately 1 in 5 callers. Female Veteran callers were 15% more likely to report suicidal thoughts

or crisis than male Veteran callers. The VCL program evaluation efforts found that VHA using Veteran callers were over 5

times more likely to have less distress at the end of the call than at the beginning, were almost 5 times more likely to have

less suicidal ideation at the end of the call than at the beginning and were 11 times more likely to have a reduced suicidal

urgency at end of call than beginning.

113

Further, among Veterans who had suicidal thoughts who called VCL, 82.6%

reported that using VCL played a role in stopping them from acting on those thoughts.

114

In addition to the significant expansion of crisis services through VCL, under section 201 of the COMPACT Act, most

Veterans, including those not traditionally eligible for VHA health care, who experience an acute suicidal crisis can go to

any VA or non-VA health care facility for emergent suicide care at no cost — including inpatient or crisis residential care

for up to 30 days and outpatient care for up to 90 days. Like VCL, these services do not require VA enrollment, increasing

access to acute suicide care for all eligible Veterans. Since the launch in January 2023 through August 20, 2023, 30,674

Veterans have received care under the provisions of the COMPACT Act.

115

There has been a tremendous expansion of

access for Veterans in times of crisis both with the COMPACT Act and with the implementation of 988. Yet more must be

done to reach Veterans prior to the time of crisis, which includes laying a foundation for early prevention efforts through

work in the community.

Reection: Crisis Intervention

Summary: Despite the signicant expansion of crisis services through the Veterans Crisis Line and the COMPACT Act,

more work remains with each of you. Many Veterans are not aware that these services are available to them 24/7/365

— and at no cost. With nancial stressors being a critical suicide risk factor, we must ensure Veterans not only know

about the service but that it is free of charge.

What You Can Do: More upstream communications are needed to reach Veterans and their loved ones, reminding

them of support available to them at any time. Help is needed to spread the word about VCL and the COMPACT Act

emergency suicide prevention services by saving 988 (then Press 1) in your phones and using your social media

platforms and local connections to spread the word about VCL and the COMPACT Act.

113

Dichter ME, Krishnamurti LS, Chhatre S, Hoffmire CA, Monteith LL, Bellamy SL, Iverson KM, Montgomery AE, Agha A, McCoy I. 2022. Gender

Differences in Veterans’ Use of the Veterans Crisis Line (VCL): Findings from VCL Call Data. General Hospital Psychiatry. 74:65-70. https://doi.

org/10.1016/j.genhosppsych.2021.12.006

114

Britton PC, Karras E, Stecker T, Klein J, Crasta D, Brenner LA, Pigeon WR. 2022. Veterans Crisis Line Call Outcomes: Distress, Suicidal Ideation, and

Suicidal Urgency. American Journal of Preventive Medicine. 62(5):745-751.

https://doi.org/10.1016/j.amepre.2021.11.013

115

This data is based on notifications, claims, and visits and includes both VA direct care and VA authorized community care.

Improve Tailoring of Prevention and Intervention Services to the Needs, Issues,

and Resources Unique to Veteran Subpopulations

The Veteran population is made up of diverse racial and ethnic groups, with minorities currently comprising 26% of

the Veteran population with expectations to rise to 40% by 2040.

116

Women Veterans are likewise a growing Veteran

population, comprising 4% of the Veteran population in 2000 and forecasted to make up 18% of the Veteran population

by 2040. Further, 43% of women utilizing VHA services in FY 2020 belonged to a racial or ethnic minority group.

117

Rural

Veterans comprise approximately 34% of the VHA population and there is an estimated 1 million Veterans who identify

as LGBTQ+.

118,119,120

It is important to note that Veterans are not uni-dimensional in their identity, but rather are defined

by multiple dimensions (e.g., age, race, gender, disability status, rurality, etc.), with each factor impacting their daily

experiences. This intersectionality of diversity is important to attend to as we adapt suicide prevention services for each

Veteran. Focused work is required to study the specific suicide risk factors for each subpopulation and to create suicide

prevention interventions to meet the unique needs for each subpopulation.

121

Below we describe efforts focused on

meeting the diverse needs of Veterans in 2021 and beyond.

Communication and Outreach

The launch of a new PSA for the 2023 Suicide Prevention Month with the “Don’t wait. Reach out.” campaign continued

the ongoing focus of reaching the diverse population that make up America’s Veterans (across age, gender, race, and

ethnicity) through PSA placements in donated media, outreach, influencer engagement and other communication

strategies. Since its first launch in 2021, over 2.8 million Veterans are aware of the campaign and have taken action to

reach out for help. To date, the PSAs have secured over $40 million in donated media support, resulting in more than

3.5 million visits to VA.gov/REACH. Phase II of the national secure firearm storage communication campaign is being

prepared for launch in 2024, continuing a similar focus of designing PSAs to speak to the diverse subpopulations

comprising Veterans across the Nation. This includes specific focus on Veteran subpopulations, particularly those at

higher risk for suicide, including, but not limited to, women Veterans under age 35-years-old, Veterans 18- to 34-years-

old, American Indian or Alaska Native Veterans, Asian American Pacific Islander Veterans, LGBTQ+ Veterans, rural

Veterans, survivors of military sexual trauma and White male Veterans over the age of 55-years-old.

Community Prevention

With the implementation of the Staff Sergeant Fox Suicide Prevention Grant Program (SSG Fox SPGP), VA awarded 80

grants in 43 states, the District of Columbia and American Samoa for services in FY 2023. In awarding grants under the

program, VA prioritized funding of applications to organizations that proposed to serve eligible individuals and their

families in rural communities, on tribal lands, in U.S. territories, in medically underserved areas, in areas with a high

number or percentage of minority Veterans or women Veterans and in areas with a high number or percentage of

calls to VCL. Twenty-one grantees are furnishing services specifically across tribal lands, including: the Navajo Nation,

Cherokee Nation, and Choctaw Nation under this inaugural round of funding. In addition to significantly advancing

the reach to diverse Veteran populations through the SSG Fox SPGP, the ongoing expansion of the CBI-SP work to all

50 states, 5 territories and over 1,700 coalitions also provided the opportunity to reach a larger population of Veterans.

116

National Veteran Health Equity Report (https://vha-healthequity.shinyapps.io/NVHER_Shiny).

117

Facts and Statistics - Women Veterans Health Care (va.gov).

118

LGBTQ+ refers to lesbian, gay, bisexual, transgender, and queer identities. The “+” sign captures identities beyond LGBTQ, including but not limited

to questioning, pansexual, asexual, agender, gender diverse, nonbinary, gender-neutral, and other identities.

119

Washington DL (ed). National Veteran Health Equity Report 2021. Focus on Veterans Health Administration Patient Experience and Health Care Quality.

Washington, DC: VHA Office of Health Equity; September 2022.

120

VA LGBTQ+ Veterans (dav.org).

121

Ramchand R, Gordon JA, Pearson JL. Trends in Suicide Rates by Race and Ethnicity in the United States. JAMA Netw Open. 2021;4(5):e2111563.

doi:10.1001/jamanetworkopen.2021.11563.

One of the unexpected yet positive outcomes of the local and state suicide prevention work is the broad and diverse

groups engaging, with almost 95% of local coalition membership coming from non-VHA sources. Key members include

a diverse set of individuals from faith-based groups, local government, education, media, community wellness, health

care, business, and public safety along with traditional collaborators focused on mental health. This is resulting in

strong coalitions, driven by the community, with broad representation that can bring additional resources to the work

and address upstream prevention before the point of crisis. CBI-SP is also supporting more than 300 VA employees

both locally, at the Veterans Integrated Service Network (VISN) level and nationally devoted to implementing the CBI-

SP program at all levels by providing technical assistance, education, training, public health expertise and community

coalition facilitation support to local and state efforts. By focusing on supporting local efforts, VA helps communities

adapt evidence-informed models to local opportunities and resources and plan interventions that fit the community

and the diverse populations they serve. In FY 2024, VA looks forward to continuing to support communities, applying

lessons learned, and moving towards broader coverage of Veteran populations, including specific sub-populations, with

coalitions moving to implementation of strategies.

Research and Innovation

In 2023 and beyond, VA Suicide Prevention continued expansion of its funding of demonstration projects, research, and

innovation to support meeting the needs of a diverse population. This included a process for prioritizing several high-

risk for suicide populations and broader subpopulations for which additional research and intervention development

is needed: Asian American and Pacific Islander Veterans, American Indian and Alaskan Native Veterans, Veterans with

co-morbid medical conditions that increase suicide risk (e.g., non-mental health drivers of services to high-risk Veterans),

LGBTQ+, Older Veterans, Transitioning Service Members (TSM), Women Veterans, Black Veterans, Hispanic Veterans and

younger Veterans (aged 18- to 34-years-old). In particular, VA will be moving forward with a study of the adaptation of

suicide prevention evidence-based treatments for effective delivery of these treatments within diverse subpopulations,

with specific study of treatments, such as: Cognitive Behavioral Therapy for Suicide Prevention, Problem Solving Therapy

for Suicide Prevention and Dialectical Behavioral Therapy for Suicide Prevention. Additional efforts are underway for

the development and delivery of Lethal Means Safety interventions with older Veterans, Veterans aged 18- to 34-years-

old, caregivers and concerned others. This research will include efforts to understand the unique drivers of suicide

risk and effective approaches for serving Asian American and Pacific Islander Veterans, defining methods for reducing

firearm risks among Veterans with substance use disorders, the most effective outreach and engagement methods to

reduce suicide risk among American Indian and Alaska Native Veterans, risk reduction strategies for homeless Veterans,

establishing suicide risk reduction outreach strategies for LGBTQ+ Veterans, collaboration opportunities with firearm

retailers to promote and provide out-of-home firearm storage options and transitioning Service member risk reduction

strategies. Please see Appendix A for a full listing of all projects.

Additionally, VA’s Suicide Prevention Research Impact NeTwork (SPRINT) continues its critical work to accelerate VA

suicide prevention research to improve care and reduce suicidal thoughts and behaviors among Veterans. In the coming

year, SPRINT is specifically focusing studies upon the following 4 Veteran groups to advance efforts: younger Veterans,

women Veterans, underserved Veterans and minority Veterans, including those from disadvantaged groups. In 2023,

VA also announced the final winners of Mission Daybreak, VA’s $20 million suicide prevention grand challenge. Sourcing

outside entities, such as academia, industry experts, nonprofits, and community organizations, can improve Veteran

suicide prevention efforts by providing platforms to engage solutions for a multifactorial problem. This open innovation

program created an opportunity for a diversity of solvers, including Veterans, researchers, technologists, advocates,

clinicians, and health innovators, to offer solutions for Veteran suicide prevention. One of the 2 first-place winners,

Televeda’s Project Hózhó, developed the first mental health app for American Indian and Alaska Native populations in

collaboration with American Indian and Alaska Native communities and communities for Navajo Veterans.

Clinical Innovation

In addition to the efforts in Diversity, Equity and Inclusion (DEI) communication and outreach, community prevention

and research and innovation, VA worked extensively to incorporate DEI principles within its rollout of Suicide Prevention

2.0 Clinical Telehealth.

122

DEI subject matter experts (SME) worked in collaboration with each suicide prevention

evidence-based psychotherapy (SP-EBP) training program, and provided feedback related to training materials (e.g.,

didactic PowerPoint slides, training videos, case formulation templates) and practices (e.g., workshops, case-based

consultation meetings). SMEs participated in training events and actively collaborated in the creation or review/audit

of materials. Each SP-EBP training program implemented DEI SME recommendations related to training components

(e.g., checklist to promote awareness of one’s own cultural biases; rehearsal of positionality statements; considerations

of disability accommodations; video recordings demonstrating cultural discussions in both the therapeutic setting and

in the therapist-training context; integration of DEI elements in training PowerPoint slides; provision of theoretical and

empirical literature regarding cultural considerations in the context of suicide prevention, etc.). Ongoing efforts are

underway to translate SP-EBP training material to Spanish.

Reection: Suicide Prevention Eorts for Diverse Populations

Summary: A one-size-ts-all approach will not be eective in meeting the needs of the diverse Veteran population.

Ongoing work is needed to ensure prevention and intervention frameworks are modied in a culturally appropriate

manner to meet the unique needs of each population in the broader Veteran community, not just those engaged in

VHA or VBA services.

What You Can Do: If you are a researcher with expertise in suicide prevention focused on meeting the needs of

diverse populations, reach out to VA’s Suicide Prevention Research Impact NeTwork (SPRINT) to discuss potential

opportunities for joint research. VA also collaborates with external organizations in research through the VA

Partnered Research Program. If you are part of an organization providing suicide prevention services in a diverse

subpopulation of Veterans, consider submitting a future application to the Sta Sergeant Parker Gordon Fox Suicide

Prevention Grant Program. If you are a Veteran, consider visiting the Make the Connection website, where you can

search for Veterans from diverse backgrounds and experiences and hear their personal stories of hope and resilience.

122

Program described further in the latter part of this report.

Part 2: Veterans with VHA or VBA Contact

This section of the report provides information regarding suicide among Veterans who have had contact with VHA and

among Veterans who have had contact with VBA.

123

Findings include suicide rates for annual cohorts of Veterans who received VHA health care

124

in the year or prior year,

who in this report are described as “Recent Veteran VHA Users” or as “VHA Veterans”, including by demographic and clinical

subgroups, rurality, VHA enrollment, and VA eligibility priority groups. Rates are also included for Veterans by receipt of

VBA benefits and for Veteran subgroups defined by receipt of VBA or VHA services. For Veterans who died from suicide in

2021, we report on points of VA contact, including receipt of VHA health care, VHA enrollment and receipt of VBA services.

Veterans Health Administration (VHA) Health Care

VHA Health Care Engagement, 2001–2021

From 2001 to 2021, the Veteran population decreased by 27.0%. Over these years, VA continued to expand health care

eligibility

125

and there were substantial increases in Veteran receipt of VHA health care. Despite decreases in the overall

Veteran population, the number of Veterans with VHA health care encounters in the year or prior year (Recent Veteran

VHA Users) rose 52.8%, from 3.8 million in 2001 to 5.9 million in 2021. In 2021, Recent Veteran VHA Users accounted for

31.2% of all Veterans, up from 14.9% in 2001.

Prior studies report differences between Veterans with versus without VHA health care services utilization. For example,

Veterans receiving VHA care are more likely to be unmarried, smokers and from minority populations, with less

education, lower annual incomes, poorer self-reported health status,

126

more chronic medical conditions

127

and self-

reported disability due to physical or mental health factors,

128

greater depression and anxiety,

129

and greater reporting

123

VHA delivers health services for Veterans. VBA supports Veterans in 5 areas of benefits and entitlements: Compensation and Pension; Education;

Home Loan Guaranty; Insurance; and Veteran Readiness and Employment.

124

VHA health care receipt is here defined as having at least 1 VHA inpatient or outpatient utilization record, per VHA Corporate Data Warehouse

records. VHA health care is regarded “as good as or better than non-VA care in terms of clinical quality and safety.” Apaydin EA, Paige NM,

Begashaw MM, Larkin J, Miake-Lye IM, Shekelle PG. 2023. Veterans Health Administration (VA) vs. non-VA Healthcare Quality: A Systematic

Review. J Gen Intern Med. doi: 10.1007/s11606-023-08207-2. O’Hanlon C, Huang C, Sloss E, et al. 2016. Comparing VA and non-VA Quality of Care:

A Systematic Review. 32(1):105-121.

125

For example, the National Defense Authorization Act of 2008 extended the period of eligibility for health care for Veterans who had served in a

theater of combat operations after 11/11/1998 to 5 years following discharge or release. Qualifying Veterans would be eligible for enrollment in Priority

Group 6 unless eligible for enrollment in a higher priority group. https://www.va.gov/healthbenefits/assets/documents/publications/FS16-4.pdf

126

Agha Z, Lofgren RP, VanRuiswyk JV, Layde PM. 2000. Are Patients at Veterans Affairs Medical Centers Sicker? A Comparative Analysis of Health

Status and Medical Resource Use. Arch Intern Med. 160:3252-3257.

127

Dursa EK, Barth SK, Bossarte RM, Schneiderman AI. 2016. Demographic, Military, and Health Characteristics of VA Health Care Users and Nonusers

Who Served in or During Operation Enduring Freedom or Operation Iraqi Freedom, 2009–2011. Public Health Reports. 131(6):839-843.

128

Nelson KM, Starkebaum GA, Reiber GE. 2007. Veterans Using and Uninsured Veterans Not Using Veterans Affairs (VA)

Health Care. Public Health Rep. 122:934-100.

129

Fink DS, Stohl M, Mannes ZL, Shmulewitz D, Wall M, Gutkind S, Olfson M, Gradus J, Keyhani S, Maynard C, Keyes KM, Sherman S, Martins S, Saxon

AJ, Hasin DS. 2022. Comparing Mental and Physical Health of U.S. Veterans by VA Healthcare Use: Implications for Generalizability of Research in the

VA Electronic Health Records. BMC Health Services Research. 22:1500 https://doi.org/10.1186/s12913-022-08899-y

of trauma, lifetime psychopathology and current suicidality.

130

To inform Veteran suicide prevention approaches —

including clinical-and community-focused initiatives — we continue to work to understand trends in suicide mortality

among Recent Veteran VHA Users and among Other Veterans.

Suicide Deaths

Figure 19 presents the annual number of Veteran suicide deaths, 2001–2021, and the percentage among Recent Veteran

VHA Users (“VHA Veterans”) and Other Veterans.

Among Veteran suicide decedents, the percentage with Recent VHA encounters increased from 26.2% in 2001 to 38.1% in

2021. From 2019 to 2021, the percentage of Veteran suicide decedents with Recent VHA encounters fell from 38.3% to 38.1%.

Figure 19: Veteran Suicide Decedents, Number and Percentage With and Without Recent VHA Health Care

Encounters,

131

2001–2021

130

Meffert BN, Morabito DM, Sawicki DA, Hausman C, Southwick SM, Pietrzak RH, Heinz AJ. 2019. U.S. Veterans Who Do and Do Not Utilize VA Health

Care Services: Demographic, Military, Medical, and Psychosocial Characteristics. Primary Care Companion CNS Disorders. 21(1):doi:10.4088/

PCC.18m02350.

131

With a VHA health care encounter in the year of interest or the prior year.

VHA Veterans Other Veterans

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021

Number

7,000

6,000

5,000

4,000

3,000

2,000

1,000

26%

28%

27%

29% 28%

30%

29%

30%

29%

30%

33% 33%

34%

35%

36% 35%

36%

38%

39% 38%

74%

72%

73%

71%

72% 70%

71%

70%

71%

70%

67%

66%

66% 65%

64%

65%

64%

62%

61%

62%

Suicide Rates

Table 3 presents changes in suicide rates from 2001 to 2021 and from 2020 to 2021 for age- and sex-subgroups of Recent

Veteran VHA Users

132

and Other Veterans.

Table 3: Suicide Rate per 100,000,

133

Change from 2001 to 2021 and from 2020 to 2021, Veteran VHA Users

and Other Veterans, by Sex and Age

134

2001 2021 Change 2020 2021 Change

Recent Veteran VHA Users

Men

Aged 18–34 35.6 71.5 +100.1% 73.0 71.5 -1.9%

Aged 35–54 52.1 50.9 -2.3% 44.3 50.9 +14.9%

Aged 55–74 36.5 33.2 -9.0% 33.4 33.2 -0.6%

Aged 75+ 43.9 50.3 +14.6% 55.0 50.3 -8.6%

Women

Aged 18–34 -- 40.5 -- 23.8 40.5 +70.6%

Aged 35–54 17.2 21.6 +25.6% 13.4 21.6 +61.9%

Aged 55–74 -- 12.1 -- 16.1 12.1 -24.9%

Aged 75+ -- -- -- -- -- --

Other Veterans

Men

Aged 18–34 25.5 49.9 +95.5% 44.9 49.9 +11.2%

Aged 35–54 25.9 34.3 +32.4% 32.4 34.3 +6.1%

Aged 55–74 14.2 30.7 +116.6% 27.2 30.7 +12.8%

Aged 75+ 23.8 25.6 +7.7% 27.8 25.6 -7.8%

Women

Aged 18–34 7.3 18.2 +150.1% 18.1 18.2 +1.0%

Aged 35–54 13.4 17.2 +27.7% 15.4 17.2 +11.5%

Aged 55–74 -- 15.5 -- 10.3 15.5 +50.4%

Aged 75+ -- -- -- -- -- --

132

Among Recent Veteran VHA Users between ages 55- and 74-years-old, overall, the suicide rate fell from 2020 to 2021 by 2.2% (-0.6% for men and

-24.9% for women).

133

As rates are specific to age- and sex-subgroups, adjustment was not applicable.

134

Rates are suppressed if there were fewer than 10 suicide deaths, and rates are more variable for smaller Veteran subpopulations.

Figure 20 presents age- and sex-adjusted suicide rates among Veterans overall, Recent Veteran VHA Users (“VHA

Veterans”), Other Veterans, and non-Veteran U.S. adults, 2001–2021.

Figure 20: Age- and Sex-Adjusted Suicide Rates, Veterans, Overall and by Recent VHA Care, and Non-

Veteran U.S. Adults, 2001–2021

• Age- and sex-adjusted suicide rates were higher among Recent Veteran VHA Users (VHA Veterans) than for

Other Veterans.

• From 2001 to 2021, age- and sex-adjusted rates increased by 40.1% for Recent Veteran VHA Users and by 73.7%

among Other Veterans.

• From 2020 to 2021, adjusted rates among Recent Veteran VHA Users increased by 13.9% and rates among Other

Veterans increased by 10.2%.

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

2020 2021

Age- and Sex-Adjusted Rate per 100,000

Veterans VHA Veterans Other Veterans Non-Veteran Adults

Figure 21 highlights age- and sex-adjusted suicide rates for Recent Veteran VHA Users and for Other Veterans, 2001–2021,

including 95% confidence intervals. Rates were higher for Recent Veteran VHA Users than for Other Veterans.

Figure 21: Age- and Sex-Adjusted Suicide Rate, with 95% Confidence Interval, Veterans, by Recent VHA Use,

2001–2021

Table 4 presents comparisons, by sex, of age-adjusted suicide rates, for 2021 and 2001 and for 2021 and 2020.

Adjusted rates rose substantially from 2001 to 2021 for Recent Veteran VHA Users and for Other Veterans. From 2020 to

2021, age-adjusted rates rose for Recent Veteran VHA Users and for Other Veterans.

Table 4: Age-Adjusted Suicide Rate per 100,000, Change from 2001 to 2021 and from 2020 to 2021, Veteran

VHA Users and Other Veterans, by Sex

2001 2021 Change 2020 2021 Change

Recent Veteran VHA Users

Men 43.1 53.6 +24.5% 51.9 53.6 +3.4%

Women 13.4 25.2 +87.1% 16.8 25.2 +49.8%

Other Veterans

Men 23.2 37.7 +62.6% 34.8 37.7 +8.3%

Women 8.3 16.1 +93.7% 14.4 16.1 +12.1%

• For Veteran men with recent VHA care, the age-adjusted rate rose by 3.4% from 2020 to 2021, while for Veteran

women with recent VHA care, the age-adjusted suicide rate rose by 49.8%.

135

• From 2001 to 2021, age-adjusted suicide rates rose 24.5% for male Veterans with Recent VHA use and 62.6% for male

Veterans without Recent VHA use. Age-adjusted suicide rates rose 87.1% for female Veterans with recent VHA use

and 93.7% for female Veterans without Recent VHA use.

135

Due to increases in suicides among women Recent Veteran VHA Users between ages 18–54 and those aged 75 and older. Given the relatively smaller

population size for women Veterans in VHA care, there is greater variability in rates from year to year.

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

2020 2021

Age- and Sex-Adjusted Rate per 100,000

VHA Veterans Other Veterans

Marital Status

Figure 22 presents suicide rates among Recent Veteran VHA Users by marital status.

136

In each year, suicide rates were lowest among Recent Veteran VHA Users who were married, compared to those with

other categories of marital status.

Figure 22: Unadjusted Suicide Rate, Recent Veteran VHA Users, by Marital Status, 2001–2021

Mental Health and Substance Use Disorder Diagnoses

Ensuring access to mental health and substance use disorder (SUD) services is a VHA priority and part of VA’s National

Strategy for Preventing Veteran Suicide (2018).

137

The prevalence of VHA mental health or SUD diagnoses among annual cohorts of Recent Veteran VHA Users was 27.8% in

2001; 40.7% in 2019; and then 41.7% and 41.9% in 2020 and 2021, respectively.

138

• Among annual cohorts of Recent Veteran VHA Users who died from suicide, VHA mental health or SUD diagnoses

were documented for 56.1% of those who died in 2001; 59.4% of suicide decedents in 2019; 58.0% of suicide

decedents in 2020; and 60.9% of suicide decedents in 2021.

• Among those who died from suicide in 2021, the prevalence of depression diagnoses was 38.4%, anxiety 27.6%,

posttraumatic stress disorder (PTSD) 25.4%, alcohol use disorder 19.7%, bipolar disorder 8.7%, cannabis use disorder

8.4%, opioid use disorder 4.2%, personality disorder 4.2% and schizophrenia diagnoses 3.5%.

• Conversely, 39.1% of Recent Veteran VHA Users who died from suicide in 2021 did not have a documented VHA

mental health or SUD diagnosis.

• The suicide rate among cohorts of Recent Veteran VHA Users with mental health or SUD diagnoses fell from 77.8 per

136

Per VHA visit records, using the most recent status in the year or prior year. Excludes those with unknown marital status.

137

https://www.mentalhealth.va.gov/suicide_prevention/docs/Office-of-Mental-Health-and-Suicide-Prevention-National-Strategy-for-Preventing-

Veterans-Suicide.pdf. (Accessed 7/10/2023)

138

Diagnoses were assessed in the year or prior calendar year. An individual’s likelihood of having a documented diagnosis may vary by the

number of VHA health care contacts in the relevant period. VHA transitioned from International Classification of Diseases, Ninth Revision, Clinical

Modification (ICD-9-CM), to ICD-10-CM diagnosis codes on Oct. 1, 2015. Diagnoses were not mutually exclusive, and analyses do not adjust for

demographic differences or comorbidities.

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

2020 2021

Rate per 100,000

Single or Never Married

Married

Divorced or Separated

Widowed

100,000 in 2001 to 58.2 per 100,000 in 2021. In 2019, prior to the COVID-19 pandemic, the rate was 57.2 per 100,000.

This fell to 55.5 per 100,000 in 2020 and then rose to 58.2 per 100,000 in 2021. By contrast, the rate among Recent

Veteran VHA Users who did not have documented mental health or SUD diagnoses rose from 25.5 per 100,000 in

2001 to 28.5 per 100,000 in 2021. This rose from 28.0 per 100,000 in 2019 to 29.7 per 100,000 in 2020, then fell to 28.5

per 100,000 in 2021.

• Trends in rates varied by condition. From 2001 to 2021, suicide rates fell 25.2% for patients with mental health/SUD

diagnoses, while rising 12.0% for patients without documented mental health/SUD diagnoses.

• From 2001 to 2021, suicide rates fell for Recent Veteran VHA Users with diagnoses of:

• Sedative use disorder (-40.4%);

139

• Depression (-32.9%);

• PT SD (-27.6%);

• Anxiety (-26.9%);

• Alcohol use disorder (-12.6%);

• Substance use disorders (-9.9%);

• Personality disorder (-7.3%); and

• Schizophrenia (-4.2%).

• From 2001 to 2021, suicide rates rose for Recent Veteran VHA Users with diagnoses of:

• Bipolar disorder (+7.3%);

• Opioid use disorder (+21.1%);

• Cocaine use disorder (+50.9%);

• Cannabis use disorder (+17.0%); and

• Stimulant use disorder (+18.6%).

139

In 2001, there were 21 suicides among Recent Veteran VHA Users with sedative use disorder. In 2021, there were 29.

For 2021 and 2020 Recent Veteran VHA User cohorts, Table 5 presents the number of suicide deaths and unadjusted

suicide rates per 100,000.

• From 2020 to 2021, suicide rates rose for those with any mental health or SUD diagnosis and also for those with any

SUD diagnosis, while declining for patients without a mental health or SUD diagnosis.

Table 5: Suicide Deaths and Unadjusted Suicide Rates, Recent Veteran VHA Users, by Mental Health (MH)

and Substance Use Disorder (SUD) Diagnoses,

140

2020 and 2021

Diagnoses Suicide Deaths

Suicide Rates per 100,000

Person-Years

2020 2021 2020 2021 Rate Change

141

Without MH Condition/SUD 1,024 954 29.7 28.5 -1.1

With Any MH Condition/SUD 1,416 1,483 55.5 58.2 +2.7

Anxiety 625 673 64.8 67.9 +3.1

Bipolar disorder 184 212 111.5 131.0 +19.6

Depression 859 936 60.9 66.5 +5.6

Personality disorder 112 102 148.0 142.1 -5.8

Posttraumatic stress disorder 596 620 53.0 54.1 +1.1

Schizophrenia 109 84 123.6 100.0 -23.6

Substance Use Disorder 626 618 89.9 90.8 +0.9

Alcohol use disorder 478 480 90.2 93.2 +3.1

Cannabis use disorder 202 204 108.9 112.2 +3.4

Cocaine use disorder 67 70 74.9 86.1 +11.1

Opioid use disorder 119 102 133.2 119.1 -14.1

Sedative use disorder 33 29 185.9 180.4 -5.5

Stimulant use disorder 93 95 159.9 177.7 +17.8

140

Diagnosis categories are not mutually exclusive.

141

Change in suicide deaths per 100,000; these were calculated using non-rounded numbers.

Homelessness

Figure 23 presents suicide rates among annual cohorts of Recent Veteran VHA Users, by homelessness status,

142

2001–2021.

• In each year, the unadjusted suicide rate of Recent Veteran VHA Users with indications of homelessness was

elevated compared to those without indications of homelessness.

• In 2001, the suicide rate for Recent Veteran VHA Users with indications of homelessness was 72.8% higher

than for those without indications of homelessness.

• In 2021, the suicide rate among homeless Recent Veteran VHA Users was 186.5% higher than for those

without indications of homelessness.

• In 2021, the unadjusted suicide rate among Recent Veteran VHA Users with indications of homelessness was 62.4%

higher than in 2001, 30.5% higher than in 2019, and 38.2% higher than in 2020.

Figure 23: Unadjusted Suicide Rate, Recent Veteran VHA Users, by Homelessness Status, 2001–2021

Veterans Justice Programs

Among Veterans in VHA care, those with legal system involvement are at increased risk of suicide-related behavior.

143

VHA

connects with Veterans who are at various points in the legal system, through Veterans Justice Programs. These support

Veterans in prison through the Health Care for Re-Entry Veterans (HCRV) Program and they support Veterans in courts,

jails, and law enforcement settings through the Veterans Justice Outreach (VJO) program.

142

Homelessness is identified using ICD-9 Code V60.0 and ICD-10 Code Z59.0 recorded during encounters at VA hospitals. Though additional

methods exist to identify homelessness status among VA patients (Tsai J, Szymkowiak D, Jutkowitz E. 2022. Developing an Operational Definition

of Housing Instability and Homelessness in Veterans Health Administration’s Medical Records. PLOS ONE.17(12):e0279973.) ICD codes were a

consistently available indicator across the years 2001–2021. We considered individuals as having an indication of homelessness if they had an ICD

code during an encounter in the year or year prior.

143

Palframan KM, Blue-Howells J, Clark SC, McCarthy JF. 2020. Veterans Justice Programs: Assessing Population Risks for Suicide Deaths and Attempts.

Suicide and Life-Threatening Behavior. 50(4):792-804.

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

120

100

2020 2021

Rate Per 100,000 Person-Years

Homeless Without Homelessness Indication

Figure 24 presents information on suicide rates among annual cohorts of Recent Veteran VHA Users who received

services through the HCRV or VJO programs.

• In each year, suicide rates for Recent Veteran VHA Users were elevated among those with Veterans Justice Program

services compared to those without such contact.

• The suicide rate for recipients of Veterans Justice Program services was 10.2% higher in 2021 than in 2020, while

rising 1.8% for other Veterans in VHA care.

Figure 24: Unadjusted Suicide Rate, Recent Veteran VHA Users, by Receipt of Veterans Justice Program

Services, 2010–2021

144

Assessed per VHA outpatient encounters codes 591 (Health Care for Re-Entry Veterans) or 592 (Veterans Justice Outreach) or with encounters for

which “Justice Outreach” was identified as the activity type. We considered individuals as having receipt of Veterans Justice Program services if

they had these encounters in the year or year prior.

2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

160

140

120

100

20212020

Rate per 100,000 Person-Years

Other VeteransWith Veterans Justice Program Contact

Rurality

• Among Recent Veteran VHA Users, suicide rates were elevated for residents of rural areas, compared to urban

areas (Figure 25). For example, in 2021 for individuals in rural or highly rural areas, the rate was 44.3 per 100,000,

and it was 40.0 per 100,000 for those in urban areas. These differences may be partly attributed to demographic

differences among Veteran VHA Users, by rurality status.

145

• For Recent Veteran VHA Users in rural areas, rates rose from 2019 to 2020 (43.5 per 100,000 to 44.9 per 100,000) then

fell to 44.3 per 100,000 in 2021.

• For Recent Veteran VHA Users in urban areas, rates rose from 38.6 per 100,000 in 2019 to 38.7 per 100,000 in 2020

and to 40.0 per 100,000 in 2021.

Figure 25: Unadjusted Suicide Rate Per 100,000 Person-Years, Recent Veteran VHA Users, By Urban, Rural

or Highly Rural Status, 2001–2021

Gender Identity

VA is continuing work to enhance data resources to inform suicide prevention for Veteran subgroups by gender identity.

Self-identified gender identity remains the best approach for ascertaining gender identity, including transgender

identity. However, current systems are not yet sufficiently developed for comprehensive reporting. Transgender Veterans

— whose gender identity differs from the identity assumed by their assigned sex at birth — in VHA care are at increased

risk for suicidal ideation

146

and non-fatal suicide attempts.

147

For this report, we assessed a measure of transgender

identity using diagnosis indicators

148

linked to transgender identity that are most often used in the context of gender-

affirming therapy.

149

145

Peltzman T, Gottlieb DJ, Levis M, Shiner B. 2022. The Role of Race in Rural-Urban Suicide Disparities. Journal of Rural Health. 38[2]:346-354.

146

https://www.va.gov/HEALTHEQUITY/docs/LGBT_Veterans_Disparities_Fact_Sheet.pdf

147

Blosnich JR, Boyer TL, Brown GR, Kauth MR, Shipherd JC. 2021. Differences in Methods of Suicide Death Among Transgender and Nontransgender

Patients in the Veterans Health Administration, 1999-2016.59:S31-S35.

148

Diagnoses related to gender identity include ICD-9-CM codes 302.5, 302.6, and 302.85 and ICD-10-CM codes F64 and Z87.890.

149

This approach likely undercounts the number of transgender Veterans in VHA care.

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

2020 2021

Rate per 100,000 Person-Years

Rural or Highly RuralUrban

To enhance sensitivity of ascertainment, we generated annualized suicide rates for cohorts from 2011–2020, for suicide in

the year of interest through the end of the subsequent year, for Recent Veteran VHA Users with a VHA diagnosis related to

gender identity occurring in the year or the prior 3 years.

The number of Veteran VHA patients with diagnoses related to gender identity increased from 2,514 in 2011 to 9,218 in

2020 (Table 6), and the unadjusted annualized suicide rate fell from 267.9 per 100,000 person-years in 2011 to 84.6 per

100,000 person-years in 2020.

Table 6: Unadjusted Suicide Rate in Year and Following Year, Veteran VHA Users with Diagnoses in the Year

or Prior 3 Years Related to Gender Identity, 2011–2020

150

Year

Veteran VHA Patients

with Diagnoses Related to

Gender Identity in Year or

Prior 3 Years

Percentage of Veteran

VHA Users

Suicide Deaths

in Year

or Subsequent Year

Unadjusted Suicide Rate Per

100,000 Person-Years

2011 2,514 0.04% 13 267.9

2012 2,843 0.05% -- --

2013 3,311 0.05% -- --

2014 3,830 0.06% 10 134.7

2015 4,623 0.07% 12 133.1

2016 5,556 0.09% 11 101.7

2017 6,436 0.10% 17 136.1

2018 7,426 0.11% 17 117.9

2019 8,321 0.13% 16 98.5

2020 9,218 0.14% 15 84.6

VHA Priority Eligibility Groups

Veterans who apply for VHA care are assigned to 1 of 8 priority eligibility groups, which affect care costs.

151

Group status

is based on military service history, disability rating, income, Medicaid qualification and other factors.

150

Information is not presented when based on fewer than 10 suicide deaths. Note that suicide mortality is assessed for the year and the subsequent

year. For example, for the 2020 cohort, we assess suicide mortality in 2020 and in 2021.

151

https://www.va.gov/health-care/about-va-health-benefits/cost-of-care/ (Accessed 7/12/2023).

Table 7 presents unadjusted suicide rates per 100,000 person-years for annual cohorts of Veteran VHA Users, 2011–2021.

152

Table 7: Unadjusted Suicide Rates, Enrolled Recent Veteran VHA Users, by VHA Priority Eligibility Group,

2011–2021

Suicide Rate per 100,000 Priority Eligibility Group Criteria

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021

Group 1

36.1 39.4 38.3 39.5 41.8 38.8 38.8 39.7 40.3 39.9 40.2

Service-connected disability rated as 50% or more

disabling, or have service-connected disability that

makes one unable to work, or received the Medal

of Honor.

Group 2

31.9 33.1 28.6 32.3 27.7 30.1 29.1 33.7 29.5 33.5 32.6

Service-connected disability rated as 30% or

40% disabling.

Group 3

36.8 28.5 29.7 29.7 31.9 31.9 32.9 32.9 34.6 28.8 31.6

Former prisoner of war, or received the Purple

Heart medal, or were discharged for a disability

that was caused by — or got worse because of —

one’s active-duty service, or service-connected

disability rated as 10% or 20% disabling, or

awarded special eligibility classication under Title

38, U.S.C § 1151, "benets for individuals disabled

by treatment or vocational rehabilitation."

Group 4

25.5 41.5 24.9 43.0 45.3 48.7 37.8 39.0 42.2 44.9 38.7

Are receiving VA aid and attendance or

housebound benets, or received a VA

determination of being catastrophically disabled.

Group 5

51.7 47.9 49.7 51.3 49.4 51.2 52.5 48.9 51.6 52.0 57.1

Do not have a service-connected disability, or have

a non-compensable service-connected disability

rated as 0% disabling, and have an annual income

level below our adjusted income limits (based

on resident ZIP code), or receiving VA pension

benets, or eligible for Medicaid programs.

Group 6

23.7 20.0 17.4 23.0 25.1 21.1 25.7 32.3 28.8 33.3 36.4

Have a compensable service-connected disability

rated as 0% disabling, or exposed to ionizing

radiation during atmospheric testing or during

the occupation of Hiroshima and Nagasaki, or

participated in Project 112/SHAD, or served in

the Republic of Vietnam between 1/9/1962 and

5/7/1975, or served in Persian Gulf War between

9/2/1990 and 11/11/1998, or served on active duty

at Camp Lejeune 30+ days between 8/1/1953 and

12/31/1987. VA may also assign a Veteran to priority

group 6 if they meet all of the requirements listed

below. Veterans are: Currently or newly enrolled in

VA health care, and served in a theater of combat

operations after 11/11/1998, or were discharged

from active duty on or after 1/28/2003, and were

discharged less than 5 years ago.

153

Group 7

41.8 33.4 37.4 35.8 39.9 44.9 35.7 36.0 44.7 33.5 47.7

Gross household income is below the

geographically adjusted income limits (GMT) for

where one lives and agrees to pay copays.

152

https://www.va.gov/health-care/eligibility/priority-groups/ Group 8 refers to subgroups A-D. Group 8EG (non-enrolled) is not reported, due to small

numbers for most years. In 2021, Veteran VHA Users in Group 8EG had 12 suicides and a suicide rate of 33.1 per 100,000 person-years. Reporting does not

include Veterans whose eligibility was categorized as No Priority. Per the VA Enrollment System Administrative Data Repository.

153

Returning combat Veterans are eligible for these enhanced benefits for five years after discharge. At the end of this enhanced enrollment period,

VA assigns Veterans to the highest priority group they qualify for at that time.

Suicide Rate per 100,000 Priority Eligibility Group Criteria

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021

Group 8

33.1 35.5 41.3 37.9 37.9 39.3 38.9 36.4 41.2 46.2 43.0

Gross household income is above VA income

limits and geographically adjusted income limits

for where one lives, and agree to pay copays.

Eligibility for VA health care benets will depend

on subpriority group.

• Each year from 2005–2021, rates were highest for Veterans in Group 5, which includes income-based eligibility.

• In 2021, the suicide rate per 100,000 was highest for Group 5 (57.1 per 100,000), followed by groups 7 (47.7 per

100,000), 8 (43.0 per 100,000), 1 (40.2 per 100,000), 4 (38.7 per 100,000), 6 (36.4 per 100,000), 2 (32.6 per 100,000) and

3 (31.6 per 100,000).

• From 2020 to 2021, suicide rates increased for groups 1 (+0.8%), 3 (+9.7%), 5 (+9.8%), 6 (+9.5%) and 7 (+42.2%), and

rates fell for groups 2 (-2.7%), 4 (-13.8%) and 8 (-6.9%).

• For Groups 5, 6 and 7, the suicide rates in 2021 were higher than in any of the prior 20 years.

• Figure 26 provides rates by age group for Recent Veteran VHA Users in Priority Group 5, 2001–2021.

154

Veterans

between ages 18- and 34-years-old in Priority Group 5 had the lowest suicide rate in 2001 (40.8 per 100,000) and the

highest suicide rate in 2021 (82.8 per 100,000). From 2020 to 2021, the suicide rate increased 18.3% for those aged

18- to 34-years-old, 36.8% for those aged 35- to 54-years-old, 0.6% for those aged 55- to 74-years-old and 12.0% for

those aged 75-years-old and older.

Figure 26: Unadjusted Suicide Rate, Enrolled Recent Veteran VHA Users in Priority Group 5, by Age Group,

2001–2021

154

For all other priority groups, reporting is unavailable by age groups in these years due to small numbers.

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

2020 2021

Rate per 100,000 Person-Years

18-34 55-74 75

35-54

Veteran All-Cause Mortality, Overall and by VHA Engagement

Figure 27 shows Veteran unadjusted all-cause mortality rates in the 3 years prior to the COVID-19 pandemic (2017–2019)

and in 2020 and 2021.

155

Understanding patterns of all-cause mortality over this period is helpful to understanding trends

in suicide risk factors, including medical morbidity and stressors, and patterns of risk across Veteran populations.

• All-cause mortality increased from 2017–2019 to 2020–2021.

• Consistent with reports of increased morbidity among Veterans who seek VHA care, all-cause mortality was greater

in all years for Recent Veteran VHA Users than for Other Veterans. These findings highlight the increased burdens

of morbidity and mortality among Veterans during the pandemic years and the greater morbidity and mortality

among Veterans who seek care from the VA health system.

Figure 27: Unadjusted All-Cause Mortality, Veterans, Overall and by VHA Engagement, 2017–2021

Similar patterns were observed with regard to age- and sex-adjusted all-cause mortality rates. For Veterans, these were

13.7% higher in 2020–2021 than in 2017–2019.

156

155

Unadjusted rates are presented here to document the magnitude of mortality increases in the pandemic years.

156

For Recent Veteran VHA Users, age- and sex-adjusted all-cause mortality rates were 13.7% higher in 2020–2021 than in 2017–2019, and for Other

Veterans, age- and sex-adjusted all-cause mortality rates were 13.0% higher in 2020–2021 than in 2017–2019.

Veterans Recent Veteran VHA Users Other Veterans

Rate per 100,000

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

20182017 2019

2020 2021

Leading Causes of Death, for Recent Veteran VHA Users and Other Veterans

Recent Veteran VHA Users

• Among Recent Veteran VHA Users in 2021, suicide was the 15th leading cause of death (Figure 28).

Figure 28: Top 10 Leading Causes of Death, and Suicide, in 2021, Recent Veteran VHA Users and Associated

Age-Adjusted Mortality Rates, 2019–2021

157

There is no comparison rate for 2019. COVID-19 deaths were identified based on underlying cause of death ICD-10 code U07.1, which was added as

a cause of death code in 2020.

0 100 200 300 400

(1) Heart Disease

(2) Cancer

(3) COVID-19

(5) Unintentional Injury

(6) Stroke

(7) Diabetes

(8) Alzheimer’s Disease

(9) Kidney Disease

(10) Parkinson’s Disease

(15) Suicide

(4) Chronic Lower Respiratory

Disease

Rate per 100,000

342.3

330.2

303.6

297.3

295.2

142.4

192.0

85.9

83.6

76.8

98.6

114.2

123.8

54.7

57.2

59.6

48.2

54.4

54.7

31.3

34.3

31.8

24.4

23.4

24.8

20.7

22.8

22.2

44.8

46.5

49.1

346.8

2019

2021

2020

Other Veterans

• Among Other Veterans in 2021, suicide was the 11th-leading cause of death (Figure 29).

Figure 29: Top 10 Leading Causes of Death, and Suicide, in 2021, Other Veterans and Associated Age-

Adjusted Mortality Rates, 2019–2021

158

• While sharing the same top 3 leading causes of death (heart disease, cancer, COVID-19), Recent Veteran VHA Users

and Other Veterans differed in the ranking of other leading causes of death.

• Despite suicide having a lower rank among leading causes for Recent Veteran VHA Users than for Other Veterans,

Recent Veteran VHA Users had a higher age-adjusted suicide mortality rate.

158

There is no comparison rate for 2019. COVID-19 deaths were identified based on underlying cause of death ICD-10 code U07.1, which was added as

a cause of death code in 2020.

2019

2021

2020

0 50 100 150 200 250

(1) Heart Disease

(2) Cancer

(3) COVID-19

(4) Stroke

(5) Chronic Lower Respiratory

Disease

(6) Unintentional Injury

(7) Alzheimer's Disease

(8) Diabetes

(9) Kidney Disease

(10) Parkinson’s Disease

(11) Suicide

Rate per 100,000

204.1

209.8

203.7

180.3

36.9

43.3

63.8

26.4

23.4

32.1

176.7

175.0

82.7

121.2

38.1

37.6

41.3

38.4

71.1

77.2

27.5

22.9

26.0

26.3

13.4

13.3

13.6

12.9

13.8

11.6

32.1

34.6

• For each of the leading causes listed, the age-adjusted mortality rate was greater among Recent Veteran VHA Users

than among Other Veterans.

159

For example, age-adjusted mortality rates in 2021 were:

Cause of Death Recent Veteran VHA Users Other Veterans

Heart disease 346.8 per 100,000 203.7 per 100,000

COVID-19 192.0 per 100,000 121.2 per 100,000

Unintentional injury 123.8 per 100,000 77.2 per 100,000

VA Community Care

Figure 30 presents unadjusted suicide rates among Veterans who received VHA direct care and Community Care

services

160

, by year, for 2020 and 2021.

161

• In both 2020 and 2021, suicide rates were highest for Veterans who received any Community Care services, followed

by Veterans who received any VHA care, and suicide rates were lowest among Veterans who did not receive either

Community Care or VHA care.

162

Figure 30: Unadjusted Suicide Rate, Veterans with Any Community Care and Veterans with Any VHA Care

163

in Year or Prior Year, 2020–2021

159

Differences may relate to greater prevalence of men among Recent Veteran VHA Users in older age groups than among Other Veterans. Among Recent

Veteran VHA Users aged 55-years-old and older, 93.5% were male, compared to 92.8% among Other Veterans aged 55-years-old and older.

160

Services receipt was measured by any care in the calendar year of interest or in the prior year.

161

The number of Veterans, by categories of receipt of VHA and VA Community Care in the year or prior year, were as follows for 2020 and 2021

(Counts are based on mid-year estimates.): Number of Veterans (Thousands)

2020 2021

VHA Direct Care Only 3,670 3,544

VHA Direct Care and Community Care 2,288 2,334

Community Care Only 94 111

Neither VHA Direct Care nor Community Care 13,225 12,851

162

The categories “Any Community Care” and “Any VHA Care” were not mutually exclusive.

163

Here and throughout this report, VHA care refers to VHA delivered care by VHA providers, also known as VHA direct care. Community Care refers to VA

purchased care. See: https://www.va.gov/COMMUNITYCARE/programs/veterans/CCN-Veterans.asp

2020 2021

Rate per 100,000

Neither VHA nor Community CareAny VHA CareAny Community Care

Figure 31 presents unadjusted suicide rates among Veterans by mutually exclusive categories of VHA direct care and VA

Community Care services receipt in the year or prior year, for 2020 and 2021.

In 2020 and 2021, among those receiving care through VHA, when comparing those solely receiving VA Community Care

services vs. those receiving VHA direct care services, Veterans who “received Community Care services only” had higher

suicide rates than those who “received VHA direct care alone.”

Figure 31: Unadjusted Suicide Rate, Veterans, by Mutually Exclusive Categories of VHA and VA Community

Care Services Receipt and for Any Community Care and Any VHA Care, by Year, 2020–2021

2020 2021

Rate per 100,000

VHA Only

Community Care Only

Community Care and VHA

Neither VHA nor Community Care

Veterans, by Receipt of VHA and VBA Services

Figure 32 presents the distribution of Veterans by categories of contact with VBA and VHA in the year or prior year, for

Veteran cohorts from 2019 to 2021.

164

• In 2021, nearly 6.9 million Veterans had some VBA contact, and over 5.8 million Veterans had some VHA contact in

2020 or 2021. This included over 1.9 million Veterans who only received VHA care (10.5%), over 3.0 million who only

received VBA services (16.0%) and nearly 3.9 million who received both VBA and VHA services (20.7%). In 2021, over

9.9 million Veterans (52.8%) had neither VBA nor VHA services in 2020 or 2021.

• From 2019 to 2021, the number of Veterans who received only VBA services in the year or prior year increased 12.7%,

the number receiving only VHA services fell by 14.0%, the number receiving both VBA and VHA services increased

by 0.5%, and the number receiving neither VBA nor VHA services decreased by 9.2%.

165

Figure 32: Number of Veterans, by Categories of VBA and VHA Contact

166

in the Year or Prior Year, 2019–2021

164

Analyses examined VBA data from 2018–2021, enabling assessment for 2019–2021.

165

From 2019 to 2021, the overall Veteran population fell 4.9%, from 19,817,000 to 18,841,000.

166

Counts are based on mid-year estimates.

2019 2020 2021

Number of Veterans

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

7,000,000

8,000,000

9,000,000

10,000,000

11,000,000

12,000,000

VHA and VBA

VHA Only VBA Only

Neither

Figure 33: Distribution of Veteran Population, Percentage, by VBA and VHA Contact

167

in Year or Prior Year,

2019–2021

167

Counts are based on mid-year estimates.

2019 2020 2021

Percentage

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

11.7%

19.5%

13.5%

55.3%

10.9%

20.0%

14.4%

54.7%

10.5%

20.7%

16.0%

52.8%

VHA and VBAVHA Only VBA Only

Neither

VBA Benefit Types Received, Percentage, Among Veterans with VBA Benefits,

2019–2021

Figure 34 provides information on types of VBA benefits received, for each of the 5 categories of VBA services, for cohorts

of Veterans who received some VBA services

168

in the year of interest or the prior year, for 2019–2021.

• In 2021, among VBA service recipients, most received VBA compensation and pension benefits (77.7%), followed

by home loan services (43.0%), educational benefits (9.2%), life insurance (5.6%) and Veteran Readiness and

Employment services (2.1%).

Figure 34: VBA Services Received,

169

Percentage, Veterans with VBA Services in Year or Prior Year,

2019–2021

168

https://benefits.va.gov/BENEFITS/about.asp. Also see description of VBA benefits, later in this report.

169

Veteran Readiness and Employment includes Chapter 31 benefit recipients, excluding those whose status at the beginning of the year was

“Applicant,” “Not Eligible,” “Rehabilitated,” “Interrupted” or “Discontinued.”

Percentage

Compensation

and Pension

Education Home Loan Life Insurance

Veteran Readiness

and Employment

2019 2020 2021

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

77.9%

37.5%

11.2%

2.0%

6.7%

79.1%

10.3%

2.2%

6.1%

77.7%

9.2%

43.0%

2.1%

5.6%

39.3%

Suicide Rates Among Veterans by Receipt of VBA or VHA Services

Figure 35 presents unadjusted suicide rates among Veterans by mutually exclusive categories of VHA and VBA services

receipt in the year or prior year, by year, from 2019 to 2021.

Suicide rates were highest among Veterans who only received VHA services, followed by those who received both VHA

and VBA services, then those who received neither VHA nor VBA services. Suicide rates were lowest among Veterans who

received VBA services and did not receive VHA services.

Figure 35: Unadjusted Suicide Rate, Veterans, by Mutually Exclusive Categories of VHA and VBA Services

Receipt,

170

by Year, 2019–2021

170

Suicide rates were calculated as the number of suicide deaths among individuals with that category of services receipt in the year or prior year,

divided by the mid-year population estimate of individuals with that category of services receipt, multiplied by 100,000.

2019 2020 2021

Rate per 100,000

VHA OnlyAll Veterans VHA and VBA

VBA Only Neither

44.1

37.7

32.7

30.4

25.0

30.4

22.8

22.4

32.6

33.9

33.0

37.5

38.5

47.2 47.3

Figure 36 presents age-adjusted suicide rates among Veterans who received VBA benefits, by sex and year, for 2019 to

2021. Consistent with overall Veteran suicide findings, rates were elevated among Veteran men compared to Veteran

women. Rates fell from 2019 to 2021 among Veteran men who had VBA engagement. Among Veteran women with VBA

engagement, age-adjusted suicide rates fell in 2020 and then rose in 2021 to levels comparable to those in 2019.

Figure 36: Age-Adjusted Suicide Rate, Veterans with VBA Benefits, by Sex and Year, 2019–2021

2019 2020 2021

Rate per 100,000

Male VeteransFemale Veterans

Suicide Decedents in 2021: Contacts with VHA and VBA

This section presents analyses regarding points of VA contact by Veteran decedents, including VHA health care

encounters, VHA enrollment and VBA contacts. We present findings for the 6,392 Veterans who died from suicide in

2021 (Figure 37).

Figure 37: Veteran Suicide Decedents in 2021, Sequential Mutually Exclusive Categories of VA Points of

Contact, Percentage and Average Suicides Per Day

171

Sequential mutually exclusive categories of VA points of contact are ordered from 1 to 5.

5. Veteran, no contact with

VHA or receipt of VBA benefits,

42.0%, 7.4 suicides per day

4. Veteran, any receipt of VBA

benefits in year of death or year prior,

4.1%, 0.7 suicides per day

3. VHA-enrolled Veteran, without VHA

encounters within past five years, 9.3%,

1.6 suicides per day

2. Veteran, had VHA encounter

within five years prior to death,

6.4%, 1.1 suicides per day

1. Veteran, had VHA encounter

in year of death or year prior,

38.1%, 6.7 suicides per day

17.5 Veteran Suicide Decedents per Day in 2021

Suicide Decedents, VBA Contact

Figure 38 shows the prevalence of VBA contact among annual cohorts of Veteran suicide decedents, 2019–2021. This rose

from 32.7% in 2019 to 33.9% in 2021.

Figure 38: VBA Contact in the Year or Year Prior, Percentage, Veteran Suicide Decedents, 2019–2021

Suicide Decedents with Recent VBA Contact, VBA Services Received

Figure 39: VBA Services Receipt, Percentage, Veteran Suicide Decedents with VBA Contact in the Year or

Year Prior to Death, 2019–2021

2019 2020 2021

40%

35%

30%

25%

20%

15%

10%

Percentage

32.7%

33.1%

33.9

2019 2020 2021

Percentage

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Compensation

or Pension

Home Loan

Veteran Readiness

and Employment

Education

Life Insurance

Suicide Decedents, Recent Veteran VHA Users with Behavioral Health Autopsy

Program Reviews

For Veterans, whose suicide deaths are reported to VHA suicide prevention teams,

172

the VA Behavioral Health Autopsy

Program (BHAP) gathers information that may help to prevent future suicides. Through BHAP, suicide prevention teams

perform standardized reviews of health records to identify factors relevant to Veteran suicides, considering all available

information.

173

VHA electronic health record reviews include assessment of clinical diagnoses and conditions (e.g., notes

regarding pain), life circumstances and psychosocial factors. Findings provide a unique resource for understanding the

characteristics and contexts of Veteran suicide deaths among Recent Veteran VHA Users.

174

Figure 40 presents the prevalence of documented risk factors in the year prior to death among 2,545 Recent Veteran VHA

Users whose suicide deaths occurred in 2019–2021 and were reported to VHA Suicide Prevention teams. Results are presented

in 5 domains, related to Risk Assessment, Stress, Interpersonal Factors, Death of Family or Friend and Health. The most

frequently identified risk factors were pain (55.9%), sleep problems (51.7%), increased health problems (40.7%), relationship

problems (33.7%), recent declines in physical ability (33.0%), hopelessness (30.6%) and unsecured firearms in the home (28.8%).

Figure 40: Documented Suicide Risk Factors, Percentage, Recent Veteran VHA Users Who Died by Suicide in

2019–2021 and Received BHAP Reviews

172

Palframan KM, Szymanski BR, McCarthy JF. 2021. Ascertainment of Patient Suicides by VA Facilities and Associations with Veteran, Clinical, and Suicide

Characteristics. American Journal of Public Health. 111(S2):S116-S125.

173

Sources include health records, coroner and medical examiner reports, death certificate records, reports from law enforcement agencies, media and

news outlets, and information shared by family members.

174

Caution should be exercised when drawing conclusions, as the absence of documentation of a characteristic does not necessarily indicate that the

Veteran did not experience the risk factor. It only indicates that no documentation of this risk factor was located within the medical chart or any other

available source of information.

0% 60%40% 50%30%20%10%

28.8%

30.6%

27.9%

17.1%

6.5%

6.3%

5.6%

3.8%

1.3%

24.7%

12.6%

11.5%

33.7%

55.9%

51.7%

40.7%

33.0%

17.9%

13.9%

9.1%

2.9%

10.9%

Risk Assessment

Stress

Interpersonal Factors

Death of Family or Friend

Health

Hopelessness

Unsecured Firearms in Home

Impulsivity/Poor Self-Control

Financial Loss

Legal Problems or Arrest

Risk of Homelessness

Relationship Problems

Alienation

Death of Family or Friend (past year)

Suicide of Family or Friend (past year)

Perceived Burden to Others

Recent Plan

Writing a Suicide Note

Other Preparatory Act

Recent Efforts to Acquire/Hide Lethal Means

History of Non-Suicidal Self-Harm

Giving Away Possessions

Pain in the Year Prior to Death

Sleep Problems

Increased Health Problems

Recent Decline in Physical Activity

Cognitive Decline

Reflecting Back, Looking Forward: Laying the Foundation for Future Courses of

Action for Suicide Prevention for VHA- and VBA-Engaged Veterans

Advance Suicide Prevention Meaningfully into Non-Clinical Support and

Intervention Services, Including Financial, Occupational, Legal and Social Domains

Multiple factors, in addition to mental health and clinical issues, contribute to Veterans being at increased risk for

suicide. For example, Veterans who have ever experienced homelessness are at increased risk for suicidal ideation,

suicide attempts and suicide deaths.

175

Similarly, housing instability (measured as concern over being able to pay rent

or a mortgage) is also associated with suicide. In 1 study, Veterans with past-year housing instability were 6 times as

likely as those who did not experience housing instability to report suicidal ideation.

176

Like homelessness, economic

and financial uncertainty are associated with suicide risk and increased distress, including during times of recession,

177

unemployment

178

and financial strain.

179

Additionally, disability status has been reported to be associated with suicidal

behaviors.

180

In contrast, Veterans in VHA care who have service-connected disability status benefits are less likely to die

by suicide when compared to those without a service-connected disability status.

181,182

VBA work in recent years in suicide

prevention is notable based on these findings. VA’s public health approach to suicide prevention includes interventions

targeting these issues, in addition to continuing its traditional clinical interventions within health care settings.

Beginning in 2023, VA Suicide Prevention expanded work with homelessness through developing improved methods for

enhancing suicide risk screening in homeless populations and Homeless Safety Planning in the Emergency Department

(SPED). Veterans who are homeless may be more likely to obtain care in emergency departments, and assessing suicide risk at

that time of engagement may improve the likelihood of early identification of suicide risk. VA also continues to fully focus on

meeting its 2023 goals for reducing homelessness. As of August 2023, VA has permanently housed 30,695 Veterans, on pace

to exceed its goal of housing 38,000 homeless Veterans in 2023. VA also announced at the end of August 2023, that it awarded

more than $1 billion in grants to help Veterans who are homeless and at risk of homelessness through the Supportive Services

for Veteran Families and Homeless Programs’ Grant and Per Diem Program. These grants are a critical part of VA’s efforts to

provide housing for Veterans in collaboration with the community. VA’s efforts to end Veteran homelessness are built upon the

evidence-based “Housing First” approach, which prioritizes getting a Veteran into housing and providing them with additional

services, including health care, job training, legal services, and education assistance, which also lower suicide risk overall.

175

Hoffberg AS, Spitzer E, Mackelprang JL, Farro SA, Brenner LA. 2018. Suicidal Self‐Directed Violence Among Homeless US Veterans: A Systematic

Review. Suicide and Life‐Threatening Behavior 48(4):481–498.

176

Bossarte RM, Blosnich JF, Piegari RI, Hill LL, Kane V. 2013. Housing Instability and Mental Distress Among US Veterans. American Journal of Public

Health. 103(S2):S213–16.

177

Chang SS, Stuckler D, Yip P, Gunnell D. 2013. Impact of 2008 Global Economic Crisis on Suicide: Time Trend Study in 54 Countries. BMJ 347:f5239.

178

Haw C, Hawton K, Gunnell D, Platt S. 2015. Economic Recession and Suicidal Behaviour: Possible Mechanisms and Ameliorating Factors.

International Journal of Social Psychiatry 61(1):73–81.

179

Blosnich J, Montgomery A, Dichter M, et al. 2019. Social Determinants and Military Veterans’ Suicide Ideation and Attempt: A Cross-Sectional

Analysis of Electronic Health Record Data. Journal of General Internal Medicine.

180

Fässberg MM, Cheung G, Canetto SS, Erlangsen A, Lapierre S, Lindner R, Draper B, Gallo JJ, Wong C, Wu J, Duberstein P, Waern M. 2016. A Systematic

Review of Physical Illness, Functional Disability, and Suicidal Behaviour Among Older Adults. Aging and Mental Health. 20(2):166-194. https://doi.org/10.1

080/13607863.2015.1083945.

181

McCarthy JF, Bossarte RM, Katz IR., Thompson C, Kemp J, Hannemann CM, Nielson C, Schoenbaum M. 2015. Predictive Modeling and Concentration of

the Risk of Suicide: Implications for Preventive Interventions in the US Department of Veterans Affairs. American Journal of Public Health. 105(9):1935-

1942. https://doi.org/10.2105/AJPH.2015.302737

182

Dobscha SK, Denneson LM, Kovas AE, Teo A, Forsberg CW, Kaplan MS, Bossarte R, McFarland BH. 2014. Correlates of Suicide Among Veterans Treated in

Primary Care: Case-Control Study of a Nationally Representative Sample. Journal of General Internal Medicine. 29(S4):853–860. https://doi.org/10.1007/

s11606 - 014 -3028-1.

VA is launching the National Veterans Financial Resource Center, funded by VA Suicide Prevention. The center is focused

on addressing the challenges of financial strain in Veterans at risk of suicide and will provide Veterans access to education,

tools, and resources to successfully navigate challenges to financial wellness and, thereby, reduce risk of suicide. VA is

finalizing a website and mobile platform enabling Veterans to select their own financial goals. They will be able to link

to local and national financial resources, including housing counselors, legal aid, credit and financial counseling, job

centers and food banks. Veterans will also be able to link to short videos, interactive learning, and decision tools (e.g.,

creating spending plans, managing debt, taking out a car loan, lowering utility bills). Currently, hiring is underway for

a consultation hub, which will provide consultation and financial tools/resources to VA clinicians for the Veterans they

serve. Additionally, VA staff will have access to financial resource tools to support Veterans, including a SharePoint site,

consultation services and local financial health champions. In 2023, VA is expanding outreach to justice-involved Veterans

through the Veterans Justice Program (VJP) positions, with 86.5 full-time-equivalent (FTE) employees provided across

the Nation. Incarceration is both a significant predictor of homelessness and a risk factor for suicide. Adding more VJP

positions in the field will enable VA to support more Veteran Treatment Courts and conduct outreach to Veterans in more

local jails and other criminal justice settings during times of heightened risk for homelessness and suicide. VA is also

expanding access to legal support services by building upon and expanding its current 28 Medical-Legal Partnerships.

VA awarded 75 grants under its new Legal Services for Homeless Veterans and Veterans at Risk for Homelessness (LSV-H)

program to provide legal services to Veterans who are homeless or at risk of homelessness.

VBA continues to provide significant upstream approaches for suicide prevention through the provision of a variety

of benefits and services to reduce economic and financial drivers of suicide risk. These include programs such as Solid

Start, Disability Compensation, Pension, Veteran Readiness and Employment (VR&E) and Education/GI Bill assistance, to

facilitate successful transitions to civilian life. Additional VBA supports include:

• Services to promote connections to caregiver supports and protect financial wellness:

• VBA provides need-based benefits to Veterans and their survivors. This includes tax-free, income-based

benefits for wartime Veterans who are permanently and totally disabled (or are aged 65 or older) and their

eligible survivors.

• Seriously disabled Veterans and their eligible survivors may qualify for increased benefits if they need the

aid and attendance of another person or are housebound. The Fiduciary Program oversees appointment of

fiduciaries for VA beneficiaries unable to manage their VA benefits as a result of injury, disease, advanced age

or those less than 18 years of age.

• VBA provides monthly monetary benefits to Veterans in recognition of the enduring effects of disabilities,

diseases or injuries incurred or aggravated during active military service. Monthly tax-free benefits are paid to

eligible Veterans with service-related disabilities.

• Services to support military transition and promote connections to educational supports and other social

institutes to facilitate attainment of educational objectives, connection to means for achieving career ambitions

and assistance in translating military-related skills to marketable occupational interests to foster financial security,

connection, purpose, and personal drive:

• VA Solid Start (VASS) provides caring contact to newly separated Veterans at 90-, 180- and 365-day check-in

points, post-separation. VA representatives help to navigate connections to VA and community-care resources.

• Outreach, Transition and Economic Development (OTED) provides transition assistance, Military to Civilian

Ready Framework, economic development initiatives, outreach, and personalized career planning guidance.

This program also provides information and resources to facilitate employment, special hiring authorities,

career support resources and financial tools through collaborations with the Department of Labor,

Department of Defense, and others.

• Services to promote financial independence, stabilizing housing, and assistance to navigate threats to housing and/

or food insecurity:

• VA Home Loan Guaranty helps Service members, Veterans and their families obtain and retain a home

(including supports to augment or refinance an existing home).

• Services to facilitate life skills training, employment, and educational opportunities:

• Veteran Readiness and Employment (VR&E) provides Veterans with service-connected disabilities case

management and job counseling to facilitate successful employment (including job training, resume

development, skills for job-seeking and work-readiness assistance).

• VBA offers educational benefits to advance the educational and career aspirations of Veterans, Service

members, family members and survivors.

Reection: Non-Clinical Services

Summary: A number of non-mental health and non-clinical risk factors are present for suicide including homelessness,

nancial instability, unemployment, justice involvement and more. Findings from this year’s report indicate that we

must move beyond the clinical to assist Veterans in services to address these risk factors to reduce Veteran suicide.

What You Can Do: Connect Veterans with job-search and skill-building resources. VA oers career and employment

resources. Consider connecting Veterans with a Health Care for Reentry Veterans Specialist who can provide

resources and direct Veterans to community or legal assistance or with VA’s Veterans Justice Outreach (VJO). VJO

works with local criminal justice partners to connect Veterans with resources. Save this number in your phone for

the National Call Center for Homeless Veterans that can assist any Veteran who is homeless or at imminent risk for

becoming homeless. You can contact the National Call Center for Homeless Veterans at (877)4AID-VET or (877)424-3838.

Increase Access to and Utilization of Mental Health Services Across a Full

Continuum of Care

Mental health and SUD remain a risk factor for suicide in

the Veteran population. As such, advancing access for a

full continuum of mental health care is vital for reducing

suicide for those for whom mental health treatment is

needed. Additionally, increases in mental health staffing

have been associated with decreases in suicide rates for

VHA patients.

183

Investing in expansion of mental health

services for Veterans is an important component of VA’s

National Strategy for Preventing Veteran Suicide (2018).

VA continued, in 2023, growth of SP 2.0 Clinical Telehealth,

reaching all VA health care systems in less than 2 years

of implementation by leveraging 100 highly trained

specialized therapists. Ninety percent of this staff have

been trained in 3 or more EBPs for suicide prevention. As

of August 31, 2023, the program processed over 12,350

Veteran referrals. In August 2023 alone, VA was on track

to exceed another intake volume record, having already

completed over 400 intake appointments. VA is also hearing from Veterans and referring providers about the lifesaving

work of the program (see qualitative feedback in the call-out box). VA also continues to exceed all performance metrics

on the Recovery Engagement and Coordination for Health — Veterans Enhanced Treatment (REACH VET) Program.

183

Katz IR, Kemp JE, Blow FC, McCarthy JF, Bossarte RM. 2013. Changes in Suicide Rates and in Mental Health Staffing in the Veterans Health

Administration, 2005–2009. Psychiatric Services. 64:620–625.

Intensity of Services

Self-Directed Care, Peer Support, Community Partnerships, Crisis Services

Whole Health System of Care

Mental Health Continuum of Care

Primary Care Mental Health Integration (PCMHI)/PACT

General Mental Health (Behavioral Health

Interdisciplinary Program/BHIP)

Specialty Mental Health

Residential

Inpatient

Within 2023, in alignment with the White House Strategy on

Reducing Military and Veteran Suicide (2021), VA funded a

National Academies of Sciences, Engineering, and Medicine

(NASEM) public workshop on Improving Access to High-Quality

Mental Health Care for Veterans, to explore methods for

expansion of access to services for Veterans. This included

addressing the need for access across 3 areas:

184

urgent/crisis

access (e.g., need/want an appointment now, crisis services);

engagement access (e.g., when someone is first initiating

treatment); and sustained access (e.g., ongoing access to

treatment — for evidence-based psychotherapy for 12- to

16-weeks of individual therapy with the same provider). All 3

types of access are necessary for continuity of mental health

care. When we provide initial/engagement or emergent/urgent

access, without sustained access, we are not providing quality,

evidence-based care. The NASEM forum provided an

opportunity to discuss the need for both access and quality to

move the needle in mental health treatment as part of suicide

prevention efforts in implementing the full continuum of

mental health care. While not all those who die by suicide have

a mental health or SUD, we know that mental health and SUD

are pertinent risk factors for suicide for many Veterans, and the

delivery of evidence-based treatments for mental health have

demonstrated the ability to reduce suicide.

185

With the

publication of the NASEM report, VA will move forward in

identifying other access-to-care models from SAMHSA, national

associations, and international health care systems and

statistically test the models using synthetic data to determine

which is best for access, evaluating which models of access

minimize wait times, provide critical access to rapid

engagement and provide optimal episode-of-care access. VA will test the models with movement forward for pilot

implementation across several VISNs to assess for best improvements in mental health access across the continuum of care.

Along these lines, in FY 2024, VA will advance a full hiring initiative for mental health with an expanded focus on growing the

mental health pipeline, including suicide prevention coordinators (SPC). Growth in mental health staffing is particularly

important to suicide prevention as higher levels of mental health staffing have been associated with decreased suicidal

behavior among patients within a health care system.

186,187,188

This continues to build off the expansion of general mental

health interdisciplinary team staff funding from suicide prevention to add 172 staff across the Nation.

184

Known as “tripartite access” in VA.

185

National Institute of Mental Health (2021) Treatment and Therapies for Suicide. Available at: NIMH » Suicide Prevention (nih.gov).

186

Atkinson JA, Page A, Heffernan M, McDonnell G, Prodan A, Campos B, Meadows G, Hickie IB. 2019. The Impact of Strengthening Mental Health

Services to Prevent Suicidal Behavior. Aust N Z J Psychiatry. 53(7):642-650.

187

Katz IR, Kemp JE, Blow FC, McCarthy JF, Bossarte RM. 2013. Changes in Suicide Rates and in Mental Health Staffing in the Veterans Health

Administration, 2005–2009. Psychiatric Services. 64: 620-625. doi: 10.1176/appi.ps.201200253.

188

Feyman, Y, Figueroa, SM, Yuan, Y, Price ME, Kabdiyeva A, Nebeker JR, Ward MC, Shafer PR, Pizer SD, Strombotne KL. 2022. Effect of Mental Health

Staffing Inputs on Suicide-Related Events. Health Services Research. 1-8. doi:10.1111/1475 - 6773.14 064.

Suicide Prevention 2.0 Clinical

Telehealth Feedback

Feedback from Veterans:

• “I would not be alive today if not for

this program.”

• “For the first time in my life, I don’t want

to die anymore. I never thought I would

feel that way.”

• “Suicide wasn’t something that I was

looking forward to talking openly about.

I was surprised at how comfortable I felt

within the first session and appreciated

the ability to meet individually from the

comfort of my home.”

Feedback from Referring Providers:

• “I was skeptical about the program at

first. But after a couple of my Veterans

went through it, I saw the benefit. They

made so much progress in ways that

we hadn’t been able to address in our

regular therapy. This is a great program

and has helped so many Veterans!”

Reection: Access to Mental Health Services

Summary: Both mental health and SUDs are risk factors for Veteran suicide. Obtaining prompt access to services is

critical not only during times of crisis, but when rst initiating treatment, and in a sustained manner to complete a

full episode of care.

What You Can Do: Connect Veterans with information on how to obtain same-day mental health services by visiting

this website. Save the VCL number in your phone (Dial 988 then Press 1) and spread the word about VCL through

your community connections. Link Veterans to information about the mental health and SUD services available to

them. If you are not sure about how to talk with a Veteran about available services, reach out to Coaching into Care, a

free service for families and friends of Veterans where you can learn about resources and referrals.

Integrate Suicide Prevention Within Medical Settings to Reach All Veterans

Nearly 40% of Recent Veteran VHA Users who died by suicide in 2021 did not have a mental health or SUD diagnosis.

Many Veterans will also never seek mental health treatment. Further, medical conditions, including those lasting 1 year

or more, can increase an individual’s risk for suicidal behavior.

189,190

For example, individuals diagnosed with cancer have

approximately 1.5 times the general population’s risk for suicide death, while patients with a poor prognosis have 3

times the risk for suicide death than cancer patients overall.

191,192

Likewise, there is a strong association between chronic

pain and suicide.

193

Further, prior research has shown that 45% of individuals who die by suicide have had a primary care

appointment in the prior month.

194

Thus, incorporation of suicide prevention into medical settings is a critical part of VA’s

public-health approach to address Veteran suicide.

VA continues to expand its efforts in suicide prevention in medical settings. As part of SP Now Clinical Interventions, VA

continued implementation of SPED, which is an evidence-based practice shown to reduce suicidal behaviors by 45%.

195

The program promotes safety planning with Veterans who present to the emergency department with suicidal ideation,

providing follow-up contact until treatment engagement occurs. VA is now exceeding the target on the lifesaving efforts

of SPED. Ongoing implementation of population-based suicide risk screening is underway for those with unrecognized

risk (universal), for those who may be at risk (selected) and for those at elevated risk (indicated) through VA’s Suicide

Risk Identification Strategy (Risk ID), founded in the strong evidence outlined in the clinical practice guideline.

196

Risk ID

isimplemented across settings, including ambulatory care and emergency departments, which is assisting in identifying

189

Zhu J, Xu L, Sun L, et al. 2018. Chronic Disease, Disability, Psychological Distress and Suicide Ideation among Rural Elderly: Results from a

Population Survey in Shandong. International Journal of Environmental Research and Public Health 15, no. 8:1604.

190

Wei MY, Mukamal KJ. 2019. Multimorbidity and Mental Health‐Related Quality of Life and Risk of Completed Suicide. Journal of the American

Geriatrics Society. 67(3):511–519.

191

Amiri S, Behnezhad S. 2019. Cancer Diagnosis and Suicide Mortality: A Systematic Review and Meta-Analysis. Archives of Suicide Research. 0:1-19.

192

Dent KR, Szymanski BR, Kelley MJ, Katz IR, McCarthy JF. 2023. Suicide Risk following a New Cancer Diagnosis among Veterans in Veterans Health

Administration Care. Cancer Medicine.12(3):3520-3531.

193

Ilgen, M. 2018. Pain, Opioids, and Suicide Mortality in the United States. Annals of Internal Medicine 167(7):498-499.

194

Luoma JB, Martin CE, Pearson JL. 2002. Contact with Mental Health and Primary Care Providers Before Suicide: A Review of the Evidence. American

Journal of Psychiatry. 159:909-916. doi: 10.1176/appi.ajp.159.6.909.

195

Stanley B, Brown GK, Brenner LA, Galfalvy HC, Currier GW, Knox KL, Chaudhury SR, Bush AL, Green KL. 2018. Comparison of the Safety Planning

Intervention with Follow-Up vs Usual Care of Suicidal Patients Treated in the Emergency Department. JAMA Psychiatry. 75(9):894-900.

196

Department of Veterans Affairs and Department of Defense. 2019. VA/DoD Clinical Practice Guideline for the Assessment and Management of

Patients at Risk for Suicide.

https://www.healthquality.va.gov/guidelines/MH/srb/VADoDSuicideRiskFullCPGFinal5088212019.pdf

individuals at risk for suicide not receiving mental health treatment.

197

The identification of suicide risk as part of RISK ID

was associated with increased mental health treatment follow-up, particularly for those Veterans not previously engaged

in mental health services in the prior year.

198

Suicide risk screening continues to improve in medical settings, including

a 7% improvement in primary care, 13% improvement in specialty medicine, 31% improvement in audiology, 15%

improvement in Primary Care - Mental Health Integration (PCMHI) and 10% improvement in women’s health clinic from

October 2021 to July 2023. Related to advancement of naloxone for Opioid Use Disorder, VA expanded this effort in FY

2022 to also include Veterans diagnosed with Stimulant Use Disorder. This effort resulted in a 12% increase in naloxone

prescriptions dispensed to Veterans diagnosed with Opioid Use Disorder (from 61.5% of Veterans to 69%) and a 56%

increase in naloxone prescriptions for Veterans with Stimulant Use Disorder diagnoses (from 29% of Veterans to 45%).

Reection: Suicide Prevention in Medical Settings

Summary: Nearly 40% of Veterans who died by suicide had no mental health or substance use disorder diagnoses.

Other medical conditions are also associated with higher risk for suicide (e.g., chronic pain, cancer, insomnia and more).

What You Can Do: Check in with Veterans who are struggling with medical conditions, including those who are

dealing with a newly diagnosed condition. Encourage connection to additional methods of support including VA’s

Whole Health Program, and VA mobile apps and online tools. If you work in community-care settings, promote

discussion about secure rearm storage with patients, encourage community-care providers to take training in lethal

means safety with these courses with free continuing education (e.g., an hour long version and a briefer 25-minute

version and promote gun lock distribution in clinic waiting areas.

SP Now efforts grew to specifically target methods to expand access to support services within other medical clinics,

particularly reviewing options for expansion in oncology clinics, pain clinics and primary care settings. VA’s focus on

PCMHI, embedding mental health providers directly into primary care, has been particularly successful in increasing odds

of engagement in mental health treatment, reducing wait times for services and decreasing no-show rates for mental

health appointments.

199,200,201,202

VA Suicide Prevention supported expansion of PCMHI with the addition of 129 PCMHI

staff across the Nation to support ongoing suicide prevention efforts. In addition to PCMHI, integrated services have been

extended to Pain and Oncology clinics to proactively identify risk and engage supports and resources same-day through

funding by VA Suicide Prevention, as part of FY 2022 funding. Through August 2023, this has included expansion of 58

mental health integration providers in Pain Clinics in 44 unique VA facilities and 32 mental health integration providers

in Oncology Clinics in 27 unique VA facilities. Additionally, Suicide Prevention worked with Primary Care to pilot a Lethal

Means Safety competency-based training to primary care team members in 1 VISN, to support discussions about secure

197

Bahraini N, Brenner LA, Barry C, Hostetter T, Keusch J, Post EP, Kessler C, Smith C, Matarazzo BB. 2020. Assessment of Rates of Suicide Risk Screening

and Prevalence of Positive Screening Results Among US Veterans After Implementation of the Veterans Affairs Suicide Risk Identification Strategy.

JAMA Network Open. 2020;3(10):e2022531. doi:10.1001/jamanetworkopen.2020.22531.

198

Bahraini N, Reis DJ, Matarazzo BB, Hostetter T, Wade C, Brenner LA. 2022. Mental Health Follow-Up and Treatment Engagement Following Suicide

Risk Screening in the Veterans Health Administration. PloS One. 17(3):e0265474.

199

Brawer PA, Martielli R, Pye PL, Manwaring J, Tierney A. 2010. St. Louis Initiative for Integrated Care Excellence (SLI2CE): Integrated-Collaborative

Care on a Large Scale Model. Families Systems Health. 28:175–87. doi: 10.1037/a0020342.

200

Pomerantz A, Cole BH, Watts BV, Weeks WB. 2008. Improving Efficiency and Access to Mental Health Care: Combining Integrated Care and

Advanced Access. General Hospital Psychiatry. 30:546–51. doi: 10.1016/j.genhosppsych.2008.09.004.

201

Pomerantz A, Shiner B, Watts BV, Detzer MJ, Kutter C, Street B, et al. 2010. The White River Model of collocated collaborative care: a platform for

mental and behavioral health care in the medical home. Families Systems Health. 28:114–29. doi: 10.1037/a0020261.

202

Wray LO, Szymanski BR, Kearney LK, McCarthy JF. 2012. Implementation of Primary Care-Mental Health Integration Services in the Veterans Health

Administration: Program Activity and Associations with Engagement in Specialty Mental Health Services. J Clin Psychol Med Settings. 19:105–16.

doi: 10.1007/s10880-011-9285-9.

firearm storage within their daily work. Further, VA funded 300 virtual reality headsets for chronic pain intervention with

a customizable chronic pain environment for a 60-site pilot in 2022, to provide a method for Veterans to apply evidence-

based interventions for pain treatment based in Veterans’ homes. Finally, VA’s Outreach to Facilitate Return to Care pilot

program identifies and targets outreach to Veterans who were previously engaged in VHA care but had not been seen in the

last 2 years and as of their last VHA encounter were at high risk for suicide per the REACH VET algorithm. Program evaluation

analyses indicate that eligible patients in current or former pilot facilities were more likely to engage in VHA mental health

services than those at other facilities. VA is working to expand the ongoing pilot program.

Conclusion

As we look back at 2021, we continue to be guided by our 3 core tenets of suicide prevention. 2021 humbled the Nation

as we faced significant challenges, reminding us again that suicide is a complex interweaving of issues and concerns.

Suicide has no 1 cause and, because of this, has no 1 solution. From all our research efforts with you across the Nation, we

know there are some interventions that reduce suicide, suicidal thoughts and/or suicide attempts: evidence-based

psychotherapies like Cognitive Behavioral Therapy for Suicide Prevention, Problem Solving Therapy for Suicide

Prevention, Dialectical Behavioral Therapy for Suicide Prevention,

203

safety planning in the emergency department,

204

REACH VET,

205

secure storage of firearms,

206

crisis line interventions

207,208

and more. Yet, the majority of these interventions

are still clinical in nature and primarily in mental health settings, leaving untouched the problems fueling suicide at a

broader scale outside of mental health (e.g., medical concerns like chronic pain and cancer, economic worries,

homelessness, relationship issues). Further, suicide is not just a mental health problem, as evidenced by the fact that

nearly 40% of Recent VHA Users who died by suicide in 2021 had no mental health or substance use disorder diagnosis.

This leaves us with 2 critical pathways forward: 1) continue full

force implementation of what we know from the research to

save lives and 2) encourage ongoing innovation/research paired

with strong program evaluation to assess for new effective

interventions (e.g., SP 2.0 CBI-SP, Mission Daybreak). These

2 pathways are guided by the 7 core themes revealed in the

data from 2021 focused on secure firearm storage, community

prevention, expanding crisis intervention, adaptation efforts

for diverse subpopulations, addressing broader sociocultural

suicide risk factors, improving mental health access across a

continuum of care and moving suicide prevention into all clinical

settings. To reach all Veterans, we need all of you across all levels

of government, Veterans Service Organizations, community organizations, and the Nation. We have outlined with each of

the 7 themes, potential ways anyone can help support Veterans and we invite your participation in all the outlined efforts

we at VA will be taking in 2023 and beyond. Anchored in hope, we move forward together with each of you, knowing we

have much yet to learn, but fueled by the knowledge that we can make a difference in the lives of Veterans around us.

203

Department of Veterans Affairs and Department of Defense. (2019). VA/DoD Clinical Practice Guideline for the Assessment and Management of

Patients at Risk for Suicide. https://www.healthquality.va.gov/guidelines/MH/srb/VADoDSuicideRiskFullCPGFinal5088212019.pdf

204

Stanley B, Brown GK, Brenner LA, Galfalvy HC, Currier GW, Knox KL, Chaudhury SR, Bush AL, Green KL. 2018. Comparison of the Safety Planning

Intervention with Follow-Up Vs Usual Care of Suicidal Patients Treated in the Emergency Department. JAMA Psychiatry. 75(9):894-900.

205

McCarthy JF, Cooper SA, Dent KR, Eagan AE, Matarazzo BB, Hannemann CM, Reger MA, Landes SJ, Trafton JA, Schoenbaum M, Katz IR. 2021.

Evaluation of the Recovery Engagement and Coordination for Health - Veterans Enhanced Treatment Suicide Risk Modeling Clinical Program in the

Veterans Health Administration. JAMA Network Open. 4(10), e2129900.

206

Mann JJ, Michel CA, Auerbach RP. 2021. Improving suicide prevention through evidence-based strategies: A systematic review. The American

Journal of Psychiatry

, 178(7), 611–624.

207

Johnson LL, Muehler T, Stacy MA. 2021. Veterans’ satisfaction and perspectives on helpfulness of the Veterans Crisis Line. Suicide and Life-

Threatening Behavior, 51(2), 263–273. ht t ps ://doi.org /10.1111/sltb.12702

208

Britton PC, Karras E, Stecker T, Klein J, Crasta D, Brenner LA, Pigeon WR. 2022. Veterans Crisis Line Call Outcomes: Distress, Suicidal Ideation, and

Suicidal Urgency. American Journal of Preventive Medicine, 62(5), 745–751. https://doi.org/10.1016/j.amepre.2021.11.013

Core Tenets

1. Suicide is preventable.

2. Suicide prevention requires a public

health approach combining clinical

and community-based approaches.

3. Everyone has a role to play in

suicide prevention.

To refer to this report, please use the following citation:

U.S. Department of Veterans Affairs, Office of Mental Health and Suicide Prevention. 2023 National Veteran Suicide

Prevention Annual Report. 2023. Retrieved {date} from <<location>>.

Appendix A: Brief Summary of 2021 VA Suicide

Prevention Initiatives

1. Veterans Crisis Line (VCL) 988 Preparation: Within 2021, significant preparations were underway by the

Substance Abuse and Mental Health Services Administration (SAMHSA) and VA to ensure readiness for 988

implementation, including extensive hiring, technology infrastructure modernization and expansion of quality

assurance and training. Within FY 2021, demand for VCL services grew (e.g., a 2.3% increase in calls offered, a 27.9%

increase in texts, and a 25.4% increase in chat compared to FY 2020 daily averages). Simultaneously, VCL saw a

23.3% reduction in abandonment rate and a 6.6% reduction in average time to answer (average speed of answer 9

seconds). VCL further expanded services with the launch of its Peer Support Outreach Center (PSOC), In alignment

with growing peer specialist suicide prevention efforts.

209

2. VA’s Suicide Prevention 2.0 (SP 2.0) Clinical Telehealth: The SP 2.0 Clinical Telehealth Program is the first and

only enterprise-wide fully virtual program offering evidence-based therapy for suicide prevention

210

for Veterans

with a recent history of suicidal self-directed violence. The earlier decision to launch the SP 2.0 clinical program

in a telehealth model aided the expansion of evidence-based therapies for suicide prevention across the Nation,

especially during a time when Veterans were less likely to come to in-person visits.

211

During 2021, VA continued to

move forward on its hiring goal of 100 providers to serve Veterans.

3. SP 2.0’s Community-Based Intervention for Suicide Prevention (CBI-SP) Growth: The majority of Veterans

who died by suicide in 2021 were not recently engaged in VHA services or VBA benefits. To reach all Veterans, VA

expanded SP 2.0 CBI-SP, growing community coalitions focused on ending Veteran suicide, including through

the joint VA and SAMHSA Governor’s Challenge initiatives and work by regional Community Engagement and

Partnerships Coordinators (CEPC). These community-based strategies are supported by prior work in community

prevention science and programs, combining health promotion, upstream approaches and a focus on improved

clinical and crisis-care delivery through collaboration.

212,213,214

By the end of 2021, 35 states and territories were active

members in the Governor’s Challenge and a total of 184 coalitions were developed.

4. Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program (SSG Fox SPGP) and Mission Daybreak

Development: The SSG Fox SPGP enables VA to provide resources toward community-based suicide prevention

efforts to meet the needs of Veterans and their families through outreach, suicide prevention services and connection

to VA and community resources. After the Commander John Scott Hannon Veterans Mental Health Care Improvement

Act of 2019 was signed into law on October 17, 2020, VA began the active implementation of the development of the

209

Pfeiffer PN,King C,Ilgen M,Ganoczy D,Clive R,Garlick J,Abraham K,Kim HM,Vega E,Ahmedani B, Valenstein M.2019.Development and Pilot

Study of a Suicide Prevention Intervention Delivered by Peer Support Specialists.Psychological Services. 16(3):360–371.https://doi.org/10.1037/

ser0000257

210

The treatments include Cognitive Behavioral Therapy for Suicide Prevention, Problem Solving Therapy for Suicide Prevention, Dialectical

Behavioral Therapy, and Advanced Safety Planning.

211

Department of Veterans Affairs and Department of Defense. 2019. VA/DoD Clinical Practice Guideline for the Assessment and Management of

Patients at Risk for Suicide. https://www.healthquality.va.gov/guidelines/MH/srb/VADoDSuicideRiskFullCPGFinal5088212019.pdf

212

Frieden TR. 2014. Six Components Necessary for Effective Public Health Program Implementation. American Journal of Public Health. 104(1):17-22.

213

Lai C, Law YW, Shum AK, Ip FW, Yip PS. 2020. A Community-Based Response to a Suicide Cluster: A Hong Kong Experience. Crisis: The Journal of

Crisis Intervention and Suicide Prevention. 41(3):163-171.

214

Oyama H, Watanabe N, Ono Y, Sakashita T, Takenoshita Y, Taguchi M, Takizawa T, Miura R, Kumagai K. 2005. Community‐Based Suicide

Prevention Through Group Activity for the Elderly Successfully Reduced the High Suicide Rate for Females. Psychiatry and Clinical Neurosciences.

59(3):337-344.

program, laying the foundation for its awarding of grants in FY 2022. Additionally, in 2021, VA began planning the FY

2022 launch of Mission Daybreak, a $20 million grand challenge to reduce Veteran suicides. This effort included a call

to innovators to develop suicide prevention solutions that meet the diverse needs of Veterans. Both of these programs

were critical for engaging the community in bringing solutions to Veteran suicide prevention.

5. Expansion of Special Population Suicide Prevention Efforts: Attending to the needs of age-specific, gender-

specific and race and ethnicity-specific populations with communication, outreach and intervention is critical for

Veteran suicide prevention efforts. Within 2021, VA worked to expand communication campaigns for targeted

diverse populations through 3 of its campaigns, Don’t wait. Reach out., Keep It Secure and VCL. Campaigns were

designed to reach the most diverse populations with a significant investment in purchasing airtime slots and

channels that demonstrate higher market shares representative of Black, Hispanic, Native American, Asian/Pacific

Islander, female populations, younger Veterans, transitioning Veterans and Veterans aged 55 and older utilizing

a data-driven approach and awide variety of advertising platforms.

215

In 2021, VA focused extensively on the

development of DEI consideration in its local community coalition development, including implementation of a

toolkit for CEPCs to integrate DEI in all aspects of community work and in educating Governor’s Challenge state

teams and local coalitions on how to successfully engage with Tribal Partners as part of their landscape analysis

and action planning.

216

Research and innovation are critical parts of addressing the needs of diverse Veteran

subpopulations. VA Health Services Research & Development (HSR&D) has led the effort to include and expand

research on women Veterans. The VA Women’s Health Research Network (WHRN) has significantly expanded

research in suicide prevention, particularly through its Women Veterans Suicide Prevention Research Work Group.

In February 2021, HSR&D and WHRN facilitated the publication of a supplement within the journal, Medical Care,

focused on “Advancing Knowledge of Suicide Risk and Prevention among Adult Women.”

217

In 2021, VA Suicide

Prevention also expanded funding of demonstration projects focused on diverse populations. One example is

the joint effort between the Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC) and

the Office of Rural Health (ORH) to address Native Veteran Suicide Prevention focused on developing effective

collaboration with tribal communities in creating a learning community of VA and tribal partners, adapting suicide

prevention training and developing processes and tools for enhancing culturally appropriate engagement.

Additionally, VA Suicide Prevention launched funding for Rocky Mountain MIRECC efforts in “Understanding Suicide

Risk and Enhancing Suicide Prevention among Asian American and Pacific Islander Veterans.” This project seeks to

obtain novel information to prevent suicide among Asian American and Pacific Islander (AAPI) Veterans, including

initial research on needs within the population with culmination of the development of culturally relevant suicide

prevention resources and interventions for implementation.

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Advertising assets were tailored with photography and messaging aligned to each subpopulation with input directly from Veterans, as well as

experts from the Center for Minority Veterans, Women Veterans Health Program Office, LGBTQ+ Office, Veterans Experience Office, and Veterans

Service Organization liaisons, which assist with reflecting the diverse populations of Veterans served. Examples of more age-specific targeted

outreach, reflective of a racially and ethnically diverse population, include the Don’t wait. Reach out. “Battle Buddy” video or Keep It Secure “Space

Between Thought and Trigger” targeting older Veteran populations, or the Don’t wait. Reach out. “Women Veterans” video or Keep It Secure “Space

Between Thought and Trigger” targeting younger 18–34 Veterans. The Don’t wait. Reach out. campaign’s website, VA.gov/reach, also was created

with a diversity of topics and representative of diverse population, including application to younger Veterans (e.g., Career, financial, relationships).

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VA’s efforts through Governor’s Challenge includes efforts to guide states to inviting tribal leaders to join planning teams as members,

incorporating culturally competent panels that allow for tribal representatives to share directly with our audiences at conferences and events

and reminding ourselves that we have access to subject matter experts from the AI/AN communities that we can seek support and guidance

from. Leveraging the interdepartmental relationship with SAMHSA, VA utilized tools such as the National Tribal Behavioral Health Agenda, a tool

designed to improve the way agencies address and improve behavioral health for American Indian and Alaska Native populations.

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This special supplement published new research addressing suicide risk, resilience, surveillance, and prevention among adult women, with a

special emphasis on women Veterans and active-duty Service women.

6. Firearm Lethal Means Safety (LMS) Efforts: In 2021, VA significantly expanded its focus in LMS focused on secure

firearm storage through LMS training, enhancement of gun lock distribution, expansion of partnership efforts

in LMS and launching of the first national-level suicide prevention campaign focused on secure firearm storage.

A critical piece of this effort was mandating lethal means safety training for all providers in VHA, which was later

extended to all new providers.

218,219

The SP Now program also launched LMS training for the newly created VCL Peer

Support Outreach Center (PSOC) employees and 100% of VCL responders. VA also continued an extensive focus on

gun lock distribution, distributing 276,900 gun locks in 2021, and launching a pilot within VCL on distributing gun

locks via mail for those Veterans who desired one after calling VCL. As 1 of the 3 major goals of CBI-SP is focused

on lethal means safety, Governor’s Challenge state teams received training in lethal means safety and assist in

distributing gun locks and promoting discussions about secure firearm storage within their local communities.

VA also continued partnerships with organizations like NSSF and American Foundation for Suicide Prevention, to

create and disseminate messages on secure storage with shared branding (e.g., A Toolkit for Safe Firearm Storage in

Your Community), which laid a foundation for broader work in coming years. Along with NSSF, VA began designing

a series of short videos focused on secure firearm storage. In 2021, VA also launched the Keep It Secure campaign

(focused specifically on Lethal Means Safety and firearms) promoting awareness of Veteran-specific drivers of risk

and the steps Veterans and their support networks can take to increase safety through secure storage of firearms. In

FY 2021, these efforts resulted in 1.2 billion engagements (impressions), 726 million completed video views and 3.8

million website visits.

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VHA Assistant Under Secretary for Health for Operations, Lethal Means Safety (LMS) Education and Counseling memo, November 2, 2020.

219

Assistant under Secretary for Health for Clinical Services/Chief Medical Officer (CMO), Lethal Means Safety (LMS) Education and Counseling memo,

March 17, 2022.

Appendix B: Suicide Prevention Demonstration

(Pilot) Projects, FY 2024

Suicide Prevention demonstration (pilot) projects for FY 2024 are listed below:

• Asian American Pacific Islander (AAPI) Project: Multi-method project designed to further clarify the unique

needs and drivers of suicide risk among AAPI Veterans and gain new knowledge essential to understanding suicide

risk and prevention among AAPI Veterans.

• Acceptance and Commitment Training for Health Care Providers (ACT-HCP): Online, self-guided application

based on health care providers needs and will test the acceptability and feasibility of the intervention among VA

medical and mental health providers.

• Artificial Intelligence (AI) Firearms SUD Project: This project is developing AI methods to identify firearm and

substance use risk factors and provides VHA automated methods to efficiently measure which Veterans have

access to firearms, and which Veterans, among those with substance use disorders (SUD), are in a state of ongoing

substance misuse, versus in early rehabilitation or long-term maintenance.

• American Indian/Alaska Native (AI/AN) Suicide Prevention Project: This project is using existing VA data to

increase understanding of social determinants and Veterans health care use-related factors that may contribute to

the high suicide risk for AI/AN Veterans.

• The Brief Intervention and Contact (BIC) Pilot: This pilot is a brief, personalized intervention prior to discharge

from an acute inpatient hospitalization and continues with regular contact after discharge by a BIC coach to reduce

suicide risk and expand resources.

• Coaching Into Care (CIC) Suicide Prevention Project: This project is a post-hospitalization risk-reduction project

focused on lethal means safety (LMS) conversations with Veterans and their concerned supporters when a Veteran

has recently discharged from inpatient psychiatric hospitalization.

• Community Coalition Functioning Evaluation Project: This project will support VA’s Community-Based

Interventions for Suicide Prevention by assessing the strengths, weaknesses and opportunities that inform

community coalition successes in providing Veteran suicide prevention services.

• Co-Occurring Homelessness and Suicide Risk Clinical Processes Project: This project will focus on the

refinement of methods and procedures across VA to screen and identify homelessness in Veterans at risk for suicide.

• Establishing and Sustaining a National Suicide Prevention Program for LGBTQ+ Veterans Project: This

project will focus on the expansion and sustainability of “PRIDE in All Who Served,” a manualized, evidence-based

intervention to ensure at-risk LGBTQ+ Veterans have access to an effective, tailored health promotion program that

reduces suicide risk regardless of where they access care.

• Improving Safe Firearm Storage in Veterans through Involving a Concerned Significant Other Project: This

project will develop and test LMS interventions with concerned supporters, providing resources and education on

how to discuss lethal means safety with their Veteran loved ones.

• Leveraging Digital Platforms for Communicating Lethal Means Safety (LMS) Messages to Younger Veterans:

This is a project that seeks to address gaps in effective messaging and evidence-based recommendations to

younger Veterans via digital platforms by proposing to apply more rigorous methods to evaluate the use of LMS

messaging and the impact of digital platforms to inform subsequent campaign development and deployment.

• Leveraging Social Media to Reach LGBTQ+ Veterans at Risk of Suicide Project: This project is engaging Non-

Engaged Veterans and examines optimal methods for engagement of LGBTQ+ Veterans at risk of suicide, to identify

barriers to engaging in care and to understand the needs and key targets for interventions.

• Optimizing the Use and Dissemination of brief Cognitive Behavioral Therapy for Insomnia for the Purpose

of Suicide Prevention (bCBTI-SP) Project: This project translates the online training package for bCBTI-SP to

community providers to reach Veterans outside of VHA care with this evidence-based intervention.

• Partnering with Firearm Retailers to Promote and Provide Out-of-Home Firearm Storage Project:

This project will support the sustainability and scalability of The Armory Project (TAP), a community-engaged

approach to develop and maintain networks to promote and provide temporary out-of-home firearm storage for

suicide prevention.

• Postvention Project: This project will implement enhancements to the United for Postvention resource hub,

including the development of an enterprise-wide infrastructure available to all VHA staff, consultation, and

resources for postvention care.

• Project Life Force (PLF) Project: This project delivers suicide prevention clinical intervention via clinical telehealth

hubs that includes providing safety planning, lethal means counseling and other emotional regulation and

interpersonal skills that is delivered by VA providers for Veterans at risk for suicide, including those in rural settings.

• Social Determinants and Mortality Study: Study of patterns and trends project incorporates all-cause mortality

and “deaths of despair” (overdose, substance use and suicide) to improve visibility of disproportionately affected

areas to inform and evaluate VA’s suicide prevention efforts.

• Suicide Risk Identification and Prevention in Reproductive Healthcare Settings (SP-RHC) Project: This project

is a mixed-methods study that seeks to address the critical knowledge gap and generate findings and products that

can be leveraged to tailor suicide prevention practices for, and facilitate implementation in, reproductive health

care (RHC) settings serving women Veterans.

• Suicide Prevention through Whole Health for VA Police and VA Police Peer Support National Initiatives:

This project focuses on VA Police Veteran suicide prevention through Whole Health wellness/empowerment and

Peer Support for VA Police.

• Suicide Prevention Among Older Veterans Project: This project addressing Firearm Safety will support the

completion and distribution of a 20-minute video training for clinicians across VHA on how to conduct firearm

safety discussions with older Veterans and family members.

• Surveillance and Reporting of Suicidal Ideation Assessment in Post Traumatic Stress Disorder (PTSD)

Specialty Care Clinical Notes Project: This project will use Natural Language Processing to surveil and monitor

the conduct and quality of suicide ideation assessment during treatment in PTSD specialty care.

• VHA Service Use Proximal to Firearm Suicide Among U.S. Veterans: This project will describe the frequency

and settings of VHA health care service use prior to Veterans’ deaths by firearm suicide among all Veterans who

used VHA services and develop dissemination tools to clinical care settings to inform VHA setting specific LMS

counseling initiatives.

• Veteran Sponsorship Initiative+ (VSI): This initiative provides expansion to support High-Risk Transitioning Service

members (TSM) and Veterans and will use a precision medicine approach to identify TSMs at high risk for suicide, for

targeted enhanced care and management, to reduce suicide risks during this vulnerable transition period.

• Integrated Mental Health Providers Project: This project will provide prevention, early intervention, education,

and access for at-risk Veterans in non-mental health clinic settings, to include neurology, sleep and oncology clinics.

• Center of Excellence Hub for the Study of Younger Veterans Pilot: This will pilot outreach (18- to 34-year-old

outreach and engagement), care coordination and continuity projects focused on 18- to 34-year-old at-risk Veterans.

• The National Center for Veteran Financial Well-being (NCVFW): The NCVFW ensures Veterans have ready-

access to education, tools and resources necessary for the successful navigation of barriers to financial wellness and,

thereby, reduce risk of suicide in those circumstances where financial stressors are the primary driver of risk.

• VA Risk ID Universal Suicide Screening: This is an evidence-informed population-based approach designed to

detect and manage suicide risk among Veterans presenting to a wide range of health care settings.

• Safety Planning in the Emergency Department (SPED): SPED is an evidence-based intervention required in

VA after research demonstrated that safety planning and structured outreach was associated with a reduction in

suicidal behavior in the 6 months following an emergency department visit.

• Suicide Risk Management (SRM) Consultation Program: This program supports all providers (VA or the

community) by disseminating evidence-informed suicide prevention strategies, training and resources offering case

consultation at no cost.

• United for Postvention Program: This program establishes guidelines and resources specific to suicide

postvention, to achieve VHA’s goal to address the care of bereaved survivors, caregivers, and health care providers.

Department of Veterans Affairs

November 2023