The other side of Veterans Day
By Joe Simonetti, MD MPH, Tracy Hauver, MPH, and Andrea Austin, MD
November 11th marked the 101st annual Veterans Day celebration in the United States of America. Initially dubbed Armistice Day to mark the end of conflict in World War I, it was later renamed by President Eisenhower to acknowledge the sacrifice of those who served in or supported the large-scale military conflicts of the 1940’s and 1950’s. As in years past, many of us set aside time on Monday to think about the contributions of our nation’s veterans and active service members, or show appreciation in other ways. However, as evidenced by tweets, news stories and our own conversations, many of us found ourselves unable to escape a sobering fact for much of the day. If Monday was an average day in the United States, 17 veterans were likely to have fallen from suicide.1
Suicide is the 10th leading cause of death in the United States, and rates have been steadily increasing among nearly every age group for 20 years.2 If this one doesn’t stun you, it should – suicide is the 2nd leading cause of death among our nation’s adolescents… our kids.2 The story is just as gut-wrenching among the nearly 20 million living adults who served in the U.S. Armed Forces. Veterans have a higher risk of suicide than other Americans of the same age and gender (about 50% higher).1 In fact, veterans account for 14% of all suicide deaths in the U.S.1
An important subheading to the story of suicide among U.S. veterans is that 69% of their suicide deaths are attributable to firearm injuries.1 For comparison, firearm injuries account for around 51% of suicides among other adults.3 Suicide is a complex and tragic event, and there is no single answer as to why veterans have a higher risk of both suicide and firearm-related suicide than their peers. The impact of service-related traumas, such as posttraumatic stress disorder and traumatic brain injury, along with their well-known and widespread effects on well-being, both physical and psychological, clearly play a role. However, some of this risk is likely attributable to the fact that veterans are simply more likely to own firearms than other adults.4 Study after study after study has shown that firearm access independently predicts who in our society while die by suicide.5
For this reason, recommending that individuals with elevated suicide risk voluntarily reduce their access to firearms and other lethal methods is considered critical. But there are challenges to making this happen. As nearly any firearm owner, veteran or not, will tell you – many attach a special value to owning and using their firearms. Perhaps you’ve been there and seen it. A group of Vietnam vets shooting clays on a Saturday, jokingly ribbing each another about long ago experiences that probably weren’t so funny in the moment. A quick meetup of vets at the pistol range after work. We don’t pretend to understand the lived experiences of our veterans. However, it’s nearly impossible to miss the bond they share and where firearms sometimes fit in. If you haven’t seen it, at the very least, you might understand why a Vietnam Vet who slept in the mud, under monsoon-soaked skies with his firearm by his side to stay alive, might today feel comforted by having one nearby.
Despite this value, we will continue to argue that there are times when firearm access is simply too risky. This is not a foreign concept to most, including many of our veterans. One study found that 82% of veterans across the U.S. would ensure that a suicidal household member was unable to access a firearm.6 In another study, of 677 veterans receiving mental health care from the VA, 93% agreed that the VA should implement voluntary interventions allowing for at-risk veterans to reduce their access to firearms.7
The VA is already making important strides in having conversations with veterans about their firearms. An important next step for VA, and other healthcare systems and public health practitioners willing to face this challenging issue, is how to go about supporting ongoing efforts within the veteran community to prevent firearm-related suicides. When it comes to community approaches to suicide prevention, healthcare systems and other agencies are lagging far behind the efforts of veterans who are already doing this work. Don’t believe us? Walk into a local veterans organization and start talking… ask them what they’ve done for one another after their service ‘ended.’
Some veterans and others in crisis are lucky enough to have loved ones or friends who are willing to do a tough thing in a desperate time… talk about the guns. But that doesn’t happen for everyone. In some cases, well-meaning friends or family members simply aren’t aware of the risk of firearm access for someone in crisis. Others might think that firearm access may be “less risky” for veterans, some of whom have been training and living with firearms for much of their adult lives. In some cases, efforts are hampered by a common misconception that suicides aren’t preventable (they are). Many times, friends, family members, and healthcare providers realize the risk, but aren’t sure how they should go about discussing firearm access with someone they cherish and don’t want to upset. The truth – a near absence of funding for research in this area means that we lack a clear understanding of the best ways to talk about firearms with adults who have elevated suicide risk.
Suicide prevention is a challenging endeavor and finding ways to respectfully facilitate safety around firearms and other lethal methods is especially so. Fortunately, there is a clear path forward. Public health and healthcare systems have tackled other complex problems, such as high mortality among patients with HIV or from motor vehicle collisions. These tremendous feats were accomplished by adopting a public health approach to solving public health problems - scientific inquiry that parallels and fuels innovation and interventions at various levels, from the development of novel HIV medications and vehicle airbags to the identification of effective methods to prevent firearm-related suicides.
For us, Monday may have been accompanied by this sobering footnote of suicide, but that footnote didn’t impact our sincere appreciation for those who served. Because of that appreciation, we’re going to continue doing the tough thing, and talk about firearms with those at risk of suicide. After all, if we don’t do that, we’re not doing everything. We urge you to support AFFIRM, which is doing the back-breaking work of supporting us in doing it better.
REFERENCES
2019 National veteran suicide prevention annual report VOoMHaSP, US Department of Veterans Affairs. Available at: https://www.mentalhealth.va.gov/docs/data-sheets/2019/2019_National_Veteran_Suicide_Prevention_Annual_Report_508.pdf.
Hedegaard H, Curtin SC, Warner M. Suicide mortality in the United States, 1999–2017. NCHS Data Brief, no 330. Hyattsville, MD: National Center for Health Statistics. 2018.
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. Available from URL: www.cdc.gov/ncipc/wisqars. Accessed November 12, 2019
Cleveland EC, Azrael D, Simonetti JA, Miller M. Firearm ownership among American veterans: findings from the 2015 National Firearm Survey. Inj Epidemiol. 2017;4(1):33.
Miller M, Swanson SA, Azrael D. Are We Missing Something Pertinent? A Bias Analysis of Unmeasured Confounding in the Firearm-Suicide Literature. Epidemiologic reviews. 2016;38(1):62-69.
Simonetti JA, Azrael D, Miller M. Firearm Storage Practices and Risk Perceptions Among a Nationally Representative Sample of U.S. Veterans With and Without Self-Harm Risk Factors. Suicide Life Threat Behav. 2018.
Valenstein M, Walters H, Pfeiffer PN, et al. Acceptability of potential interventions to increase firearm safety among patients in VA mental health treatment. Gen Hosp Psychiatry. 2018;55:77-83.