September is Suicide Awareness Month in the United States. I would like to use this opportunity to discuss three ideas that are important in bringing awareness to the effort of reducing the burden of suicide. I will briefly touch on the stigma of suicide, the extent of suicide among Veterans, and the warning signs of suicide as they relate to Service members and Veterans.
Awareness of the Stigma of Suicide:
Often when an individual has died by a self-inflicted wound the surviving family members and friends refrain from revealing the method of death and sometimes even seek evidence that their loved one didn’t intend to die. Some surviving family members would rather learn that their loved one was murdered than accept the idea that the death was a suicide. The resistance to characterizing a death as a suicide in the face of forensic and medical evidence is a sign of stigma. Generally, only stigmatized disorders are avoided as an acknowledged cause of death. It is rare for a family to deny cancer or heart attack as a cause of death, but many families doubt suicide as a cause of death (Joiner, 2010). In addition, surviving family members often feel that friends turn away from them or distance themselves after a suicide. There is a tendency to want to distance ourselves from suicide, as if it might be a contagious disease. People don’t feel comfortable asking friends and family if they are suicidal or talking about suicide. There may be many reasons for this discomfort talking about suicide or being around surviving family members, but the unifying factor is stigma (Joiner, 2010). Considering the suicidal individual, think about the high levels of stigma against such thoughts and imagine how difficult it would be to seek help. Compounding the difficulty for Service members and Veterans in seeking help could also be beliefs that treatment won’t work, others will see them as crazy, they may lose their jobs, and others will be angry with them or not understand.
Awareness of the Extent of the Problem:
Recently my Facebook feed has been filled with videos of people doing pushups each day as they participate in the 22 a Day challenge to raise awareness about the burden of suicide. This campaign focuses on awareness of the high rate of suicide among Veterans. Service members and Veterans are vulnerable to suicide with alarmingly higher rates than their civilian counterparts. A recent report released by the US Department of Veterans Affairs provided comprehensive comparisons of differences in suicide rates among Veterans and civilians matched by age and gender as well as comparing Veterans who access VHA services and those without VHA service. The report looked at over 50 million records and focused on the period from 1999 – 2014. It found that on average, 20 Veterans die by suicide daily, with 14 of those deaths being among those without VHA services. The report also found that Veterans accounted for 18% of all deaths by suicide in the US. Interestingly, the majority of the Veterans who died by suicide, 65%, were over age 50, indicating that the burden does not fall solely on the shoulders of Iraq and Afghanistan Veterans (U.S. Department of Veterans Affairs, Office of Suicide Prevention, 2016). Furthermore, although PTSD often gets discussed in the press and on social media as a related factor to the increased risk among Veterans, this is not in the top four mental health disorders with the highest rate of suicide. In a review of almost 6 million charts of patients receiving VHA services between 2007–2008, Ilgen et al. (2012) found the top mental health diagnostic contributors to suicide risk were bipolar disorder, substance use disorders, depression, and anxiety disorders other than PTSD. In the 2016 VA report bipolar disorder again had the highest rate of suicide among Veterans, followed by schizophrenia and substance use disorders, depression and other anxiety disorders, substance use disorder comorbid with some other mental health disorder, and finally PTSD. It is also important to note that suicide does not exclusively belong to any disorder, rather it is trans-diagnostic, and the absence of a particular diagnosis does not preclude someone from experiencing suicidal thoughts.
Awareness of the Warning Signs of Suicide:
Over the past few weeks as I’ve watched countless friends doing their push-ups and we’ve entered Suicide Awareness Month, the information that I have most wanted to share has been the acute warning signs of suicide. Similar to knowing the warning signs of stroke or heart attack, David Rudd and colleagues developed a consensus group to develop a 2-Tiered list of warning signs for suicide. The first tier are considered the highest risk and direct the individual or concerned individual to call 9-1-1 or seek immediate professional help. The 2 tiers are listed below:
Threatening to kill oneself
Seeking ways to kill oneself
Talking or writing about death, dying or suicide
Rage, anger, seeking revenge
Recklessness or engaging in risky behavior
Increased alcohol and or substance use
Withdrawal from family, friends, society, healthcare systems etc.
Anxiety, agitation, insomnia or hypersomnia
Dramatic mood changes
No reason for living; no sense of purpose in life
A simple mnemonic for remembering the warning signs can be found on the American Association of Suicidology’s website, http://www.suicidology.org/resources/warning-signs. The mnemonic is “IS PATH WARM.”
S Substance Abuse
M Mood Changes
These warning signs are perhaps one of the most important tools we can all carry to prevent suicide among Veterans and Civilians alike. As we are in the midst of Suicide Awareness Month please share the warning signs with your friends, family, and co-workers. My own personal goal for raising awareness this year, is achieving the widest level of awareness of the warning signs of suicide. Please join in!
Dr. Elizabeth Parins, Psy.D. is a project developer and trainer in military and civilian programs with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
American Association of Suicidology (2016). USA suicide: 2013 official final data. Retrieved from: http://www.suicidology.org/Portals/14/docs/Resources/FactSheets/2013datapgsv2alt.pdf
Ilgen, M.A., McCarthy, J.F., Ignacio, R.V., Bohnert, A.S.B., Valenstein, M., Blow, F.C., and Katz, I.R. (2012). Psychopathology, Iraq and Afghanistan service, and suicide among Veterans Health Administration patients. Journal of Consulting and Clinical Psychology, 80 (3), 323-330.
Joiner, T. (2010). Myths about suicide. Cambridge, MA: Harvard University Press.
Rudd, M.D., Berman, A.L., Joiner, T.E., Nock, M.K., Silverman, M.M., Mandrusiak,M.,Van Orden, K., & Witte, T. (2006). Warning signs for suicide: Theory, research, and clinical applications. Suicide and Life-Threatening Behavior, 36(3), 255-262.
U.S. Department of Veterans Affairs, Office of Suicide Prevention.(2016). Suicide Among Veterans and Other Americans 2001-2014. Retrieved from: http://www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf