The Loss of Our Veterans is Here in America

We lose close to 18 veterans to suicide on a daily basis. Veteran Andrew “Andy” Marckesano was born in Phoenix, Arizona on October 22, 1986; and  just three days after taking a job with the Pentagon in 2020, he took his own life in our nation’s capital. The suicide rate of veterans goes up to 20 suicides daily if active-duty troop members are included
(https://www.militarytimes.com/news/pentagon-congress/2020/11/12/suicide-rate-among-veterans-up-again-slightly-despite-focus-on-prevention-efforts/). Despite the numerous programs and ongoing research of the Veterans Health Administration (VHA), suicide is still a complex problem with too many unknowns that leaves our veterans at high risk.

“Andy” Marckesano graduated as a Green Beret in 2015. As a Special Forces Weapons Sergeant in the 2nd Battalion – 7th Special Forces Group (Airborne)– Andy was once again deployed to Afghanistan in 2017. Despite his history of multiple deployments, it was the one back in 2009, as part of the 82nd Airborne and 75th Ranger Regiment to the Arghandab Valley, that hit him the hardest, according to family and friends. Many of those close to him said he became a “changed man.” Andy, like the story of many veterans, continued taking on redeployments – perhaps feeling disconnected to the “real world.” He was an accomplished soldier, having been recognized with many accommodations including the Silver Star. At the time Andy committed suicide his loved ones recall that there was no notable downward shift or spiral. As with many suicides it was not foreseeable (https://www.wearethemighty.com/mighty-culture/andy-marckesano/).
     
Mental health service in our country is a weak link in the chain of our healthcare system. We know the value of early interventions in many areas of mental health, yet we have failed miserably in putting measures in place. With all Americans, we need “coordinated efforts at the local, regional, and national levels to implement public health approaches to end suicide”
(https://www.mentalhealth.va.gov/docs/data-sheets/2020/2020-National-Veteran-Suicide-Prevention-Annual-Report-11-2020-508.pdf). According to the 2020 National Veteran Suicide Prevention Annual Report, there has been an unfortunate increase in overall suicidal rates with veterans (after a slight decline from 2016 – 2018). In contrast and more hopeful, there is a decrease in suicides among those veterans utilizing mental health services.
    
Where do we begin with resolving this crisis? Suicide has no singular cause or pathway, which means the solutions cannot follow a single path. For example, there is a complex interaction of factors (at various levels) that can contribute to an individual’s suicide:

1. International level with examples being wars or pandemics
2. National level to include economic or healthcare disparities
3. Community level involving employment rates, availability and access to mental health services
4. Familial and Relational levels, which entail quality of support systems or relationship problems
5. Individual level, which addresses the individual’s health issues and suicide risk (https://www.mentalhealth.va.gov/docs/data-sheets/2020/2020-National-Veteran-Suicide-Prevention-Annual-Report-11-2020-508.pdf).

In trying to understand the suicide of veterans, we must also examine the many contributing details of cultural and socioeconomic context:

1. Economic Disparity: The transition from military to civilian life can be difficult. Vets are less likely to be employed and have lower incomes than the general population. Of course, unemployment and poverty are correlated with homelessness.
2. Race, Ethnicity, LGBT Disparities: American Indians and Alaska Native populations have the highest rates of suicide. Discrimination impacts access to care, as well as  quality of care.
3. Homelessness contributes to higher suicide rates.
4. Social Connection: Vets tend to have an increase in divorce rates, are widowed more, and experience social isolation. With COVID, social isolation is even more of an issue with depression and suicide.
5. Health and Well-Being: Vets who die from suicide are more likely to have had sleep disorders, substance abuse issues, traumatic brain injury, pain disorders, and personality and/or anxiety disorders.

{The research is extensive in the above-noted areas. Here are a few sample studies utilized for this article:

• Turecki, G.,Brent, D.A. (2016) Suicide and suicidal behavior. Lancet. 387:12271,227–39.
  
• McCarthy, J.F., et al (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):1935–42.
  
• Cochran, B.N., et al. (2013). Mental Health Characteristics of Sexual Minority Veterans. Journal of Homosexuality, 60(2–3), 419–435.}
  

The key to any health issue is prevention; the Suicide Prevention (SP) Now Initiative is a nationally-backed program that focuses on:

1. Healthy, empowered veterans with family and community support: paid medical plans, increased outreach and state-of-the-art services – including telehealth hubs. Lethal Means Safety (LMS), which addresses the training of police forces, emergency department staff, and healthcare providers. “Research shows that approximately 70% of military suicides involve firearms, compared with around 50% of suicides in the U.S. general population” (https://www.apa.org/monitor/2020/01/ce-corner-suicide). In one study done on firearm storage practices, “they found that nearly 36% of participants reported having a firearm in or around their homes, but less than a third of those with firearms said their weapons were safely stored, and nearly half indicated their firearms were either loaded and unlocked or not safely stored” (https://www.apa.org/monitor/2020/01/ce-corner-suicide). This past November in the US bill for bettering the VA’s suicide prevention efforts, the portion of the bill to promote the safeguard storage of firearms among veterans was unfortunately not accepted into the bill.
   
2. Clinical and Community Prevention Services with improved risk screenings, enhanced services for high-risk vets, and outreach programs to homeless vets. Educational materials in key locations and the promotion of media campaigns. For example, Dr. Philip Smith at the University of South Alabama is looking at opportunities for prevention before a veteran enters a crisis situation. His Operation Deep Dive is really “trying to understand not so much the specific mental health concerns of veterans but is looking instead at where in the community might there be prevention points where we can divert an individual who is on the trajectory to death by suicide to a different path”  (https://www.apa.org/monitor/2020/01/ce-corner-suicide).
   
3. Treatment, Recovery and Support Systems: Evidence-based modalities with a focus on same-day mental health screenings and treatments, expansion of the Veteran’s Crisis Lines, as well as developing measures to engage more vets in VA service. Suicide rates dropped between 2-6% from 2005 to 2018 with certain conditions (anxiety, depression and substance abuse) for those veterans under VHA care (https://www.mentalhealth.va.gov/docs/data-sheets/2020/2020-National-Veteran-Suicide-Prevention-Annual-Report-11-2020-508.pdf).
   
4. Surveillance, Research, and Evaluation: Evaluate which evidence-based modalities are effective, utilize data & technology for early warning surveillance and enhance the REACH VET program, (https://www.mentalhealth.va.gov/docs/data-sheets/2020/2020-National-Veteran-Suicide-Prevention-Annual-Report-11-2020-508.pdf). The REACH VET program is a computer-based statistical risk program that flags veterans and identifies mental health problems early on – e.g., before suicidal thoughts occur (https://www.apa.org/monitor/2020/01/ce-corner-suicide).
   

The roadmap that addresses how to change the culture surrounding mental health and suicide prevention is called PREVENTS or the President’s Roadmap to Empower Veterans and End a National Tragedy of Suicide (https://www.va.gov/PREVENTS/EO-13861.asp). As with the subjects addressed in this article, the outcomes focus on implementing strategies to effectively lower the rate of suicide and analyze opportunities for collaboration within federal, state, local, tribal, and nongovernment entities. https://www.apa.org/monitor/2020/01/ce-corner-suicide). This visionary roadmap of PREVENTS outlines three major missions: to end military suicide, to provide legislation and funding, and to carry out research. We lose too many veterans in combat; we need to end the loss at home.

This article is dedicated to my daughter’s friend, who is a Green Beret. To find out more about The Green Beret Foundation, visit: https://greenberetfoundation.org/msg-marckesano-suicide-prevention-fund/