Veterans and Suicide

I don't typically bring work home with me. Not literally, not figuratively. But last week I had a tough session with a patient, and it's since been on my mind.

I've been seeing a veteran, we'll call him Mr. S, for over a year, to help him with attention and learning difficulties. He's in his mid-20s, a combat veteran, with a childhood history of ADD/ADHD, and cognitive issues complicated by chronic pain, sleep difficulties, developmental trauma, history of concussion, and likely PTSD/adjustment disorder. If you didn't have access to his medical record, you'd never know there was anything "wrong" with him. Except the ADHD; his hyperactivity is palpable, in a totally endearing way. Maybe it falls outside the bounds of my "professional ethics," but I consider Mr. S to be one of my favorite patients at the VA, or anywhere.

As a speech-language pathologist, our cognitive-communication therapy sessions typically focus on training and practicing time management and study skill strategies, particularly since he returned to school on the GI Bill. Although he is bright with a lot of good ideas, insight, and drive to learn, he struggles significantly in the traditional academic environment. He was technically referred to me because he was evaluated for TBI (traumatic brain injury) in our clinic, which he sustained while deployed. He reported difficulties with attention and memory, and while these symptoms can indeed be sequelae of concussion, it would be unexpected to note several years after the head insult. Instead, these issues are ongoing problems for Mr. S, and with his return to school - the less structured schedule, the distracting learning environment, the quantity and speed of new information with expectations for comprehension and retention - his cognitive deficits resurfaced. 

But last week, rather than work on writing organization strategies, he impulsively confessed to me that he tried to kill himself over the weekend. That in the throes of his ever-increasing panic attacks, he hastily grabbed a loaded gun and held it in his mouth. He said he was ready to pull the trigger. To make it all stop. His girlfriend, fortunately home at the time, was able to kick him in the chest and get the weapon away from him. Mr. S was understandably overwhelmed and frightened by his actions, just how close he got to the edge of the very, very high cliff. This wasn't the first time he'd made such a gesture, he confided in me, but the first time he resorted to such measures in front of someone else. And the first time it drove him to seek help. He promised his girlfriend he would tell one of his providers about the attempt. I was that provider. 

I have been trying for months to get him connected with mental health services. I refer him, they reach out for scheduling, he makes an appointment, and then he never shows or doesn't follow through. He has told me that he knows he needs psychotherapy, but that he doesn't want to "go there." That he has been able to successfully compartmentalize, bury, and ignore developmental and military traumas for most of his life, and that he feels like he should continue to be able to do so now. I tell him that, in my clinical experience, the brain and body just don't work that way. 

I know that mental health professionals regularly deal with these heightened emotions and threats of self harm. I am fortunate not to. Thinking is my area of expertise, not feeling. For a reason. I am ill-equipped to deal with other people's severe expressions of emotion. Cognitive-communication therapy is my bread and butter. But I'm not blind to the issues that many, many of my patients are suffering.

According to one report from 2010, 20+ veterans die by suicide every day. Another 1,000 attempt to do so each month. Apparently the VA system in 2007 initiated extensive efforts to reduce suicide rates, although by what means I am unclear. Another report found that rates of suicide in veterans is 30 per 100,000, compared to 14 civilians per 100,000. One medical study found that not only are combat veterans more likely to have suicidal ideation, they are also more likely to act on a plan. In 2012, 6,500 veterans were reported to have died by suicide. I can only imagine the actual number was higher.

When it comes to assessing for suicide risk, there are three components:
- ideation, which refers simply to thoughts of suicide
- plan
- means, referring to access to weapons or drugs, for example
Therapists will also always inquire about protective factors, such as a support system, religious beliefs, pets, etc.

There are resources. The Veteran's Crisis Line, for one. In fact, a documentary about the New York-based crisis line won an Academy Award in February. There is the VA health system, including giant mental health departments with every team you can think of - the PTSD Clinical Team, Substance Abuse Treatment Programs, Dialectical Behavior Treatment, ACT and PET for PTSD, pain therapy, etc. etc. And there are vet centers all over the country, equipped with therapists who are typically veterans themselves. Not to mention the hundreds of nonprofit organization designed to assist the veteran population with a variety of issues, from complementary healthcare to suicide prevention to providing housing for the homeless.

As for Mr. S, with his permission I conferred with the psychologist on my Polytrauma team, and she met with him immediately after me and together they created a "safety plan." He scheduled an appointment with his mental health provider for the following day, agreeing to work hard to develop rapport with her. He also inquired with his primary care provider about psychotropic medication options. And his girlfriend took the keys to his gun safe. As for me, I keep visualizing this tall, strong, typically composed individual, and how his face fell and he broke down in sobs when he told me about his attempt. In front of my eyes he transformed from this stoic man into a weepy young boy. I try not to picture him with that loaded handgun pointed in his mouth, desperate for relief from whatever tortures him. I feel for him, and can only hope that with the right tools he can learn to silence, or at least quiet, the demons he carries.

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As Memorial Day is intended to honor those who died while serving in our nation's armed forces (compared to Veteran's Day, which celebrates the service of all military veterans), it's only fitting to provide some information about suicide in the active duty population.

Back in 2012, according to the Department of Defense, troops on active duty were successfully committing suicide at rates of nearly 23 per 100,000, compared to 19 per 100,000 in age- and SES-matched civilian population. In 2013 that number had supposedly decreased, but then was reported to inch back up in 2014. In January of this year the DoD released numbers for 2014 - 288 active duty personnel were reported to die by suicide in 2014. But you know what statistic really speaks to me? The one that reports more deaths by suicide than from combat in Afghanistan since 2001. At one point suicide was reported to be the leading cause of death among active duty personnel. The best article I've seen on both military and veterans suicide rates is from 2014 and here.

I find this all very discouraging. But there are numbers that shed some promise - the statistics that report an increase in both active duty and veteran "help seeking" behaviors. That tells me that, however slowly, the military culture is starting to change from one of scorn for admitting weakness to one that values asking for assistance. I can only hope.