Reducing Military and Veteran Suicide

House Veteran Affairs Subcommittee on Economic Opportunity

Witness: Christopher M. Jones, PharmD, DrPH, MPH, CAPT, US Public Health Service
Acting Director of National Center for Injury Prevention and Control, Centers for Disease Control and Prevention

Chairman Levin, Ranking Member Moore, and distinguished members of the Committee, it is an honor to appear before you today to discuss the Centers for Disease Control and Prevention’s (CDC’s) ongoing response to suicide. I am grateful for this opportunity to share CDC’s comprehensive public health approach to suicide prevention and how we leverage that work to protect the populations most at risk, including our nation’s Veterans.

CDC’s vision is clear: no lives lost to suicide. Currently, suicide is a leading cause of death overall in the United States (U.S.). Suicide was the second leading cause of death for people ages 10-14 and 25-34, and among the top 9 leading causes of death among people aged 35-44, 45-54, and 55-64.¹ In 2020, nearly 46,000 suicide-related deaths occurred while many more people thought about or attempted suicide – critical risk factors for future suicide.²

While anyone can experience suicide risks, certain groups have substantially higher rates of suicide than the general U.S. population. Veterans bear a disproportionate but preventable burden. Tragically, out of the 130 suicides per day in 2019, 17 of those lives lost were veterans. In 2019, among the average 17.2 Veteran suicides per day, an estimated 6.8 suicides per day were among those with VHA encounters in 2018 or 2019, whereas 10.4 per day were among Veterans with no VHA encounter in 2018 or 2019.³ Veteran suicide-related deaths are also increasing at a greater rate than that of the general U.S. population. From 2001 to 2019, the rate of suicide among Veterans increased nearly 36% relative to an increase of 30% in the general population.

These facts underscore the urgency of implementing evidence-based prevention strategies that will protect both the general population and the nation’s veterans. These strategies, when implemented comprehensively, can make a profound and lasting difference.

CDC uses data to understand the contributors to suicide, including its scope and magnitude, who is most impacted, and to track trends over time to inform prevention and response efforts.

For almost 20 years, CDC has collected suicide-related data through the National Violent Death Reporting System (NVDRS). This system is now in all 50 states, Washington, DC and Puerto Rico, enabling the combination of reports from medical examiners and coroners, vital statistics, and law enforcement to give a much richer picture to better understand the details surrounding a suicide death. This information helps states and communities to better tailor suicide prevention efforts. Investigating a suicide is time consuming and includes abstracting up to 600 data points from multiple sources (e.g., death certificates, coroner/medical examiner reports, law enforcement reports). States often require 16 months or more to determine suicide as a manner of death and post the information into the NVDRS.

Data on nonfatal suicidal behavior is also critical for states and communities to pinpoint and identify emerging trends and target prevention efforts. CDC is currently funding ten states to track non-fatal suicide-related visits, such as suicide attempts and ideation, to emergency departments (EDs) in near real-time. With these timely data, generally available within 24 hours, CDC and funded jurisdictions can detect potential suicide spikes, clusters, or outbreaks and rapidly share this information with local practitioners and organizations focused on suicide-prevention among populations and locations at greatest risk. In addition to immediate response efforts and tracking.

CDC also has ongoing collaborations with the Departments of Defense (DoD) and Veterans Affairs (VA) to strengthen suicide-related data. CDC is collaborating with the Department of Defense to link and analyze data from the DoD’s Suicide Event Report and CDC’s NVDRS. This project leverages these two unique data systems to collect information on military service members (Veteran and active-duty are combined), and civilian suicides for a unique opportunity to better understand the contributors to suicide in these populations. Combining different data elements from each system creates a more holistic picture to inform upstream prevention. Staff from DoD and CDC have linked over 1,000 suicide cases to date. This project will create detailed mapping of suicide prevalence by county, as well as a thorough description of the characteristics of Veteran and active-duty suicides in areas with the highest incidence. These maps can be overlaid with military installations, mental health clinics, and suicide prevention programs to see which hotspots may lack infrastructure to address suicide burden and to highlight areas in need of suicide prevention resources, including upstream prevention. In addition, CDC works with the VA to link mortality data from CDC’s National Death Index to VA data to improve understanding of Veteran suicide.

Suicide has no single cause and is influenced by a range of risk and protective factors at the individual, relationship, community, and societal levels. These include economic issues, lack of individual or community connectedness, underlying mental health and substance use disorders, and easy access to lethal means among people at risk. Other key factors include depressed mood, history of suicidal thoughts or plans, crisis in the preceding or upcoming two weeks, intimate partner problems, physical health problems, and alcohol dependence.⁴

CDC also recognizes the interconnection between suicide, substance use, and adverse childhood experiences (ACEs). Experiences during childhood, such as witnessing violence, experiencing abuse or neglect, or losing a loved one to suicide are considered ACEs. While suicide, overdose, and ACEs can be viewed as independent challenges, they are also consequences of shared root causes that can be prevented by upstream prevention strategies that address common, underlying shared risk and protective factors at the individual, family, and community levels. Incorporating this holistic perspective is critical as we work to address suicide, including suicide among Veterans.

Among Veterans and non-Veterans alike, mental health and substance use are significant contributors to suicide risk, but CDC data show that there are also other important risk factors to consider when implementing prevention strategies. Economic insecurity, housing insecurity, isolation and stress, among others, are risk factors that require a multi-sectoral approach. Given the range of factors that may contribute to a person’s risk of suicide, no single prevention strategy will work. Instead, the most effective response is a comprehensive approach including implementation and evaluation of multiple complementary strategies with the best available evidence.

Comprehensive suicide prevention requires the coordination of public health, healthcare, jobs and economic development, education, housing and other sectors. One key role for public health is to bring these partners together to focus on comprehensive state and community efforts with the greatest likelihood of preventing suicide. Such an approach focuses both upstream, to prevent people from becoming suicidal in the first place, as well as addressing the needs of people at risk by connecting them to services and supports. This comprehensive public health approach to suicide prevention reflects the priorities outlined in the White House’s strategy for Reducing Military and Veteran Suicide.⁵

CDC’s Comprehensive Suicide Prevention Program, initiated in 2019, funds 10 state Departments of Health (California, Colorado, Connecticut, Louisiana, Maine, Massachusetts, Michigan, North Carolina, Tennessee and, Vermont) and the University of Pittsburgh to implement and evaluate a comprehensive public health approach to suicide prevention, with attention to populations at disproportionate risk (such as veterans, LGBTQ people, American Indians and Alaska Natives, homeless individuals, and people with disabilities). Under CDC’s Comprehensive Suicide Prevention Program recipients:

• Promote partnerships with a focus on organizations representing disproportionately affected populations, including Veterans
• Use data to understand suicide in disproportionately affected populations
• Track and monitor nonfatal suicidal behaviors, such as suicide attempts, in near real-time to inform prevention and response efforts
• Leverage existing prevention activities in the community
• Implement programs from CDC’s compendium of the best available evidence-based suicide prevention programs, Preventing Suicide: A Technical Package of Policy, Programs, and Practices, focused on upstream, community-based, and healthcare-related suicide prevention approaches.
  • Prevention strategies include strengthening economic supports through improving household financial security and housing stabilization, and skills training to support individuals and families. At the individual level, financial strain, including evictions and foreclosures, unemployment, and other unexpected financial issues are a risk factor for suicide.
  • The Technical Package also highlights strengthening access to and delivery of suicide care through implementing mental health parity laws and reducing provider shortages.
  • Healthcare-related interventions include identifying and supporting people at risk through crisis intervention, strengthening access to and delivery of care through healthcare systems improvements, and treatment to prevent suicide re-attempts.
  • Community-based interventions include promoting connectedness through peer norm programs and community engagement activities and identifying and supporting people at risk. This includes gatekeeper training, designed to teach community members to identify and respond effectively to people who may be at risk of suicide. Another intervention is postvention, designed to support community members after a suicide.

• Evaluate intervention outcomes to ensure quality and sustainability
• Develop a communication plan to share progress, lessons learned and successes with partners and the community

The comprehensive approach also relies on data and partnerships to identify populations that shoulder a disproportionate burden of the problem and can benefit from focused prevention efforts. This approach is effective for overall suicide prevention and for Veterans.

Under CDC’s Comprehensive Suicide Prevention program, multiple states have identified Veterans as a key risk group and are implementing interventions to address Veteran suicide. For example, the Louisiana Department of Health is providing gatekeeper trainings to Veterans so they can identify suicide risks and support Veteran peers. They are also training peer support leaders to promote connectedness. The Connecticut Department of Public Health is planning to work with the Army National Guard to implement a social norms campaign for military recruits to promote connectedness and normalize help-seeking behaviors. The North Carolina Department of Health and Human Services is teaching healthcare providers to identify Veterans potentially at risk of suicide and to counsel those at risk about secure storage of lethal means, such as medications and firearms.

Last month, with the additional funding appropriated in FY 2022, CDC released a new notice of funding opportunity, (CDC-RFA-CE22-2204) to expand the Comprehensive Suicide Prevention program to a second cohort of up to six additional recipients to develop a comprehensive suicide prevention program, for a total of up to 17 recipients this year. The goal of these cooperative agreements is a 10% reduction in suicide and suicide attempts among populations disproportionately affected by suicide. Through these initiatives, CDC aims to build a national program in all states and territories that will contribute to the national goal of reducing suicide 20% by 2025.

In addition to our funded CSP states, other states and organizations use these comprehensive strategies to develop suicide prevention plans. For example, CDC collaborates with both the Substance Abuse and Mental Health Services Administration (SAMSHA) and the VA each year on the Governor’s Challenge Policy Academy to train state teams to develop strategic plans for veteran, service member, and family suicide prevention. Through this collaboration, CDC provides technical assistance to the state teams regarding Preventing Suicide: A Technical Package of Policy, Programs, and Practices which focuses on the best available evidence for primary suicide prevention among high-risk populations like Veterans.

Most Veterans who die by suicide are not engaged in Veterans Health Administration (VHA) care and depend on community-based resources to improve quality of life, reduce risk factors, and increase protective factors to prevent suicide.³ In 2017, CDC launched an initiative to better understand how to prevent suicide among young (18-34 years old) Veterans not engaged in VHA care. Using insights gained from this project, it became clear that Veteran-serving organizations (VSOs) have an established, trusted relationship with Veterans and can help reach those Veterans not served by other services. To advance this work, CDC and the CDC Foundation are collaborating on a Veteran Suicide Prevention Evaluation (VSPE) Demonstration Project. VSPE is funding a total of 14 VSOs to implement and evaluate Veteran programs that address upstream approaches to suicide prevention, such as increasing connectedness between Veterans and the community and linking Veterans to resources and supports. When implemented effectively, this model can reduce the social isolation and other stressors that are risk factors for suicide.

One example from America’s Warrior Partnership (AWP), a three-time VSPE grantee, uses the Community Integration Model (Model) to strengthen upstream factors that promote Veteran wellness and build trusted relationships with Veterans, their families, and caregivers. AWP’s Model collaborates with affiliated communities to assess Veterans’ needs and existing community resources. It also incorporates connecting with partner organizations and links Veterans to upstream services, such as housing, employment, and healthcare. With CDC funding and technical assistance, AWP built capacity in formative, process, and outcome evaluation to assess and improve the implementation of their Model to better serve communities and Veterans. This year, AWP is using that funding to address disparities by assessing the extent to which the Model is achieving intended outcomes within the Navajo Nation. The findings from this evaluation will be used to inform future adaptions of the Model to best serve Veterans across the nation.

The Arizona Coalition for Military Families, also a three-time participant in VSPE, formed a Risk Reduction Operation Team to assess how Veterans with diverse military experiences perceive care and support during and post-military service. They are partnering with other organizations to address suicide risk among Veterans with food insecurity and among those participating in select Arizona Medicaid plans. The purpose of the project is to assess the extent to which upstream program outcomes are being achieved as expected. Arizona Coalition for Military Families has used VSPE funding to build evaluation capacity to improve their programmatic processes and share successful evaluation tools with other VSOs working to prevent Veteran suicide.

Another funded VSO, Objective Zero Foundation (OZF), has a mobile app that helps Veterans and community members 1) independently access wellness tools, trainings, and resources; 2) seek support through a crisis hotline or Ambassador; and 3) provide support and resources to Ambassadors. The program is currently evaluating outcomes, including social connectedness, awareness, and user intent to access mental health and other resources and skills to help others. This year they will disseminate findings, including a scientific publication, to contribute to the evidence base for upstream suicide prevention.

To contribute to the evidence base for upstream Veteran suicide prevention, VSPE is currently funding four returning VSO recipients to build capacity to evaluate program outcomes and communicate results to key partners and decision-makers. This bidirectional learning gives CDC a better understanding of the gaps and opportunities in the Veteran suicide prevention field and provides VSOs with long-term skills they can immediately put into practice. True to a community-based public health model, VSPE has built sustainable skills among VSOs and improved their credibility, confidence, and ability to enhance the lives of Veterans. The VSPE program approach has been transformational in a field too often focused on addressing immediate crises, with little time to build capacity for sustained solutions – both of which are needed to protect our nation’s Veterans and prevent suicide.

Suicide and suicidal behavior affect millions of individuals, families, and communities, and can result in lasting health, emotional, and economic consequences. Veterans disproportionately experience factors linked to suicide, including post-traumatic stress disorder, social isolation, and access to lethal means. CDC continues its dedication to using data, science, action, and collaboration to identify disproportionately affected populations including Veterans, with a focus on upstream prevention strategies across the U.S. that complement the work of our sister agencies in HHS as well as the DoD and VA.

Every life lost to suicide is a tragedy, magnified when evidence-based prevention strategies exist that can make a profound and lasting difference. At CDC, our comprehensive approach to suicide prevention uses data and the best available evidence to inform strategic partnerships and programming with a vision for societal-level change. At this moment in history, it is imperative to address the challenges Veterans face head-on and provide supports to increase hope and resilience at the individual, family, and community level. Through a collaborative and comprehensive public health approach centered on the experiences of those most impacted, CDC can achieve our ultimate shared vision of no lives lost to suicide.