An enemy at home: Suicide

Forth of six parts.

Veterans are killing themselves at more than double the rate of the civilian population, with about 49,000 taking their own lives between 2005 and 2011, according to data collected over eight months by News21.

Records from 48 states show the annual suicide rate among veterans is about 30 deaths for every 100,000 of the population, compared with a civilian rate of about 14 per 100,000. The suicide rate among veterans increased an average 2.6 percent a year from 2005 to 2011, or more than double that of the 1.1 percent civilian rate, according to News21's analysis of states' mortality data.

Nearly one in every five suicides nationally is a veteran - 18 percent to 20 percent annually. Census data show that veterans make up about 10 percent of the adult population.

"Any time a veteran who fought our enemies abroad or helped defend America from within our borders dies by their own hand, it's completely unacceptable," Rep. Jeff Miller (R., Fla.), chairman of the House Committee on Veterans Affairs, told an American Legion conference in Washington this year.

"It's not enough that the veteran suicide problem isn't getting worse," he said. "It isn't getting any better."

A 2007 law required the Department of Veterans Affairs to increase suicide-prevention efforts. In response to the Joshua Omvig Veteran Suicide Prevention Act - named for an Iraq veteran who committed suicide in 2005 - the department's efforts include educating the public about suicide risk factors, providing additional mental health resources, and tracking veteran suicides in each state. The VA's mental health care staff and budget have grown by nearly 40 percent during the last six years and more veterans are seeking mental health treatment.

The law mandated that the VA design a comprehensive program to reduce suicides. Provisions included training VA staff in suicide prevention, factoring mental health concerns into veteran health assessments, providing referrals at veterans' request to treatment programs, and designating suicide-prevention counselors at VA medical centers. It also required the VA to work with other federal departments on researching "best practices" for preventing suicides.

VA efforts since 2007 have shown some results. The Veterans Crisis Line - a national phone line - has experienced a steady increase in the number of calls, texts, and chat-session visits. In 2007, its first year, 9,379 calls went to the line. Each year the call volume has increased, reaching a high of 193,507 calls in 2012, totaling about 840,000 overall, according to the VA.

"It's discouraging to keep looking at the [suicide] rates, and we have to keep plugging away," said Dr. Jan Kemp, the VA national suicide-prevention coordinator and program manager of the crisis line. But she said that without resources such as the crisis line, "the rates would be higher."

The VA is analyzing mortality data collected from states and Department of Defense records to try to understand veteran suicides. The task has been "almost impossible" until recent years, Kemp said, because the federal Centers for Disease Control and Prevention does not track veteran deaths and most veterans are not enrolled in the VA system.

News21 sought data on post-9/11 veteran suicides, but state statistics rarely included identifying information or detailed service records. However, a 2012 report from the Substance Abuse and Mental Health Services Administration (SAMHSA) showed that between 2002 and 2005, 144 veterans of post-9/11 wars committed suicide out of a total veteran population of 490,346. In 2009, 98 men and women from post-9/11 wars took their own lives, according to that report.

A plurality of veteran suicides has been among those 65 or older, according to the data. About 19 percent of suicides that took place between 2005 and 2011 were veterans between 18 and 44, among the 36 states with available age data. War can exact a heavy toll on the mental health of soldiers, but veterans have the same risk factors for suicide as the general population, said Craig Bryan, research director at the University of Utah National Center for Veterans Studies. Those factors include feelings of depression, hopelessness, post-traumatic stress disorder, a history of trauma, and access to firearms.

"Veterans who die by suicide look a lot like Americans who die by suicide," Kemp said.

Veterans experience periods of readjustment as they reintegrate into civilian life. Traits and training needed to survive in a war zone - such as constant alertness - might contribute to troubling behaviors in civilian life, including edgy feelings while being easily startled, according to the SAMHSA report.

Suicide warning signs include feelings of being hopeless, out of control, angry, or trapped. Combat veterans might experience stress reactions including nightmares, sleeplessness, sadness, and feelings of rejection, abandonment, or hopelessness. Lack of concentration, aggressive behavior, reckless driving, and increasing use of alcohol, tobacco, and drugs are other indicators.

Concussions also are a chronic risk factor leading to suicidal thoughts, Bryan said, because head trauma makes people more vulnerable to such thoughts.

In 2010, Veterans Affairs Secretary Eric Shinseki asked governors to collaborate on collecting veteran suicide information in their states. Through November 2012, according the VA report, 34 states had submitted data and agreements had been forged with eight others to provide information.

News21 filed a Freedom of Information Act request for the raw data collected by the VA to this point, but it was denied because the "disclosure of raw research data poses a serious threat to the scientific process" and because of fears the information would be misinterpreted without peer review.

Most states provided veteran suicide information gleaned from death certificates. VA research, Kemp said, shows death certificates are "good enough" to help understand veteran suicides.

Veterans are overrepresented among suicides compared with the general population, a trend seen in most states between 2005 and 2011.

Among states with the widest disparities and highest rates, Idaho had an average annual veteran suicide rate of 49.5 per 100,000 people, according to News21 analysis, compared with a civilian rate of 20 per 100,000. Montana had an average annual veteran suicide rate of 55.9 per 100,000 people and a 23.9 civilian rate.

In Pennsylvania, the suicide rate for veterans was 30.2 per 100,000 people, compared with 13.9 for civilians. New Jersey had among the lowest annual veteran suicide rates across the time period, with 17.2 dying by suicide per 100,000 people and a civilian rate of 8.6.

As with suicides in general, veterans taking their own lives have been overwhelmingly male - about 97 percent among the 30 states that reported gender demographics.

In June, the VA hired 1,600 clinicians to assist with mental health counseling for veterans in compliance with an executive order last year from President Obama. This is only part of the solution, Utah researcher Bryan said, because "veterans don't come to mental health treatment."

The challenge is understanding suicide in the general population, Bryan said, and then translating those factors for the military and veterans, who are part of a "unique subculture" in the United States.

Part of that culture is mental toughness, he said, along with "elitism" and "feelings of superiority," mind-sets that render traditional suicide-prevention methods less effective. "They are very much like elite athletes," he said of those least likely to complain of pain or injury.

The new challenges facing female veterans.

This report is part of a project on post-9/11 veterans produced by the News21 program involving top college journalism students across the country and based at Arizona State University. It is funded by the John S. and James L. Knight Foundation and the Carnegie Corp. For additional stories, photos, and interactive elements - including a look at the problem of homelessness among veterans - go to http://backhome.news21.com.