by R. Keith Hotle, J.D., MPA
Chief Program Officer, Stop Soldier Suicide
As many Americans already know, the statistics related to veteran suicide rates are grim. According to VA reporting, 6,139 veterans killed themselves in 2017, compared with 5,787 in 2005. In the same year, veterans accounted for 13.5% of all deaths by suicide among U.S. adults, yet constituted less than eight percent of the adult population. The veteran suicide rate is 50% higher than non-veteran adults, and suicide is one of only three leading causes of death in the United States not on the decline. Unfortunately, the Coronavirus (COVID-19) pandemic sweeping through our nation is likely to exacerbate the already dire public health crisis of veteran suicide.
The United States has not experienced a national health catastrophe of the scope and scale of COVID-19 since the Spanish Flu pandemic, which infected an estimated 500 million people worldwide from 1918-1922—about one-third of the planet’s population—and claimed the lives of as many as 50 million victims, including some 675,000 Americans. On March 11, 2019, the World Health Organization declared COVID-19 a global pandemic, and two days later the United States declared it a national emergency. In their efforts to contain the spread of the virus, most states and local jurisdictions have implemented stay-at-home orders of varying types. These policies will almost certainly get broader in scope and stricter in degree as the nation continues to grapple with this highly virulent disease.
As Dr. Eric Caine, co-director of the Center for the Study of Prevention of Suicide at the University of Rochester Medical Center recently remarked: “There are ramifications, sometimes fatal, with events like these that are not just related to getting infected or dying from infection or consequences of infection.” Suicide is one such ramification. Calls to crisis lines across the country are increasing rapidly, as are demands for mental health services — particularly telehealth. Given this early anecdotal evidence, many Americans fear the nation may soon see significant increases in suicidal thoughts, attempts and deaths.
Despite the lack of reliable epidemiological data from the Spanish Flu, there appears to a positive correlation between the pandemic and increased suicide deaths. While the true influence of the Spanish flu pandemic on national suicide rates remains unknowable, analogy to smaller-scale events is informative. For example, research demonstrates a positive correlation between natural disasters and suicide rates. An analysis of the impact of Hurricane Maria on Puerto Rican residents indicated a 32% increase in suicide deaths in the three months after it struck the island; rates of suicidal ideation and PTSD also rose during this time. (Alfonso) Authors of an earlier study conducted to determine the relationship between major catastrophes (floods, hurricanes, earthquakes) and suicide offered the following apt observations of the impacts of these events:
There are several possible reasons why people may commit suicide after a natural disaster, even months or years later. The victims of disasters may be injured or may lose family members, friends, property, or jobs. Even people who incur no direct losses can be affected by a disaster. At least as important as the consequences of the immediate physical effect of a disaster are the long-lasting alterations of day-to-day life and the disruption of social networks. Stores, bars, clubhouses, or churches — places where people found friends and support — may have been destroyed. After natural disasters, factors such as bereavement, property loss, and the disruption of social networks have been associated with mental-health problems, including depression and hopelessness, which are known risk factors for suicide. Strong social support is a protective factor against suicide. However, research shows a decrease in feelings of social support and belonging after natural disasters. (Krug)
Equally troubling is the fact that suicide rates rise during periods of economic recession, especially when broadly realized across the population. Negative public perceptions of the economy as measured by the Consumer Sentiment Index are directly associated with increases in suicide rates. Government austerity measures introduced in response to recessions also contribute. Long durations of sustained societal financial hardship increase stressors such as higher personal debt, auto repossessions and home foreclosures, relationship difficulties, unemployment and under-employment, and cuts in mental health services. Of these, unemployment may be the strongest risk factor for the veterans we serve at Stop Soldier Suicide.
Persons already vulnerable due to pre‐existing mental illness are among those individuals most likely to lose their jobs during recessionary times, thus compounding the adverse effect of unemployment and financial difficulties. Men of working‐age appear to be at greatest risk during periods of economic hardship and unemployment, which is consistent with prevailing suicide theories that posit suicides typically occur when those at-risk experience feelings of hopelessness, perceive themselves as burdens to their families and others, and become disconnected from natural networks of support – which for most middle-aged men is their employer. Add into the cocktail veterans’ familiarity with (and greater access to) firearms and the results are deadly.
Implications from the research are several. The COVID-19 pandemic as a standalone global phenomenon will likely have an independent effect on suicide rates by virtue of collective experiences with widespread death and serious illness. This rise will be amplified by significant disruptions to the social fabric — many of which are already being witnessed. The most difficult of these for our struggling veterans may be the negative effects of extended periods of physical isolation from their families, friends and other supportive people.
The secondary effects of the pandemic – unemployment, financial losses, PTSD, mental health issues, social isolation – are likely to result in even greater increases in suicidality — particularly among at-risk veterans who experience these issues more acutely than the general population. Confounding these problems will be severe limitations on providers’ ability to directly serve persons at risk or to connect them to face-to-face supports. The expected burden on healthcare systems across the county will amplify the problem, as shortages of doctors and mental health providers inhibit the ability of suicidal persons to get timely, effective services. As these economic impacts stretch into the future, their influence on veteran suicide will become more pronounced and enduring. Responsible, balanced messaging will be essential in fostering a positive public sentiment as the nation collectively confronts this challenge.
Stop Soldier Suicide already has started to see a significant uptick in veterans reaching out for help, a trend we fully expect to continue into the foreseeable future. Reports from crisis call centers and front-line providers across the country reflect similar increases in volume. To plan for this influx, we are growing our team and redoubling our efforts, understanding that now is the time to lean in to support our active military and veterans through and beyond this crisis. We are also looking for ways to better serve our at-risk clients during these difficult days, through proactive outreach and education on Coronavirus resources and more frequent check-ins for our veterans who may be at particular risk due to social isolation, increased anxiety, and housing insecurity and other pandemic-related problems.
Ai, A., Santangelo, L., & Cascio, T. (2006); The Traumatic impact of the September 11, 2001 terrorist attacks and the potential protection of optimism. Journal of Interpersonal Violence, 21, 689–700; https://journals.sagepub.com/doi/10.1177/0886260506287245.
Alfonso, C. (2018); PTSD and suicide after natural disasters. Psychiatric Times, 24; https://www.psychiatrictimes.com/ptsd/ptsd-and-suicide-after-natural-disasters.
Bad economic news increases suicide rate, research shows. World Economic Forum; https://www.weforum.org/agenda/2019/06/bad-economic-news-increases-suicide-rates-new-research/ (retrieved 03/27/20).
Collins, et al., (2019); Suicide, sentiment and crisis; Portsmouth Research Portal, University or Portsmouth; https://researchportal.port.ac.uk/portal/en/publications/suicide-sentiment-and-crisis(48b25326-2d39-4796-ac74-3810e6c9d906).html.
Gunnell, D. and Chang, S. (2016); Economic Recession, Unemployment, and Suicide. The International Handbook of Suicide Prevention (eds. R.C. O’Connor and J. Pirkis).
Joiner, Thomas E. Why People Die By Suicide. Cambridge, MA : Harvard University Press, 2005.
Krug, E., et al. (1998); Suicide after natural disasters. New England Journal of Medicine, 338:373-378; https://www.nejm.org/doi/full/10.1056/NEJM199802053380607?query=recirc_curatedRelated_article (while the measures originally reported in this study were retracted because of errors in the authors’ statistical analyses, the study’s conclusions were not affected).
Reeves, et al. (2014); Increase in state suicide rates in the USA during economic recession. The Lancet, vol.380, no.9856, pp. 1813-1814; https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61910-2/fulltext#articleInformation.
Sweeney, D. (3/25/20); Suicide hotline calls soar as coronavirus spreads. ‘There is a flood coming.’ Miami Herald; https://www.miamiherald.com/news/coronavirus/article241493126.html.
U.S. Dept. of Veteran Affairs, Office of Mental Health and Suicide Prevention. 2019 National veteran suicide prevention annual report; https://www.mentalhealth.va.gov/docs/data-sheets/2019/2019_National_Veteran_Suicide_Prevention_Annual_Report_508.pdf.
U.S. Dept. of Veteran Affairs, Veterans Health Administration. The Effect of unemployment on suicide risk. From Science to Practice; MentalHealth.VA.gov source.