The largest study yet on suicide risk among veterans suggests that younger returning soldiers may be at greatest risk of taking their own lives and that more resources may be needed to curtail suicide in this age group.
The study focused on 807,694 depressed veterans in the VA health care system from 1999 to 2004.
Authors note that the findings are not unique to the Middle East conflict, implying they could be applied to other wartime situations as well.
"Most were not involved in the current war," said co-author Dr. Marcia Valenstein, research scientist in the Department of Veterans Affairs Health Services Research and Development Service, of the veterans studied.
For some researchers, the findings are not surprising. Dr. Paul Ragan, associate professor of psychiatry at Vanderbilt University Medical Center in Nashville, Tenn., said the scientific community has been aware for some time now that younger veterans are heavily affected by suicide.
He added that suicide rates in the general population tend to peak in two age groups -- one at ages 15-24 and another at ages 40 and up. Such a pattern, he suggests, may also be consistent with that of the military population.
Moreover, he said, "suicide rates among ages 15-24 have been steadily increasing over the last 20 years in the U.S.
"This is not a new finding."
But Ragan said what disturbs him most is the sheer magnitude of suicide among U.S. veterans compared with the general population, and he is concerned that it will only escalate as young vets return home from the Middle East.
Dr. Harold Koenig, professor of psychiatry and behavioral sciences at Duke University School of Medicine in Durham, agrees with this theory.
"I think it's been everybody's impression that suicide rates in veterans, especially those coming home from the Middle East, were much, much higher than for people in the general population," he said.
Suicide and PTSD
Some psychological experts say that younger soldiers are at greater risk of suicide because they lack the life experience of older veterans, which may serve as a protection of sorts from succumbing to suicide.
"One could hypothesize that older veterans have a higher resilience level as compared to older nonveterans," said Dr. Israel Liberzon, chief of psychiatry service at AAVAHS in Ypsilanti, Mich. "The fact that the 'older' veterans remain in active military potentially pre-selects to higher-functioning individuals."
Koenig agrees with this assessment. "Younger veterans... have probably experienced less trauma and tragedy," he said. "That is all new for them, and first experiences of anything are more traumatic than if you've experienced it many times before."
Another factor cited by Koenig suggests that older veterans are particularly "hardy" survivors. "[Those with] suicidal tendencies may have already committed suicide," he said.
More surprising, the lead authors note, may be the finding that depressed patients who also had post-traumatic stress disorder, or PTSD, appeared to have a lower suicide risk than those with clinical depression alone.
The authors hypothesize that veterans with service-connected disability may have reduced suicide risks as a result of their greater access to VA health services and regular compensation payments that stabilize their income. Depressed veterans with PTSD, they point out, more often receive therapy or medication based treatment than veterans without PTSD because VA funding is allocated specifically for treatment of the condition.
"Those veterans with PTSD and depression are probably getting more mental health care, and may also be getting antidepressants, both of which help to reduce the risk of suicide," Koenig said.
The Fight Doesn't End at Home
However, even though access to care could lower the chances of suicide among veterans, many are often hesitant to seek medical attention for fear of stigma.
Dr. Bruce Spring, assistant professor of clinical psychiatry at the University of Southern California in Los Angeles, fears this stigma could be deadly.
"[We must] have a culture where seeking psychological and psychiatric care is promoted," he said.
Some experts feel that therapy and medication are only a part of the solution and instead encourage a multidisciplinary approach.
"Of course, we need greater availability and encouragement of psychiatric care," said Koenig. But, he added, "some veterans don't want to see mental health professionals."
Koenig feels that many veterans would feel less stigmatized if they were able to see a chaplain to talk to about their emotional distress; he favors increasing the availability of chaplains in the military.
"One of the most powerful deterrents to suicide is religious belief," Koenig said. "Any of the stresses that veterans face has a spiritual component that is typically ignored by mental health professionals."
Others in the field are concerned that even if veterans choose to seek out treatment, the nation may not be able to provide the infrastructure -- and access to that infrastructure in terms of policy and insurance -- to meet the needs of those who will need it.
"It will only get worse with returning veterans," said Ragan. "Do we need to link increased funding for wars with increased funding for the resources to take care of these individuals when they return home from war?
"We must decide, as a nation, if we should fund the resources to take care of these individuals."
Regardless of the method, other experts agree that the psychiatric needs of veterans must be targeted in an effort to curtail the rising suicide rates.
Valenstein and her colleagues hope that the findings presented in their study will assist policy makers and clinicians in targeting and monitoring specific veterans for signs and symptoms of potential suicidal behavior. It is her goal to better address the psychiatric needs of depressed veterans in an effort to stymie suicide rates.
After all, she said, "the mission is to improve the quality of care."