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The VA's Suicide Problem

Mark Dombeck, Ph.D.

veterans administration medical center image

Last week, a lawsuit was brought against the Department of Veteran's Affairs in the San Francisco U.S. District Court, alleging that the large federal agency responsible for running the VA medical system (comprised of hundreds of hospitals and clinics scattered around the nation) through which military veterans receive health care benefits has been negligently slow to respond to the needs of suicidal traumatized veterans returning from Iraq and Afghanistan. You can read about the case here, and also here.

Though the case may ultimate become broader than the simple issue of suicide, the issue of suicide is squarely in the spotlight as the case begins to unfold. Presented into evidence was, apparently, an email from a top VA mental health official, Ira Katz, documenting that veterans were committing suicide at a rate of 18 per day. Separately, a suicide expert testified that the rate of suicide amongst veterans receiving care within the system is 7.5 times the public national average. If we total the number of suicides, we are told, they outnumber the actual direct casualties of the ongoing war. These are sobering numbers by any accounting.

It is easy to get behind a lawsuit like this one. Most of the country is against the war it seems, but the politicians can't get their act together to stop it from progressing. The democrats are impotent and the republicans seem to rubber stamp anything the white house wants, whose occupants are firmly supporting the war. There is a lot of anger about the situation that people are feeling, but since the situation is stalemated (probably until the next major election in November some seven months from now) there is no where for that anger to go. By painting the VA to be an unfeeling institution who has let people down rather than fulfill its responsibilities, some of that rage can be channeled towards the VA. After all, everyone is determined to "support the troops" through it all, and to not repeat the mistakes of Vietnam (when returning military felt abandoned). One way to do that is to help make sure that today's veterans won't be let down. If the VA system is messing up (or is at least perceived to be messing up), then there is a place for the anger to flow towards. To those who are eager to make the institution seem incompetent, I'll simply observe that it is easier to attack the broken institution charged with fixing broken men and women than to challenge the broken institutions responsible for breaking those men and women in the first place.

The absolute size of the statistics doesn't really matter, at least to me. Any suicides that could have been prevented but which still occur are that many suicides too many. The VA does need to be doing everything it can to help traumatized veterans heal. If they are not doing everything they can do (without compromising other essential services providing benefits to veterans), then reform is necessary, and will hopefully occur.

The key phrase is, as always, "everything they can do". It is likely that the VA system will need more clinical staff if it is to effectively treat veterans' PTSD. Simply stopping veterans from killing themselves is not enough. Ongoing mental health care in the form of medication and most especially psychotherapy as well as related services such as addiction treatment and occupational therapy will be necessary for many of these men and women if they are to be fully returned to civilian life. Doing it right is going to cost significant money, and that money is going to come from taxes. Me personally, I'm fine with that. But the necessary tax hike will not likely happen, at least not until the present administration is out of office, and even then it is not likely. If such a thing were to happen at all, the money is more likely to come from cutting away at resources devoted to serving other urgent (domestic) social needs, like education. Everyone is down with supporting the troops until it comes time to actually pony up and pay for it. It should be more than rhetoric.

One of the things that I find difficult about the lawsuit is the implied notion that suicide is easy to prevent if only the VA would get off its institutional derriere. This is not the case. Preventing suicides is one of the most difficult tasks that mental health professional are faced with. The reason for this is that suicide is an inherently low probability event even among high risk patients so there is no good way to know who is really at high risk. In any given sample of people being treated for suicide-inducing mental disorders such as depression or bipolar disorder or significant PTSD, a great number of such individuals will contemplate suicide on a regular basis and will appear actively suicidal at some level. Only a few will end up killing themselves, however.

The things that can be done to prevent suicide come down to monitoring, treatment and incarceration. Monitoring helps clinicians be aware of the risk, treatment helps reduce it, and incarceration is a last resort when someone is actively suicidal and will otherwise kill themselves and needs to be restrained.

The VA has been faulted for not having a good monitoring and data sharing system so that veterans who have been judged to be suicidal at one location can be instantly identified at another. That is a problem which should be remedied as soon as possible, if it is the case. The VA is faulted for not adequately screening veterans in care, allowing them to pass through the system without receiving a thorough suicide screening. That is a problem if it is the case, and remedying it shouldn't be all that difficult.

Once you've monitored and identified populations at risk, you need to offer treatment for the underlying disorders that are causing the suicidal feelings. In the case of PTSD, treatment is difficult. No medication exists that can remove traumatic memories (although medication does exist to help elevate mood, reduce anxiety and regulate sleep). The really effective treatments for PTSD involve psychotherapy as the primary therapy, and the work tends to be difficult and the relief only partial in some cases. Maladaptive coping strategies such as substance abuse "self-medication" problems must also be dealt with, complicating the treatment picture. Even with the best available treatments, a significant number of traumatized people remain symptomatic and suicidal, because suicidality is simply a fact of life for people struggling with emotional disorders like PTSD. People want to believe that there is a cure that is being withheld, but that isn't always the case. Sometimes clinicians do the best they can and it isn't enough, and they get blamed anyway for not having that desired magic pill to offer.

Some people get better, more or less, and some people develop a chronic disability and experience ongoing suicidal thoughts among other symptoms. And then we are back to the original problem which is how do you balance a person's need for liberty and freedom against their need to be protected from themselves. Suicide is a low frequency event. You have to trust people when they say that despite the fact that they are experiencing ongoing suicidal ideation, that they won't kill themselves. If you can't trust them in that way, the alternative is to lock them up, and there are really a lot of people who will qualify for needing to be locked up if the need for keeping people safe starts to trump the need to keep them free.

Once you can pay for adequate state of the art treatment for those who need it (which is not a given, but should be), the problem of the need for forced treatment in order to further reduce the suicide statistics starts to rear it ugly head. Not everyone will be fixable enough, unfortunately, and some will end up choosing to kill themselves rather than suffer further their private torments. This is an ugly part of the reality of PTSD and similar conditions, and an ugly part of war. There isn't any good way to prevent it save not sending people into situations where they will be traumatized in the first place.

So I guess what I'm saying is that I feel sorry for the VA which is charged with a semi-impossible "Humpty Dumptyesque" task of putting back together again the lives of broken men and women in an environment of underfunding, and under a demand that they ultimately cannot meet. However many people they manage to help, there will be some they can't help for numerous reasons, and those people and those who love them will be outraged. I feel sorry for the VA. Not as sorry as I feel for the thousands of truly brave men and women who have been through the wringer and now need significant care they can't get fast enough, but still, I feel sorry. As usual, there are no winners to be found, except for the lawyers and a few politicians.