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Letter to the Editor

Rethinking the Approach to Veteran Suicides

Nancy Lutwak, MD

Published: March 29, 2018

Rethinking the Approach to Veteran Suicides

To the Editor: The recent article by Kuramoto-Crawford and colleagues1 is eye-opening. It demonstrated that of the 8,400 adult respondents who had serious thoughts of suicide during the previous year, of those who did not receive mental health treatment, three-fourths did not feel the need for treatment.1

More than 1.6 million veterans received mental health treatment from the Department of Veterans Affairs (VA) during fiscal year 2015.2 Despite this effort, veteran suicides continue to be a national health crisis. In 2014, a mean of 20 veterans died of suicide each day, making the risk for suicide 21% higher among veterans compared to US civilian adults.3-5 During that year, veterans accounted for 18% of all deaths from suicide among US adults, while veterans constituted 8.5% of the US population.3-5 Transgender veterans are at even greater risk for suicide.6

The VA has implemented several strategies to reduce the number of at-risk veterans whose symptoms have not been previously detected. Sensitive and reliable screens are in place for posttraumatic stress disorder (PTSD), alcohol misuse, and depression. A suicide risk assessment is performed when a veteran has psychiatric disorders or has been hospitalized for mental health issues. Patients at high risk for suicide receive care from suicide prevention coordinators, and a safety plan is instituted.7

Cognitive-behavioral therapy (CBT) has been used extensively at the VA for PTSD, which is often associated with depression and suicidal ideation, but nonresponse rates are high.8

Current initiatives for every veteran include a toll-free crisis line, suicide prevention coordinators at all medical centers, improvement in case management, expanding telemental health care, and building collaborations between VA programs and community services. Other approaches being assessed for efficacy include 6 weeks of combined group and individual therapy, employment of canine companions, and web-delivered CBT.9-11

The article by Kuramoto-Crawford et al1 is significant in that it focuses on the notion that many individuals who despite having serious thoughts of suicide do not seek mental health care and feel such care is not needed. The reasons for not seeking help or continuing with therapy lie with both individual veterans and the VA system. Changes at the VA will lead more individual veterans to seek care and provide greater motivation to proceed with therapy.

The VA needs improvement in multiple areas to encourage veterans to seek and continue mental health care treatment. There should be greater focus on needs of this vulnerable group with attention to their experiences. Empathetic "listening" by the VA would go far to ensure veterans feel comfortable accessing and continuing therapy.

Indifferent support staff sometimes responds negatively to requests of mental health patients or do not relay messages to providers. Veterans may feel their care is not sufficiently individual and providers are not listening to specific needs and difficulties. Those who are enrolled in therapy trials may sense the outcome of the research is more meaningful than their own improvement.

Homeless veterans, who are particularly vulnerable and require mental health care, may feel abandoned by the VA system and that they have "fallen through the cracks" with uncaring agencies. This feeling of abandonment may contribute to a sense of hopelessness and despair, leading to inability to continue care, which requires motivation and energy.

Younger veterans may miss appointments, not because of lack of motivation, but because of real-world demands. They may have small children and financial pressures and find it difficult to attend scheduled sessions due to competing job responsibilities. For those veterans, more flexible appointment scheduling by mental health providers would be very helpful. VA support for educational opportunities, although beneficial, needs revision regarding full-time versus part-time studies to allow veterans to attend to family and work requirements.

Lesbian, gay, bisexual, and transgender (LGBT) veterans lack trust in the VA and are reluctant to access care.12,13 Transgender veterans, who are at greater risk of suicide, are especially affected by negative impressions of the VA.6 Blosnich14 investigated sexual orientation differences in satisfaction with health care. His findings revealed lesbian, gay, and bisexual status was associated with lower satisfaction with health care with individually purchased insurance as well as with TRICARE, VA, or military health care. The author14 suspects previous policies of the Department of Defense such as ‘ ‘ Don’ t Ask, Don’ t Tell,’ ‘ which openly banned LGB individuals from military service, created negative lasting impacts on those affected with residual ill feelings toward military-affiliated medical centers. Publications12-14 have revealed the inability to reveal gender identity while in the military frequently resulted in depression and PTSD, prompting risk-taking behavior. The illicit drug use, alcohol dependence, and cigarette smoking then compromised overall health. In addition, past inappropriate and insensitive behavior by doctors and nurses in medical environments have tainted LGBT veterans’ views of VA health care. The lingering negative feelings resulting from the Don’ t Ask, Don’ t Tell policy in addition to previous negative experiences in medical environments have created reluctance of LGBT veterans to seek mental health care for depression, particularly at VA medical centers.12-14

There is a need to motivate veterans to access mental health care at VA medical centers and to ensure the environment and staff are welcoming, respectful, and attentive to the specific needs of those who are depressed, who suffer from PTSD, and who face financial strain. Veterans with reluctance to seek help or continue therapy should be actively encouraged to do so by VA doctors and nurses through improvement of communication skills, attention to issues of financial stress, and recognition of greater challenges faced by those with inadequate housing. The VA is aware of the many difficulties faced by the LGBT community and acknowledges that the previous Department of Defense initiatives have left deep scars. It is also clear that rude, insensitive, and poor treatment in health care settings experienced by LGBT veterans has added to negative impressions of medical professionals.12-14

Veteran suicides remain a national emergency, particularly among transgender individuals.3-6 The current strategy to reduce veteran suicides is commendable and helpful but needs improvement. Listening to veterans and adjusting VA policies to better accommodate their needs would improve compliance, reduce depression, and lower risk of suicide. Addition of mental health experts to teams in primary care and geriatric clinics is a positive step forward.1 Extension of mental health service clinic hours to provide more flexibility for those patients with educational and job obligations would lead to greater attendance. Additionally, the VA has already instituted policies and programs nationally to ensure excellent, sensitive care is provided to LGBT veterans.15 It is the goal of the VA to offer exceptional medical and mental health care, treat PTSD and depression effectively, and make the environment welcoming to all veterans.


1. Kuramoto-Crawford SJ, Han B, McKeon RT. Self-reported reasons for not receiving mental health treatment in adults with serious suicidal thoughts. J Clin Psychiatry. 2017;78(06):e631-e637. PubMed CrossRef

2. Department of Veteran’s Affairs. The number of veterans that use VA health care services: a fact sheet. Federation of American Scientists website.

3. Department of Veteran’s Affairs. VA suicide prevention program facts about veteran suicide July 2016. website.

4. Department of Veteran’s Affairs. Suicide among veterans and other Americans 2001-2014. website.

5. Department of Veteran’s Affairs. VA releases report on nation’s largest analysis of veteran suicide. website.

6. Blosnich JR, Bossarte RM, Silenzio VM. Suicidal ideation among sexual minority veterans: results from the 2005-2010 Massachusetts Behavioral Risk Factor Surveillance Survey. Am J Public Health. 2012;102(S1):S44-S47. PubMed CrossRef

7. Britton PC, Ilgen MA, Valenstein M, et al. Differences between veteran suicides with and without psychiatric symptoms. Am J Public Health. 2012;102(suppl 1):S125-S130. PubMed CrossRef

8. Steenkamp MM, Litz BT, Hoge CW, et al. Psychotherapy for military-related PTSD a review of randomized clinical trials. JAMA. 2015;314(5):489-500. PubMed CrossRef

9. Department of Veteran’s Affairs. Veterans Health Administration. Using technology to improve access to mental health care. website.

10. Krause-Parello CA, Sarni S, Padden E. Military veterans and canine assistance for post-traumatic stress disorder: a narrative review of the literature. Nurse Educ Today. 2016;47:43-50. PubMed CrossRef

11. Department of Veteran’s Affairs. PTSD treatment programs in the US Department of Veterans Affairs. website.

12. Lutwak N, Byne W, Erickson-Schroth L, et al. Transgender veterans are inadequately understood by health care providers. Mil Med. 2014;179(5):483-485. PubMed CrossRef

13. Lutwak N, Dill C. Improved health care for sexual minority and transgender veterans. Am J Public Health. 2012;102(8):e10. PubMed CrossRef

14. Blosnich JR. Sexual orientation differences in satisfaction with healthcare: findings from The Behavioral Risk Factor Surveillance System, 2014. LGBT Health. 2017;4(3):227-231. PubMed CrossRef

15. Kauth MR, Shipherd J. Transforming a system: improving patient-centered care for sexual and gender minority veterans. LGBT Health. 2016;3(3):177-179. PubMed CrossRef

Nancy Lutwak, MDa

aDepartments of Psychiatry and Emergency Medicine, VA New York Harbor Healthcare System, New York University School of Medicine, New York, New York

Potential conflicts of interest: None.

Funding/support: None.

Published online: March 29, 2018.

Prim Care Companion CNS Disord 2018;20(2):17l02159

To cite: Lutwak N. Rethinking the approach to veteran suicides. Prim Care Companion CNS Disord. 2018;20(2):17l02159.

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