Suicide Risk Among US Veterans With Military Service During the Vietnam War.

Importance: There are persistent questions about suicide deaths among US veterans who served in the Vietnam War. It has been believed that Vietnam War veterans may be at an increased risk for suicide. Objective: To determine whether military service in the Vietnam War was associated with an increased risk of suicide, and to enumerate the number of suicides and analyze patterns in suicides among Vietnam War theater veterans compared with the US population. Design, Setting, and Participants: This cohort study compiled a roster of all Vietnam War-era veterans and Vietnam War theater veterans who served between February 28, 1961, and May 7, 1975. The 2 cohorts included theater veterans, defined as those who were deployed to the Vietnam War, and nontheater veterans, defined as those who served during the Vietnam War era but were not deployed to the Vietnam War. Mortality in these 2 cohorts was monitored from 1979 (beginning of follow-up) through 2019 (end of follow-up). Data analysis was performed between January 2022 and July 2023. Main Outcomes and Measures: The outcome of interest was death by suicide occurring between January 1, 1979, and December 31, 2019. Suicide mortality was ascertained from the National Death Index. Hazard ratios (HRs) that reflected adjusted associations between suicide risk and theater status were estimated with Cox proportional hazards regression models. Standardized mortality rates (SMRs) were calculated to compare the number of suicides among theater and nontheater veterans with the expected number of suicides among the US population. Results: This study identified 2 465 343 theater veterans (2 450 025 males [99.4%]; mean [SD] age at year of entry, 33.8 [6.7] years) and 7 122 976 nontheater veterans (6 874 606 males [96.5%]; mean [SD] age at year of entry, 33.3 [8.2] years). There were 22 736 suicides (24.1%) among theater veterans and 71 761 (75.9%) among nontheater veterans. After adjustments for covariates, Vietnam War deployment was not associated with an increased risk of suicide (HR, 0.94; 95% CI, 0.93-0.96). There was no increased risk of suicide among either theater (SMR, 0.97; 95% CI, 0.96-0.99) or nontheater (SMR, 0.97; 95% CI, 0.97-0.98) veterans compared with the US population. Conclusions and Relevance: This cohort study found no association between Vietnam War-era military service and increased risk of suicide between 1979 and 2019. Nonetheless, the 94 497 suicides among all Vietnam War-era veterans during this period are noteworthy and merit the ongoing attention of health policymakers and mental health professionals.

Risk of suicide among U.S. veterans who deployed as part of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn.

BACKGROUND: There has been concern about the risk of suicide among veterans returning from deployment to Afghanistan and Iraq as part of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND). This study assessed suicide risk among OEF/OIF/OND veterans by gender and unit component. Firearm related suicide was also briefly examined. FINDINGS: The study cohort was identified from records of the US Department of Defense. Vital status and cause of death through 2016 was obtained from the Mortality Data Repository, which obtains data from the National Death Index. Suicide risk was first assessed using standardized mortality ratios (SMR)s, comparing the rate of suicide among all veterans, both collectively and separately by gender and unit component (active vs. reserve/National Guard) to the expected based on the US population adjusted for age, race, sex, and calendar year. Risk of suicide among active duty compared to reserve/National Guard veterans and male compared to female veterans was assessed with hazard ratios (HR) s, generated by Cox proportional hazards models, that included the covariates race, age, marital status, rank, and branch of service. There was an increased risk of suicide when all OEF/OIF/OND Veterans were compared to the US population, (SMR = 1.42; 95%, C.I., 1.38,1.46). Both male and female veterans had an increased risk of suicide when compared to their gender specific non-veteran counterparts, (SMR = 1.40; 95%, C.I., 1.36,1.45 and SMR = 1.85; 95%, C.I., 1.60,2.13), respectively. Active duty veterans had an increased risk of suicide compared to reserve/National Guard veterans, (HR = 1.22; 95%, C.I., 1.14,1.30). Male veterans had an almost 3-fold increased risk compared to female veterans, (HR = 2.85; 95%, C.I., 2.47,3.29). Among all veteran suicides 68.3% involved a firearm, including 68.7% among males and 59.5% among females. CONCLUSIONS: All OEF/OIF/OND veterans have an increased risk of suicide compared to non-veterans. Veterans will benefit from enhanced access to mental health services and initiatives to promote suicide prevention. Strategies that emphasize lethal means safety, an evidence based suicide prevention strategy which includes increasing safe storage practices (i.e., storing firearms unloaded and locked) can help address this increased risk of veteran suicide.

Cause-specific mortality risks among U.S. veterans: 25 years after their service in the 1990-1991 gulf war.

PURPOSE: There is concern about adverse health effects related to military service in the 1990-1991 Gulf War. This study assessed cause-specific mortality risks among Veterans who served in the war. METHODS: The mortality of 621,244 veterans deployed to the Gulf War was compared to that of 745,704 Veterans who served during the war but were not deployed to the Gulf Theater. Cause-specific mortality of both deployed and nondeployed was also compared to that of the US general population. RESULTS: There was no increased risk of disease-specific mortality among deployed Veterans compared to nondeployed. Deployed Veterans did have an increased risk of motor vehicle deaths compared to nondeployed Veterans, (hazard ratio, 1.12, 95% confidence interval, 1.04-1.21). Cause-specific mortality of both deployed and non-deployed Veterans was less than that of the US population. When stratified by gender, only female Veterans, both deployed and nondeployed, had increased risks of suicide compared to the female US population (standardized mortality ratio, 1.40; 95% confidence interval, 1.13-1.71 and standardized mortality ratio, 1.22; 95% confidence interval, 1.05-1.40, respectively). CONCLUSION: There was no increased risk of disease mortality among Veterans of the 1990-1991 Gulf War. Both deployed and nondeployed female Veterans had increased risks of suicide compared to US female population.

Mortality experience of US veterans following service as international peacekeepers in Bosnia/Kosovo theater, 1996-2002.

BACKGROUND: Beginning in 1996 US military personnel served as peacekeeping forces in Bosnia/Kosovo. No studies have assessed the long-term post-deployment health of this US cohort. Based on the health concerns raised in studies of military personnel from other countries, this study focused on mortality due to Leukemia, respiratory disease, respiratory cancer, and heart disease. METHODS: This study compared the post-war cause-specific mortality of 53,320 veterans who deployed to Bosnia/Kosovo between 1996-2002 to that of 117,267 veterans who also served in the military between 1996-2002, but were not deployed to Bosnia/Kosovo. Expressed as standardized mortality ratios (SMR)s the cause-specific mortality for both deployed and non-deployed were compared separately to that of the US general population. Cause-specific mortality risks among Bosnia/Kosovo veterans relative to that of non-deployed veterans were assessed using Hazard Ratios (HR)s generated by Cox proportional-hazards models. RESULTS: The overall mortality of both deployed and non-deployed veterans was almost half that of the US population, SMR = 0.59, 95%, C.I., 0.55-0.62 and SMR = 0.66, 95%, C.I., 0.64-0.68, respectively. Neither group of veterans had any excess of disease related mortality compared to that of the US population. Compared to non-deployed, deployed veterans did not experience any increased risks for any of the diseases of a priori interest. CONCLUSION: It does not appear that US military deployed to Bosnia/Kosovo have any increased risks of disease related mortality. However, this study would not have been able to detect increased risk of cancers with latency periods that exceeded the 18 years of follow-up available in this study.

Suicide Risk Among US Peacekeepers Serving in the Bosnia and Kosovo Theater, 1996-2002.

The risk of suicide among US military personnel deployed for peacekeeping missions is unknown. We compared the risk of suicide through December 2014 among 70,608 veterans who deployed as peacekeepers to Bosnia and Kosovo between 1996 and 2002 with that of 141,715 veterans who served in the military between 1996 and 2002 but were not deployed to Bosnia and Kosovo. Both cohorts also were compared after removing those who had other conflict deployments. Suicide risk among Bosnia- and Kosovo-deployed veterans (BKDVs) relative to non-BKDVs was assessed using a hazard ratio. Among all veterans, without excluding those with other conflict deployments, deployment to Bosnia and Kosovo was not associated with an increased risk of suicide (hazard ratio = 0.83, 95%, confidence interval: 0.72, 0.96). Removing those with other conflict deployments, BKDVs again had a decreased risk of suicide compared to non-BKDVs (hazard ratio = 0.84, 95% confidence interval: 0.72, 0.99). The rates of suicide among all 4 groups were higher than expected based on the US population. The risk of suicide based on US population comparison was greater among non-BKDVs than BKDVs. The absence of an increased risk of suicide associated with Bosnia and Kosovo deployment may be due to predeployment psychological and behavioral characteristics that affect fitness for deployment.

Relative Importance of Posttraumatic Stress Disorder and Depression in Predicting Risk of Suicide among a Cohort of Vietnam Veterans.

OBJECTIVE: Research has demonstrated that posttraumatic stress disorder (PTSD) among Vietnam veterans is associated with increased risk of suicide. It is also widely reported that suicide is related to depression. This study examined the effect of PTSD and depression on risk of suicide among a cohort of Vietnam veterans. METHOD: All study subjects were selected from the Department of Veterans Affairs Agent Orange Registry. Suicide risk associated with PTSD was first assessed by comparing the number of suicides among a cohort of 2,874 veterans with PTSD to that of 8,537 veterans not diagnosed with PTSD. Risk of suicide was approximated by hazard ratios (HRs), generated by Cox proportional hazard models, including a model that utilized competing risk analyses. RESULTS: The risk of suicide associated with PTSD and depression when examined separately was similar, HR = 7.1 (95% confidence interval (CI): 4.9, 10.3) and HR = 7.2 (95% CI: 4.8-10.8), respectively. Competing risk analysis indicated that veterans with both PTSD and depression compared to veterans with neither diagnosis had the highest risk of suicide, HR = 15.22. CONCLUSIONS: This study suggests that depression as well as PTSD should be monitored as a way of reducing suicides among Vietnam veterans.

Suicides, homicides, accidents, and undetermined deaths in the U.S. military: comparisons to the U.S. population and by military separation status.

PURPOSE: To compare rates of external causes of mortality among individuals who served in the military (before and after separation from the military) to the U.S. METHODS: This retrospective cohort study examined all 3.9 million service members who served from 2002 to 2007. External cause mortality data from 2002 to 2009 were used to calculate standardized mortality ratios. Negative binomial regression compared differences in the mortality rates for pre- and post-separation. RESULTS: Accident and suicide mortality rates were highest among cohort members under 30 years of age, and most of the accident and suicide rates for these younger individuals exceeded expectation given the U.S. population mortality rates. Military suicide rates began below the expected U.S. rate in 2002 but exceeded the U.S. rate by 2009. Accident, homicide, and undetermined mortality rates remained below the U.S. rates throughout the study period. Mortality rates for all external causes were significantly higher among separated individuals compared with those who did not separate. Mortality rates for individuals after separation from service decreased over time but remained higher than the rates for those who had not separated from service. CONCLUSIONS: Higher rates of death for all external causes of mortality after separation suggest prevention opportunities. Future research should examine how preseparation characteristics and experiences may predict postseparation adverse outcomes to inform transition programs.

Suicide Risk by Unit Component among Veterans Who Served in Iraq or Afghanistan.

This study assessed the risk of suicide by time since separation from the military for US veterans who served in Iraq or Afghanistan. Suicide risk was assessed by comparing the number of suicides among veterans, when stratified by active vs. reserve/National Guard status to the expected number based on rates of suicide in the US general population. Hazard rates were used to assess suicide risk since the time each veteran separated/deactivated from active duty service. Compared to the US general population, active duty veterans had a 56% increased risk of suicide and reserve/National Guard veterans had a 29% increased risk. Suicide risk decreased as time since separation/deactivation increased for both groups. The risk of suicide for both groups was greatest during the first year of follow-up.

Risk of motor vehicle accident death among 1.3 million veterans of the Iraq and Afghanistan wars.

OBJECTIVE: We conducted a cohort study of recent wartime veterans to determine the postservice mortality risk due to motor vehicle accidents (MVAs). METHODS: Veterans were identified from the Defense Manpower Data Center records. Deployment to te Iraq or Afghanistan war zone was determined from the Contingency Tracking System. Vital status of 317,581 deployed and 964,493 nondeployed veterans was followed from their discharge dates between 2001 to 2007 until earlier of date of death or December 31, 2009. Underlying causes of death were obtained from the National Death Index Plus. RESULTS: Based on 9,353 deaths (deployed, 1,650; nondeployed, 7,703), of which 779 were MVA deaths as drivers (166; 613), both cohorts had 25 to 24% lower mortality risk from all causes but had 44 to 45% higher risk of MVA deaths relative to the U.S. general population. The higher MVA mortality risk was not associated with deployment to the war zone. After controlling for age, sex, race, marital status, branch of service, and rank, the risk for deployed veterans was comparable to that of nondeployed veterans (hazard ratio = 0.91; 95% confidence interval, 0.77-1.09). CONCLUSIONS: Veterans exhibit significantly higher risk of MVA deaths compared to the U.S. general population. However, deployment to the Iraq or Afghanistan war was not associated with the excess risk.

Suicide Risk Among Wounded U.S. Service Members.

The association between suicide and combat injuries sustained during the wars in Iraq and Afghanistan was examined. A retrospective population-based cohort design was conducted using official military records to identify combat injuries (October 7, 2001, to December 31, 2007). Those who were injured during combat had higher crude suicide rates than those who deployed and were not injured (incidence rate ratio [IRR] = 1.50; confidence interval [CI] = 1.06, 2.12), or never deployed (IRR = 1.46; CI = 1.04, 2.06). After adjusting for demographics, these findings were no longer statistically significant. Although our data did not support an elevated suicide risk among wounded service members, additional research is needed to examine the impact of injury severity.

Findings From the Department of Veterans Affairs Qarmat Ali Medical Surveillance Program.

OBJECTIVE: To review the Veterans Affairs (VA) medical surveillance program for Veterans with potential hexavalent chromium (CrVI) exposure that occurred during 2003. METHODS: Retrospective review of medical records of the 124 Veterans that participated in standardized, in-person clinical evaluations for possible CrVI exposure during the incident in question. The evaluations were reviewed to define population level effects. In addition, a mortality analysis was conducted for the 808 unique personal identifiers available to Veterans Health Administration. RESULTS: Mean reported number of days exposed was 21 (median 10). A history of respiratory (n = 78) and skin (n = 38) symptoms were reported during the period of exposure. No abnormalities that were specific to chromium exposure (e.g., nasal septum perforation) were found. Eight deaths occurred between 2005 and 2012. CONCLUSIONS: The lack of severe nasal abnormalities in the VA evaluations supports a time-limited peak exposure. However, the overall low participation rate (15%) severely compromises any ability to generalize to the entire potentially exposed population. Regardless, since the actual level of exposure to CrVI will never be known with certainty, the VA will continue to monitor these Veterans with periodic evaluations to identify and manage any pathologic findings that might be associated with past CrVI exposure.

All-Cause Mortality Among US Veterans of the Persian Gulf War: 13-Year Follow-up.

OBJECTIVE: We determined cause-specific mortality prevalence and risks of Gulf War deployed and nondeployed veterans to determine if deployed veterans were at greater risk than nondeployed veterans for death overall or because of certain diseases or conditions up to 13 years after conflict subsided. METHODS: Follow-up began when the veteran left the Gulf War theater or May 1, 1991, and ended on the date of death or December 31, 2004. We studied 621   901 veterans who served in the 1990-1991 Persian Gulf War and 746   247 veterans who served but were not deployed during the Gulf War. We used Cox proportional hazard models to calculate rate ratios adjusted for age at entry to follow-up, length of follow-up, race, sex, branch of service, and military unit. We compared the mortality of (1) Gulf War veterans with non-Gulf War veterans and (2) Gulf War army veterans potentially exposed to nerve agents at Khamisiyah in March 1991 with those not exposed. We compared standardized mortality ratios of deployed and nondeployed Gulf War veterans with the US population. RESULTS: Male Gulf War veterans had a lower risk of mortality than male non-Gulf War veterans (adjusted rate ratio [aRR] = 0.97; 95% confidence interval [CI], 0.95-0.99), and female Gulf War veterans had a higher risk of mortality than female non-Gulf War veterans (aRR = 1.15; 95% CI, 1.03-1.28). Khamisiyah-exposed Gulf War army veterans had >3 times the risk of mortality from cirrhosis of the liver than nonexposed army Gulf War veterans (aRR = 3.73; 95% CI, 1.64-8.48). Compared with the US population, female Gulf War veterans had a 60% higher risk of suicide and male Gulf War veterans had a lower risk of suicide (standardized mortality ratio = 0.84; 95% CI, 0.80-0.88). CONCLUSION: The vital status and mortality risk of Gulf War and non-Gulf War veterans should continue to be investigated.

Risk of Suicide Among US Military Service Members Following Operation Enduring Freedom or Operation Iraqi Freedom Deployment and Separation From the US Military.

IMPORTANCE: A pressing question in military suicide prevention research is whether deployment in support of Operation Enduring Freedom or Operation Iraqi Freedom relates to suicide risk. Prior smaller studies report differing results and often have not included suicides that occurred after separation from military service. OBJECTIVE: To examine the association between deployment and suicide among all 3.9 million US military personnel who served during Operation Enduring Freedom or Operation Iraqi Freedom, including suicides that occurred after separation. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort design used administrative data to identify dates of deployment for all service members (October 7, 2001, to December 31, 2007) and suicide data (October 7, 2001, to December 31, 2009) to estimate rates of suicide-specific mortality. Hazard ratios were estimated from time-dependent Cox proportional hazards regression models to compare deployed service members with those who did not deploy. MAIN OUTCOMES AND MEASURES: Suicide mortality from the Department of Defense Medical Mortality Registry and the National Death Index. RESULTS: Deployment was not associated with the rate of suicide (hazard ratio, 0.96; 99% CI, 0.87-1.05). There was an increased rate of suicide associated with separation from military service (hazard ratio, 1.63; 99% CI, 1.50-1.77), regardless of whether service members had deployed or not. Rates of suicide were also elevated for service members who separated with less than 4 years of military service or who did not separate with an honorable discharge. CONCLUSIONS AND RELEVANCE: Findings do not support an association between deployment and suicide mortality in this cohort. Early military separation (<4 years) and discharge that is not honorable were suicide risk factors.

Suicide risk among 1.3 million veterans who were on active duty during the Iraq and Afghanistan wars.

PURPOSE: We conducted a retrospective cohort mortality study to determine the postservice suicide risk of recent wartime veterans comparing them with the US general population as well as comparing deployed veterans to nondeployed veterans. METHODS: Veterans were identified from the Defense Manpower Data Center records, and deployment to Iraq or Afghanistan war zone was determined from the Contingency Tracking System. Vital status of 317,581 deployed and 964,493 nondeployed veterans was followed from the time of discharge to December 31, 2009. Underlying causes of death were obtained from the National Death Index Plus. RESULTS: Based on 9353 deaths (deployed, 1650; nondeployed, 7703), of which 1868 were suicide deaths (351; 1517), both veteran cohorts had 24% to 25% lower mortality risk from all causes combined but had 41% to 61% higher risk of suicide relative to the US general population. However, the suicide risk was not associated with a history of deployment to the war zone. After controlling for age, sex, race, marital status, branch of service, and rank, deployed veterans showed a lower risk of suicide compared with nondeployed veterans (hazard ratio, 0.84; 95% confidence interval, 0.75-0.95). Multiple deployments were not associated with the excess suicide risk among deployed veterans (hazard ratio, 1.00; 95% confidence interval, 0.79-1.28). CONCLUSIONS: Veterans exhibit significantly higher suicide risk compared with the US general population. However, deployment to the Iraq or Afghanistan war, by itself, was not associated with the excess suicide risk.

Neurological mortality among U.S. veterans of the Persian Gulf War: 13-year follow-up.

BACKGROUND: This study focuses on long-term mortality, specifically brain cancer, amyotrophic lateral sclerosis (ALS), Parkinson's disease, and multiple sclerosis (MS) of 621,902 veterans who served in the 1990-1991 Persian Gulf War (GW), and 746,248 non-GW veterans. METHODS: Follow-up began with the date the veteran left the GW theater or May 1, 1991 and ended with the date of death or December 31, 2004. Cox proportional hazard models were used for analyses. RESULTS: Adjusted mortality rate ratios (aRR) of GW veterans compared to non-GW veterans were not statistically significant for brain cancer (aRR = 0.90, 95% confidence interval (CI): 0.73, 1.11), MS (aRR = 0.61, 95% CI: 0.23, 1.63), Parkinson's disease (aRR = 0.71, 95% CI: 0.17, 2.99), or ALS (aRR = 0.96, 95% CI: 0.56, 1.62). GW veterans potentially exposed to nerve agents for 2 or more days and GW veterans exposed to oil well fire smoke were at increased risk for brain cancer mortality (aRR = 2.71, 95% CI: 1.25, 5.87; aRR = 1.81, 95% CI: 1.00, 3.27; respectively). CONCLUSIONS: The risk of death due to ALS, MS, Parkinson's disease, and brain cancer was not associated with 1991 GW service in general. However, GW veterans potentially exposed to nerve agents at Khamisiyah, Iraq, and to oil well fire smoke had an increased risk of mortality due to brain cancer.

Impact of a home-based primary care program in an urban Veterans Affairs medical center.

OBJECTIVES: Describe how an interdisciplinary home-based primary care program (HBPC) affected hospital and emergency department (ED) use in an urban Veterans Affairs medical center. DESIGN: A retrospective review. SETTING: HBPC of the Washington, DC, Veterans Affairs Medical Center (VAMC-DC). PARTICIPANTS: All HBPC patients enrolled for at least 6 months during the period of January 1, 2001 through December 31, 2002. MEASUREMENTS: Baseline demographic variables (such as age, gender, race, living arrangement, community services used), major medical diagnoses, functional measures (MMSE, ADL, IADL, Braden), advance directives, episodes of ED, and hospital use for the 6-month period before and after HBPC enrollment from the VAMC-DC and discharge status (obtained from electronic medical records). RESULTS: A total of 183 patients were enrolled in HBPC for at least 6 months during the 24-month study period. Ninety-five percent were male with a mean age of 73.6 years (range 36 to 95). Most were African American (71%) and lived with a caregiver (65%). The average number of comorbidities was 6 per patient. At the end of the 2-year study period, 45% remained active in HBPC and 17% had died. Using paired score analysis t tests, patients enrolled in HBPC for 6 months had 43.7% fewer hospital admissions (P = .001) and spent 49.9% fewer days in the hospital (P = .001). The 18.5% reduction in ED visits was not statistically significant (P = .2632). CONCLUSIONS: Use of HBPC for 6 months for frail chronically ill patients in an urban VAMC may be associated with fewer hospital admissions resulting in reduced total hospital days, but no significant change in ED use.