The Together With Veterans (TWV) Program enlists rural Veterans and their local partners to join forces to reduce Veteran suicide in their community.
Framing the Problem of Veteran Suicide
Suicide is a major public health problem1 that disproportionately impacts Veterans living in rural communities.2 Suicide is also preventable — and preventing Veteran suicide is the top clinical priority of the U.S. Department of Veteran Affairs (VA).1
The VA Suicide Data Report of June 2018 revealed that 2015 suicide rates among U.S. Veterans were 2.1 times higher than suicide rates among non-Veteran adults.3 Veterans represent 14.3% of all suicide deaths among U.S. adults, despite making up only 8.3% of the U.S. population.3 Further, from 2005 to 2015, age-adjusted suicide rates of Veterans who did not receive Veterans Health Administration (VHA) care increased faster than suicide rates among Veterans using VHA care (by 32.6% versus 27.1%, respectively).3
Rural Veterans have a 20% greater risk of suicide compared to urban Veterans.2 Rural Veterans represent nearly one-fourth of the Veteran population.4 Compared to urban Veterans, rural Veterans are less likely to use VHA primary care, mental health care, and specialty care.5 Veterans who reside in rural communities also report lower quality of life related to both mental health and physical health, compared to Veterans who reside in urban areas.6 Rural Veterans’ lower access to and use of health care, as well as their health status, may partially explain their elevated risk for dying by suicide. However, living in a rural community is associated with higher suicide rates among Veterans after taking into account mental health, population differences (such as gender and age), and availability of care nearby.2
To reduce rural Veteran suicide deaths, all social, economic, and cultural factors related to rural communities and Veterans must be addressed. For example, rural communities experience inequalities related to income, education, job opportunities, and community resources,7 all of which play a more significant role in health than do individual behaviors.8 Military culture and experiences unique to Veterans introduce another set of factors that can further influence suicide risk.9-13 Further, attitudes towards seeking help are widely cited as a barrier to suicide prevention in both rural and military cultures.10,14 An effective suicide prevention process must address the community and social factors affecting rural Veterans’ health.
The Solution: Community-Based Suicide Prevention
The VA has adopted the National Strategy for Preventing Veteran Suicide 2018-2028.1 The National Strategy is a comprehensive public health and community-based approach, which emphasizes involvement of Veterans and family members. The National Strategy states that “collaborat(ion) with partners and communities nationwide to use the best available information and practices to support all Veterans” (p. 1) is a critical component of preventing suicides.1 Other critical components include:
- Emphasis on population-level strategies to improve health on a large scale;
- Focus on primary prevention by addressing a broad range of risk and protective factors to prevent all forms of suicidal self-directed violence; and
- The use of multidisciplinary strategies that bring together many different perspectives and foster collaboration among diverse groups in a community.
The Veterans Health Administration has historically focused on providing clinical care to Veterans. However, various estimates suggest that, at best, only 10-15% of preventable deaths can be attributed to medical care, and that social determinants of health outside the control of the medical system are far more impactful.15 The National Strategy recognizes that suicide prevention must continue to address these approaches, but must also expand beyond medical care and crisis services to address community and social factors.1 Therefore, the public health model to suicide prevention includes “upstream” strategies to prevent crises from ever emerging, as well as crisis services—strategies that reach all members of a community, programs for select groups, and clinical interventions for individuals at elevated risk of suicide. Effective models and programs that take this public health approach are needed to improve health outcomes and prevent suicide in rural Veterans.
Together With Veterans Rural Veteran Suicide Prevention
Together With Veterans (TWV) is a community-based suicide prevention program for rural Veterans. TWV involves partnering with rural Veterans and their communities to implement community-based suicide prevention. TWV aligns community strategies with five suicide prevention best practices:
The evidence behind these strategies and the Together With Veterans approach is described on page O-5.
TWV is funded by the Veterans Administration Office of Rural Health and carried out via collaboration between the Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC) for Suicide Prevention, the Western Interstate Commission for Higher Education Behavioral Health Program (WICHE BHP), local Veterans, and other community stakeholders. Through these partnerships, TWV supports the dissemination of best practices in public health suicide prevention to rural communities consistent with the goals of the National Strategy for Preventing Veteran Suicide.
At the heart of the TWV model is local Veteran leadership. TWV is grounded in the principle of “Nothing
about us without us.” Through the leadership of rural Veterans, TWV engages broad community partners in assessing community needs and planning local efforts. The TWV mission statement and guiding principles reflect this intent.
The Together With Veterans Program (TWV) enlists rural Veterans and their local partners to join forces to reduce Veteran suicide in their community.
- Veterans provide permission and work together to implement TWV in their community
- Veterans provide leadership to guide the TWV process
- Community partners play a key role in successfully supporting Veterans and their families
- Informed and educated community partners are better equipped to address the needs of Veterans
- Collaboration and education will strengthen the suicide prevention network for Veterans, their families, and friends
- TWV strategies are drawn from well-researched models that have been shown to effectively reduce suicide
- TWV partnerships develop a unique suicide prevention action plan based on community strengths and addressing community needs
- TWV action plans are reviewed and revised as needed to promote success
Five suicide prevention strategies are used by TWV to support the local planning efforts. These strategies are for community-wide implementation to improve community response to the needs of local Veterans.
Reduce Stigma and Promote Help-Seeking
Challenges with mental health, emotions, and substance use are common factors related to suicide. One study found that of Veterans who died by suicide, 62.2% of them experienced a mental health problem or depressed mood prior to their death.16 Although obtaining help for mental health problems can reduce risk of suicide, research suggests that individuals who attempt suicide may be less likely to seek professional help.17 As such, it is critical to reduce stigma as a barrier to seeking help for suicide, mental health, and substance use problems. Merriam-Webster dictionary defines stigma as a “mark of shame”18 and the stigma of suicide is known to be a factor in people not seeking care.19 Conducting public awareness campaigns can shift knowledge, attitudes, and behaviors about seeking help.
The TWV Teams will develop a public awareness campaign tailored to their specific community. Elements of an effective public awareness campaign involve multiple media such as flyers, billboards, social media, websites, and public service announcements. In addition, TWV action items might include hosting community events, disseminating information through Veteran social networks, holding public awareness events and talks, and providing media guidelines for reporting on suicides.
Promote Lethal Means Safety
Lethal means are methods, such as medications, firearms, and sharp objects, that can be used to attempt suicide. Almost 50% of suicide attempts occur within one hour of the decision to attempt suicide, and approximately 25% occur within five minutes of the decision.20 Therefore, temporarily decreasing access to lethal means during periods of elevated suicide risk can save lives.21,22 Firearms-inflicted injuries are responsible for approximately two-thirds of Veteran deaths by suicide and rural Veterans are more likely to use firearms as a means of suicide.2 Research has shown that increased risk for death by suicide is associated with both accessibility to firearms and unsafe storage practices.23-25 About 90% of firearm-related suicide attempts are fatal, as compared to approximately 5% of suicide attempts by all other mechanisms combined.
TWV recommends promoting lethal means safety by partnering with local firearm retailers and shooting clubs regarding suicide prevention awareness and safe firearm storage. Specific TWV action items can include distributing gunlocks, flyers, and other resources that promote safe firearms storage, as well as distributing awareness materials and suicide prevention education to individuals within the firearms community.
Provide Suicide Prevention Training
Suicide prevention training identifies and refers individuals who may be at risk for suicide and provides improved knowledge, skills, and attitudes in the community. It may also be associated with decreases in suicide, suicide attempts, and suicidal ideation.26 Training community members who may interact with at-risk individuals is considered an essential component of public health suicide prevention.21,22
The TWV Teams identify target audiences based on those who may know and serve Veterans and coordinate appropriate training for them. Based on need, the TWV Teams may increase the number of trainers in their community who have specific expertise in Veteran suicide prevention. Target audiences for suicide prevention trainings may include Veterans and Veteran groups, family members of Veterans, clergy, college instructors, emergency medical technicians, law enforcement professionals, and others. The trainings are designed to increase the number and reach of individuals in the community who can identify Veterans at risk for suicide and refer them to appropriate services. The anticipated impact of this intervention strategy is that it will increase the community’s ability to identify and provide help to Veterans who are at elevated risk for suicide.
Enhance Primary Care Suicide Prevention
Rural areas tend to have limited mental health practitioners and fewer medical specialists.27 In addition, the stigma of seeking mental health treatment can be particularly severe in rural communities.14,27 For these reasons, rural primary care providers may be responsible for covering an even broader range of services, including mental health care.28 Approximately 80% of people who die by suicide have seen a primary care provider in the last year and 45% have seen one in the last month.29 As a result, screening for suicide risk in primary care settings may improve the detection of suicide risk among Veterans who are not seeking or receiving treatment from mental health specialists.
To address this issue, TWV seeks to enhance primary care providers’ knowledge of suicide and use of best practices for identifying and treating individuals who are at risk for suicide. This may occur by facilitating evidence-based suicide prevention trainings for rural providers and offering guidelines for caring for at-risk Veterans.
Improve Access to Quality Care
Ensuring that individuals have access to crisis and support services is essential.22 If an individual has access to high-quality crisis services and mental health care, it can help them survive a suicidal crisis and effectively manage their ongoing risk.22
To make certain that individuals are aware of the potential resources available to them, TWV seeks to increase public awareness of crisis resources. This includes information related to local and national crisis resources, such as the Veterans Crisis Line (VCL), local crisis centers, “warm lines” and crisis living rooms, and local mental health centers.
Additionally, several interventions and strategies have been developed to enhance the quality of care delivered to Veterans at elevated risk. Safety Planning is a brief intervention for patients at elevated risk for suicide.30 Therapeutic Risk Management (TRM) is an approach to assessing and managing suicide risk among Veterans.31 The Home-Based Mental Health Evaluation (HOME) program seeks to engage Veterans in care after they have been discharged from psychiatric hospitalization.32 Additionally, the
VA has developed a Suicide Risk Management (SRM) Consultation Program, which offers free consultation on suicide risk assessment and management practices for any provider who works with Veterans, including both VHA and non-VHA providers (www.mirecc.va.gov/visn19/consult). Lastly, military cultural competency is an important aspect of enhancing care delivered to Veterans. Several online and in-person trainings are available to support this.
The TWV Process to Prevent Veteran Suicide
The Together With Veterans Suicide Prevention Strategies above are implemented using a five-phase process to support rural communities in developing a local Veteran suicide prevention action plan. The five phases in this toolkit guide the community through identifying Veterans and other key partners, learning about suicide prevention, specific community strengths and needs, and developing and carrying out an effective local Veteran suicide prevention action plan. These phases are:
- Department of Veterans Affairs. (2018). National Strategy for Preventing Veteran Suicide 2018-2028.
- McCarthy, J.F., Blow, F.C., Ignacio, R.V., Ilgen, M.A., Austin, K.L., & Valenstein, M. (2012). Suicide among patients in the Veterans Affairs health system: Rural–urban differences in rates, risks, and methods. American Journal of Public Health,102(S1), S111-S117.
- Office of Mental Health and Suicide Prevention. (2018). VA National Suicide Data Report 2005-2016.
- Department of Veterans Affairs. (2018). Rural Veterans, https://www.ruralhealth.va.gov/aboutus/ruralvets.asp. Accessed 2/15/2019.
- Weeks, W.B., Bott, D.M., Lamkin, R.P., & Wright, S.M. (2005). Veterans Health Administration and Medicare outpatient health care utilization by older rural and urban New England veterans. The Journal of Rural Health, 21(2),167-171.
- Wallace, A.E., Weeks, W.B., Wang, S., Lee, A.F., & Kazis, L.E. (2006). Rural and urban disparities in health-related quality of life among veterans with psychiatric disorders. Psychiatric Services, 57(6), 851-856.
- Crosby, R.A., Wendel, M.L., Vanderpool, R.C., & Casey, B.R. (2012). Rural populations and health: Determinants, disparities, and solutions. John Wiley & Sons.
- Miller, W., Simon, P., & Maleque, S. (2009). Beyond health care: New directions to a healthier America. Washington, DC: Robert Wood Johnson Foundation Commission to Build a Healthier America.
- Braswell, H., & Kushner, H.I. (2012). Suicide, social integration, and masculinity in the U.S. military. Social Science & Medicine, 74(4), 530-536.
- Bryan, C.J., Jennings, K.W., Jobes, D.A., & Bradley, J.C. (2012). Understanding and preventing military suicide. Archives of Suicide Research, 16(2), 95-110.
- Castro, C.A., & Kintzle, S. (2014). Suicides in the military: The post-modern combat veteran and the Hemingway effect. Current Psychiatry Reports, 16(8), 460.
- Pease, J.L., Billera, M., & Gerard, G. (2015). Military culture and the transition to civilian life: Suicide risk and other considerations. Social Work, 61(1), 83-86.
- Simonetti, J.A., Azrael, D., Rowhani-Rahbar, A., & Miller, M. (2018). Firearm storage practices among American veterans. American Journal of Preventive Medicine, 55(4), 445-454.
- Hirsch, J.K., & Cukrowicz, K.C. (2014). Suicide in rural areas: An updated review of the literature. Journal of Rural Mental Health, 38(2), 65.
- Braveman, P., & Gottlieb, L. (2014). The social determinants of health: It’s time to consider the causes of the causes. Public Health Reports, 129(1_suppl2), 19-31.
- Logan, J.E., Fowler, K.A., Patel, N.P., & Holland, K.M. (2016). Suicide among military personnel and Veterans aged 18–35 years by county—16 states. American Journal of Preventive Medicine, 51(5), S197-S208.
- Barnes, L.S., Ikeda, R.M., & Kresnow, M-j. (2001). Help-seeking behavior prior to nearly lethal suicide attempts. Suicide and Life-Threatening Behavior, 32(Supplement to Issue 1), 68-75.
- Clement, S., Schauman, O., Graham, T. et al. (2015). What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychological Medicine, 45(1),11-27.
- Simon, T.R., Swann, A.C., Powell, K.E., Potter, L.B., Kresnow, M-j, & O’Carroll, P.W. (2001). Characteristics of impulsive suicide attempts and attempters. Suicide and Life-Threatening Behavior, 32(Supplement to Issue 1), 49-59.
- Mann, J.J., Apter, A., Bertolote, J. et al. (2005). Suicide prevention strategies: A systematic review. Journal of the American Medical Association, 294(16), 2064-2074.
- Van Der Feltz-Cornelis, C.M., Sarchiapone, M., Postuvan, V. et al. (2011). Best practice elements of multilevel suicide prevention strategies. Crisis.
- Anestis, M.D., & Houtsma, C. (2018). The association between gun ownership and statewide overall suicide rates. Suicide and Life-Threatening Behavior, 48(2), 204-217.
- Anglemyer, A., Horvath, T., & Rutherford, G. (2014). The accessibility of firearms and risk for suicide and homicide victimization among household members: A systematic review and meta-analysis. Annals of Internal Medicine, 160(2), 101-110.
- Miller, M., Lippmann, S.J., Azrael, D., & Hemenway, D. (2007). Household firearm ownership and rates of suicide across the 50 United States. Journal of Trauma and Acute Care Surgery, 62(4), 1029-1035.
- Isaac, M., Elias, B., Katz, L.Y. et al. (2009). Gatekeeper training as a preventative intervention for suicide: A systematic review. The Canadian Journal of Psychiatry, 54(4), 260-268.
- Varia, S.G., Ebin, J., & Stout, E.R. (2014). Suicide prevention in rural communities: Perspectives from a Community of Practice. Journal of Rural Mental Health, 38(2), 109.
- Mueller, K.J., Coburn, A.F., Lundblad, J.P., MacKinney, A.C., McBride, T.D., & Watson, S. (2011). The high performance rural health care system of the future. Rural Policy Research Institute.
- Luoma, J.B., Martin, C.E., & Pearson, J.L. Contact with mental health and primary care providers before suicide: A review of the evidence. American Journal of Psychiatry, 159(6), 909-916.
- Stanley, B., & Brown, G.K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256-264.
- Wortzel, H.S., Matarazzo, B., & Homaifar, B. (2013). A model for therapeutic risk management of the suicidal patient. Journal of Psychiatric Practice, 19(4), 323-326.
- Matarazzo, B.B, Farro, S.A, Billera, M., Forste, J.E., Kemp, J.E., & Brenner, L.A. (2017). Connecting veterans at risk for suicide to care through the HOME program. Suicide and Life-Threatening Behavior, 47(6), 709-717.