Exploring Suicide Rate Trends Among Post-9/11 US Military Veterans

Key Takeaways

• Suicide rates among post-9/11 veterans declined from 2020 to 2022 after years of increase, though rates remain higher among those with a history of traumatic brain injury (TBI).
• There are ongoing challenges in TBI classification and the persistence of stigma surrounding mental health care.
• Findings underscore the importance of continued investment in suicide prevention, outreach, and support programs across US Veterans Affairs (VA) and community settings.

Introduction: In this video, Jeffrey Howard, PhD, professor in the Department of Public Health at the University of Texas at San Antonio, discusses key findings from his recent study, “Suicide Rate Trends for Post–September 11, 2001, U.S. Military Veterans.” Dr  Howard shares insights into the decline in suicide rates among post-9/11 veterans between 2020 and 2022, explores possible factors influencing this change, and highlights ongoing challenges in addressing suicide risk among veterans with TBI.

Please introduce yourself by stating your name, title, organization, and relevant professional experience.

Jeffrey T. Howard, PhD: My name is Jeffrey Howard. I am a professor in the Department of Public Health at the University of Texas (UT) at San Antonio. I’ve been studying traumatic injury epidemiology for about the past 11 or so years. Prior to joining UT San Antonio as a faculty member, I worked for the Department of Defense as an epidemiologist from 2014 through 2018, and then I joined UT San Antonio in 2018. I have a long history of experience researching not just TBI, but also other types of traumatic injuries and how those exposures are related to subsequent health outcomes.

Your study found that suicide rates among post-9/11 veterans declined from 2020 to 2022 after years of steady increase. From a clinical perspective, what changes in care delivery, outreach, or veteran engagement might explain this reversal?

Dr Howard: I’ll preface this by saying I’m not a clinician by training; I’m a PhD researcher. So, I can’t really speak to clinical matters per se. The other thing I’ll say is that the data we have for this particular study doesn’t really include information about what might have changed in terms of clinical care during these time periods, so it’s a little hard to say.

Certainly, there could be changes in protocols. We know that there have been changes over the years to better recognize and diagnose exposure to traumatic brain injury. There have also been increasing efforts over the last 10 years, particularly in the last 5, to reduce suicide. Perhaps there is some combination of things, both clinical and nonclinical, such as additional support resources that have become available in recent years, which could help explain the change. That’s all speculation on my part; we don’t have data indicating what specifically led to the changes.

The purpose of this study was really to foster awareness of what the trends look like. This was a follow-up paper to a previous one we published showing the increase in suicides from 2006 to 2020. When we got updated information for 2021 and 2022, we discovered that the rates had decreased. Our motivation was to get the word out that something has changed. We don’t exactly know why, but it’s important to recognize—and it suggests that after many years of effort to curb these trends, perhaps something is finally turning the tide.

Veterans with a history of TBI continue to show markedly higher suicide rates despite the recent decline. What are the most pressing challenges clinicians face in assessing and managing suicide risk specifically in veterans with TBI?

Dr Howard: I think there are a lot of components to it. One is the way that TBIs are classified. They’re typically lumped into mild, moderate, or severe, which is a very crude way to do it. Research shows a lot of variability in symptoms, severity, and impacts on quality of life—even within those categories.

For instance, some patients diagnosed with mild TBI actually have persistent symptoms and poorer outcomes compared to others with mild TBI. So, one of the challenges is that our current classification system isn’t sufficient to describe the complexity of the injury. There is broad recognition among researchers that we need a better way to classify TBIs.

I’m involved in another study that is trying to address this issue by developing new ways to further stratify within these categories to identify patients more likely to have certain health trajectories or be at greater risk for specific outcomes.

Another major challenge is stigma. Historically, and still today to some extent, there is a stigma in this population associated with mental health challenges. That can lead some patients not to disclose how they’re feeling or to avoid seeking care when they need it. I can’t quantify how much this has improved over the past decade, but it’s an ongoing issue. Despite efforts to destigmatize mental health, some stigma remains, which can impair clinicians’ ability to reach those most in need.

For clinicians working in VA and community settings, how can findings like these—particularly the identification of change-points and trends—be translated into actionable screening or intervention strategies?

Dr Howard: My first thought is that the results of this particular study can’t necessarily be directly translated into therapeutic strategies. What this study provides is awareness—understanding what the trends have been and that a change has occurred. We still don’t know why, but it’s important to recognize that suicide rates in this population are decreasing.

That supports continued investment in efforts that appear to be having an impact. If I were a clinician treating these patients, I’d want to know that things are starting to move in the right direction. That awareness can be motivating—it provides encouragement to continue doing what’s working. So, while the study doesn’t point to specific changes in treatment plans, it can reinforce the value of ongoing efforts.

Given that national suicide rates in the general adult population have begun to rise again, what should clinicians and policymakers prioritize to ensure that the decline in veteran suicides continues, particularly amid possible budget constraints for VA programs?

Dr Howard: We alluded to this in our paper. We don’t know exactly what programs, or combinations of programs, or which elements of them are driving these changes. So, it’s hard to say specifically what should be prioritized.

However, in a broader sense, something is helping. My hope is that policymakers will take this information and use it to make more informed decisions about how to allocate budgets. Ideally, they’ll continue funding existing programs rather than cutting them, even amid fiscal constraints. We don’t yet have the data to pinpoint what’s working, but future studies may shed light on that.

Do you have any final thoughts or takeaways from your perspective as an epidemiologist?

Dr Howard: One thing I’d add is that suicide rates rising again in the general population suggests issues that go beyond the military and veteran communities—it’s something affecting society as a whole. So, while we focus on veterans here, especially those exposed to TBI, the lessons extend beyond this group. The same kinds of resources and efforts should be directed toward society as a whole. We still have a long way to go to improve these outcomes.