The Urgent Need to Rethink Suicide: Lessons for Veterans & All Americans

240613_Conversations_Bryan_01.mp3

Speaker 1 [00:00:04] But that turn suicide rate is currently 1.5 times the rate of the general
population, and the United States Department of Veterans Affairs says its top clinical
priority is preventing suicide among all those who have served.

Speaker 2 [00:00:19] Now, years later, I would say the military and veteran community are
absolutely on the leading edge of this. Now, the veteran community is found to be way
more open to this issue, and I think it's because so many of us have lost friends and loved
ones, and we're sick and tired, and we know that it's a gun related issue and we know
what gun safety is.

Speaker 3 [00:00:44] Clinical psychologist Doctor Craig Bryan is an Iraq war veteran and
the author of Rethinking Suicide Why Prevention Fails How We Can Do Better. His
research is revealing new insights about what's leading to suicide and the role that firearm
safety can play in preventing more death.

Speaker 2 [00:01:02] To more than half who die by suicide do not have a known mental
health condition. Mental illness is actually something that is known about suicide as a
whole. The same is true amongst civilians. And so in that sense there's a similarity
amongst veterans and non backgrounds in terms of risk factors. What this means is that I
think a lot of our historic approaches to how we understand how we could best prevent
suicide, at least in the United States, is really focused on mental health treatment, mental
health screening, things like that. And I think what what the statistics there would suggest
is that that might be useful for helping out some veterans, but not many others.

Speaker 3 [00:01:42] This is conversations on health care.

Speaker 1 [00:01:53] Welcome Doctor Craig Bryan to conversations on health care.

Speaker 2 [00:01:58] Oh, thanks so much for having me.

Speaker 1 [00:02:00] Yeah. And, you know, before we dive into your research, let's start
with an overview. Veterans are 72% higher risk of suicide than those who haven't served.
This is a reversal from earlier trend. For instance, prior to 2001, veterans suicide rates
were far lower than those in the general population when comparing age groups. Suicide
is also the second leading cause of death among veterans under 45. And finally, the
female suicide rate for female veterans is 166% higher when compared to their civilian
counterparts. I'm wondering, what do we know about the story behind these statistics, and
why are we seeing such suicide increases right now?

Speaker 2 [00:02:46] Yeah. Yeah. We we think that all of these trends are related to a
multitude of factors. You know, not one single contributing cause. But we know, for
instance, that some of these, contributors to that, the veteran population as a whole is
aging. We know that the majority of veteran suicides, as in the the highest number of
deaths, occur amongst veterans above the age of 55, who are now typically more of like
Korean War and Vietnam War era. That maps on to a little bit what we know amongst us
suicide rates as a whole. The highest rates are amongst older adults, and so we think that
it's a combination of an aging veteran population. At least for those who served several
decades ago. And on top of that, you're going to have a lot of health related issues. Higher
rates of disability are related, higher rates of psychological conditions. And all of these
things, we think maybe come together to increase risk within the veteran community.

Speaker 1 [00:03:53] So I'm wondering if it was the number of conflicts that we had since
2001, obviously, you know, nine, 11 and lots of subsequent engagement around the globe,
seem to be more veterans. I wondering if that, also played a factor.

Speaker 2 [00:04:13] Yeah. That was, that was one of the early hypotheses. It's, you
know, not long after nine, 11, especially around 2006 or 2007, when the military rates
started to increase. Interestingly, a lot of research has been done on this and has
generally not been able to support that conclusion. And what we're seeing, for instance, is
that the majority of servicemembers since 911 who died by suicide, were what we call first
termers they had just joined the military. They were at their first duty assignment. And so
those with a deployment history were not necessarily disproportionately, more likely to die
by suicide. So, it took many, many years. But after about a decade of research, it really
seemed like that might not actually have been a major contributor. And maybe there were
some other issues at play that, honestly, I don't think we've fully figured out yet.

Speaker 3 [00:05:12] Well, we we note, in, some of your work and what we've read that
over half of veterans who die by suicide don't have a known, mental health diagnosis or
mental illness, according to the Department of Veteran Affairs. I found that a little bit
surprising, to read that the VA goes on to say that even though mental health, issues can
be a factor when it comes to suicide risk, it doesn't paint the full picture, which goes to
what you're saying about many factors. I wonder, if you can, speak to the issue we've
been reading about, people who are perhaps exposed to, traumatic brain injury risk just
from, constant exposure to testing artillery and, issues like that. Is that been identified as a
contributing factor?

Speaker 2 [00:06:01] Yeah. So a couple of points, I think, related to that statistic. So that
that, number that you just cited for veterans, more than half who died by suicide did not
have one known mental health condition or mental illness is, actually something that is
known about suicide as a whole. The same is true among civilians. And so in that sense,
there's a similarity amongst veterans and non veterans in terms of risk factors. And what
this means is that I think a lot of our historic approach to how we understand to we could
best prevent suicide, at least in the United States is really focused on mental health
treatment, mental health screening, things like that. And I think what, what the statistics
there would suggest is that that might be useful for helping out some veterans, but not
many others. And so we perhaps need to have a broader perspective on things. And I
think one of the things you note there, traumatic brain injury. So this is something that has
been identified as another risk factor for suicide, that, increases risk independent of mental
health conditions. I published some research years ago when I first got out of the military
around this, showing that, service members had a history of multiple traumatic brain
injuries over the course of their lives. Right? Increased risk for suicide. This has
subsequently been shown to be true in the veteran community more broadly as well as
non veterans. And it seems to be something like that over the course of the entire lifespan.
It might include sports related injuries, car accidents, slips and falls, but also work related,
injuries and accidents, perhaps explosions, blast exposure, but also other mishaps that
sometimes occur and are oftentimes more common in the military. Another common
source of head injuries in the military that it's often overlooked is, combatives training. You
know, just hand-to-hand self-defense. A lot of people get knocked out. Wow. You're
learning martial arts, things like that. And so there, there is this, I think, unrecognized and
underappreciated risk for veterans that, you know, this injury, these head injuries
oftentimes come part parcel with the career field. So.

Speaker 1 [00:08:20] You know, Doctor Bryan, I want to talk a little bit about access to
mental health services. And I know there was a study, Blue Star Family survey that found
one fourth of active duty US military personnel say they are not receiving mental health
care, but would like to. I'm wondering what more can be done by the armed forces to,
provide mental health services. And we're certainly seeing post-Covid an enormous
demand for mental health services, really, a lack of of of, staffing for, for the, for the
demand, but specific to the armed forces. What's your thought about, ways that they can,
expand mental health support, to veterans service?

Speaker 2 [00:09:05] Yeah. So, a couple of years ago, Secretary of defense, Austin
commissioned an, a review committee to focus on suicide prevention response in the
Department of Defense. And, access to care mental health services was a major section of
that report. And some of the findings of this independent review commission over that, of
course, we have a national behavioral health shortage. And so just across the United
States, we don't have enough counselors and therapists and psychiatrists. And, of course,
that's, affecting the military as well. There's also been a move, particularly within the
military, to increase screening, for suicide risk, for other mental health concerns. And
unfortunately, decades of research has shown that a lot of the screening tools that we use,
tend to identify the wrong people. And so it ends up creating this backlog, demand for
mental health care services. And that was one problem identified by the independent
review Committee, is that, in essence, we're using screening methods, perhaps are not
particularly effective, and we are flooding the zone. And so it's hard to get in for an
appointment. And so what this means is that perhaps we need to be much more judicious
about how we go about, mental health screening, with the military. And then I think a third
related issue that's not Department of Defense specific, but, perhaps is more broad within
the federal government to society. Is that right now, a lot of veterans are not eligible to
receive mental health services from the V.A.. It's a dirty little secret that most Americans
don't know is that under congressional law, the majority of veterans cannot receive health
services from the VA. And so part of the reason why more veterans don't get help is
because by federal law, they're not allowed, or at least their services are not covered. I
talked.

Speaker 1 [00:11:06] Through that a little because that's, that may be new to some of our
listeners.

Speaker 2 [00:11:10] Yeah, yeah, yeah, yeah. Exactly. Right. And yet new to a lot of
people. Like I said, it's surprising. I think a lot of us have this assumption, right, that, well,
you served in the military, and then you get out and you go to the VA for your health care.
That's actually not true. There are all these rules. It's a very, very convoluted, confusing
process, which is why we often hear about, you know, veterans complaining about the
review process, to get approved for health care benefits, their rules on, discharge status.
So if you have an other than honorable discharge, federal law says you don't get service.
It's from the VA. There's even income limits. And so, and if you historically did not have a
medical condition or health problem that was directly related or caused by military service,
in essence, Congress said, no, we're not going to provide benefits, health care coverage
for you. So, now that has changed a lot. In the past year or two. There have been a lot of
movement to open the door for more veterans. The Pact act and the compact, are two
different efforts. And, I like to call attention to this because I've been out of the military
myself for like 15 years, and it was only six months ago that I became eligible for VA
services and had my first VA medical appointment. And so I think there's positive
movement. We need to continue that momentum. But that is 100% the congressional

issue. And so my hope is that one of the things your listeners and viewers will take away is
that that's something you should be talking with your legislators about.

Speaker 3 [00:12:45] So let me well, thank you so much for sharing with us. I think that
that really is news to a lot of people. And as you say, certainly the development of the
community based primary care centers, for veterans has helped with that. But you have to
have the eligibility piece to go with it. Craig, I want to talk about your work or give you a
chance to talk about your work a bit, in developing, a brief form of CBT, cognitive
behavioral therapy, to use for suicidal military personnel, and you have some evidence to
suggest that the. Can significantly reduce suicide attempts. So tell us about that. How brief
is brief? Does it, allow for a telehealth approach as well as an in-person approach? Tell us
more about this.

Speaker 2 [00:13:32] Yeah. So, brief in this case, the average or the typical duration of the
treat protocol is 12 shots or 12 appointments. And, you know, in most cases, therapy or
counseling is scheduled, you know, one hour appointment every week. And so you're
typically looking at maybe a three, three month, commitment for the therapy, which is
much briefer than a lot of, historic, traditional forms of psychotherapy that can be
sometimes years in duration, with multiple sessions per week. And so it's a really a
significant advance that in essence, within 10 to 12 hours of outpatient therapy, we can
lead up to 60% reductions in suicide attempts is remarkably effective. We've tested this
with military personnel and and published those results. We've since done follow up
research, and we have several new studies that we anticipate being published in the
coming year. They are currently under review or at different stages of the publication
process. But what we're finding is we're reconfirming those initial results. And one of the
studies, that we have just finished up, to answer your question about telehealth. That was
what we did. We tested can we deliver the therapy effectively and safely? Virtually over an
online video based platform? And the answer is yes. Absolutely. It works. It reduced
suicide attempts by 50%. And now actually, a big part of the work that we do here at the
Ohio State University, we have specialty clinic that does nothing but suicide for care for all
adults who are experiencing suicidal thoughts. And, around half of the therapy that we
provide is virtual, where people are not actually coming in to our building, to our clinic face
to face. We're connecting with them online, in their homes, in their communities, wherever
they happen to be.

Speaker 1 [00:15:33] Okay. You know, Doctor Bryan, in your advocacy, you speak truth to
power, and I. And I want to, quote something that you wrote in the Hill newspaper. Little to
no progress in suicide prevention will be made until we directly address the central role of
firearms. Nearly 70% of military suicides in 2020 were caused by self-inflicted gunshot
wounds, and almost all of them were from personally owned firearms. So I'm wondering,
how do you navigate the sort of tricky politics of gun rights and your suicide prevention
goals?

Speaker 2 [00:16:11] Yeah, yeah. This is, I've I've classified this topic sometimes or
characterize it as the third rail. Suicide prevention. And it's because, these, these
interesting statistics like you just cited here, you know, almost 70%, military and veteran
suicides involved firearm. We know that, by and large, within the United States, when we
look at gun related deaths as a whole, two thirds of them are suicides. And so the topic of
suicide in the topic of gun violence, I guess, are these overlapping circles, right? And it's
almost impossible to have a meaningful discussion about either of these things if we don't
talk about gun suicide. And so a lot of the work that we've been doing with the military over
the past decade has actually been very eye opening. I think when we first started moving

into this space ten or so years ago, everyone's initial reaction is there's this is a no go
issue. It's a nonstarter. This you're just gonna piss everyone off. So why even do this?
Now, years later, I would say the military and veteran community are absolutely on the
leading edge of this. You know, the veteran community is found to be way more open to
this issue. And I think it's because so many of us have lost friends and loved ones, and
we're sick and tired, and we know that it's a gun related issue, and we know what gun
safety is. And many of us, you know, we're trained at firing ranges and we qualified
annually or more frequently. And we had all these safety rules. When we go to the rage to
make sure people don't get hurt. And stay safe. And then a lot of what we talk about now
is to take those rules about secure storage, and now just take them to our homes and be
just as responsible at home as we are at the firing range. And so the way that we have
approached the issue of firearm suicide is to say we need to lock up our guns. Because
the same way that we lock up our car, so we lock the front doors of our homes to help
deter unwanted behaviors. You know, who coming. We can lock up our guns in the same
way, which will deter some people in heat of the moment when they're really overwhelmed.
That extra step of having to unlock their gun can be enough to actually save their lives.

Speaker 3 [00:18:41] Craig, you've highlighted the Department of Defense has
implemented several firearm injury prevention strategies, one of which is the distribution of
firearm locking devices. But you also point out a severe limitation that Congress has
enacted. So tell us about that.

Speaker 2 [00:18:59] Yeah. There was, you know, as part of the. The NDAA. Who knows,
maybe ten or more years ago, something like that. I can't remember what year it was.
Now, there was this provision that was included that had language that in essence, that's
something along the lines of that the Secretary of Defense shall not keep records of which
servicemembers own personal firearms, how they store and things like that. And so that
was subsequently interpreted as you're not allowed to ask about guns, you're not allowed
to really address, gun related safety. And so this has created a significant barrier for not
only commanders and leaders to try to promote safety within their units and ranks. But it's
actually been a big obstacle for researchers. We we were doing some studies several
years ago, for instance, where we've been trying to understand how do service members
store their firearms at home? What do they prefer? What are they willing to do and what
would motivate them to be safe around this topic? And we had a hard time getting, you
know, the approvals to ask those types of questions because of this one particular
example. And so a lot of time and energy resources have been spent trying to promote
firearm safety and secure storage without actually asking about it, without using certain
language. And it was this politically contentious issue that, again, the the initial intent was
to protect the Second Amendment rights of service members. So it was well intentioned.
And then, as is often the case, you know, many, many years later, people interpret the
rules in the language in a certain way. And it actually is has served as a barrier to helping
to prevent suicide.

Speaker 1 [00:20:55] You know, I want to just remind our audience that anybody who's
who's got any concerns or is, contemplating suicide or having, real mental health issues
that they can dial nine, eight, eight, this is a suicide crisis lifeline. And I'm wondering,
Doctor Brian, do explain how this lifeline is specifically helping veterans who call in.

Speaker 2 [00:21:25] Yeah. The so the lifeline if you call 988 which is a national lifeline. It
used to be this really long one 800 number that no one could remember. And so a few
years ago, due to federal legislation, we were able to enact 98. So it's so much easier to
remember, military personal veterans when they call nine, eight, eight. They have the

option after the the system picks up to press one. And it actually redirects to call centers
in, New York as well as Atlanta, Georgia, to trade, crisis counselors and some of the
benefits of this, this aside from, you know, being able to listen to help, the caller to try to
walk them through whatever they're experiencing right now, listening to them with
empathy. Because of the link with the VA, there's also an opportunity, in some cases for a
veteran to be connected with an appointment, to have other assistance in providing and
receiving health care services as well. And so, we we see it as a really important part of
the overall suicide prevention strategy. And it's something that I make sure that all the
veterans that I work with as my patients, that they have access, we write it down on a card
so that, you know, if they have a dark mode, especially oftentimes it happens in the middle
of the night when doctors aren't awake and family members oftentimes aren't awake.
There is someone who's awake and they will answer the phone and they'll listen.

Speaker 3 [00:23:00] This may be ties, to that, but I really appreciate that. Part of your
research involves studying people who've survived, a suicide attempt. And I wonder, in
your research, are there any themes, that you've taken from those, conversations in that
research? Either in terms of, you know, underlying mental health concerns or pre
preexisting issues or, as you say, the phenomena of, you know, help's not around
necessarily in the moment when you need it. Tell us a little bit about what you're saying.

Speaker 2 [00:23:31] Yeah, I would say. I mean, I've learned a lot, so it's hard to kind of
pick one. But I would say right now, perhaps one of the takeaways of listening and learning
from, suicide attempt survivors is. How often the urge comes very rapidly. And I think
we've. We have historically, I think, talked about suicide is this incremental process where,
you know, people get upset and then they wish that they were dead, and then they think
about killing themselves and they start to make a plan, and then they start to prepare.
Then they give away items and things like that, and then they attempt, but what we have
found is that probably more than half of those who attempt suicide describe what we now
refer to as rapid intensification. They go from a low risk to a high risk state very fast, within
minutes to hours. And so often times, if there are warning signs, people, family members,
friends, loved ones oftentimes are not around to see it because it happens so fast. And so
this has this has really, I think, fundamentally shifted how I personally think about suicide
and what this means about how to best prevent it, because I think if we rely only on here's
like a whole bunch of warning signs, and if you see people do these things or you hear
them talk about these things, you know, get them to a hospital or something like that, we're
going to miss the majority of veterans die by suicide. We continue. We will continue to.
And then you throw on top of that, you sprinkle in the mix that rapid intensification of risk
and easy access to a highly lethal a loaded weapon. That's a perfect storm for a bad oak.
And so this, I think, is another reason why we really emphasize and really stressed and
heard from survivors that, things like secure firearm storage, locking up your medications,
taking other steps to create a safer environment, in some cases will save their lives. Same
way that if we buckle up our seatbelts when we get to a car, because we never know when
we're going to get to an accident. Right. It happens suddenly. But it won't prevent the
accident. But when you wear that seatbelt, it can save your life. And it secure storage can
do save.

Speaker 1 [00:25:58] You know, Doctor Brian, I'd like to pull a little more on the research
that you obviously have a really great handle on it, particularly about World War One
veterans who were suffering from shellshock, the term they used for what we now call
PTSD. Is there something different about the war today that's leading to higher suicide
rates?

Speaker 2 [00:26:22] Yeah, that's a good question. I guess the honest answer is I don't.
We don't fully know. But I do know one thing that is different now that maybe it's related, or
consideration is, way more, servicemembers survive their injuries. There was a case of
World War II. And so, as a result, many veterans, have lifelong disabilities, physical
limitations. And, despite, you know, despite the Ada, the American Disabilities Act, the
world in which we live is not built for people with mobility limitations. And other disabilities.
And so it can be a very challenging experience. And so we see a much higher percentage
of surviving veterans with, long term injuries and wounds and medical conditions that 100
years ago would have killed people. No one would have survived.

Speaker 1 [00:27:22] It's so, so, so, so difference. Yeah. We've seen the the, improvement
in terms of emergency room service because of what's happened in the military
environment. Right. All of those have transitioned over to your local emergency room,
which is probably saving veterans. And what a what a terrible. Yeah. Not here. That's
gotten tied between those two, factors.

Speaker 2 [00:27:50] Yeah, absolutely. I mean, the it's a medical advances. It's, you know,
evolution of, like, body armor and other protective equipment as well that has come
together. Yeah. But I think your point about, you know, the the lessons learned on the
battlefields then come back and often benefit all of us who are in severe motor vehicle
accidents or, house fires and other horrific experiences like that. I, I feel compelled to
even, kind of tie a thread where we've had similar translational knowledge on the
psychological injury. So one of the ways that, my, my research and my team has really
pushed forward in treating PTSD is to use an approach that is referred to now as mast
therapy mast, as in like crammed together and compressed in a short time frame. And so
the again, the historic way of doing therapy for some with PTSD is we meet once a week
for months, you know, on end, and hope that things get better. And what we do in the mast
format is we meet every single day for two weeks. And so we just compress the therapy
into a short window. The idea from this came from the battlefield, because when many of
us psychologists were deployed to Iraq and Afghanistan, we do not have the luxury of
scheduling a Tuesday appointment every afternoon for the next few months. We had to
make decisions fast. We had to help people return to flight, or go home. And so we started
cramming the therapy into these really short windows, meeting with, injured and
traumatized service members daily, multiple times a day. And we found that it worked. And
a lot of us military psychologists brought that idea back to the United States. And it's now
considered to be one of actually the more effective ways to treat all people with PTSD,
veterans and civilians.

Speaker 3 [00:29:45] Well, Doctor Craig Bryan, we want to thank you for joining us for this
important conversation. I think we could continue for quite a while with additional
questions. But we're we're grateful to our audience as well for being here. Be sure to
subscribe to our videos on YouTube, find us on Facebook and X with our account name,
CAC radio. And as always, you can go online to CSC Radio.com to sign up for email
updates. And please share your thoughts and your comments about this program. Craig,
thank you so much for your service, for your research. And really groundbreaking efforts.
And thank you for joining us today on conversations.

Speaker 2 [00:30:22] Thank you.

Speaker 3 [00:30:26] This copyrighted program is produced by Conversations on
Healthcare and cannot be reproduced or retransmitted in whole or in part, without the
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