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Risk of Suicide Among US Veterans After Returning From the Iraq or Afghanistan War Zones
To the Editor: To our knowledge, there has been no scientific evaluation of suicide risk among veterans of Operations Iraqi Freedom and Enduring Freedom (OIF/OEF). We therefore compared suicide risk among OIF/OEF veterans with the US population. We also assessed suicide risk among veterans who were diagnosed with selected mental disorders using the patient care data available from the Department of Veterans Affairs (VA).
Methods
All potential study veterans were identified by the Defense Manpower Data Center. The final cohort included all 490 346 veterans who served in OIF/OEF and were separated alive from active duty between October 2001 and December 2005. Health care utilization data were based on electronic inpatient and outpatient data recorded at all VA medical centers. The mental disorder diagnoses (from the International Classification of Diseases, Ninth Revision, Clinical Modification) were affective psychoses, neurotic disorders, alcohol/drug dependence, acute reactions to stress, adjustment disorders, and other depressive disorders. Race was self-reported using fixed categories. Vital status follow-up ended with date of death or December 31, 2005, the most recent cause-of-death data available from the National Death Index.
Suicide risk among all OIF/OEF veterans and subgroups was assessed by a standardized mortality ratio (SMR) method using the life table analysis system software provided by the National Institute for Occupational Safety and Health. The SMR is the ratio of observed number of suicides to expected number of suicides based on the US general population suicide rates, adjusted for age at entry to follow-up, race, sex, and year of death. A 95% confidence interval (CI) that excluded 1.0 was considered statistically significant. The estimated study power was 80% to detect a 25% increase in suicide mortality among OIF/OEF veterans using a 2-tailed test with  = .05. This study was approved by the Washington, DC, VA institutional review board.
Results
The overall risk for suicide was not significantly elevated (SMR, 1.15; 95% CI, 0.97-1.35) and varied little by military service branch (Table). However, the suicide risk was increased for former active duty veterans (SMR, 1.33; 95% CI, 1.03-1.69) and for veterans diagnosed with a selected mental disorder (SMR, 1.77; 95% CI, 1.01-2.87). The most common methods of suicide were by firearm (n = 105; 73%) and by hanging (n = 30; 21%). The overall mortality of OIF/OEF veterans was half that of the US population (SMR, 0.56; 95% CI, 0.52-0.60).
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Table. Risk of Death From All Causes and Suicide Among OIF/OEF Veterans Compared With US Population
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Comment
Although the risk of suicide among OIF/OEF veterans as a group was not statistically significantly different from that in the US general population, there may be vulnerable subgroups, notably active component service members and those with mental disorders. Moreover, rates of all causes of death and suicide among military personnel have historically been 50% to 55% and 20% to 30% lower than those of the US general population, respectively1-2; thus, an SMR of 1.0 may represent an increase in the risk of suicide among combat-exposed personnel in comparison with prewar rates. Studies of Vietnam veterans suggest that suicide risk could be higher among veterans who experienced severe physical or psychological trauma during war.3-4 Based on studies of Vietnam veterans and veterans with war-related traumas, an Institute of Medicine committee concluded that there is sufficient evidence of an association between deployment to a war zone and suicide in the early years after deployment.5
Study limitations include the potential for misclassification and underreporting of suicide, although this would be expected to have a nondifferential effect; the inability to stratify veterans based on combat trauma; and potential problems in generalizing suicide risk among veterans with a selected mental disorder to veteran patients outside of the VA. Given the high percentage of returning veterans screening positive for a mental disorder,6 certain mental disorders being risk factors for suicide,7 and the potential for delayed risk, we plan to extend the follow-up period when cause-of-death data for later years become available through the National Death Index.
Author Contributions: Dr Kang had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Kang.
Acquisition of data: Kang, Bullman.
Analysis and interpretation of data: Kang, Bullman.
Drafting of the manuscript: Kang, Bullman.
Critical revision of the manuscript for important intellectual content: Kang.
Statistical analysis: Kang, Bullman.
Obtained funding: Kang.
Administrative, technical, or material support: Kang.
Study supervision: Kang.
Financial Disclosures: None reported.
Funding/Support: This work is supported by the Department of Veterans Affairs.
Role of the Sponsor: The Department of Veterans Affairs had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.
Han K. Kang, DrPH
han.kang{at}va.gov
Tim A. Bullman, MA
Environmental Epidemiology Service
Department of Veterans Affairs
Washington, DC
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2. Kang HK, Bullman TA. Mortality among US veterans of the Persian Gulf War. N Engl J Med. 1996;335(20):1498-1504.
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3. Bullman TA, Kang HK. Posttraumatic stress disorder and the risk of traumatic deaths among Vietnam veterans. J Nerv Ment Dis. 1994;182(11):604-610.
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4. Bullman TA, Kang HK. The risk of suicide among wounded Vietnam veterans. Am J Public Health. 1996;86(5):662-667.
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5. Institute of Medicine. Deployment-Related Stress and Health Outcomes. Vol 6. Washington, DC: National Academy Press; 2007. Gulf War and Health.6. Milliken CS, Aushterlonie JL, Hoge CW. Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq War. JAMA. 2007;298(18):2141-2148.
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7. Zivin K, Kim M, McCarthy J; et al. Suicide mortality among individuals receiving treatment for depression in the Veterans Affairs health system: associations with patient and treatment setting characteristics. Am J Public Health. 2007;97(12):2193-2198.
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JAMA. 2008;300(6):652-653.
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