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The National Strategy for Preventing Veteran Suicide 2018-2028

Community-Based Emphasis Undercuts Veterans Health Administration Successes
July 21, 2018

In June 2018, the U.S. Department of Veterans Affairs issued the National Strategy for Preventing Veteran Suicide, 2018-2028.(1) Its 14 goals and 43 objectives contain many farsighted ideas that will help mitigate the crisis of veteran suicide.

Here’s the problem:

The National Strategy calls for community initiatives almost exclusively. While community-based engagement is undeniably necessary to prevent suicide among all veterans, this should occur by augmenting, not diminishing, existing effective VA suicide prevention programs.  Modifications that bolster VA are needed, or else the plan will divert funds from where they make a vital difference.

Undercutting the VA’s Unparalleled Suicide Prevention ProGram

As the recent review in the Federal Practitioner(2) documented, VA’s multiple levels of evidenced-based suicide prevention practices are pre-eminent in the field. Its innovative use of predictive analytics to identify and intervene with at-risk individuals is more advanced than anything available in the community. For older veterans who constitute the majority of veterans and the majority of veteran suicides, the VA has more comprehensive and integrated mental health care services than those found in community-based care systems. The embedding of suicide prevention coordinators at every VA facility is unequaled.

But one would never know about such superior quality from the National Strategy.  Indeed, the VA is barely mentioned at all. The report never advocates for strengthening – or even maintaining – VA’s resources, programs and efforts. It never recommends that eligible veterans be connected to VA mental health services.

The strategy recognizes that employment and housing are key factors that protect against suicide risk. It does not, however, call for boosting and resourcing VA’s integrated approach that wraps in social services better than any other program. Similarly, it acknowledges the role of family involvement in mitigating risk, but doesn’t propose expanding VA treatments to improve relationship wellbeing, leaving the handling of such services to the private sector.  

The National Strategy builds on the recent suicide prevention Executive Order (EO) for supporting veterans during their transition from military to civilian life. Yet, the EO has no funding allocated to this long-overdue initiative. The National Strategy makes the same error. In failing to advocate for additional allocations to pay for vastly enhanced outreach and treatment, the plan will drain the VA of existing resources needed to maintain its high-quality, suicide prevention services.

Skipping the Crucial Step of Gathering Information

The National Strategy wisely specifies that the initial step in any suicide prevention effort should be to: “Define the problem. This involves collecting data to determine the ’who,’ ‘what,’ ‘where,’ ‘when,’ and ‘how’ of suicide deaths.”

Yet the report doesn’t heed its own advice. Although little is known about the 14 of 20 veterans who die by suicide daily who are not recent users of VHA, the National Strategy foregoes the necessity of first ascertaining crucial factors, including whether they were (a) eligible for VA care, (b) receiving any mental health or substance use treatment, (c) going through life crises, etc. What’s needed before reallocating funds to the community is for Congress to finance a post-suicide, case-by-case study of these veteran decedents who did not use VA.

Proceeding in this manner has two benefits. First, it would allow initiatives to be targeted. Second, it will preserve funds for successful VA programs which otherwise would be cut to pay for private sector programs.

A Positive Starting Point  

There are many positive components of the National Strategy that will make an important difference. That said, they fall short of their potential and could be strengthened.

Given the overwhelming use of firearms by veterans who die by suicide, the strategy acknowledges that effective suicide prevention strategy must attend to this essential element. It prudently calls for expansion of firearm safety / suicide prevention collaboration with gun constituencies, firearm owners, firearm dealers, shooting clubs, and hunting organizations. This will help ensure that lethal means safety counseling is culturally relevant and technically accurate, comes from a trusted source, and has no anti-firearm bias.

Nothing would be more useful in diminishing suicide than correcting the false belief among many veterans that “the VA wants to take away our guns.” If that misperception were replaced with an accurate message, not only would more at-risk veterans seek out mental health care, more veterans/ families/friends would adopt a new cultural norm akin to “buddies talk to vets in crisis about safely storing guns.” Establishing a collaborative workgroup, with gun constituencies represented, could spearhead such a shift.

It emphasizes the benefits of using peer supports. Yet, peers currently express hesitation that they have too little expertise intervening with this vulnerable population. Peers could be given extensive training and continued supervision in suicide prevention techniques.

It calls for expanded use of big data predictive analytics, whose initial implementation has shown great promise. But the strategy does not mention that this approach depends on linked electronic medical records, and therefore best succeeds for at-risk veterans in VHA, but not in community care. 

The strategy perceptively recognizes that reshaping media and entertainment portrayals could have a positive impact on preventing veteran suicide. Yet it omits the importance of correcting the sullied narrative about the VA. The disproportionate negative image contributes to veterans’ reticence to seek VA health care. One simple solution would be to require that service members transitioning to civilian life be informed about the superior nature of VA’s mental health care. Another is to more routinely provide the media with positive VA stories.

The strategy suggests that enhanced community care guidelines be developed but it never recommends that community partners should equal VA’s standards. Those providers should be mandated to conduct the same root cause analyses and comprehensive documentation of suicide risk assessments that VA does.

Conclusion

In sum, the National Strategy’s public health, community-based plan contains many favorable ideas, but needs to explicitly support and further strengthen successful VA suicide prevention programs.

References

  1. National Strategy for Preventing Veteran Suicide, 2018-2028, U.S. Department of Veterans Affairs, retrieved August 5, 2018 https://www.mentalhealth.va.gov/suicide_prevention/docs/Office-of-Mental-Health-and-Suicide-Prevention-National-Strategy-for-Preventing-Veterans-Suicide.pdf

  2. Lemle, R. B. Choice Program Expansion Jeopardizes High-Quality VHA Mental Health Services Fed Pract. 2018 March;35(3):18-24