J Am Acad Psychiatry Law 37:1:82-91 (March 2009)
Suicide Among Incarcerated Veterans
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Author Affiliations
- Dr. Wortzel is Assistant Professor with the VISN
(Veterans Integrated Service Network) 19 MIRECC (Mental Illness Research,
Education, and Clinical Center), Denver VA, Denver, CO, and the
Neurobehavioral Disorders Program, Department of Psychiatry, University of
Colorado, Denver, CO. Dr. Binswanger is Assistant Professor, Department of
Medicine, Division of General Internal Medicine, University of Colorado,
Denver, CO. Dr. Anderson is Associate Professor, Departments of Neurology
and Psychiatry, Denver VA and University of Colorado, Denver, CO. Dr.
Adler is Director of the VISN 19 MIRECC and Professor and Vice-Chair (VA)
of the Department of Psychiatry, University of Colorado, Denver, CO
- Address correspondences to: Hal S. Wortzel, MD,
Department of Psychiatry, CPH Room 2508, 4200 East 9th Avenue C268-25,
Denver, CO 80262. E-mail: hal.wortzel@uchsc.edu
Abstract
Both veterans and jail/prison
inmates face an increased risk of suicide. The incarcerated veteran sits at the
intersection of these two groups, yet little is known about this subpopulation,
particularly its risk of suicide. A Pubmed/Medline/PsycINFO search anchored to
incarcerated veteran suicide, veteran suicide, suicide in jails/prisons, and
veterans incarcerated from 2000 to the present was performed. The currently
available literature does not reveal the suicide risk of incarcerated veterans,
nor does it enable meaningful estimates. However, striking similarities and
overlapping characteristics link the data on veteran suicide, inmate suicide,
and incarcerated veterans, suggesting that the veteran in jail or prison faces
a level of suicide risk beyond that conferred by either veteran status or
incarceration alone. There is a clear need for a better characterization of the
incarcerated veteran population and the suicide rate faced by this group.
Implications for clinical practice and future research are offered.
Few outcomes represent a greater
failure at reintegration into civilian life among our returning veterans than
suicide. The problem has received considerable media attention, on television,
in print, and on the Internet, thus increasing public awareness and concern for
the problem.1,2 There is a vital need to identify veterans at greatest risk
of this unfortunate outcome and for effective interventions to reduce risk.
While suicide among veterans may represent a disturbing manifestation of failed
reintegration into civilian life, incarceration is another outcome with
unfortunate ramifications for the returning veteran and high costs to society.
Various publications describe the forgotten warriors3
of various conflicts3,4 languishing in jails and prisons around our nation.
Incarcerated veterans may represent a group particularly at high risk of
suicide. No outcome is more dissonant with the dignity and debt owed to
veterans than incarceration in correctional facilities followed by suicide.
While substantial research has focused on suicide risk among veterans in
general and on suicide among inmates of jails and prisons, there remains a
paucity of research literature on suicide among incarcerated veterans. The
suicide rate and degree of excess risk faced by our incarcerated veterans
remain essentially unknown. However, existing literature from these two areas
points out that incarcerated veterans may face a level of suicide risk that
exceeds that attributable to either veteran status or incarceration alone,
suggesting a need to clarify the extent of the problem. The authors hypothesize
that the incarcerated veteran population faces a level of suicide risk that
exceeds that of the general veteran population and that of the overall
incarcerated population, facing a combination of risk factors that potentially
interact to increase lethality.
Method
The authors performed a review based
on a Medline/Pubmed/PsycINFO literature search. The initial search was anchored
to the terms “incarcerated veteran suicide.” Because of an inability to
identify studies containing information on suicide rates among incarcerated
veterans, additional searches were performed to identify data that might assist
in estimating the level of suicide risk faced by the incarcerated veteran
population. Medline/Pubmed/PsycINFO searches anchored to “veteran suicide,”
“jail and prison suicide,” and “veteran incarceration” were performed.
Regarding veteran suicide, studies describing suicide rates and characteristics
among the general U.S. veteran population published since 2000 were selected
for further review. Similarly, studies describing suicide rates and
characteristics in jails and prisons published since 2000 were reviewed and
were augmented with recent statistics generated by the U.S. Justice Department.
Studies characterizing the incarcerated veteran population published since 2000
were reviewed and augmented with the most recent data offered by the U.S.
Justice Department.
It is important to note that this
review of the suicide literature was focused on rates of completed suicides and
characteristics of persons completing suicide. Studies involving only suicide
attempts or suicidal ideation were excluded. While these latter aspects of
suicide remain important and are represented in the medical literature, the
rates and characteristics of individuals who attempt suicide or experience
suicidal ideation often differ from those of persons who have completed
suicide, which is the intended focus of the present study.
Suicide
Among Veterans in the General Population
Our veteran population faces a
suicide rate that exceeds that of the general population (Table 1). Several studies suggest an
increased risk of suicide among veterans seeking services from the Veterans
Administration (VA).5,10,11
Thompson et al.5
performed a cause-of-death search of 1,075 veterans from VA case rolls who died
in 1998 and then chart reviews to characterize those patients who had completed
suicide. These authors reported substantially increased suicide rates among
male veterans, between two and three times those of the general population.
They attributed this excess of suicides to the high proportion of behavioral
health patients within the VA system. Prior diagnoses represented among this
group of patient suicides included depression (31.6%), psychotic disorder
(15.8%), and substance abuse (15.8%). The authors noted a difference between
elderly and nonelderly suicides: none of the former had any listed psychiatric
diagnoses in their charts, and they were less likely to have engaged mental
health services, while over half of the nonelderly suicides carried a
psychiatric diagnosis.
Suicide Among Veterans in the
General Population
Price et al.6
looked at the role of post-traumatic stress disorder (PTSD) and drug dependence
in suicidality among male Vietnam veterans. Price et al.6
suggest that the impact of psychiatric comorbidity is additive over time,
placing patients with comorbid conditions in socially disadvantaged positions
that result in feelings of hopelessness, ultimately culminating in suicidality.
Of the 943 veterans in the Price et al. study,6
9 died of suicide, with all but one of the victims being white, and all having
voluntarily enlisted into military service. Of note, Lester12
argued that suicides among Vietnam veterans are highly underreported, possibly
due to mischaracterizations as accidents. Price et al.6
found that major depression, followed by drug dependence, has the largest
effect on the timing of suicidality. They described a vicious cycle wherein
drug dependence exacerbates PTSD and suicidality, and then PTSD and suicidality
promote ongoing drug dependence, indicating a need to recognize and treat PTSD
and substance abuse early in their courses. While Price et al.6
describe completed suicides in their database, they focus on nonfatal
suicidality in their study, and the results thus may be less applicable to
veterans who eventually complete suicide.
Zivin et al.7
used longitudinal, nationally representative data from the years 1999 to 2004
to determine suicide rates among depressed veterans, reporting on the clinical
and demographic factors associated with suicide within this group. Zivin et
al.7 note the very high rate of depression
among veterans—two to five times that of the general U.S. population13—and
the typical association with suicide and depression and substance disorders,
with individuals featuring comorbid mental health disorders being at the
greatest risk.14,15 Of the 807,694 veterans included in
the study, 1,683 (0.21%) died of suicide. Male gender and white race were more
frequently associated with suicide. Younger veterans (age 18–44) were found to
have higher rates than middle-aged and elderly patients. Substance abuse was
associated with higher suicide rates, while PTSD was associated with lower
rates. The reduced risk of suicide in patients with PTSD was unexpected and
warrants further investigation. Rates of suicide were higher in the South and
West relative to the Northeast or Central regions of the United States. Service
connection (disability benefits related to military service yielding greater
access to VA services and regular compensation payments) was noted to be a
protective factor against suicide. The authors emphasize results supporting
higher suicide rates in the setting of depression and substance abuse and the
substantial suicide risk among young veterans in the context of a changing VA
population with the influx of returning veterans of Operation Enduring Freedom
(OEF) and Operation Iraqi Freedom (OIF).16,17
Desai et al.8
combined VA data with the National Death Index to determine suicide rates among
VA mental health outpatients during a period of extensive bed closures and
systemwide reorganization and to establish predictors of suicide. The authors
describe the dramatic changes in mental health service delivery in the 1990s,
particularly noting changes within the VA system,18 including the closure of nearly two-thirds of all
inpatient mental health beds. They point out the deficient state of knowledge
regarding suicide trends within the VA, even though it is the largest provider
of mental health services in the country. A U-shaped association between age
and suicide was observed, with higher rates among younger and older veterans.
Among psychiatric diagnoses, bipolar disorder had the highest suicide rates,
while PTSD and anxiety disorders were noted to be marginally protective. Money
spent on outpatient mental health services was associated with reduced suicide
rates, with every $100 per capita increase being associated with a six percent
reduction in suicide. Increased spending on inpatient services as a proportion
of mental health budget also had a protective effect. Conversely, bed closures
and system changes did not appear to be significantly associated with suicide
rates in this study. Rosenheck et al.19 looked at incarceration rates during a similar time
period, and although they noted a substantial rate of incarceration among
veterans, system changes did not seem to affect the incarceration rate.
Notably, these two studies use VA data, and do not account for the substantial
number of veterans who have never entered or have discontinued treatment with
the VA. Since recent findings seem to emphasize heightened suicide rates among
young veterans, and the nation is presently experiencing an influx of returning
OEF and OIF veterans who may have failed to establish care at the VA since
arriving home, such results may not reflect the true status of our present
veteran population. In light of the relationships reported between mental
health budgets and service connection to suicide, it does seem that timely
access to quality care plays an important role in the mental health well-being
of veterans.
Of course, not all veterans seek,
receive, or qualify for VA benefits, and accurate assessment of veteran suicide
rates requires accounting for veterans outside of the VA system as well. Kaplan
et al.,9
utilizing data from the National Health Interview Survey for 1986 to 1994,
compared suicide risk between veterans and the general population, and found
that the former were nearly twice as likely to die of suicide (adjusted hazard
ratio, 2.04; 95% confidence interval [CI], 1.10–3.80). These results are
particularly noteworthy as they reflect the risk among the entire U.S. veteran
population, whether or not they are in treatment in the VA system.
Suicide
Among Inmates of Jails and Prisons
Numerous studies describe the
increased rates of suicide that exist behind jail and prison walls, both
domestically and internationally (Table 2). Shaw et al.20
performed a two-year national clinic survey of self-inflicted deaths in English
and Welch prisons. One hundred seventy-two suicides were identified, with an
average rate of 133 per 100,000, in dramatic excess to the general population's
risk of 9.4 per 100,000. Thirty-two percent of these suicides occurred within
seven days of reception, and self-strangulation was the most common method
used. Men exceeded woman by a ratio of 12:1. Eighteen percent of the suicides
involved persons age 21 years or younger. Twenty-six percent had been
incarcerated for violent crimes, and 49 percent were on remand. Seventy-two
percent of the suicide cases featured at least one psychiatric diagnosis, with
drug dependence being the most frequent primary diagnosis, as well as the most
frequent secondary diagnosis. Fazel et al.21 identified 1,312 suicides among English and Welch
prisoners from 1978 to 2003. They reported a suicide rate nearly five times
that of the general population, and that the excess risk of suicide among male
prisoners appears to have increased over the past quarter century.
Suicide in Jails and Prisons
Blaauw et al.22 reviewed 19 previous studies in an effort to identify
demographic, psychiatric, and criminal characteristics of those prisoners most
at risk for suicide. Characteristics of 95 suicide victims in Dutch prisons
were identified and then applied to 209 suicides in U.S. jails and 279 suicides
in English and Welch prisons. Six characteristics were identified as being
particularly useful in identifying potential suicide victims: age 40+,
homelessness, history of psychiatric care, history of drug abuse, one prior
incarceration, and a violent offense. Matschnig et al.23 echoed previous findings, indicating suicide rates in
correctional facilities significantly in excess of that of the general
population. They also suggested that the problem is on the rise. Pretrial
inmates are reported to face the highest risk. Long-term sentences,
single-inmate cells, mental illness, substance abuse, and history of
suicidality are all associated with increased suicide risk. Clearly, inmates of
jails and prisons at home and abroad face considerable risk of suicide. This
problem, and its possible escalation in recent years, has been attributed to
deinstitutionalization and the shift of care of persons with mental illness
from psychiatric hospitals to correctional systems. As individuals with mental
illness accumulate in jails and prisons, the suicide rates in those facilities
will escalate.24
Furthermore, incarceration is an inherently stressful situation,25,26
as is navigating the criminal justice system for pretrial inmates, and these
factors represent likely substantial stressors that exacerbate mental illness
and pre-existing suicide risk, particularly when combined with the relative
paucity of mental health services existing in most correctional settings and
the extreme demand for services within them.27–29
The Bureau of Justice Statistics
released a special report on suicide and homicide in state prisons and local
jails in August of 2005.30
The report was based on data generated from the Deaths in Custody Reporting
Program from 2000 to 2002, and indicated that despite progress in recent years,
suicide remained a considerable problem within the U.S. correctional system.
The 2002 suicide rate in jails was 47 per 100,000, and in prisons it was
approximately 14 per 100,000. Sex was identified as a strong factor, with males
being 56 percent more likely to commit suicide in jails. Race was also an
important factor, with white jail inmates being nearly six times more likely to
die of suicide than black jail inmates, and nearly three times more likely than
Hispanic jail inmates. Violent offenders in jail were found to face a suicide
rate nearly three times that of nonviolent offenders, and violent offenders in
prison were more than twice as likely to die by suicide. In jails, 48 percent
of all suicides occurred within the first two weeks of admission, with 14
percent occurring on the day of intake and an additional 9 percent on the day following
admission. Thus, inmates carrying risk factors of suicide should be more
closely monitored during the first two weeks of their transition into the jail
environment.
Incarcerated
Veterans
A significant proportion of the
veteran population has faced incarceration in jails and prisons. Several
researchers have made efforts to characterize this population and have argued
for expanded services to meet the particular needs of veterans behind bars (Table 3). Rosenheck et al.19 examined the effect of bed closures within the VA
health care system on the incarceration rate of veterans. System changes did not
seem to affect the incarceration rate. However, 15.7 percent of all male users
of VA mental health services had been incarcerated at some point between 1994
and 1997. The proportion was substantially higher among those veterans between
ages 18 and 39 years (39.6 percent). The authors reported that substantial
proportions of VA mental health users had been incarcerated, particularly those
who were young and those with substance use and mental health disorders.
Incarcerated Veterans
Saxon et al.31 examined exposure to trauma, symptoms of PTSD,
functional status, and treatment history among a population of incarcerated
veterans. In so doing, they described several important characteristics of this
group. Eighty-seven percent of the veterans reported at least one lifetime
traumatic event, and 39 percent screened positive for PTSD. Before
incarceration, only 47 percent of the group held regular employment, and 22
percent reported experiencing homelessness in the preceding 3 years.
Substantial drug and alcohol use was noted in veterans screening positive and
negative for PTSD. Among those screening negative, mean dollars spent on drugs
and alcohol in the 30 days preceding incarceration was $277.21 and $111.86,
respectively. For those screening positive, the corresponding costs were
$846.86 and $168.45. A wide variety of psychological traumas were reported in
both groups. Among those screening positive for PTSD, 70 percent reported
witnessing death or injury, 56 percent reported being physically assaulted, 34
percent had experienced physical abuse as a child, 32 percent reported neglect
as a child, 28 percent reported combat, and 16 percent reported being raped or
sexually molested.
McGuire et al.32
compared the characteristics of veterans contacted while incarcerated in a Los
Angeles jail with those of homeless veterans contacted in the community
setting. Twenty-one percent of veterans contacted in jail reported long-term
homelessness (more than six months), and 73 percent were unemployed. Current
drug and alcohol abuse were endorsed by 37 and 50 percent, respectively.
Psychiatric illness, as assessed by a counselor, was reported in 35 percent of
the jailed veterans, with 23 percent having a dual diagnosis. Fifteen percent
had mood disorders, seven percent had schizophrenia, and six percent had PTSD.
Of note, emerging data indicate that military deployment to war zones, even
without combat exposure, carried substantial mental health effects, with
associated psychiatric disorders (mood and anxiety), substance abuse, and
family conflict.33,34 Stress in war zones extends beyond
that instilled by combat and includes exposure to isolation, poor living
conditions, sexual trauma, family separation, and exposure to environmental
hazards.33
Even absent combat exposure resulting in PTSD, substance abuse, psychiatric
symptoms, traumatic life events, and homelessness remain significant risk
factors among incarcerated veterans.
The Bureau of Justice Statistics
published its special report on veterans in state and federal prison in May
2007.35
The report is based on personal interviews with inmates conducted with the
Survey of Inmates in State and Federal Correctional Facilities in 2004.
Compared with nonveterans in 2004, male veterans were less than half as likely
to be in prison, but this finding appears to be largely explained by age. When
age controlled, the rates become very similar, only 10 percent lower for
veteran men. Of note, the report was conducted in 2004, and only five percent
of veterans in state or federal prison at that time had served during the
Afghanistan and Iraq wars. Given the emerging difficulties among veterans of
these conflicts,16,17,36
and the fact that a survey conducted in 2004 allowed little time to reflect
trends emerging with OEF/OIF and this latest generation of veterans, it is not
unreasonable to hypothesize that the gap in incarceration rates between
veterans and nonveterans is closing, perhaps even reversing.37,38
Combat experience does not
necessarily explain the frequency of incarceration among veterans. In 2004,
only 54 percent of incarcerated veterans in state prisons had served during
wartime, and only 20 percent reported experiencing combat duty. Several
interesting characteristics that distinguish veterans from the general prison
population emerged. Half of veterans in state prison were white, compared with
only a third of nonveteran prisoners. Veterans were, on average, 12 years older
than nonveterans, and they tended to be much better educated, with 91 percent
reporting at least a high school diploma or GED. The college attendance rate
among veterans was triple that of the nonveteran prison population. Veterans
were considerably more likely to be imprisoned for violent crimes. Fifty-seven
percent of veterans in state prisons were serving for violent crimes, 15
percent for homicide, and 23 percent for rape or sexual assault. Among
nonveterans in state prison, 47 percent were serving for violent crimes, 12
percent for homicide, and 12 percent for rape or sexual assault. Veterans were
more likely to be violent offenders, and the targets of their violent offenses
were more likely to be female, minors, or known by the offender. Among
veterans, 60 percent of victims were female, 40 percent were minors, and 71
percent knew their victims. Among nonveterans, the corresponding rates are 41
percent, 24 percent, and 54 percent, respectively.35
These statistics are offered to point out that there is something unique about
this subpopulation that requires further investigation. Why is a group that is
generally older and better educated more likely to be incarcerated for these
sorts of offenses? Assault directed at familiar victims, especially women and
children, may suggest impulsivity, perhaps related to diagnoses such as PTSD,
traumatic brain injury (TBI), and substance abuse. And impulsivity, if it
partially explains the statistics surrounding incarcerated veterans, is also a
risk factor for suicide.
Inferring
Suicide Risk Among Incarcerated Veterans
Perhaps the most striking result of
the present analysis is the lack of data available on suicide rates among
incarcerated veterans. Based on the above findings, offering a meaningful
estimation of suicide rate for this group remains impossible, and the authors’
hypothesis that incarcerated veterans face a high suicide risk can, at present,
be neither confirmed nor safely rejected. What clearly emerges is that
incarcerated veterans are at the intersection between two populations with
well-established elevations in suicide rate. The true suicide rate among
incarcerated veterans is still unknown (Fig. 1 ). Defining the scope of this
problem should be an obvious priority.
View larger version:
Figure 1.
Incarcerated veterans are at the
intersection of two populations with elevated suicide rates. The risk incurred
by this status remains unknown.
Despite the missing information on
suicide among incarcerated veterans, by applying the available data from the
intersecting populations and making some reasonable inferences, potentially
disturbing hypotheses are generated. Given the present conflicts in the Middle
East, the growing number of returning veterans from those conflicts, and the
difficulties some in this group are experiencing in readjusting to civilian
life, the population of incarcerated veterans may be growing. Hoge et al.16,17,36
described a substantial degree of psychopathology among veterans returning from
Iraq and Afghanistan, and the barriers to adequate care. Milliken et al.39 reported that a substantial proportion of returning
veterans with mental health needs are missed in initial screening, calling for
re-evaluation several months after returning from deployment. If it is true
that elevated suicide rates in correctional settings reflect the shift of psychiatric
care from hospitals and clinics to jails and prisons,24,40
and returning veterans are unable to access treatment for mental illness
effectively16,41,42
or are missed on initial screening,39
then some veterans may end up in jails and prisons and potentially face the
elevated suicide risk that may be associated with that status. In addition,
many veterans prefer not to register for care at the VA, and mental health
treatment remains highly stigmatized.43–45
Demographically, there are striking
similarities between the population of incarcerated veterans and those most
likely to commit suicide while incarcerated. Both groups are disproportionately
represented by white males, both are heavily represented by violent offenders,
and both feature high rates of mental illness and substance abuse. Blaauw et
al.22 identified age 40 or over, homelessness,
history of psychiatric care, history of drug abuse, one prior incarceration,
and violent offense as being associated with suicide among those incarcerated.
These are features commonly shared by veterans in jails and prisons. The
prevalence of violent crimes among veterans is unfortunate, as is the higher
proportion of assaults directed at women, children, and familiar persons by
incarcerated veterans. The neuropsychiatric causes of this phenomenon require
research to define the problem further. The tendency to attack familiar victims
may reflect the neuropsychiatric quality of impulsivity and certainly suggests
hostility. Significantly, impulsivity and hostility have been associated with
suicide risk,46,47
particularly in the setting of PTSD.48
In addition, traumatic life events have been associated with suicide risk among
jail inmates.49
Given the frequency with which veterans are incarcerated for seemingly
impulsive and violent crimes and the frequency with which they are involved in
traumatic events, not to mention the already heightened suicide risk
attributable to veteran status in the general population, the incarcerated
veteran population may face a high risk of suicide.
Little is also known about the
frequency of TBI among incarcerated veterans; this may contribute to the unique
qualities of this subpopulation of veterans as well, adding to disturbances in
cognition, emotion, and behavior (impulsivity). Of note, forensic psychiatric
populations feature relatively high rates of TBI,50
and survivors of TBI appear to face a heightened risk of suicide,51
which raises the disturbing possibility that there is a population of veterans
incarcerated for crimes related to the cognitive and behavioral sequelae of
TBIs sustained during military service and facing elevated suicide risk related
to the very same service-related injury.
The extent to which the suicide risk
attributable to veteran status combines with the risk associated with
incarceration in an additive or aggravating fashion remains unclear, but there
is almost certainly an overlap in the variance of suicide risk associated with
each. Still, it seems likely that a component of dangerous interactions are at
play, with the stress related to incarceration potentially inflaming the
conditions that place veterans in the general population at an already
increased risk of suicide. As such, incarcerated veterans may represent a
population to target if the problem of veteran suicide is to be optimally
addressed.
Other potential targets for
intervention involve the multiple periods of transition faced by our returning
veterans. As individuals move from one system to another, treatment lapses often
occur, and critical information may fail to move along with the patient.
Integration across services and systems has been identified as crucial in
repairing the nation's mental health system.29
This need seems particularly evident in the returning veteran, who moves from
the active military to the VA or other community-based health care systems and
then potentially on to jail and then prison. Clearly, sealing the treatment and
information gaps between these entities will benefit our veterans and patients.
Binswanger et al.52 powerfully demonstrated the potential consequences of
unaided transition from prison to the community, with released inmates facing
death rates over 12 times that of the general populations in the first two
weeks following release. Leading causes of death included suicide, homicide,
and overdose. How veterans in this study group fared remains unknown but is an
ongoing focus of inquiry. Similar problems surround the transition from
inpatient psychiatric units to the community, with the immediate postdischarge
period being a time of heightened suicide risk.53–59
The VA is the nation's largest
mental health provider, and a portion of its patients face incarceration. The
need to partner with correctional systems to seal gaps, exchange information,
and facilitate transitions is clear. Similarly, the transition between the
active military and the VA or other community-based mental health resources
should be targeted for better coordination. Given the frequency with which VA
patients and returning soldiers face difficult transitions and the problems
that seem to emerge during such periods of change, the transition seems to be a
worthwhile target for aggressive intervention. One such intervention is known
as Critical Time Intervention (CTI), which consists of a nine-month,
three-stage intervention that strategically develops individualized linkages in
the community and seeks to enhance engagement with treatment and community
support through building problem-solving skills, motivational coaching, and
advocacy with community agencies. CTI is empirically supported and appears to
enhance continuity of care for people with mental illness after discharge from
homeless shelters and psychiatric hospitals.60–63
Soldiers returning home, as well as veterans discharged from psychiatric units
or correction facilities, may benefit substantially from such programs.
Implications
The inferences drawn herein are
based on results compiled from various databases and studies of very different
populations. Certainly, this method has major limitations, and the extent of
the problem remains ill defined. There is a critical need to establish a better
estimate of the suicide risk faced by incarcerated veterans. Enhanced efforts
are needed to identify and characterize our incarcerated veteran population.
Reports by the Justice Department represent massive undertakings and present a
tremendous volume of important data. However, future reports would benefit from
including veteran status for all subjects. Similarly, jails and prisons ought
to include veteran status as a part of intake screening. Clinicians treating
veterans in the community or inmates in correctional facilities should
routinely inquire about veteran status, suicide risk factors, and incarceration
histories, as these may provide important insights into the individual's
psychiatric history and risk profile. Legal histories, particularly those
involving violence, should be documented to the greatest extent possible.
As discussed, the incarcerated
veteran population features some unique characteristics, many of which are
liable to be predicated on distinct neuropsychiatric factors. Little is known
about the rates of TBI among incarcerated veterans, including the emotional,
cognitive, and behavioral consequences of such injuries, and what, if any,
relationship exists between such injuries and the veterans’ criminal behaviors.
Similar worthwhile inquiries might also surround PTSD and various other
cognitive deficits and mental health impairments associated with deployment.
The findings of Vasterling et al.34 of neuropsychological compromise following deployment
to Iraq is particularly striking in this regard. Iraq deployment, compared with
nondeployment, was associated with neuropsychological compromise on tasks of
sustained attention, verbal learning, and visual-spatial memory, and was also
associated with increased negative state affect on measures of confusion and
tension. In addition, deployment was associated with improved simple reaction
time. Deployment effects remained statistically significant even after
accounting for deployment-related head injuries, stress, and depression
symptoms. Although Hoge36
offered a different interpretation of the data and found no objective evidence
of cognitive deficits from deployment alone, it remains conceivable that simply
serving in a war zone may result in a mixture of cognitive deficits and
reactivity that enhances the likelihood of aggressive behavior, whether this be
directed inward (suicide) or outward (assault). The need for better definition
of the neuropsychiatric status of our returning veterans in the general
population is apparent, along with the need to identify and address the factors
contributing to either suicide or incarceration.
Certainly, ongoing efforts to study
and comprehend suicide in general are needed. The paucity of data described in
this report does not truly reflect the level of attention and commitment being
paid to this problem. The VA is actively researching suicide and has facilities
dedicated to this purpose. However, many challenges surround study in this
field and limit the speed and manner in which results can be generated. While
suicide has captured tremendous public attention, it still remains a relatively
uncommon occurrence. Studies must run for considerable periods and numerous
subjects must be observed to develop statistically meaningful results.
Furthermore, suicide, the multiple associated neuropsychiatric conditions, and
the interventions that target these problems do not lend themselves to simple
study design. Ethics-related considerations challenge treatment and research in
the area, as individuals at risk command attention and aggressive clinical
intervention, and may not be relegated to observation or less-than-optimal
treatment arms in studies.
Research focusing on incarcerated
populations is also not without its particular challenges, as prisoners are
rightfully regarded as a special group in need of extra protection by
institutional review boards. At the same time, many urgent mental health
problems (violence, substance abuse, and suicide, to name a few) are
overrepresented in jails and prisons, and results from research in correctional
settings could benefit inmates as a population. Compelling reasons to forge
ahead with such research lie in the potential for developing treatments and
interventions that benefit both these patients and society. Fostering the
understanding that these persons are worthy of study, frequently value
research, and respond positively to the experience of being a part of something
valuable, should help to sustain and encourage research, with appropriate
safeguards, within correctional settings.64,65
Our returning veterans endure a
constellation of neuropsychiatric factors that increases the risk of suicide,
factors that may interact dangerously with and be exacerbated by those
associated with incarceration. Defining the extent of suicide within
incarcerated veterans can help us appropriately allocate resources. And only by
more precisely understanding the underlying causes may we identify the best
targets for intervention. Suicide among veterans is a national problem. That
many veterans return home and eventually are incarcerated is an unacceptable
result of failed reintegration into civilian life, with significant costs to
society in terms of human suffering and finances. When these two unfortunate
outcomes converge, resulting in the suicide death of an incarcerated veteran,
the most reprehensible of endpoints is realized. The debt and respect owed to
our veterans demand immediate attention to this problem.
- American Academy of Psychiatry and the Law
Comments