Does psychiatric treatment prevent suicide?

Dr. Bossarte anticipates that the VA will have the data necessary to calculate more accurate statistics by the end of the year. “More than 70% of veteran suicide are in people over age 50; but the rates are going up most among the youngest.”

A notable drop in veteran suicide rates for those who used services occurred between 2001 and 2003, and that decrease remains unexplained; it preceded later changes in mental health services and enhanced suicide prevention programs. Dr. Bossarte also pointed out that just under half of veterans who die from suicide have no mental health diagnosis, despite yearly screening to identify people who may be suffering from posttraumatic stress disorder, alcohol-related disorders, and depression.

“The attention on veteran suicide started around 2007,” Dr. Bossarte explained. “Mark Kaplan published a study using publicly available mortality data; those who reported they were veterans were twice as likely to die of suicide as those who were not.”

While this sparked interest in veteran suicide, it’s important to note that a replication of that study in 2012 by Matthew Miller did not have the same findings.

“Then, in 2008, for the first time in recent history,” Dr. Bossarte continued, “the suicide rate among active duty military personnel exceeded that of the general population. Traditionally, rates of suicide in this population have been 40%-50% lower than in the general population. The increased rate was seen primarily in the Army and Marines. Serious mental illness may make people ineligible for military service, as can violent and disruptive behavior – things that are associated with suicide – so you tended to get a healthier population in the military.”

Dr. Bossarte noted that there was conjecture that increased suicide rates among active military might be related to more waivers that allowed people to enlist who would not ordinarily be eligible, and/or to higher rates of deployment. He went on to talk about Army STARRS (Army Study to Assess Risk and Resilience in Servicemembers).

“STARRS devoted $50 million over 5 years to the largest suicide study and did not find an effect of waivers. They did report a higher suicide rate among those who were deployed, however. But then Tim Bullman in my office looked at suicide rates 7 years after separation from service, and he reported a higher suicide rate among those who were never deployed.” The VA studies, I quickly realized, were also confusing and contradictory.

The VA has greatly expanded its mental health and suicide prevention services. For veterans overall, suicide rates have stabilized, but they have not decreased. For those veterans with psychiatric disorders, however, the suicide rates have gone down.

“When you ask ‘does treatment matter?’ it’s so hard to disentangle psychotherapy from pharmacotherapy. Over the past decade, we’ve seen a significant decrease in the suicide rate among those veterans with mental health disorders. We’ve looked at suicide rates every way you can think of. One thing we do know is that the better the relationship with the clinician, the lower the suicide risk.”

We talked about the role of hospitalization in preventing suicide, and Dr. Bossarte noted that the highest risk for suicide is immediately following hospital discharge.

“We are looking at people hospitalized after their first-ever suicide attempts and rates of mortality, including suicidal behavior, for 1 year after discharge. In very preliminary findings, we didn’t see any difference in the outcome for either all-cause mortality or repeat suicide attempts in those who were hospitalized, compared to those who were not. We don’t yet know about completed suicide.”

I left my discussion with Dr. Bossarte with more questions than answers. We have reason to believe that treatment helps, but we still don’t know which treatments help which people, and we do know that treatment doesn’t prevent suicide in every patient. In a culture where “treatment” has come to be equated with “prescribing” and is often based on a checklist of symptoms done by a primary care clinician, one might wonder if combining psychotherapy and medication – an increasingly rare offering – might have a better outcome. Simply put, for a problem that prematurely takes more than 40,000 lives a year, we know much too little.

Dr. Miller is a coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: Johns Hopkins University Press, 2011).