Iraq war vets' suicide rates analyzed
High numbers found among members of Guard, Reserves
Kimberly Hefling, Associated Press

Wednesday, February 13, 2008
More than half of veterans who took their own lives after returning from Iraq or
Afghanistan were members of the National Guard or Reserves, according to new
government data that prompted activists on Tuesday to call for a closer
examination of the problem.

A Department of Veterans Affairs analysis of ongoing research of deaths among
veterans of both wars found that Guard or Reserve members accounted for 53
percent of the veteran suicides from 2001, when the war in Afghanistan began,
through the end of 2005.

The research, conducted by the department's Office of Environmental
Epidemiology, provides the first demographic look at suicides among veterans
from those wars who left the military.

Joe Davis, public affairs director for the Veterans of Foreign Wars, said the
Pentagon and VA must combine efforts to track suicides among those who have
served in those countries to get a clearer picture of the problem.

At certain times in 2005, members of the Guard and Reserve made up almost
half the troops fighting in Iraq. Overall, they were almost 28 percent of all U.S.
military forces deployed to Iraq or Afghanistan or in support of the operations,
according to Defense Department data through the end of 2007.

Many Guard members and Reservists have done multiple tours that kept them
away from home for 18 months, and that is taking a toll, Sen. Patty Murray,
D-Wash., said in a statement Tuesday.

"Until this administration understands that repeated and prolonged deployments
are stretching our brave men and women to the brink, we will continue to see
these tragic figures," Murray said.

Paul Rieckhoff, executive director of Iraq and Afghanistan Veterans of America,
said the military's effort to rescreen Guard members and Reservists for mental
and physical problems three months after they return home is a positive step, but
a more long-term, comprehensive approach is needed to help them.

The VA has said there does not appear to be an epidemic of suicide among
returning veterans, and suicide among the newer veterans is comparable to the
same demographic group in the general population.

But an escalating suicide rate in the Army, as well as high-profile suicides such
as the death of Joshua Omvig - an Iowa Reservist who shot himself in front of his
mother in December 2005 after an 11-month tour in Iraq - have alarmed some
members of Congress and advocates.

In November, President Bush signed the Joshua Omvig suicide prevention bill,
which directed the VA to improve its mental health training for staff.

According to the VA's research, 144 veterans committed suicide from the start of
the war in Afghanistan on Oct. 7, 2001, through the end of 2005. Of those, 35
veterans, or 24 percent, served in the Reserves and 41, or 29 percent, served in
the National Guard. Sixty-eight - or 47 percent - had been in the regular military.
Statistics from 2006 and 2007 were not yet available, the VA said.

Among the total population of Iraq and Afghanistan veterans who have been
discharged from the military, almost half are formerly regular military and a little
more than half were in the Guard and Reserves, according to the VA.

Among those studied, more than half of the veterans who committed suicide were
aged 20 to 29. Almost three-quarters used a firearm to take their lives. Almost 82
percent were white.

The VA study does not include those who committed suicide in the war zones or
those who remained in the military after returning home from war.

Last year, the Army said its suicide rate in 2006 rose to 17.3 per 100,000 troops,
the highest level in 26 years of record keeping. The Army said recently that as
many as 121 soldiers committed suicide last year. If all are confirmed, the
number would be more than double the number reported in 2001.

Hot line
Veterans Affairs Department suicide hot line: (800) 273-8255
15,000 or more US casualties
in Iraq War          
By Mike Whitney

11/17/07 "ICH" -- -- The Pentagon has been concealing the
true number of American casualties in the Iraq War. The real
number exceeds 15,000 and CBS News can prove it.

CBS’s Investigative Unit  wanted to do a report on the number
of suicides in the military and “submitted a Freedom of
Information Act request to the Department of Defense”. After
4 months they received a document which showed--that
between 1995 and 2007--there were 2,200 suicides among
“active duty” soldiers.


The Pentagon was covering up the real magnitude of the
“suicide epidemic”. Following an exhaustive investigation of
veterans’ suicide data collected from 45 states; CBS
discovered that in 2005 alone “THERE WERE AT LEAST

That is not a typo. Active and retired military personnel,
mostly young veterans between the ages of 20 to 24, are
returning from combat and killing themselves in record
numbers. We can assume that "multiple-tours of duty" in a
war-zone have precipitated a mental health crisis of which the
public is entirely unaware and which the Pentagon is in total

If we add the 6,256 suicide victims from 2005 to the “official”
3,865 reported combat casualties; we get a sum of 10,121.
Even a low-ball estimate of similar 2004 and 2006 suicide
figures, would mean that the total number of US casualties
from the Iraq war now exceed 15,000.

That’s right; 15,000 dead US servicemen and women in a war
that--as yet--has no legal or moral justification.

CBS interviewed Dr. Ira Katz, the head of mental health at the
Department of Veteran Affairs. Katz attempted to minimize the
surge in veteran suicides saying, “There is no epidemic of
suicide in the VA, but suicide is a major problem.”
Maybe Katz right. Maybe there is no epidemic. Maybe it’s
perfectly normal for young men and women to return from
combat, sink into inconsolable depression, and kill
themselves at greater rates than they were dying on the
battlefield. Maybe it’s normal for the Pentagon to abandon
them as soon as soon they return from their mission so they
can blow their brains out or hang themselves with a garden
hose in their basement. Maybe it's normal for politicians to
keep funding wholesale slaughter while they brush aside the
casualties they have produced by their callousness and lack
of courage. Maybe it is normal for the president to persist with
the same, bland lies that perpetuate the occupation and
continue to kill scores of young soldiers who put themselves
in harm’s-way for their country.  
It’s not normal; it’s is a pandemic---an outbreak of despair
which is the natural corollary of living in constant fear; of
seeing one’s friends being dismembered by roadside bombs
or children being blasted to bits at military checkpoints or
finding battered bodies dumped on the side of a riverbed like
a bag of garbage.
The rash of suicides is the logical upshot of Bush’s war.
Returning soldiers are traumatized by their experience and
now they are killing themselves in droves. Maybe we should
have thought about that before we invaded.

Check it out the video at: CBS News “Suicide Epidemic
among Veterans”
Iraq War-Related Soldier and Veteran Suicides Top 430
Aaron Glantz

The War Comes Home - KPFA

It’s time to change of count of American war dead upward.

The Associated Press has got hold of a preliminary government study on suicides by Iraq and Afghanistan war veterans. According to the VA, at
least 283 combat veterans who left the military between the start of the war in Afghanistan on October 7, 2001 and the end of 2005 took their own
lives. In addition, 147 troops have killed themselves in Iraq and Afghanistan since the wars began bringing the government count to 430.

The VA’s count is not a complete one, however. It does not include members of the military who returned from Iraq and then killed themselves before
being discharged from the service – people like Sgt Brian Rand who shot himself in the head after returning home from his second tour.

It also doesn’t include the deaths of people like Sgt. James Dean who was shot by Maryland state troopers after he barricaded himself in his father’s
farmhouse. Observers call those deaths “suicide by cop.”

And it doesn’t include the deaths of people like Sgt. Gerald Cassidy, a 32 year old Indiana National Guardsman, who died at Fort Knox five months
after returning from Iraq with brain damage from a roadside bomb.

How many more American deaths continue to go uncounted?

Regardless, it’s clear is that we need to change our count of casualties upward from 4,229 US military deaths (3,842 in Iraq and 387 in Afghanistan)
to closer to 5,000 – possibly more when you consider those deaths that still haven’t been counted.

Veterans for Common Sense
Post Office Box 15514
Washington, DC 20003



OEF/OIF Veteran Suicide Toll: Nearly 15% of Overall U.S. Military Casualties Result from Suicide

Back in February, the Marines released their military branch's updated suicide statistics. They revealed the number of Afghanistan and
Iraq combat troops and veterans who took their own lives in 2007 had doubled over the previous year.

Earlier this month, the Army reported its own current soldier suicide data, reflecting another year of record increases. And just last
week, the VA chimed in with their latest OEF/OIF veterans suicide figures -- also another record-breaker -- for its Afghanistan and Iraq
veteran clients.

Gregg Zoroya of USA Today:

In 2006, the last year for which records are available, figures show there were about 46 suicides per 100,000 male veterans ages 18-
29 who use VA services. That compares with about 20 suicides per 100,000 men of that age who are not veterans, VA records show.

The statistics accompany the release of a study conducted by a group of mental health experts appointed by VA Secretary James
Peake to investigate the department's efforts to track and prevent suicides among veterans. ...

VA records show that 141 veterans who left the military after Sept. 11, 2001, committed suicide between 2002 and 2005. In the one
year that followed, an additional 113 of the Iraq- and Afghanistan-era veterans killed themselves.

The report did not specify how many of those 113 saw combat. The increase in the number of suicides can be attributed in part to the
rising number of veterans since 2001. The overall suicide statistics include veterans who served during the wars in Iraq and
Afghanistan but were stationed outside the combat zones. ...

The release of the VA data comes days after the Army said 2008 may be another record year for suicides among active-duty soldiers.
If the trend continues, it would surpass a record of 115 suicides set in 2007. The Army reported last week that through August, there
have been 62 confirmed suicides and 31 deaths suspected of being suicides.

"If this holds true, suicide rates for the Army will surpass" the U.S. rate for the general population, an Army news release says.

What follows below the fold is a partial, quite incomplete look at where we're at today as far as Iraq and Afghanistan troop/veteran
suicides are concerned. It's exasperating work; but, I'm in good company. Congress for years has struggled to get a straightforward
and full data set out of the DoD and the VA, too.

Click on 'Article Link' below tags for much, much more...

In educational interest, article(s) quoted from extensively.

First, a few caveats: There are all sorts of problems that exist with the data in the table below.

DoD and VA statistics -- and a description of just what incidents are and are not counted, and why one incident is included and
another not -- never seem to appear in a concise format.

Some reports, for example, don't break things down easily for us. Is the Army active-duty tally for all OEF/OIF troops or formerly-
deployed forces/veterans, or does it include non-OEF/OIF forces (for example, serving in Korea), too?

I've weeded through and broken it all down to reflect only Afghanistan and Iraq figures to the best of my knowledge and ability. I
welcome any additions of data and/or corrections that you may find and care to share.

OEF/OIF Suicides

Active-duty military forces

Marines, active-duty forces, deployed, 2003: 2
Army, active-duty forces, deployed, 2003: 25
Marines, active-duty forces, deployed, 2004: 7
Army, active-duty forces, deployed, 2004: 11
Marines, active-duty forces, deployed, 2005: 4
Marines, active-duty forces, deployed, 2006: 4
Army, active-duty forces, deployed, 2005-2006: 120
Marines, active-duty forces, deployed, 2007: 6
Army, active-duty forces, deployed, 2007: 115
Army, active-duty forces, deployed, January-August 2008: 62
Army, active-duty forces, deployed, through August 2008 (suspected): 31
Army, active-duty forces, between deployments, 2002-2008: ???
Army, active-duty forces, suicide attempts, 2002: 350
Army, active-duty forces, suicide attempts, 2007: 2,100 [5 per day]

Marines, active-duty, prior deployed, 2003: 6
Marines, active-duty, prior deployed, 2004: 10
Marines, active-duty, prior deployed, 2005: 8
Marines, active-duty, prior deployed, 2006: 5
Marines, active-duty, prior deployed, 2007: 12
Veterans, separated from service, under VA care, 2002-2005: 141
Veterans, separated from service, under VA care, 2006: 113
Veterans, separated from service, not under VA care, 2002-2008: ??? [*at least 139]

OEF/OIF Suicide Totals
Active-duty military forces: 356 [+another 31 suspected]
Veterans: 295 [+another 139 not officially counted by DoD or VA]
356+295=651 OEF/OIF active-duty troop or veteran suicides.

If we were to add in the 139 the DoD and the VA appear not to be counting (see note below), the figure rises to 790. And, if we add
in the 31 suspected 2008 suicides still being investigated by the DoD, the number grows to 821.

As of today, there have been over 4, 700 U.S. OEF/OIF casualties.

If we use the conservative suicide figure above of 651, doing the math, that translates to nearly 15% (13.82 to be exact) of our
Afghanistan and Iraq war losses are as a result of suicide.

If we plug in the higher figure (821), the percentage jumps to over 17% (17.43).

*Important note on the above figures:

In October, AP reported on preliminary VA research at the time, which revealed that 283 OEF/OIF veterans had committed suicide
between 2001-2005.

This was the figure that I was prepared to use when testifying before the House Veterans Affairs Committee in December on this
issue at the Stopping Suicide: Mental Health Challenges Within the Department of Veterans Affairs hearing.

I noted in my testimony [read | view] that the combined reported DoD and VA figures reflected the fact that 10 percent (at the
time) of our overall service member casualties in the Iraq and Afghanistan wars are as a result of suicide.

The night before the hearing, I reviewed the VA's prepared remarks slated to be delivered the following day. That's when I first
noticed the change. The VA figure had been decreased by 139 (from the original 283), to a total of 144 OEF/OIF suicides. Of
course, I became curious: What happened to the 139 no longer being counted?

I was able to get my question answered pretty quickly.

Following my testimony, VA Mental Health Director Dr. Ira Katz (who was quite gracious and kind to me, although he's come
understandably under fire quite a bit since then for his less-than-full disclosure of the VA's suicide data) introduced himself,
giving me the chance to ask him privately about the changed suicide tally.

Why had the figure been reduced?

He went into a long explanation, saying that the VA incorrectly counted some veterans in their system, who in reality were still
considered a part of the DoD when they died. Therefore, they weren't official VA clients and need not be included in their count.

After going back-and-forth a bit to get some more clarification, my best understanding of this logic is that 139 OEF/OIF veterans
aren't being recognized in our official OEF/OIF veterans suicide data due to a mere technicality.

For example, Iraq veterans like Timothy Bowman, who'd returned to the states but had not yet enrolled in the VA for care when he
committed suicide, for some strange reason doesn't need to be considered part of the overall data.

Since he wasn't a VA client, he isn't counted in the VA statistics. And since he wasn't deployed when he committed suicide, the
DoD doesn't appear to include him, either, when it reports on how many of its combat zone troops have perished this way.

Is this really the best way for us to go about trying to get a real handle on the depth and breath of the OEF/OIF suicide issue?

I don't think so. Anyone else feel the same way?

Some related stats:

Nearly 40% of Army suicides in 2006 and 2007 were taking psychotropic drugs like Zoloft and Prozac for depression and PTSD.

Nearly 60% of 948 Army suicide attempts in 2006 had been seen by mental health providers before the attempt - 36 percent
within just 30 days of the event.

More than 43,000 U.S. troops since 2003 were sent into combat even though they had been listed as medically unfit in the weeks
before their scheduled deployment.

The "typical" soldier who commits suicide is a member of an infantry unit who uses a firearm to carry out the act, according to
the Army.

53% of veteran suicides from 2001-2005 came from the Guard or Reserve population; for a period during 2005, they accounted
for about 50% of forces serving in Iraq and Afghanistan. However, when averaging all war years, they made up 28% of all U.S.
military forces deployed.

100,000 OEF/OIF vets have sought help for mental health issues, including 52,000 for post-traumatic stress disorder alone.

According to the DoD, there were almost 2,200 active-duty soldier suicides between 1995-2007.

CBS News reported in November that there were at least 6,256 veteran (of all wars) suicides in 2005 [this figure includes data
collected from 45 states; the figure is, therefore, higher if taking all 50 states into account]. That’s 120 each and every week. In
addition, on any given night, nearly 200,000 veterans are counted among the homeless.

In 2005, OEF/OIF veterans aged 20 through 24 had the highest suicide rate among all vets, about 2-4 times higher than their
civilians peers. (Civilian suicide rate: 8.3 per 100,000; Veterans suicide rate: between 22.9 and 31.9 per 100,000.)

A 2007 survey of U.S. troops revealed that about 12% of OIF and 17% of OEF combat troops are taking prescription
antidepressants or sleeping pills to help them cope.

The new VA suicide prevention hotline, recently reported that it's received more
than 55,000 calls, averaging 120 per day, with about 22,000 callers saying they were

Related Posts

Tallying War's Increasing Costs and Strains

The War List: OEF/OIF Statistics

VA Patient Suicide Attempts Rise Dramatically

AP: Over 50% of VA's OEF/OIF Veteran Suicides from Guard/Reserve

Groundbreaking CBS News Investigation Into Veteran Suicide 'Epidemic'

CBS Evening News Veteran Suicide Investigation Follow-up

VA Reports Nearly 300 Estimated OEF/OIF Veteran Suicides
More than 50% of Army's 948 Suicide Attempts in 2006 Sought Help First

OEF/OIF Vets Seeking PTSD Care from VA Jumps 70%, Mental Health Counseling Tops 100,000

Fort Campbell: 9 Suicides in 2007, 3 in Last 2 Weeks Moves Commanding General to Act

Is the Army 'Spinning' its Increase in Suicides?

Last Year's 99 Army Suicides Highest in Recorded History

As Another Suicide Occurs, Minnesota Leaders Urge DoD to Revise Post-Deployment Contact Rules

Family Sues VA for Iraq Veteran Son's 2004 Suicide

Flash Video Remembers 100+ OEF/OIF Veteran Suicides

Returning Veterans and Suicide: Alaska's Perfect Storm?

Family 'Respectfully Disagrees' With VA Report on Son's Suicide

Montana Iraq Vet Suicide Reflects VA, Military System Failure

PTSD Timeline: The Latest Incidents

20 War Zone Suicides So Far in 2006

WUSF 89.7 News: Report on Combat Zone Suicides

Combat PTSD Timeline: 41 Stateside OEF/OIF Suicides

Combat PTSD: Incident Database for Reporters, Researchers

Army: 83 suicides in 2005, 67 in 2004

Marine Corps Suicides Spiked 29% in 2004
Fear That Suicides May Top
War Deaths
May 06, 2008
Agence France-Presse

Suicides and "psychological mortality" among U.S. Soldiers who
served in Iraq and Afghanistan could exceed battlefield deaths if
their mental scars are left untreated, the head of the U.S. Institute
of Mental Health is warning.

Of the 1.6 million U.S. troops who have been deployed in Iraq and
Afghanistan, 18-20 percent -- or around 300,000 -- show
symptoms of post-traumatic stress disorder (PTSD), depression or
both, said Thomas Insel, head of the National Institute of Mental

An estimated 70 percent of those at-risk Soldiers do not seek help
from the Department of Defense or the Veterans Administration,
he told a news conference May 5 launching the American
Psychiatric Association' s 161st annual meeting here.

If "one just does the math", then allowing PTSD or depression to
go untreated in such numbers could result in "suicides and
psychological mortality trumping combat deaths" in Iraq and
Afghanistan, Insel warned.

More than 4,000 U.S. Soldiers have died in Iraq since the U.S.
invasion of 2003, and more than 400 in Afghanistan since the U.S.
led attacks there in 2001, of which some 290 were killed in action
and the rest in on-combat deaths.

"It's predicted that most Soldiers -- 70 percent -- will not seek
treatment through the DoD or VA," Insel said at the meeting, at
which the psychological impact of war is expected to top the
agenda over the next four days.

Left untreated, PTSD and depression can lead to substance
abuse, alcoholism or other life-threatening behaviors.

"It's a gathering storm for the civilian and public health care
sectors," Insel said.

He urged public-sector mental health caregivers to recognize the
symptoms of psychological troubles resulting from deployment to a
war zone and be ready to provide adequate care for both Soldiers
and their families.

Other items on the agenda at the meeting, set to be attended by
some 19,000 psychiatrists and mental health practitioners from
around the world, include violence in schools, the psychology of
extremism, and more light-hearted topics such as how music
affects mood.
'Houston Chronicle' Uncovers Another
Iraq Vet Suicide -- And His Wife Soon
Joined Him

By Greg Mitchell

Published: May 18, 2008 9:40 PM ET

NEW YORK Literally every day now brings a report on a suicide by a
veteran of the Iraq war who served multiple tours there and/or suffered from
PTSD. In most cases, the stories emerge from small town newspapers, as
E&P has chronicled for nearly five years. Today's example comes from a
much bigger paper, the Houston Chronicle, and probes at length a case
that occurred last year.

And in this case, the soldier's wife joined him as a suicide the following day.

The article by Lindsay Wise on Aron Andersson and Cassy Walton
observes that when the former "killed himself on March 6, 2007, he
became one of at least 16 Army recruiters to commit suicide nationwide
since 2000. Five of those suicides occurred in Texas, including three at the
Houston Recruiting Battalion, where Andersson worked after serving two
tours of duty in Iraq.

"Roughly one in five U.S. troops returning from Iraq and Afghanistan reports
symptoms of post-traumatic stress disorder or major depression, but only
slightly more than half have sought treatment, according to a recently
published Rand Corp. study. Of those who did seek care, only about half
received minimally adequate treatment, the study found.

"Amid increasing concerns about failure to screen, diagnose and treat
soldiers with mental health problems adequately, Andersson's story raises
questions about the pressures faced by the growing number of veterans
who return from multiple combat deployments to high-stress recruiting
assignments back home."

The article talks about the soldier's experience in Iraq and return home:
"The only thing the father knew for sure was that his son had changed. He
was more frustrated, less patient and harder to talk to. 'Did he come back
different? Yeah,' Bob Andersson said. 'I don't think there's anybody who
goes over there and fights on the front lines who ever comes back the

"The soldier once told his father about working a barricade in Iraq when a
white van barreled toward U.S. troops, ignoring warning shots and orders
to stop. 'It was definitely a suicide mission, and he said this van full of
people came in and they had to, quote, light it up,' Bob Andersson said.
'And he said there were children in there and everything. I could tell that
really, really, bothered him.'"

The lengthy article is at:
Inpatient Suicide and Suicide Attempts in Veterans Affairs Hospitals

The Joint Commission Journal on Quality and Patient Safety

National Patient Safety Goals 482 Suicide is the eleventh leading cause of death in theUnited States

1>> taking the lives of 30,622 people in2001.2>> In 2002, 132,353 individuals were hospitalizedfollowing suicide attempts; 1>>16,639
were treated in emergencydepartments and released.2>> Approximately 1,500 suicides takeplace in inpatient hospital units in the United
States each year,and one third of these take place while the patient is on 15-minute checks.3,4A review of inpatient suicides conducted
byThe Joint Commission found that 75% of suicides involvedhanging and that another 20% resulted from patients jumpingfrom a roof or
window.5Other studies of inpatient suicideinclude patients that committed suicide while on pass or elop-ing from the hospital, so it is
difficult to discern the methods ofthose who committed suicide while in the hospital itself.6–9However, all report hanging and jumping to be
the most com-mon methods. Lambert and Fowler10described how veterans possess manyof the common risk factors for suicide, and
Kaplan et al.11reported that veterans are twice as likely as nonveterans to dieof suicide, making suicide prevention in Department
ofVeterans Affairs (VA) medical centers a particular challenge.Previous suicide attempts are a primary risk factor for complet-ed suicides,
which underscores the importance of trying tounderstand and prevent not only completed but also attempt-ed suicides. One powerful
method of determining underlyingcauses of a suicide or suicide attempt is to conduct a root causeanalysis (RCA),12,13as mandated by
the Joint Commission since1997 for accredited hospitals. To encourage the development of a culture of safety withinthe VA health care
system—a system that provides comprehen-sive health care services to more than 6 million veterans acrossthe United States through 154
VA medical centers nested within 21 geographically defined integrated service networks—in 1999 the VA established the National Center
for PatientSafety (NCPS). The NCPS instituted an RCA program to indi-vidually and collectively analyze adverse events.14,15The NCPS
defines adverse events as “untoward incidents,Article-at-a-GlanceBackground: Suicide is the eleventh leading cause of deathin the United
States. Approximately 1,500 suicides occur ininpatient hospital units in the United States each year. In anattempt to determine the
methods and environmental fac-tors involved in inpatient suicide and suicide attempts inDepartment of Veterans Affairs (VA) hospitals, all
rootcause analysis (RCA) reports of inpatient suicides and sui-cide attempts submitted to the VA National Center forPatient Safety (NCPS)
before June 2006 were reviewed. Methods:VA medical centers are required to conductRCAs on all inpatient suicides and report all
suicides andserious suicide attempts to the NCPS. All reports of inpa-tient suicide and suicide attempts submitted betweenDecember 1999
and June 2006 were reviewed, includingmethods and environmental factors involved in the events. Results: A total of 185 inpatient suicide
and suicideattempts were reported; 42 were completed suicides and143 were suicide attempts. Approximately 52% of the totalnumber of
events occurred while the patient was on aninpatient psychiatry unit. Three methods of self harm—intentional drug overdose, cutting with
a sharp object, andhanging—accounted for 71% of the total number ofevents. Doors and wardrobe cabinets accounted for 41% ofthe
anchor points when hanging was the method of self-harm. For suicide attempts involving cutting behaviors,razor blades accounted for
37% of the total number ofevents; 57% of jumping-related events occurred from bal-conies and walkways. Conclusions:Careful review of
RCA reports of inpatientsuicide has resulted in focused interventions to improvepatient care and patient safety in VA medical centers,
including a comprehensive environment-of-care checklistfor reviewing inpatient psychiatry units. Peter D. Mills, Ph.D., M.S.; Joseph M.
DeRosier, P.E., C.S.P.; Bryan A. Ballot, M.D.; Michael Shepherd, M.D.; James P.Bagian, M.D., P.E.Copyright 2008 Joint Commission on
Accrediation of Healthcare Organizations
Page 2
483August 2008 Volume 34 Number 8The Joint Commission Journal on Quality and Patient Safetytherapeutic misadventures, iatrogenic
injuries, or other adverseoccurrences directly associated with care or services providedwithin the jurisdiction of a medical center,
outpatient clinic, orother facility.”16Adverse events “may result from acts of com-mission or omission, e.g., administration of the wrong
medica-tion, failure to make a timely diagnosis or institute theappropriate therapeutic intervention, adverse reactions or neg-ative
outcomes of treatment, etc.”16In VA medical centers, serious adverse events and “potential”adverse events that meet the selection
criteria as defined in theSafety Assessment Code (SAC) are subjected to mandatoryreview using RCA methodology.14,17In addition, VA
medicalcenters report less severe events as safety reports to the NCPS.Each VA facility supports a full-time patient safety
managerresponsible for investigating all adverse events at the local level.Although other studies have summarized patient character-istics
that are indicative of suicidal risk and made recommenda-tions for the psychosocial and medical treatment for suchpatients4or have
described the specific characteristics ofpatients who have committed suicide while in the hospital,18–20few have analyzed environmental
factors relevant to inpatientsuicide or suicide attempts.3,5Moreover, none has reviewed allreported inpatient suicides and suicide attempts
within a largenational health care system to allow for the systematic compar-ison of locations and methods. In an effort to better
understandthe underlying methods of inpatient suicide and suicideattempts in VA hospitals, all completed RCA reports of inpa-tient suicide
or suicide attempts were reviewed [J.M.DeR].This article summarizes the results of this review and makes rec-ommendations for
environmental interventions aimed atreducing inpatient suicide and suicide attempts. MethodsCODINGEVENTS FOR THERCA
PROCESSAll adverse events that are reported within the VA are rated bythe patient safety manager against two criteria: harm (from cat-
astrophic to minor) and probability (from frequent to remote).Each event is coded both for the actual harm and the potentialharm that
could have been caused. Harm and probability arecombined to produce a SAC score from 1 to 3.14,17 A rating of 1represents the lowest
level of priority, whereas 3 represents thehighest level of priority for undergoing an RCA. All eventscoded as a “SAC 3” are analyzed using
the RCA process. (Thosewith scores of 2 or 1 may receive an RCA at the discretion ofthe patient safety manager at each facility) RCA
reports comeinto the NCPS via a secure computerized report system. RCAreports are submitted to the NCPS throughout the year
andinclude narrative descriptions of the event, all contributing fac-tors, a final understanding of the event, and a specific actionplan for
addressing underlying causes. VA medical centers arerequired to conduct RCAs on all completed inpatient suicides,and patient safety
managers are required to report all complet-ed suicides, serious suicide attempts, and related RCAs to theNCPS.ANALYSIS OFRCA
REPORTSTo identify RCA reports on inpatient suicide and suicideattempts, we conducted a search of all RCA reports receivedbetween
December 1, 1999, and June 30, 2006, to identify anyevents that involved suicide or suicide attempts that occurredwhile the patient was
being treated on an inpatient unit. Forthis review, suicide attempt was defined to be an uncompletedsuicide where action had been taken
(for example, neck innoose, cut wrists) verses a threat or gesture.Results A total of 185 inpatient suicides and suicide attempts
werereported; 42 were completed suicides and 143 were suicideattempts. In this period, there were 4.8 million total inpatientadmissions in
the VHA system, 819,947 of which were psychi-atric admissions. There were 19 inpatient suicides on psychia-try units, or 2.31 completed
suicides for every 100,000psychiatric admissions. Figure 1 (page 484) displays the location of the events. Ap-proximately 52% of the total
number of events occurred whilethe patient was on an inpatient psychiatry unit. Figure 2 (page484) displays the methods for the events;
patient-induced drugoverdose (18.9%), cutting with a sharp object (20.1%) andhanging (31.4%) accounted for 70.4% of the total number
ofevents. Table 1 (page 485) displays the breakdown of the ninemost common methods of suicide or suicide attempts by theirlocation;
note that hangings, cuttings, strangulation, asphyxia-tion, and fire took place primarily on inpatient psychiatry units,whereas a large
percentage of overdoses, jumpings, stabbings,and ingestion of chemicals took place on other units. Figure 3(page 486) displays the
anchor points for the 58 cases of hang-ing. Doors and wardrobe cabinets accounted for 41.4% of theanchor points listed. Figure 4 (page
486) displays the materialsused as nooses in the 58 cases of hangings; 39.7% of the totalused bedding. Figure 5 (page 487) displays the
cutting imple-ments used in the 38 reported cases of serious cutting; razorblades accounted for 36.8% of the total. Figure 6 (page 487)
displays locations for the 14 cases of jumping; 57.1% of theevents originated from medical center balconies and walkways. Copyright 2008
Joint Commission on Accrediation of Healthcare Organizations
Page 3
484August 2008 Volume 34 Number 8The Joint Commission Journal on Quality and Patient SafetyDiscussion Our findings are similar to
those found in the private sector.3,5In comparison with the 1998 Joint Commission study of inpa-tient suicides, in which 75% of the cases
involved hanging andanother 20% jumping from a roof or window, as stated, in ourstudy, 18 (43%) of the 42 completed inpatient suicides
werehangings, 15 (36%) were drug overdoses, and 4 (9.5%) werejumping from a high place. Although we found a lower per-centage of
suicides involving the physical environment, clearly,the inpatient physical environment continues to be a factor ininpatient suicides. The
most recent summary of sentinel eventsprovided by the Joint Commission listed deficiencies in theenvironment as one of the root causes
in almost 73% of sui-cides that were reported.21Similarly, 109 (76%) of the 143reported VA inpatient suicide attempts that we
reviewedinvolved the environment of care. In 1998, the Joint Commission recommended a number ofstrategies to reduce inpatient
suicides, including removing orreplacing non-breakaway hardware, weight testing all break-away hardware, and blocking patient access to
sharp objectsand potentially harmful items such as cleaning solvents.5Yeageret al.3also recommends removing curtains, replacing
regulardoors with accordion or pocket doors, building safety featuressuch as a stainless steel box around plumbing fixtures, andadding
plates to grab bars to reduce the risk of hanging. Inaddition, weekly “safety rounds” are recommended to identifypotential environmental
components that could be used eitherto commit suicide or to harm someone else. For example, partsof some beds can be removed and
used to harm another, andsome types of drawers can be pulled out, splintered, and usedto stab.3The majority of suicides and suicide
attempts, especiallyhangings and cutting, in our review occurred while the patientwas on an inpatient psychiatry unit. It is not surprising
thatthese units would have a higher rate of suicide because theyhave a much higher percentage of suicidal patients.Accordingly, these
are also the units that should be the bestequipped to anticipate and prevent suicidal behaviors. Patientcharacteristics that are associated
with completed suicides(depressed mood, hopelessness, disconnection from others, sui-cidal idea, previous suicide attempts) are often
not helpful inthe prediction of imminent risk for a specific patient, especial-ly on the psychiatric unit, where most of the patients will
havemany of the risk factors for suicide. As a result, staff vigilanceand, more importantly, a reduction of environmental hazardsFigure 1.
Approximately 52% of the total number of events occurred whilethe patient was on an inpatient psychiatry unit. ER, emergency room; TCU,
treatment care unit; NHCU, nursing home care unit; detox, detoxification;ICU, intensive care unit.Location and Percent of Inpatient
Suicidesand Suicide Attempts, December 1999–June 2006, N = 185Figure 2. Patient-induced drug overdose (18.9%), cutting with a sharp
object(20.1%), and hanging (31.4%) accounted for 70.4% of the total number ofevents. Reported Methods and Percent for
InpatientSuicides and Suicide Attempts, December 1999–June 2006, N = 185Copyright 2008 Joint Commission on Accrediation of
Healthcare Organizations
Page 4
485August 2008 Volume 34 Number 8The Joint Commission Journal on Quality and Patient
SafetyLocationHangingCuttingOverdoseNumberPercentNumberPercentNumberPercentInpatient psychiatry unit4781.0%1743.6%1028.6%
Emergency department35.2%615.4%12.9%Acute care 11.7%37.7%411.4%Common space23.4%37.7%411.4%Domiciliary11.7%25.1%
720.0%Grounds11.7%12.6%12.9%Nursing home or Alzheimer’s unit11.7%25.1%25.7%Clinic00.0%25.1%25.7%Other00.0%25.1%00.0%
Intensive care unit00.0%00.00%25.7%Detoxification unit23.4%12.6%25.7%Total58100.0%39100.0%35100.0%
LocationStrangulationJumpingStabbingNumberPercentNumberPercentNumberPercentInpatient psychiatry unit964.3%00.0%228.6%
Emergency department00.0%00.0%342.9%Acute care 214.3%214.3%00.0%Common space17.1%17.1%00.0%Domiciliary00.0%17.1%
00.0%Grounds00.0%857.1%00.0%Nursing home or Alzheimer’s unit17.1%17.1%114.3%Clinic00.0%00.0%114.3%Other17.1%00.0%
00.0%Intensive care unit00.0%17.1%00.0%Detoxification unit00.0%00.0%00.0%Total14100.0%14100.0%7100.0%
LocationAsphyxiationFireIngestion of ChemicalsNumberPercentNumberPercentNumberPercentInpatient psychiatry unit480.0%375.0%
00.0%Emergency department00.0%125.0%00.0%Acute care 00.0%00.0%00.0%Common space00.0%00.0%00.0%Domiciliary00.0%00.0%
00.0%Grounds120.0%00.0%00.0%Nursing home or Alzheimer’s unit00.0%00.0%266.7%Clinic00.0%00.0%133.3%Other00.0%00.0%
00.0%Intensive care unit00.0%00.0%00.0%Detoxification unit00.0%00.0%00.0%Total5100.0%4100.0%3100.0%Table 1. Common
Methods of Inpatient Suicide or Suicide Attempts by LocationCopyright 2008 Joint Commission on Accrediation of Healthcare Organizations
Page 5
486August 2008 Volume 34 Number 8The Joint Commission Journal on Quality and Patient Safetybecome critical barriers to suicidal
behaviors. It is important to note that although the majority of inpa-tient suicides and suicide attempts occurred on psychiatryunits, 48%
occurred in other areas of the hospital, most notablythe emergency department. Because it is often impossible toeliminate environmental
hazards in these areas, it is critical todevelop systematic protocols for evaluating and managing sui-cidal patients. In some VA facilities,
specialized psychiatricemergency departments are available with many of the environ-mental modifications of an inpatient psychiatry unit.
In this study, we found that although belts and shoelacesaccount for a significant number of the materials employed asa noose, bedding is
by far the most common material used. Fora variety of reasons, including infection control and patientcomfort, bedding has not been
eliminated on most psychiatryunits, and as a result there may be potential noose material.Consequently, the fact that hanging is the
number-one methodfor suicide makes the reduction of anchor points on the ward avery important goal. A number of potential anchor
points areidentified in Figure 3. Corridor doors are needed for fire safetyand so cannot be eliminated; however, interior doors and cabi-net
doors can often be removed or replaced by accordion doorsthat cannot be used as anchor points. In addition, any type ofdoor knob,
faucet, railing, hook, or protrusion should be con-sidered a possible anchor point and eliminated or modified sothat it will not sustain much
weight, so that a potential noosewill slip off, or so that it is impossible to thread any noose mate-rial through it. This study’s results also
indicate that a significant number ofinpatient suicides and suicide attempts were caused by inten-tional drug overdoses. Although the
presence of drugs on aninpatient unit is not technically a structural issue, access tothese drugs can have environmental causes. In a
review of sui-cide prevention strategies, Mann et al. concluded that restrict-ing access to lethal means for committing suicide was one of
thefew interventions found to be effective.22On an inpatient unit,this can take the form of systematic contraband checks, carefulevaluation
of whether the patient has swallowed his or her med-ication, and clear education for visitors not leave any type ofdrug. More than 71% of
the overdoses took place on unitsother than the psychiatry inpatient units, notably the residen-tial units (domiciliary) and detoxification
units. Of the 11adverse events reported on domiciliary units, 7 (63.6%) wereoverdoses. Similarly, of the 5 events on detoxification units,
Figure 3. Doors and wardrobe cabinets accounted for 41.4% of the anchorpoints listed. IV, intravenous.Hanging Anchor Points for
Inpatient Suicideand Attempted Suicide by Hanging,December 1999–June 2006, N = 58Figure 4. Of the 58 cases of hangings, 39.7%
entailed the use of bedding.Materials Used as a Noose for InpatientSuicide and Attempted Suicide by Hanging,December 1999–June
2006, N = 58Copyright 2008 Joint Commission on Accrediation of Healthcare Organizations
Page 6
487August 2008 Volume 34 Number 8The Joint Commission Journal on Quality and Patient Safety40% were overdoses. By comparison,
on psychiatric inpatientunits, only 10.4% of the events were drug overdoses. This study has several limitations. First, our RCA
databaseonly contains those adverse events that are reported. It is possi-ble that other adverse events and close calls occurred that
werenot accounted for in the RCA data. Second, we did not controlfor patient characteristics, such as diagnosis, presence of psy-chosis,
or severity of risk for suicide. Third, we did not controlfor facility characteristics such as the level of staffing, the designof patient units,
level of observation, or the numbers of patientson specific units. Fourth, we did not consider what preventiveefforts were already in place
on the units where the attemptedsuicides and suicides occurred. For example, when bedding wasused as noose material, we did not
determine whether there wasa policy banning belts and shoelaces from the unit.Despite these limitations, this study provides an
initialunderstanding of some of the highest-frequency environmentalhazards for inpatient suicide and suicide attempts. Our resultsare
similar to other findings in the field and can be generalizedto the inpatient population in non–VA hospitals. Furtherresearch is needed to
determine the interaction effects ofpatient, staff, and facility characteristics on overall patient out-comes. Data on actual suicide attempts
are useful in considera-tion of ward design and furnishings and can be an invaluableevidence-based tool for those performing
environmentalrounds on inpatient units where suicide is determined to be arisk factor for patients. RecommendationsOn the basis of our
preliminary findings, the following recom-mendations are made for modifying psychiatric inpatient unitsto prevent suicide: ■ Eliminate doors
when not required by code.■ Remove doors on wardrobe cabinets and replace rods andhangers with shelves.■ Eliminate belts, shoelaces,
and safety razors (shave high-risk patients or observe while shaving).■ Ensure there is a protocol in place to eliminate access todrugs that
could be used for an overdose. ■ Conduct environmental rounds using active observationsskills and a comprehensive checklist of
potential environmentalhazards.A mental health environment-of-care checklist has beendeveloped and implemented in the VA and is
available by e-mail request. This article is the result of work supported with resources and the use of facilitiesat the Department of
Veterans Affairs (VA) National Center for Patient Safety at AnnArbor, Michigan, and the VA Medical Centers at White River Junction,
Vermont, andWest Palm Beach, Florida, and the VA Office of Inspector General, Washington,D.C. The Research and Development
Committee, White River Junction VA MedicalCenter, approved this project, and the Committee for the Protection of HumanSubjects,
Dartmouth College, considered this project exempt. The views expressedin this article do not necessarily represent the views of the
Department of VeteransAffairs or of the United States government. JFigure 5. Razor blades accounted for 36.8% of the 38 cases, none of
whichresulted in death.Cutting Implements for Inpatient AttemptedSuicide by Cutting, December 1999–June 2006, N = 38 Figure 6. Of the
14 cases of jumping, 57.1% originated from medical centerbalconies and walkways.Jumping Locations for Inpatient Suicide andAttempted
Suicide by Jumping, December 1999–June 2006, N = 14Copyright 2008 Joint Commission on Accrediation of Healthcare Organizations
Page 7
488August 2008 Volume 34 Number 8The Joint Commission Journal on Quality and Patient SafetyReferences1. National Center for Injury
and Prevention Control: Welcome to WISQARS(Web-based Injury Statistics Query and Reporting System). http://www.cdc.
gov/ncipc/wisqars/ (last accessed Jun. 20, 2008).2. Centers for Disease Control and Prevention: Understanding Suicide FactSheet. 2006. accessed Jun. 20, 2008).3. Yeager K.R., et al.: Measured response
to identified suicide risk and vio-lence: What you need to know about psychiatric patient safety. Brief Treatmentand Crisis Intervention 5:
121–141, May, 2005. 4. American Psychiatric Association: Practice guideline for the assessment andtreatment of patients with suicidal
behaviors. Am J Psychiatry 160:1–60, Nov.2003.5. The Joint Commission: Inpatient suicide: Recommendations for preven-tion. Sentinel
Event Alert 7, Nov. 6, 1998. (last accessed Jun. 20, 2008).6.
Blain P.A., Donaldson L.J.: The reporting of inpatient suicides: Identifyingthe problem. Public Health 109:203–301, Jul. 1995.7. Jimmy Y.S.,
Dong T.P., Kan C.K.: A case-controlled study of 92 cases of in-patient suicide. J Affect Disord 87:91–99, May 2005.8. Proulx F., Lesage A.
D., Grunberg F.: One hundred in-patient suicides. Br JPsychiatry 171:247–250, Feb. 1997.9. King E.A., et al.:The Wessex recent in-
patient suicide study, 2: Case-controlstudy of 59 in-patient suicides. Br J Psychiatry 178:537–542, Jun. 2001.10. Lambert M.T., Fowler D.
R.: Suicide risk factors among veterans: Riskmanagement in the changing culture of the Department of Veterans Affairs. J Ment Health
Adm 24:350–358, Summer 1997.11. Kaplan M.S., et al.: Suicide among male veterans: A prospective popula-tion-based study. J
Epidemiol Community Health 61:619–624, Jul. 2007.12. The Joint Commission: 2008 Comprehensive Accreditation Manual forHospitals:
The Official Handbook (CAMH). (SE2–SE6, Reviewable SentinelEvents). Oakbrook Terrace, IL: Joint Commission Resources, 2007.13.
Wald H., Shojania K.G.: Root cause analysis. In: Making Health CareSafer: A Critical Analysis of Patient Safety Practices. Agency for
HealthcareResearch and Quality, 2001, pp. 51–56. accessed Jun. 20, 2008).14. Bagian J.P., et al.:
Developing and deploying a patient safety program ina large health care system: You can’t fix what you don’t know about. Jt CommJ Qual
Improv 27:522–532, Oct. 2001.15. Weeks W.B., Bagian J.P.: Developing a culture of safety in the VeteransHealth Administration. Eff Clin
Pract 3:270–276, Jun. 2001.16. VA National Center for Patient Safety: Glossary of Patient Safety Terms.http://www.patientsafety.
gov/glossary.html (last accessed Jun. 20, 2007).17. Bagian J.P., Lee C., Cole J.: A method for prioritizing safety relatedactions. In
Proceedings of Enhancing Patient Safety and Reducing Errors inHealth Care. Chicago: National Patient Safety Foundation, 1999, pp.176–
185.18. Cassells C., et al.: Long- and short-term risk factors in the prediction ofinpatient suicide: A review of the literature. Crisis 26(2):53–
63, 2005. 19. Marusic A., et al.: Comparison of psychiatric inpatient suicides with sui-cides completed in the surrounding community. Nord
J Psychiatry56(2):335–338, 2002.20. Lloyd G.G.: Suicide in hospital: Guidelines for prevention. J R Soc Med88:344–346, Jun. 1995.21.
The Joint Commission: Sentinel Events Statistics. Dec. 31, 2005. (last accessed
May21, 2007; root cause analysis statistics no longer available).22. Mann J.J., et al.: Suicide prevention strategies: A systematic review.
JAMA294:2064–2074, Oct. 2005.Peter D. Mills, Ph.D., M.S., is Director, Field Office of the NationalCenter for Patient Safety (NCPS),
Veterans Health Administration(VHA), White River Junction, Vermont; and Adjunct AssociateProfessor of Psychiatry, Dartmouth Medical
School, Hanover, NewHampshire; and a member of The Joint Commission Journal onQuality and Patient Safety’s Editorial Advisory Board.
Joseph M.DeRosier, P.E., C.S.P., is a Program Manager, Department ofVeterans Affairs (VA) NCPS, Ann Arbor, Michigan. Bryan A. Ballot,
M.D., is Chief, Mental Health and Behavioral Science Service, WestPalm Beach VA Medical Center. Michael Shepherd, M.D., is aMedical
Officer, VA Office of Inspector General, Washington, D.C.James P. Bagian, M.D., P.E., is the Chief Patient Safety Officer,VHA, and
Director, VA NCPS. Please address requests for reprintsto Peter D. Mills, Copyright 2008 Joint Commission on
Accrediation of Healthcare Organizations