The rate of suicide in the military (note 1) has attracted national attention recently. Reports released in late 2019 from the Department of Defense and the Department of Veteran Affairs show that military suicides are at an all-time high. Based on these data, we can anticipate that there will be more than 500 military suicides during January.
Suicide Prevention Efforts
Suicide is the 10th leading cause of death in the US. Between 1999 and 2016, the rate of suicide increased by more than 30 percent. In the US military population, there have been a staggering 45,000 suicides in the past six years, and particular groups in the military such as veterans have especially high suicide rates. In fact, the suicide rate for veterans is 1.5 times the rate of non-veterans. There has been recent attention paid to veteran suicides in particular and widespread political support to increase efforts to help prevent military suicides in general. In March, President Donald Trump issued an executive order—the President’s Roadmap to Empower Veterans and End a National Tragedy of Suicide (PREVENTS)—which creates a task force charged with developing a comprehensive public health plan to prevent veteran suicides. In addition, over the past few months, four of the top Democrats running for president have released plans to reduce veteran suicides.
Looking Beyond Behavioral Health Risk Factors
To date, reliable methods to predict suicide have proven elusive. Although experts have developed numerous suicide prediction tools, research indicates that the accuracy of predicting a future event is near zero, and that in some cases, tools may actually do more harm than good. Instead, efforts to prevent suicide generally focus on measures such as treating the behavioral health conditions known to increase the risk of suicide. In the military population, these conditions are particularly common; in fact, a comprehensive study several years ago found that the rate of depression in active duty troops was five times the rate of civilian depression, while the rate of post-traumatic stress disorder (PTSD) was more than 15 times higher.
Certainly, efforts to reduce stigma, increase screening, and improve access to high-quality behavioral health care for military members are critical ways to help prevent suicide. However, a key problem with this approach is that the majority of people who commit suicide in both civilian and military populations do not have a mental health diagnosis. Because of this, expanding the scope of suicide prevention efforts beyond those with high-risk diagnoses is necessary.
Loneliness Is Deadly
When veterans who have survived suicide attempts are asked to describe what led them to this action, one of the top three reasons given is “feeling alone.” Loneliness is a known risk factor for suicide, and the prevalence of suicidal thoughts appears to increase with the degree of loneliness. Specifically, a seminal study in 2011 showed that fewer than 2 percent of individuals who did not report loneliness had suicidal thoughts compared to 29 percent of the individuals who reported feeling lonely.
Loneliness is remarkably common in the US population. In fact, one in three adults in the US older than age 45 reports being lonely. Loneliness has been described as “an unpleasant experience specifically related to one’s social connections and is characterized by a person sensing a deficiency, either quantitatively or qualitatively, in their social network.” Loneliness appears to be particularly prevalent among veterans. In the 2014 National Health and Resilience in Veterans Study, 44 percent of veterans reported feeling lonely at least some of the time, and factors such as older age, difficulties with activities of daily living, lifetime traumas, depression, and PTSD were associated with loneliness.
While loneliness is a subjective feeling of being alone, social isolation is an objective lack of social connections. Reducing loneliness and social isolation would have impact well beyond suicide prevention. Among Medicare beneficiaries alone, $6.7 billion in annual federal spending is attributable to social isolation. Loneliness and social isolation have been associated with a 64 percent increase in the risk of dementia, a 32 percent increase in the risk of stroke, and a 29 percent increase in the risk of coronary artery disease, as well an increase in emergency department visits, hospitalizations, and nursing home placements. Moreover, there is evidence from numerous studies that social isolation and loneliness are associated with increased mortality, and in fact, the magnitude of this increase is comparable to the effect caused by smoking 15 cigarettes a day.
A Role For Medicare Advantage Plans
As our health care system increasingly embraces population health, and as value-based payment models help align providers and payers around quality and outcomes, there are new opportunities—and mandates—to focus on social determinants of health such as loneliness and social isolation. A number of stakeholders in the health care system are taking notice of the impact of these factors on health outcomes. Medicare Advantage plans are now able to offer supplemental benefits designed to address social determinants of health, and some plans are offering benefits that are focused specifically on loneliness and social isolation.
Humana has built a loneliness predictive model and is using it to identify Medicare Advantage members who are at risk of being lonely to pilot innovative interventions including: the PapaPals program, which connects at-risk members to college students who provide companionship; SilverSneakers group fitness classes; and other loneliness-focused resources and toolkits. Because Humana also provides services to six million TRICARE beneficiaries in the US (for example, active duty service members, retirees, and their families), the company has designed interventions focused on loneliness and social isolation for this population. To that end, Humana Military recently launched an Office of Population Health to address loneliness and other social determinants of health impacting the military community. Through this platform, community organizations (for example, nonprofits, military service organizations, veteran service organizations, and so forth) will be invited to co-create collaborative projects to break down these barriers to health, improve health outcomes, and lower the cost of care. Learning about which interventions are most helpful will be critical, and sharing this learning will enable other stakeholders to offer more customized and effective programs for the military community.
Call To Action: We Must Address The Social Determinants Of Military Suicide
Our military members deserve and require special attention. Health care initiatives that take the unique needs of this population into account are essential, and efforts to reduce military suicides must include tailored interventions to address loneliness. Health plans, providers, community organizations, and government agencies can all play a role in better understanding and combatting loneliness in the military. Targeting the social determinants of suicide is all of our responsibility.
Note 1
For the purposes of this post, references to the “military” includes all military populations (for example, veterans, active duty service members, reserve, National Guard members, and so forth) unless otherwise specified.
