Surveillance of Suicide and Suicide Attempts Among Veterans: Addressing a National Imperative

In 2008, the Department of Veterans Affairs (VA) implemented a suicide event reporting system designed to collect standardized information on all suicide attempts reported to VA clinicians and suicide prevention coordinators in VA medical centers and outpatient facilities. Since that time, the VA has collected information on nearly 46 000 suicide attempts, and the suicide event reporting system has transitioned from an aggregate spreadsheet submitted monthly to an electronic reporting system capable of achieving near “real time” surveillance of suicide events among veterans. The VA's suicide event reporting system, known collectively as the Suicide Prevention Applications Network (SPAN), and complimentary programs such as the Department of Defense's (DoD's) Suicide Event Reporting system (DoDSER), represent vertical advances in the surveillance of suicide and provide a foundation for the development of similar efforts among broader segments of the US general population. However, these systems alone are not sufficient to fill existing gaps in the availability of timely and comprehensive data on suicide-related events among members of the broader US general population.

The need for improved and expanded surveillance of suicide and suicide attempts is well recognized. The 2001 National Strategy for Suicide Prevention (NSSP)¹ called for improved systems for collecting data on suicide and suicide attempts and included objectives to implement a national violent death reporting system, increase the utility of hospital data, and increase the number of states that produce annual reports on suicide and suicide attempts using information from multiple linked data systems. The Institute of Medicine's (IOM's) 2002 report on reducing suicide similarly called for the “sustained and systematic collection, analysis, and dissemination of accurate information on the incidence, prevalence, and characteristics of suicide and suicide attempts” and noted “serious inadequacies in the availability and quality” of information on suicide and similar limitations associated with of data on suicide attempts.² The 2010 document “Charting the Future of Suicide Prevention” reviewed progress toward achieving the goals set forth in the 2001 National Strategy for Suicide Prevention. In a 2010 review of progress data and surveillance, the Charting the Future report supported the 2002 IOM report conclusion that there exists significant deficiencies in the availability of data on nonfatal suicidal behavior and concluded that the NSSP goal of achieving regular systematic reporting of suicide and suicide attempts is still occurring on a “very limited” basis.³

Models for comprehensive data systems that provide a foundation for surveillance of suicide exist internationally in the population registries of Denmark⁴ and more locally in population-specific efforts such as mandatory reporting of suicide attempts among youth in Oregon.⁵ However, US public health agencies have been slow to respond to calls for standardization of data elements and integrated systems for surveillance of suicide. Limitations associated with the availability of population registries or event reporting are compounded by differences in terminology that complicate comparisons across systems or populations.

The suicide event reporting systems established by the Department of Veterans Affairs (SPAN) and Department of Defense (DoDSER) provide templates for the continued expansion of suicide event reporting that is consistent with existing calls for action. As reported by Gahm et al.,⁶ DoDSER is an event-based reporting system collecting systematic information on a standardized set of variables for all suicide events known to the Department of Defense. Similarly, SPAN collects information on a standardized set of variables for all suicide events (fatal and nonfatal) known by VA providers. Importantly, officials for both systems have agreed to collect information on suicide events using a single standardized suicide event nomenclature that was developed as a result of an integrated effort including partners from the VA, DoD, Centers for Disease Control and Prevention, and National Institutes of Health.⁷ The adoption of a standardized nomenclature increases the utility of suicide event data by providing a mechanism for comparability across systems and time. Together these distinct but interrelated systems represent the most comprehensive information available for the surveillance of suicide among any single US population.

The efforts of the VA and DoD are necessary but not sufficient components of adequate suicide surveillance. In 2010, the Action Alliance for Suicide Prevention was formed as a public–private partnership with the primary mission of revisiting the goals of the 2001 National Strategy and advancing suicide prevention in the United States.⁸ Once again, addressing gaps in the availability of data for the surveillance of suicide and suicide attempts has been identified as a priority for prevention programs. The surveillance systems implemented in the VA and DoD provide a foundation for the development of comparable systems among broader segments of the US general population. Together, these systems will provide the information necessary for the identification of emerging risk populations, changes in characteristics or context associated with increased risk, and the evaluation of suicide prevention needed for the development of effective and evidence-based programs.

Since October 1, 2008, the Department of Veterans Affairs has recorded information on nearly 46 000 suicide events among more than 38 000 individuals. Information from the SPAN system has been used to inform clinical management of high risk Veterans, identify periods of increased risk, measure the impact of prevention programs on suicide and suicide attempts, and identify changes in the distribution of risk across populations and time. Additional efforts include the assessment of risk for suicide and suicide attempt, including an emphasis on the impact of prevention programs on repeat suicide attempts. Over time, information obtained from SPAN, linked with data from DoDSER and comparable surveillance systems, is expected to provide the single-most comprehensive source of information on the identification and management of suicide risk available to clinicians and public health professionals. In 2008, suicide was once again a top ten leading cause of death in the US general population. The time for action is now. The development of comparable surveillance systems for veterans and others who do not receive care from the VA is needed for the adequate and timely assessment of suicide and improved clinical management for those with established risk. The systems implemented by the VA and DoD provide a foundation for integrated and active suicide surveillance, but should not stand alone. Addressing the challenge of suicide prevention will require interagency synergism to enhance and extend existing VA and DoD efforts.⁹ Comparable systems, utilizing a common nomenclature, are needed to supplement these systems and support our national effort to reduce the burden of suicide.