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Abstract
Introduction Research into the factors resulting in suicide in the military veteran population has yet to reach a consensus. Available research is concentrated on a small number of countries, and there is a lack of consistency with contradictory conclusions. The USA has produced a significant amount of research in a country where suicide is identified as a national health crisis, but in the UK, there is little research regarding veterans from the British Armed Forces.
Methods This systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Corresponding literature searches were conducted in PsychINFO, MEDLINE and CINAHL. Articles that discussed suicide, suicidal ideation, prevalence or risk factors among British Armed Forces veterans were eligible for review. A total of 10 articles met the inclusion criteria and were analysed.
Results Veterans' suicide rates were found to be comparable to those of the general UK population. The method of suicide used was most commonly found to be hanging and strangulation. Firearms was recorded in 2% of suicide cases. Demographic risk factors were often contradictory with some research stating that there was risk in older veterans and some in younger. However, female veterans were found to be at higher risk than female civilians. Those who had deployed on combat operations were at lower risk of suicide, with research finding that veterans who took longer to seek help for mental health (MH) difficulties reported more suicidal ideation.
Conclusions Peer-reviewed research publications have revealed that UK veteran suicide prevalence is broadly comparable to the general population while highlighting differences across international armed forces. Veteran demographics, service history, transition and MH have all been identified as potential risk factors of suicide and suicidal ideation. Research has also indicated that female veterans are at higher risk than that of their civilian counterparts due to veterans being predominantly male; this could skew results and requires investigation. Current research is limited and further exploration of suicide prevalence and risk factors in the UK veteran population is required.
- Suicide & self-harm
- MENTAL HEALTH
- PUBLIC HEALTH
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information. Data came from openly accessible articles and a table has been included to highlight the included papers and information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Despite recent investment into preventing UK veteran suicides, there is a lack of research within a British Armed Forces context.
WHAT THIS STUDY ADDS
There is no significant difference in rates of suicide in the UK veteran community with the civilian population.
Research findings were often contradictory with some stating that older veterans were at higher risk of suicide and others indicating younger veterans. Female veterans were found to be at higher risk than female civilians.
Veterans who took longer to seek help for mental health difficulties reported more suicidal ideation and mood disorders, and they were found to be associated with an increased risk of suicide.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
There are considerable knowledge gaps regarding the prevalence of suicide and suicidal ideation in the UK veteran community. Further research is required to inform policy and provide targeted support for vulnerable individuals during transition to civilian life.
A particularly unexpected finding was that female veterans were found to be at higher risk than that of their civilian counterparts; there has been some recent investment into the female veteran population, though it is clear this requires additional research.
Introduction
The possibility that suicide may be associated with military veteran status is clearly troubling, and there remains no consensus as to whether military service increases the risk of suicide, self-harm or suicidal ideation.1 2 The available research is concentrated on a small number of countries and there is a lack of consistency with contradictory conclusions. However, there is evidence that military veterans present with high levels of mental health (MH) difficulties3–5 and that they were poor at seeking help, often not pursuing support until they were in crisis.6 Factors that are associated with risk of suicide in veterans include being a young male veteran (under 28 years), discharging as an early service leaver (ESL) (within 4 years of enlistment), being an older (over 40 years) female veteran, or having depression or alcohol problems.7–9 The literature also suggests that veterans who experienced adverse life events before enlisting or who have difficulties adjusting to civilian life may be at higher risk.10
Currently, there is a scarcity of research on suicide prevalence and risk in veterans within a UK context. This extends to learning lessons from the veteran’s time within the British Armed Forces, although there are some indictors from active-duty research. These include the identification that the situational stressors of relationship issues, family problems and occupational stressors were the primary significant factors leading to depression in serving personnel,11 or for some young men, the primary stressor is a desire to leave the armed forces, but this is curtailed by their terms and conditions of service12 and service personnel’s self-harming behaviour is correlated with alcohol misuse.13
One of the countries with a large body of literature on suicide prevalence, risks and interventions among the veteran population is the USA. Veteran suicide in the USA has been identified as a national health crisis, with an average of 16 veteran suicides per day.14 In 2020, there were 6146 veteran suicides, a slight decrease from the trend that has seen a year-on-year increase since 2006. The suicide rate for veterans was 57.3% greater than for non-veterans, with 71% using firearms.14 Canada has a picture similar to the USA, with the risk of suicide for both male and female veterans being consistently higher than that in the Canadian general population.15 By contrast, Australian male veterans have suicide rates comparable with non-serving men, although the suicide rate is significantly higher in female veterans.16 Dutch17 and Swedish18 veterans have a suicide risk comparable with their respective general populations. Switzerland is somewhat unique in that it has a suicide rate of just below the European average19 and has the 16th highest gun ownership in the world.20 Regarding method of suicide, 37% of male suicides in Switzerland use firearms.19 Within the UK veteran population, one might speculate that suicide by firearms is low due to lower availability and higher restrictions. However, firearms extend to incidents of ‘suicide by cop’ or law enforcement-assisted suicide,21 22 and while rare, when involving UK military veterans they are high-profile events.23 This suggests that suicide prevalence within the veteran community is dependent on the specific country in which they reside and may be influenced by contextual factors.
There has been a significant investment into suicide prevention in UK veterans with programmes such as the Armed Forces Covenant Fund Trust’s ‘One Is Too Many’ initiative24 and a pledge to better document veterans whose cause of death is listed as suicide.25 In addition, the withdrawal of troops from Afghanistan in 2021 has raised concern regarding MH and potential suicide risk.26 27 Therefore, it would be of benefit to conduct a systematic review of the literature to identify the prevalence and risk factors of suicide and suicidal ideation in British Armed Forces veterans.
Methodology
Literature search strategy
This systematic review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (figure 1).28 Literature searches were conducted using PsycINFO, MEDLINE and CINAHL databases. The selected databases offer a variety of indexes that provide comprehensive and up-to-date peer-reviewed publications. Grey literature was also included as part of this review to allow the inclusion of reports commissioned by organisations related to veterans including the Forces in Mind Trust, Armed Forces Covenant Fund Trust, Ministry of Defence (MOD), Royal British Legion and suicide (Samaritans). Each country’s governmental literature was also searched for potential statistical information. Reference lists of reports and articles were also manually searched as was BMJ Military Health for any additional articles. There were no database limitations applied to the search. Due to the focus on the British Armed Forces, all publications were written in English and the earliest article in the original search dated back to 1980.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram of literature review publication selection.
Inclusion–exclusion criteria
Articles that discussed suicide and suicidal ideation prevalence or risk factors among British Armed Forces veterans were eligible for review. Self-harm and associated synonyms were included within the search terms. However, self-harm was only included when discussed as a risk factor for suicide or suicidal ideation and not when discussed independently. Any form of review such as a systematic review or rapid review was not included. However, the reference lists were manually searched for any additional articles. Those discussing prevalence and risk factors for attempted suicide were also included due to the intent of completing suicide.
Articles that solely discussed serving personnel were not included in the review. In some publications, the findings for serving personnel and veterans were combined. Therefore, it is difficult to extrapolate data specifically related to veterans due to the combined nature of the results. However, publications that presented serving personnel and veterans’ data separately were eligible for review.
Procedure
A literature search and screening of the titles and abstracts of the eligible articles were conducted by the second author. The full articles that met the inclusion criteria were equally split between three authors and screened against the inclusion criteria of the systematic review. The authors extracted data from the selected papers and completed the data extraction tables, followed by regular meetings to discuss and agree on inclusion.
The stages of the literature search were as follows:
Initial search: keyword search using the criteria in table 1.
Removal of duplicates: Duplicates across databases were removed.
Title and abstract screening: The relevancy of the titles and abstracts were checked.
Full-text screening: Publications were then screened to check that the text included the prevalence or risk factors of suicide or suicidal ideation in the British Armed Forces veteran population.
Grey literature screening: Grey literature was also reviewed in accordance with the inclusion criteria.
Reference list search: The reference lists of the included publications and grey literature were searched for additional articles.
Search parameters of the literature review
Results
The 10 included articles were published from 2008 to 2022. Of these, nine were quantitative articles and one adopted a mixed methods approach. Quantitative studies consisted of self-reporting surveys and database searching. The qualitative approach in the mixed methods study used interviews. Three studies directly compared the veteran population with a demographically matched civilian population. The current narrative considers the prevalence of suicide and suicidal ideation within the UK veteran population and also explores the risk factors that are within the included publications (see table 2).
Summary of included papers and reports
Prevalence
There was a significant lack of research directly comparing the prevalence of suicide and suicidal ideation in the veteran community with the civilian population. However, of the research available, there was found to be no significant difference in rates of suicide.2 7 29 However, there was found to be increased risk in specific subgroups such as different age categorises and ESLs. Rodway et al9 found that veterans had a marginally lower risk of suicide, though this difference was not significant. Death by suicide has been found to range from 6.6% to 7.6% of overall veteran deaths with civilians ranging from 7.8% to 8.4%, highlighting the small difference between the two groups. Bergman et al7 29 matched the civilian comparison population in areas such as age, gender and socioeconomic status with that of the veteran population to produce a highly valid comparison, ensuring that any differences were more likely due to veteran status. However, there was no information on personal factors that could influence suicide risk such as combat exposure and alcohol misuse.
In addition, statistics presented by the MOD explored the deaths of veterans who had been deployed to the Gulf and Falkland conflicts. Those deployed in the Gulf conflicts were found to have a statistically decreased risk of suicide compared with the general population.30 Veterans deployed to the Falklands were found to have a 33% decreased risk compared with the UK general population.31 However, it is possible that there may have been suicides that were missed within these statistics as categories which may include suicidal deaths such as accidental deaths or deaths associated with drug/alcohol misuse were not included. These statistics appeared to match by age but did not consider gender or socioeconomic status, all of which could potentially influence rates of suicide.
Methods of suicide
The methods of suicide most commonly used among the UK veteran population were found to be hanging and strangulation.2 30 However, the method used did not differ from that of the civilian population, with differences only found across genders regardless of veteran status.29 The least common method of suicide among veterans was found to be firearms, with as little as 2% using this method,2 30 and male veterans were less likely to use firearms than male civilians.29 This contrasts with the USA, where firearms are the most common method of suicide,14 likely due to higher accessibility.
Risk factors
There were numerous risk factors for suicide and suicidal ideation in UK veterans, including factors related to demographics such as age and gender, service history such as deployment, transition into civilian life, MH disorders such as post-traumatic stress disorder (PTSD) and a history of self-harm. The lack of literature suggests that there may potentially be risk factors that have not been fully explored or have been missed.
Demographics
Demographically, the age of the veteran was found to be a risk factor, though the age at which this may be has differed across the literature. Bergman et al29 found that risk was lower in younger veterans but higher in those over the age of 40. Contrastingly, Kapur et al2 found that the younger veteran groups were at two to three times higher risk than the civilian population with veterans aged 30–49 being at lower risk. This was also supported by Rodway et al.9 However, the latter studies did not control for socioeconomic factors, something which Bergman et al29 ensured and could explain the contradictory findings. In support of Bergman et al,29 Harden and Murphy8 found that veterans aged between 35 and 44 and between 45–54 were more likely to report suicidal ideation. However, this sample included only veterans who were seeking treatment, and the results may be skewed as it may be that younger veterans are least likely to seek help and therefore are at higher risk of suicide.
In addition to age, gender was also found to be a risk factor, particularly among female veterans who were found to be at higher risk of suicide than female civilians, and there were no statistical differences between male veterans and female veterans.29 This could be due to women adopting the masculine and stoic culture surrounding the military, meaning that they are less likely to seek help for MH difficulties and are therefore at a higher risk of suicide than female civilians. However, Rodway et al9 found that overall, men were at an increased risk of suicide, though due to the veteran population being predominantly male, it is possible that this demographical difference may skew the results. Furthermore, there were significant interaction effects between gender and age among veterans with younger male veterans and older female veterans being at higher risk of suicide and/or suicidal ideation.7 9
Service history and transition
The service history of the veteran, that is, their experiences during their time in the military, has been observed to be a risk factor. For example, veterans who served in the Royal Navy or Royal Air Force were at a reduced risk of suicide compared with those who had served within the British Army.9 In addition, those veterans who experienced what they believed to be classed as a morally injurious event were more likely to report suicidal ideation, suggesting that those involved in combat may be at increased risk of suicide.32 However, more recent research indicates that those who were deployed on combat operations were at a decreased risk of suicide,9 and this is supported by fatality statistics from the Gulf and Falkland wars showing that there is little to no difference compared with the general population.30 31 Veterans who experience an increase in suicidal ideation or suicide risk may be due to the symptoms such as nightmares and flashbacks that they are experiencing following a morally injurious event, rather than the exposure to the event itself.33
ESLs were significantly more likely to report suicidal ideation and to be at higher risk of suicide.8 9 More specifically, those within the British Armed Forces who had not completed basic training, served for less than 10 years or those who had been medically, administratively or dishonourably discharged.9 In addition, there are significant interaction effects between ESLs and demographics, with an increased risk in older age groups and female veteran ESLs.29 Furthermore, some research implies that it may be difficulties during the transition that lead to an increased risk of suicide and/or suicidal ideation. Veterans who rejected the prospect of civilian life were more likely to report suicidal thoughts, plans and/or have made previous suicide attempts.33 In addition, unemployed veterans were also at an increased risk of suicidal ideation,8 further highlighting that difficulties during the transition may be an increased risk factor for suicide and suicidal ideation, though the research is currently limited.
MH and self-harm
Veterans who took longer to seek help for MH difficulties reported more suicidal ideation,8 supporting the idea that veterans often fail to seek help until they are in crisis. As expected, mood disorders were found to be associated with increased risk of suicide, with veterans at a marginally higher risk compared with the general population, though this difference was not significant.33 PTSD increased the risk of suicide in veterans compared with the civilian population and was found to be significantly related to suicidal thoughts, plans and previous attempts.7 33 This risk was found to be associated with the symptoms of those who were diagnosed with PTSD, such as living with a consistent paranoia and fear of death, with the exposure to a traumatic experience alone not necessarily associated with an increased risk of suicide.33 This may be related to the help-seeking behaviour of the veteran population who often believe they can self-manage any MH symptoms. Furthermore, UK veterans who died by suicide were found to be at a non-significantly lower risk than their civilian counterparts of having a diagnosis of alcoholic liver disease,7 though this is focused on heavily excessive drinking to the point of liver damage and therefore may be different when looking at general alcohol misuse. Though these risk factors are not surprising, there is limited research into the associations of MH with suicide risk and suicidal ideation.
Bergman et al34 found that 18% of veterans who died by suicide had a previous history of self-harm. These associations were lower in younger veterans under the age of 30 and higher in older veterans over the age of 50. In addition, 50% of veterans who had previously self-harmed also had a secondary diagnosis of a MH disorder, with 37% having a diagnosis of a mood disorder. As mood disorders have been found to be associated with an increased risk of suicide,7 it may be that there are significant interaction effects between self-harm, MH and suicide risk.
Conclusions
There is a scarcity of research regarding the prevalence and risk factors of suicide and suicidal ideation in veterans who served in the British Armed Forces, with direct comparisons with the civilian population being even less so. Overall, it appears that UK veteran suicide prevalence is broadly comparable to the UK general population. With veteran suicide being a national health crisis in the USA, like that of Canada, there remains questions over why these differences exist. The method of suicide appears to be a disparity with firearms being used in 71% of US veteran suicides compared with just 2% in UK veteran suicides.2 9 Further research may consider contextual influences in veteran suicide.
Risk factor research within a British armed forces context was also limited, with some literature conflicting. Factors such as the age and gender of the veteran were found to influence suicide risk, with female veterans found to be at significantly higher risk than their civilian counterparts.29 This finding is unexpected and provides evidence for the stoic culture of the military influencing attitudes towards MH and suicide; therefore, further research would be beneficial to explore this potential difference, though due to the veteran population being predominantly male, this may cause difficulty. In addition, service history and transition were found to be risk factors of suicide, though transition was under-researched despite the risk factor of ESLs being at increased risk of suicide and suicidal ideation.8 9 In addition, associations between suicide risk and MH and self-harm research is minimal, with only one article found looking into previous history of self-harm in veterans who died by suicide. To conclude, there is limited overall research in suicide and suicidal ideation in veterans within a British Armed Forces context, and further exploration and research are needed on the prevalence and risk factors.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information. Data came from openly accessible articles and a table has been included to highlight the included papers and information.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
References
Footnotes
Twitter @becky_randles
Contributors RR: coordination of review, inclusion decisions, writing of results and conclusion draft and editing. HB: conducting initial searches, inclusion decisions, writing of introduction draft and editing. NG: inclusion decisions, writing of methodology draft and editing. AF: final draft review and editing, guarantor of the publication.
Funding This systematic review was funded as part of the Armed Forces Covenant Fund Trust’s 'One Is Too Many' programme (agreement reference 2018-108214), effective from 1 July 2021.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.