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By Taylor Knopf

Every day, 20 veterans take their own lives somewhere in the United States. In North Carolina, five veterans die by suicide each week.

This is a growing problem. Since 2001, the rate of suicide among veterans has increased by 32 percent, according the U.S. Department of Veterans Affairs (VA).

Graphic courtesy: Dept of Veterans Affairs

Reducing the number of veteran suicides is the top priority at the VA, said Harold Kudler, acting assistant deputy under secretary for patient care services at the VA central office. Kudler spent decades working as a psychiatrist at the Durham VA Medical Center, where he focused on post-traumatic stress disorder.

Kudler spoke at a veteran suicide prevention conference in Raleigh on Tuesday, along with N.C. Health and Human Services Sec. Mandy Cohen.

Cohen said this is a personal issue for her.

“I have a lot of veterans in my family, and unfortunately lost an uncle to suicide. He was a veteran,” she said. “This is a very personal topic for me.”

Kudler said the rate in North Carolina is no better or worse than the rest of the country.  In 2014, 249 N.C. veterans died by suicide, 235 were male.

The Veterans Crisis Line 1-800-273-8255, Press 1 is available 24/7, 365 days a year.

Confidential chat at VeteransCrisisLine.net or text 838255

“There is no one cause. There won’t be a single answer. It’s complex,” said Susan Robinson, coordinator for suicide prevention and mental health promotion with the state DHHS.

However, there are higher risk populations and precipitating factors, she added. Robinson said risk factors include: life setbacks, prior suicide attempt, alcohol abuse, substance abuse, access to weapons, trauma, family history, childhood trauma, and depression.

Integrated care model

The VA has been trying to step up its game on mental health service access for its members. It has the nation’s largest integrated mental health system, meaning VA primary care doctors are addressing the majority of mental health needs in the same building where they check for high blood pressure or do cancer screening. Often, veterans don’t have to go to a separate location for mental health services.

There are 22.5 million veterans and another 2.5 million currently serving in the military. The VA offers services to all service members, veterans and their families. Kudler estimates that about 50 million Americans are eligible for VA services.

Psychiatrist Harold Kudler spent years at the Durham VA Medical Center treating PTSD and other mental health issues. Now, he’s leading the effort to get more mental health care to veterans countrywide. Photo credit: Taylor Knopf

“We are increasing access during a time where demand for mental health services is rising,” Kudler said.

More than 1.6 million veterans received mental health services in  FY 2015. That’s up from about 1 million in 2005, and it’s an 80 percent increase in mental health services over a decade. Meanwhile, the total number of veterans receiving care went up from 4.7 million to 5.8 million over that time period.

But the system has had trouble recruiting mental health workers. Recently, the system announced plans to hire another 1,000 professionals who would have a particular focus on suicide prevention and reduction.

“People in the VA don’t have more mental health issues than the general public,” Kudler said. “They have better access.”

In the past, there had been some wait time issues within the VA, Kudler said. But as of Dec. 31, 2016, every hospital director at the 144 VA medical centers had to commit to seeing any veteran who showed up with an urgent mental health need on the same day.

Kudler added that effective Dec. 31 of this year, the VA’s 1,200 plus community outpatient clinics will be told to make that same pledge.

“There is no one that will show up that will be turned away. Those facilities were not developed for walk-in services, but they are now,” he said.

Cohen said she has so much respect for the integrated model of care within the VA. Her first clinical job after residency was working with women at the VA.

She said it’s so important to think about the whole person, their physical, emotional and behavioral health.

“I think this is where the VA has done a tremendous job in thinking holistically about a person and co-locating services for folks,” Cohen said. “I’m excited to learn from the VA.”

The VA helps veterans and their dependent  family members with housing, education, jobs and healthcare.

“Frankly all health systems should do this because these are the real social determinants of health,” Kudler said. “Your genes are only a small part of it.”

5 suicide prevention steps

The VA is focusing on five ways to prevent veteran suicide.

1) Improve transition

Leaving the military is a dangerous time, said Kudler. The rate of death for veterans increases the first two years they are out from all causes: medical, accidents and suicides.

“We are trying to work with Department of Defense on a one-year transition out of the military,” he said. “Now, it may begin during their time of service. But it has to be more than an hour and a half with brochures.”

He said many service members look forward to “beer, sex and pizza” and are unlikely to remember the VA crisis line.

“It takes a long time to train people for the military,” Kudler said. “Nobody trains you to be a civilian when you get out.”

2) Know all veterans

The VA statistics show that of the 20 veterans that die by suicide each day, only six are using VA healthcare, Kudler said.

“We don’t know them and can’t reach them,” he said.

One way to reach more veterans is by using tele-mental health services. The VA has the largest telemental health system in the nation, but Kudler said it’s not where it could be.

“It’s our intention to use federal supremacy to do something no telehealth program in the country can do, which is treat any veteran anywhere in the nation,” he said.

Graphic courtesy: Dept of Veterans Affairs

Telemedicine is a way of connecting doctors and patients using digital technology. Right now, there are restrictions in place that prevent most providers from treating patients outside of their state.

3) Partner across communities

Kudler said that North Carolina has done a great job of building a system from a state level and partnering across communities. He praised the Governor’s Working Group on Veterans, Service Members and their Families, which meets regularly.

4) ‘Lethal means’ safety

Veterans tend to have a high suicide success rate because they often use firearms. Guns are 90 percent effective, whereas poison is only 10 percent, Kudler said.

“Suicide experts tell us that if we can reduce access to firearms in the first 10 minutes that someone gets the idea of dying, that will have single biggest impact of suicide prevention,” he said.

The VA gives out gun locks and encourages veterans to keep their weapon unloaded.

“We are not against weapons and are not taking a side on gun safety or gun restriction,” Kudler said.

If someone has just five minutes to think while taking the gun lock off, they might rethink their decision, he said.

5) Improve access

The VA is partnering with communities in the #BeThere campaign. The goal is to spread awareness and encourage the general public to simply be there with a text, call or visit for their veteran friends.

Saturday is Veterans Day  and the president declared November Veterans month, leading into the 100th Veterans Day  in 2018. So Kudler urged everyone to be there for a veteran this week.

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Taylor Knopf

Taylor Knopf writes about mental health, including addiction and harm reduction. She lives in Raleigh and previously wrote for The News & Observer. Knopf has a bachelor's degree in sociology with a...