• Home Base Training Institute offers Suicide Postvention: Survivor Care for Families of Service Members & Veterans and Recognizing Suicide Risk in Returning Veterans.

• William James College offers Suicide Prevention for Military Veterans Through Lethal Means Counseling trainings for service providers.

• Riverside Trauma Center offers support services, training, and resources for Postvention.

• VA Rocky Mountain MIRECC’s Suicide Risk Management Program offers How to Talk to a Child about a Suicide Attempt in Your Family in addition to providing free consultation, support, and resources promoting therapeutic best practices for providers.

• PsychArmor offers VA S.A.V.E. Suicide Prevention and VA S.A.V.E. Preventing Caregiver Suicide and other suicide prevention, intervention, and postvention trainings.

• Swords to Plowshares offers information on Suicidality Among Veterans via TOOLBOX.vet.

• OneOp has Suicide Awareness webinars focused on military families.

• American Association of Suicidology offers resources for Suicide Loss Survivors along with various other toolkits and briefs for service providers.

• MIA Continuing Education offers an 11-seminar training on Innovative Approaches with People Who Are Suicidal.

• STRONG STAR Training Initiative offers a free continuing education webinar series focused on advanced training topics for clinicians implementing evidence-based treatments with trauma-exposed populations, and training through CPT and PE learning communities.

• Visit our Mental Health & Recovery Support page for a full listing of the resources below.

• VA Boston: Trista Maccini, 774-273-3668 – Suffolk County and Somerville, Cambridge, Watertown & Newton in Middlesex County

• VA Bedford: Buffy Gamache, 781-825-3510 – Essex & Middlesex County

• VA Central Western Massachusetts: Michelle Glaser, 413-472-7576 – Marlborough & Framingham in Middlesex County

• VA Central Western Massachusetts: Thea Faust, 413-309-2648 – Berkshire, Hampshire, Hampden & Franklin County

• VA Central Western Massachusetts: Michelle Glaser, 413-472-7576 – Orange in Franklin County

• VA Central Western Massachusetts: Michelle Glaser, 413-472-7576 – Worcester County

• VA Providence: Barnstable County and New Bedford in Bristol County

• VA Boston: Trista Maccini, 774-273-3668 – Norfolk, Plymouth & Bristol County

VA recognizes the importance of suicide postvention as prevention. At least 135 people are estimated to be impacted by each suicide death; between 57–65% of service members and veterans are estimated to experience a suicide loss.

Individuals bereaved by suicide have an increased risk of dying by suicide compared to other causes of death. The catalyst of the collaborative was a gathering of veterans and service providers in Boston with IAVA announcing the shocking results of their 2014 Member Survey:

• Nearly half of the roughly 2,000 member veterans surveyed knew an OIF/OEF veteran who died by suicide and nearly a third considered taking their own life since joining the military.

These numbers have only increased. In IAVA’s 2022 Member Survey of more than 5,000 members:

• 64% of respondents knew another OIF/OEF veteran who died by suicide and 44% had considered taking their own lives since joining the military. 

From 2001–2021, suicide rates increased for recent VHA users with bipolar disorder (+7.3 percent); opioid use disorder (+21.1 percent); cocaine use disorder (+50.9 percent); cannabis use disorder (+17 percent); and stimulant use disorder (+18.6 percent).

The suicide rates decreased for VHA users with mental health or substance use diagnoses overall (from 77.8 per 100,000 to 58.2 per 100,000 in 2021) and for veterans with depression (-32.9 percent), PTSD (-27.6 percent), anxiety (-26.9 percent), and schizophrenia (-4.2 percent).

According to RAND’s 2021 report, Suicide Among Veterans: Veterans Issues in Focus, the highest suicide rates among VA enrolled veterans were in veterans with:

• opioid use disorder or bipolar disorder (100–130 per 100,000);

• schizophrenia and substance use disorders (80–100 per 100,000); 

• depression or anxiety (66–67 per 100,000); and 

• PTSD (50–60 per 100,000).

According to VA’s 2023 National Veterans Suicide Report, from 2001–2021, suicide rates increased less severely among veterans engaging in VHA care. Over 20 years, the age-adjusted suicide rates among veterans increased overall by: 

• 62.6 percent among male veterans without VHA care (vs. a 24.5 percent increase with VHA care) and

• 93.7 percent among female veterans without VHA care (vs. a 87.1 percent increase with VHA care).

By Priority Group, the highest suicide rate among veterans using VHA care was in Priority Group 5 (57.1 per 100,000) in 2021.

• The suicide rate for veterans in Priority Group 5 who were under age 35 increased notably from 40.8 in 2001 to 82.8 per 100,000 in 2021.

Priority Group 5 includes low income veterans who don’t have a service-connected disability (or have a 0 percent rating), are receiving the VA pension, or who are Medicaid-eligible.

According to VA’s 2023 National Veterans Suicide Report, suicide was the second leading cause of death in 2021 for veterans under age 45. Women veterans under age 35 were almost 3.5 times more likely than non-veteran women to die by suicide in 2021, despite a 24.9% decrease in suicide rates for women veterans ages 55–74 and a 1.9% overall decrease among veterans under age 35.

Over 51 percent of the 6,392 veterans who died by suicide in 2021 had not recently used VHA care or VBA benefits. Suicide rates were lowest among veterans who used VBA benefits only and among veterans who did not access VHA care in 2020 and 2021.

Suicide rates were highest among those who only used VHA care. Mortality was also higher overall among veterans with recent VHA use for all cause mortality and leading causes of death, including unintentional injury and suicide.

By VA Priority Group, the highest suicide rate among veterans using VHA care was Priority Group 5 (57.1 per 100,000).

• The suicide rate for veterans in Priority Group 5 who were under age 35 was 82.8 per 100,000 in 2021.

Priority Group 5 includes low income veterans who don’t have a service-connected disability (or have a 0% rating), are receiving the VA pension, or who are Medicaid-eligible.

The VA’s Veterans Justice Outreach Program is a homelessness prevention initiative of the VA’s Homeless Programs Office focused on identifying justice-involved veterans and reaching out to them to facilitate their access to VA care through partnerships between the VA and criminal justice system.

• The suicide rate for recent VHA users receiving VA Justice Program services increased by 10.2% between 2020 and 2021 to 151 per 100,000, the highest observed since 2001.

• The suicide rate for recent VHA users with indicators of homelessness overall increased 38.2% between 2020 and 2021 to 112.9 per 100,000, also the highest observed since 2001.

The proportion of veterans who died by suicide in Massachusetts with a known mental health condition increased from 44 percent in 2017 to 65 percent in 2020. The proportion with a known alcohol or substance use problem increased from 24 percent in 2017 to 32 percent in 2020.

• Alcohol involvement increased from 32 percent in 2017 to 36 percent in 2020 (except a decrease to 29 percent in 2019).

• Antidepressant involvement doubled from 17 percent in 2017 to 35 percent in 2020.

• Opioids were involved in 17 percent of suicide deaths, except a decrease to 15 percent in 2019  (compared to 92 percent of 90 overdose deaths among military and veterans in 2019).

The proportion with a known physical health condition increased from 21 percent in 2017 to 25 percent in 2020 (down from 34 percent in 2018) while the proportion with a known intimate partner problem decreased overall from 30 to 21 percent and the proportion with a known job or financial problem decreased from 19 to 10 percent.

Deaths involving firearms increased overall from 44 percent in 2017 to 47 percent in 2020.

• Veterans over age 75 accounted for 59 percent in 2017, which increased to 70 percent in 2018 before declining to 57 percent in 2020.

Deaths involving suffocation decreased slightly from 32 percent in 2017 to 31 percent in 2020, and those involving poisoning decreased overall from 21 to 7 percent while deaths involving “other” means increased from 3 to 15 percent from 2017 to 2020.

In September 2023, the Defense Secretary released a memo, New DoD Actions to Prevent Suicide, responding to the SPRIRC’s report with five strategies that align with the Taking Care of Our People initiative, adopting and modifying some of the SPRIRC’s recommendations:

• fostering a supportive environment (implementing 26 recommendations);

• improving the delivery of mental health care (implementing 24 recommendations);

• addressing stigma and other barriers to care (implementing 14 recommendations);

• revising suicide prevention training (implementing 20 recommendations); and

• promoting a culture of lethal means safety (implementing 8 recommendations).

DoD will evaluate nine other SPRIRC recommendations, including to further study the connection to specific suicide risk factors and public health initiatives aimed at improving the health of service members. The memo concluded recently established programs, projects, or processes met the spirit of intent of 20 recommendations and that 16 others weren’t feasible to implement right now.

The DoD memo indicates the department issued guidance to implement the Brandon Act, which allows service members to self-initiate referrals for mental health evaluations to promote a culture of reaching out for help while increasing appointment availability by revising mental health staffing models to ensure clinics have the administrative and case management support they need.

Veterans are an impacted community with a more challenging status quo than other communities and suffer high rates of chronic pain and co-morbidities. The loss of life among veterans prescribed opiates for chronic pain is staggering. Veterans impacted by opioids face a lifelong struggle.

Pain-relief medications, including controlled substances, are the most frequent form of medication used in suicide attempts via overdose. Service members are prescribed narcotic painkillers while serving in the military at three times the rate of civilians.

• An internal briefing from the Walter Reed’s Alcohol and Substance Abuse Program disclosed that nearly half of the soldiers in the Warrior Transition Units had narcotic prescriptions at the end of 2009, with roughly the same number having TBI and/or PTSD.

• In 2010, Army Surgeon General Lt. Gen. Eric Schoomaker estimated almost 14% of the force had been prescribed some form of opiate drug.

• By 2011, an estimated 25–35% of combat-wounded soldiers in WTUs experienced addiction or dependence on prescription drugs, particularly those provided in combat settings or military hospitals.

• Madigan Army Medical Center Pychiatrist Dr. Russell Hicks indicated 5% of the troops had two or more active prescriptions for opiates; 60% of the soldiers with PTSD seen in the Intensive Outpatient Program had a co-occurring substance use disorder.

Pain is the most frequent presenting complaint reported by service members in community and primary care settings, including nearly half of returning combat veterans signing into the VA with pain-related diagnoses from 2005–2008.

A VA study analyzing data on 123,946 veterans who received VA care in 2004–2005 and received opioids for non-cancer chronic pain found those being prescribed the highest doses were more than twice as likely to die by suicide between 2004–2009 compared to those with the lowest doses.

While opioid therapy was once largely in the domain of cancer and pain specialists, up to 80 percent of opioids were prescribed in VA primary care by 2010; the majority of long-acting opioids were prescribed for non-cancer pain.

Patients initiating therapy with long-acting opioids were more than twice as likely to overdose compared with persons initiating therapy with short-acting opioids, particularly within the first two weeks after initiation.

More than half of all veterans receiving care at VHA for chronic pain present with co-morbid mental health conditions. These veterans have a significantly greater risk of being prescribed the highest dose, highest risk opioid therapy by VA clinicians and for experiencing adverse outcomes.

• Veterans with PTSD experiencing chronic pain were more than twice as likely to be prescribed opioids.

• Veterans with PTSD and a history of substance use disorder were four times as likely to be prescribed opioids.

High dose, high risk opioid therapies had the worst outcomes for veterans with co-morbid mental health conditions, particularly those with PTSD. Around 75 percent of Vietnam veterans with PTSD have a co-occurring substance use disorder.

Veterans with co-morbid mental health conditions were the most likely to obtain early refills, to be prescribed higher doses, take opioids longer, and to receive concurrent opioid, sedative, and/or hypnotics prescriptions.

Long-term opioid therapy is associated with significant and well-known risks, particularly in vulnerable individuals experiencing chronic pain and co-morbid mental health and/or post-concussive conditions.

• Despite the risks and lack of evidence supporting the efficacy of long-term opioid therapy, opiate prescription rates at VA rose by 270 percent between 2001 and 2013. Of the more than a half million veterans receiving chronic or long-acting opioid therapy from the VA in 2016, more than a third were receiving sedatives concurrently; and

• Concurrent opioid and benzodiazepine prescription rates for veterans with PTSD in the VA were above 30 percent, despite the risk of their death from drug overdose increasing in a dose-response fashion.

As part of the 2013 Opioid Safety Initiative, VA stated its intent to leverage its electronic health record to identify patients with one or more risk factors, as well as providers whose prescribing practices are misaligned with medical evidence or best practices, in order to intervene.

With complete data, the VA’s electronic health record can alert providers of best practices, recommend evidence-based courses of treatment, and flag high-risk situations or potential violations of best practices, guidelines, and policy in order to improve quality and oversight and embed learning in care.

Matching of PDMP data to treatment records within the VA’s electronic health record has potential to improve care and patient safety while also opening up new opportunities for research, maximizing the value of the data at the point of care and developing best practices in data integration that can be applied across federal systems.

The VA has not yet leveraged the use of clinical alerts across the VA healthcare system to further mitigate the risk of potentially inappropriate prescribing and co-prescribing of CNS-acting medications and enhance patient safety and informed consent.

VA researchers have evaluated the impacts of veterans’ being prescribed multiple central nervous system (CNS) acting medications in multiple populations, noting that increases in the quantities prescribed have coincided with increases in overdoses and suicide-related behaviors. 

The researchers found past DoD reports of “potentially problematic use of [CNS-acting] drugs,” including a review of suicide-related events conducted by the Army Institute of Public Health that found in a review that at least one CNS-acting medication was prescribed in the year prior to:

• 90% of suicide attempts;

• 87% of suicidal ideation events, and

• 46% of suicide deaths.

TRICARE data from 2005–2011 reportedly demonstrated a shift in prescribing practices with a:

• 1,083% increase in use of antipsychotics (vs. a 22% increase within the civilian population);

• 996% increase in use of sedating anticonvulsants;

• 713% increase in use of benzodiazepines; and

• 682% increase in use of psychoactive medications.

In 2015, DoD’s Medical Command issued Policy Memorandum 15-039 to provide guidance on the management of polypharmacy involving psychotropic medications and CNS depressants specifically with the goal of reducing adverse events and optimizing the health of service members and families receiving care. 

In 2016, VA researchers examined experiences of more than 300,000 OIF/OEF veterans who received VA healthcare between 2009–2011. More than 8% were prescribed five or more CNS-acting drugs in 2011. CNS polypharmacy may independently increase the risk of overdose and suicide-related behavior. VA HSR&D released a Publication Brief about the findings here.

CNS polypharmacy was independently associated with documented overdose and suicide-related behaviors. OIF/OEF veterans with PTSD, depression, and TBI; women veterans; and veterans between ages 31–50 were more likely to have CNS polypharmacy. This may be a risk factor that could be used to “trigger” the evaluation of veterans’ care in order to decrease their risk of death.

In 2019, VA researchers evaluated menopausal symptoms and higher risk opioid prescribing. In a national sample of more than 100,000 women veterans aged 45–64 with chronic pain, menopausal symptoms were associated with potentially risky long-term opioid prescribing patterns, independent of other risk factors. Within this national sample, VA researchers found:

• 13% were prescribed high-dose long-term opioids;

• 35% were co-prescribed long-term opioids and CNS depressants; and

• 51% were prescribed long-term opioids.

The 17% of women veterans with documented menopausal symptoms were more likely to be prescribed high-dose long-term opioids, long-term opioids, and to have polypharmacy with long-term opioids co-prescribed with CNS depressants (sedative-hypnotics, gabapentin/ pregabalin, or muscle relaxants).

In 2022, VA researchers evaluated long-term psychoactive medications, polypharmacy, and risk of suicide and unintended overdose death in a national sample of more than 150,000 midlife and older women veterans. Long-term prescribing of psychoactive medications and psychoactive polypharmacy predicted their risk of suicide and/or overdose death above and beyond other factors:

• Long-term opioids and benzodiazepines were both associated with death by suicide.

• Opioids, benzodiazepines, sedative-hypnotics, antidepressants, antipsychotics, and antiepileptics were associated with unintended overdose death.

• Polypharmacy with three or more psychoactive medications was associated with a more than two-fold increased risk of both suicide and unintended overdose death.

Benzodiazepines are contraindicated with PTSD. Long-term use of benzodiazepines can increase symptoms of anxiety and depression. Women are more likely to be inappropriately prescribed benzodiazepines.

The VA has worked to de-implement benzodiazepine prescribing for PTSD, resulting in a decrease from over 31 percent in 2009 to just under 11 percent in 2019. The largest decreases were accounted for by new patients with PTSD not being prescribed benzodiazepines, as opposed to tapering and discontinuation among patients who were already prescribed benzodiazepines for PTSD.

From 2009 to 2019, the proportion of older veterans inappropriately prescribed benzodiazepines increased for both new and existing patients. The VA has not implemented clinical alerts within its electronic health record to mitigate risks of inappropriate prescribing at the point of service.

VA offers information about benzodiazepines here. In order to educate patients about the risks, VA published the pamphlet Benzodiazepines & PTSD: Do you know about this risky combination?.

In September 2020, the FDA updated the Boxed Warning for benzodiazepines to address serious risks of abuse, addiction, physical dependence, and withdrawal that may result in overdose or death. Risk is especially high when benzodiazepines are combined with opioids, alcohol, or illicit drugs – even when taken at recommended doses – even over the course of only days/weeks.

In February 2023, a committee of the National Academies of Sciences, Engineering, and Medicine began a VA-sponsored study to evaluate the effects of opioids and benzodiazepines on all-cause mortality in veterans (including suicide) and quantify the effects of opioid and benzodiazepine prescribing on the risk of death among veterans who received VA care between 2007 and 2019.

Akathisia may occur when stopping, starting, or changing the dosage or type of certain medications, and it may have a delayed onset. Akathisia is characterized by a feeling of “inner restlessness” and a compelling need or urge to be in constant movement (fidgeting, rocking, pacing, etc).​

Symptoms are often overlooked or mistaken as signs of new or worsening agitation, depression, or anxiety. Akathisia may be wrongly treated by raising the dose or adding new drugs as a result. It is important to learn about the causes and symptoms of akathisia to ensure it is promptly identified.

Patients with akathisia should be closely monitored due to suicide risk. Inner restlessness associated with akathisia is experienced as distressing and may be expressed as:

• impatience,

• difficulty paying attention,

• apprehension,

• dysphoria,

• irritation or tension,

• fear, anger, or rage,

• confusion,

• vague somatic complaints, or

• dyspnea.

Other prominent symptoms may include:

• exacerbation of hallucinations or delusions,

• manic activity,

• disruptive behavior or acting out,

• panic attacks, or

• self-destructive behaviors such as head banging.

Such symptoms may be attributed to an underlying condition and/or mask akathisia. Akathisia is most commonly understood and recognized in relation to the prescription of antipsychotic medications, but it can occur with medications prescribed for acne, depression, asthma, nausea, anxiety, malaria, insomnia, smoking cessation, high blood pressure, and others.

Akathisia has also been found more recently to occur as an adverse effect of calcium channel blockers, antiemetics, anti-vertigo drugs, and sedatives used in anesthesia. It may also occur with cocaine, methamphetamine, MDMA, ecstasy, and GHB.

People with any history of TBI may have an elevated suicide risk. TBI may also lead to akathisia. Other medical issues that may increase the risk for experiencing akathisia include hyperthyroidism, renal impairment, diabetes, iron deficiency anemia, Parkinson’s disease, and peripheral neuropathy.

Community Resources for Akathisia

• The Medication-Induced Suicide Prevention and Education Foundation (MISSD) offers educational materials and a training with CE credit focused on recognizing akathisia. MISSD works to raise awareness of medication-induced suicide.

• The Inner Compass Initiative offers information and a Help Hub for people having a psychiatric drug withdrawal journey and Quick Tips for coping with akathisia.

• The Akathisia Alliance offers general information about benzodiazepines and akathisia for clinicians, family, and friends.

The Benzodiazepine Information Coalition offers resources and information about akathisia and benzodiazepines, including Benzodiazepines: How They Work and How To Withdraw (ie, “The Ashton Manual”). 

The HeartCore Collective is a healing community committed to creating spaces that foster honest dialogues about our modern mental health care systems and we are working to empower individuals on their healing journeys with education, resources, and support so they can make informed choices about their mental health. We are dedicated to providing person-centered holistic wellness and psychiatric drug withdrawal support.

By taking a non-medical and nonpathologizing approach, we focus on self-help, compassionately guiding individuals on their healing journeys. As informed peers who know this path well we provide evidence- and lived experience-based resources and tools to help others find their way forward. Our approach draws from the emerging field of deprescribing sciences and psychiatry and the shared wisdom from individuals with lived experience.

This is a holistic health collective that centers trauma-informed care with lifestyle interventions in order to create a new paradigm and existence for a community that has been historically overlooked and underrecognized. In this healing community, we get to the heart of what’s happening first because that’s what matters most.