Suicide Among Justice-Involved Veterans: Understanding Risk and Meeting Needs
September 2023
By Ryan Holliday, Ph.D.
Introduction
Veterans are 57.3% more likely to die by suicide than non-veterans, with estimates ranging from 17 to 24 veterans dying by suicide in the U.S. each day.1 Research also suggests that veterans are at an increased risk for justice system involvement, with nearly 1 in 3 veterans reporting that they have been arrested and booked into jail, relative to only 1 in 5 people with no history of military service.2 At the intersection of these issues, an investigation from 2021 found that justice-involved veterans were nearly twice as likely to attempt suicide as veterans with no history of criminal justice involvement.3
While this research does not establish a causal connection, it does indicate an association between veteran suicide and criminal justice system involvement, from arrest to pretrial detention, prosecution, and imprisonment. This brief examines that association by exploring current research on the overlapping risk factors for veteran suicide and justice system involvement, as well as some unique effects that criminal justice contact may have on veteran suicide. In doing so, it points to avenues for future scholarship and ideas for policymakers to consider, including utilizing the criminal justice system as a critical intercept for veteran suicide prevention.
Key Takeaways
- Veterans have elevated rates of suicide and justice system involvement. The suicide rate for veterans is roughly 1.5 times higher than that for the general population, and approximately 31% of veterans have been arrested at some point in their lives, compared to 18% of non-veterans.
- Research suggests that justice-involved veterans are almost twice as likely to attempt suicide as veterans who do not encounter the criminal justice system.
- It is unclear whether this increased suicide risk is caused by justice system involvement or stems from factors that are relatively widespread among justice-involved veterans and veterans who attempt suicide. For example, justice-involved veterans and veterans who attempt suicide are both more likely to have post-traumatic stress disorder (PTSD).
- Contact with the criminal justice system creates unique problems for veterans, including disruptions in health care that often occur during transitions between the community and incarceration. These problems may cause an increased risk of suicide, but further research is needed to confirm the unique, and potentially causal, effect of criminal justice contact on suicide among veterans.
- While there are programs that identify justice-involved veterans and connect them to care that might reduce suicide risk, more evaluation of these efforts is needed, and important gaps remain. For example, contact with the criminal justice system is often not considered a factor in current efforts to identify veterans at risk of suicide, despite evidence that justice-involved veterans are more likely to attempt suicide.
- Contact with the criminal justice system could be utilized as an intervention point for suicide prevention efforts. Additional research is needed to determine how criminal justice entities could help reduce the risk of suicidal thoughts and behaviors among veterans.
Overlapping Risk Factors: Suicide and Justice Involvement Among Veterans
With no identified research demonstrating that contact with the justice system has a causal effect on suicide among veterans, examining overlapping factors prevalent among justice-involved veterans and veterans who die by suicide provides an important avenue for exploration for two reasons. First, these overlapping factors may help to explain the association between justice system involvement and suicide among veterans found in previous research. Second, better understanding of these factors may help researchers identify mechanisms to combat veteran suicide and justice system involvement simultaneously.
Traumatic Brain Injury
Veterans with a history of justice involvement often experience a range of chronic health conditions that may increase the risk of suicide. One such factor is traumatic brain injury (TBI), which can affect veterans’ ability to cope with distress or navigate complex situations. A study of more than 1.6 million veterans published in 2023 found that 15% of justice-involved veterans had a diagnosis of TBI relative to about 4% of veterans with no noted criminal justice history.4 In addition, a 2019 study found that veterans with a history of TBI are more than twice as likely to die by suicide relative to those without a TBI diagnosis.5
Trauma Exposure and Military Sexual Trauma
Justice-involved veterans also have elevated levels of trauma exposure. These traumas include those that occur before military service (e.g. childhood abuse), during service (e.g., combat exposure), and during incarceration (e.g., physical assault).6 One large-scale study of a primarily male incarcerated veteran sample found that 87% reported a history of trauma.7 In addition to combat exposure, military sexual trauma (MST) is an unfortunately common and often distressing experience for military personnel. Nearly 52% of justice-involved female veterans reported a history of MST, compared to 28% of women veterans without criminal justice involvement, 5% of male justice-involved veterans, and 2% of male veterans with no criminal justice history.8 This experience can also exacerbate the risk of suicide, with a 2016 study finding that MST survivors were 1.7 to 2.3 times more likely to die by suicide than those with no history of MST.9
Mental Health Conditions
Several mental health diagnoses are more common among justice-involved veterans, including severe mental illness (e.g., bipolar disorder and schizophrenia), depression, substance use disorders, and post-traumatic stress disorder (PTSD), compared to veterans with no history of justice involvement.10 For instance, a study of 15,000 veterans published in 2021 found that, in addition to more severe symptoms of PTSD and depression, justice-involved veterans were 28% to 44% more likely to report alcohol misuse and 191% to 328% more likely to report opioid misuse compared to veterans with no history of justice involvement.11 Research also suggests that the odds of justice system involvement are 61% greater among veterans with PTSD than veterans without PTSD.12 Notably, these same mental health conditions, including PTSD, depression, and substance use disorders, are among the most documented risk factors for suicide among veterans, with research showing that veterans with PTSD were four times more likely to experience suicidal ideation compared to veterans without PTSD.13
| Table 1. Overlapping Risk Factors | ||
| Risk Factor | Prevalence/Impact on Justice Involvement | Prevalence/Impact on Suicide |
| Traumatic brain injury (TBI) | 15% of justice-involved veterans experienced TBI compared to 4% with no justice system involvement | Veterans with TBI were twice as likely to die by suicide compared to veterans without TBI |
| Military sexual trauma (MST) | 52% of female justice-involved veterans and 5% of male justice-involved veterans experienced MST compared to 28% and 2% of female and male veterans without justice system involvement, respectively | MST survivors were 1.7-2.3 times more likely to die by suicide than veterans without MST |
| Post-traumatic stress disorder (PTSD) | Odds of justice system involvement are 61% higher for veterans with PTSD compared to non-PTSD veterans | Veterans with PTSD are four times more likely to experience suicidal ideation than veterans without PTSD |
| Homelessness | 62% of justice-involved veterans accessed VA homeless programs from 2005-2018; this is lower than the approximately 0.2-1.7% of veterans accessing homeless services in the general population | Veterans with a history of homelessness are 7.8 times more likely to attempt suicide than veterans with no history of homelessness |
| Bad paper discharge | 18% of incarcerated veterans received a bad paper discharge compared to 6% of all veterans | Veterans with bad paper discharges are three times more likely to be at risk of suicide than veterans with honorable discharges |
Homelessness
In addition to complex medical and mental health conditions, justice-involved veterans and those who die by suicide often experience concurrent stressors, including homelessness. For example, the same 2023 study of 1.6 million veterans referenced earlier estimated that 62% of justice-involved veterans had a history VA homeless services from 2005-2018.14 By contrast, other large-scale examinations have found that only 0.2-1.7% of veterans in the general population had a history of accessing VA homeless services.15 Research has documented a connection with suicide as well, with data from 2019 showing that veterans with a history of homelessness were 7.8 times more likely to attempt suicide than veterans who had never experienced homelessness.16 Ultimately, the intersection of housing instability and criminal justice involvement can ensnare veterans in difficult cycles, increasing the risk of suicide. For example, veterans may engage in criminogenic behavior to survive (e.g., stealing) or to escape physical or emotional pain (e.g., through substance use) which often exacerbates underlying drivers of housing instability, such as mental health symptoms. These behaviors, in turn, can further reinforce feelings of hopelessness and a desire to die; veterans with a history of both homelessness and justice involvement were 1.9 to 2.4 times more likely to attempt suicide in their lifetime relative to veterans with only a record of justice involvement.17
Discharge Type
Finally, the type of discharge a servicemember receives also appears to be a risk factor for both justice involvement and suicide. While most veterans receive an honorable discharge, some receive a “bad paper” discharge, making them generally ineligible for comprehensive benefits following their service. While they account for just 6% of all discharges, veterans with a bad paper discharge comprise 18% of all incarcerated veterans.18 Despite initiatives to expand access to care for these veterans, including suicide prevention care, research suggests that veterans with bad paper discharges are nearly three times more likely to be at risk of suicide.19
Overall, research indicates that several factors correlate with suicide and justice involvement among veterans. While potentially explaining the connection between encountering the justice system and suicide, this research does not demonstrate any causal impact of justice involvement on suicide risk. The following section considers the possibility of this causal role by examining the specific influence of justice system involvement on suicide.
The Unique Effect of Justice System Involvement on Suicide
Several factors specifically associated with justice system involvement among veterans suggest that it may intensify suicide risk. For instance, theory-driven research indicates that justice-involved veterans often report feeling stigmatized and pushed away by society, including, at times, by their friends, family, and other veterans.20 It is unclear, however, if these interactions alone drive suicide risk or if they exacerbate certain conditions the veteran may be experiencing (e.g., depression, PTSD, TBI).
In addition, research on non-veterans suggests that there are critical periods of risk for suicide among those interacting with the criminal justice system. Notably, nearly 10% of all suicides in the general population occur within the context of a criminal justice system stressor, including 30% of all deaths in local jails and 8% in prisons.21 The days and weeks immediately following a person’s exit from prison is also a period of significant risk; one review noted that the risk for suicide among recently released justice-involved individuals was 6.8 times greater than it is for the general population.22 While no national analysis has been replicated with justice-involved veterans, a 2018 study of more than 15,000 people did find that the risk of suicide attempt was roughly six times greater among older veterans released from prison than among older veterans who had never been incarcerated.23
Conclusion: Next Steps
The Department of Veterans Affairs (VA) and several community-based organizations offer programs to meet the health and social service needs of justice-involved veterans. For example, the Health Care for Re-entry Veterans (HCRV) program attempts to connect justice-involved veterans with VA and community services as they transition from incarceration into the community, facilitating access, to and engagement in, care. A recent analysis found that 56% of veterans seen by the HCRV program engaged with VA health care the following year, and that 93% of those diagnosed with a mental health condition entered treatment for that condition within a year.24 While this program illustrates the success of current efforts, greater efforts to enhance suicide prevention among this population of veterans remain necessary.
One challenge is that many healthcare providers and researchers working with veterans may be unaware of how criminal justice involvement affects veterans’ functioning (e.g., housing, employment, and mental health). This lack of awareness can result in a failure to consider prior criminal justice history when interacting with veterans and a lack of knowledge about how that involvement could create an increased risk for several bad outcomes, including suicide. For example, some suicide prevention predictive models do not include justice involvement when identifying veterans at a heightened risk of suicide, despite the evidence that justice-involved veterans are at a potentially increased risk of suicide. Further analysis of the link between suicide and justice system involvement by scholars, along with increased screening for criminal justice history and awareness of programs for justice-involved veterans among healthcare providers, represent pragmatic first steps.
Along with greater awareness of the potential impact of justice involvement on suicide risk, continuity of care is critical for veterans entering and exiting jails and prisons. As incarcerated veterans are largely not eligible to receive VA healthcare in jails and prisons,25 changes in diagnosis, treatment planning, and medication can occur during the transition between incarceration and the community. In addition, it can be difficult for VA and community-based service providers to obtain correctional health records after release. Variation in available treatment, including medication, between correctional facilities and the VA or other community-based service providers is another problem that can result in treatment disruptions and increased mental health symptoms associated with suicidal thoughts and behavior. As the risk for suicide is substantially elevated during reentry, enhancing stability, housing support, and mental health treatment for veterans exiting correctional settings may be critical to saving veteran lives. Initiatives and programs that facilitate continuity of care for this population are therefore paramount.
Finally, as suicide risk is higher among justice-involved veterans than veterans with no history of justice involvement, additional analyses are needed to identify the impact of justice involvement on suicidal thoughts and behavior among this group and explore whether and how the justice system may be activated as a critical intervention point for suicide prevention.
Endnotes
1 The estimate of 17 veteran suicides per day is drawn from: Department of Veterans Affairs. (2022). National veteran suicide prevention annual report. https://www.mentalhealth.va.gov/docs/data-sheets/2022/2022-National-Veteran-Suicide-Prevention-Annual-Report-FINAL-508.pdf; The estimate of 24 veteran suicides per day is drawn from: America’s Warrior Partnership. (n.d.). Operation deep dive: Summary of interim report. https://www.americaswarriorpartnership.org/deep-dive
2 Snowden, D. L., Oh, S., Salas-Wright, C. P., Vaughn, M. G., & King, E. (2017). Military service and crime: New evidence. Social Psychiatry & Psychiatric Epidemiology, 52(5), 605-615. http://doi.org/10.1007/s00127-017-1342-8
3 Holliday, R., Forster, J. E., Desai, A., Miller, C., Monteith, L. L., Schneiderman, A. I., & Hoffmire, C. A. (2021). Association of lifetime homelessness and justice involvement with psychiatric symptoms, suicidal ideation, and suicide attempt among post-9/11 veterans. Journal of Psychiatric Research, 144, 455–461. https://doi.org/10.1016/j.jpsychires.2021.11.007
4 Holliday, R., Smith, A. A., Kinney, A. R., Forster, J. E., Bahraini, N., Monteith, L. L., & Brenner, L. A. (2023). Research letter: Traumatic brain injury among veterans accessing VA justice-related services. The Journal of Head Trauma Rehabilitation, 38(2), 184. https://doi.org/10.1097/HTR.0000000000000822
5 Hostetter, T. A., Hoffmire, C. A., Forster, J. E., Adams, R. S., Stearns-Yoder, K. A., & Brenner, L. A. (2019). Suicide and traumatic brain injury among individuals seeking Veterans Health Administration services between fiscal years 2006 and 2015. The Journal of Head Trauma Rehabilitation, 34(5), E1. https://doi.org/10.1097/HTR.0000000000000489
6 Blodgett, J. C., Avoundjian, T., Finlay, A. K., Rosenthal, J., Asch, S. M., Maisel, N. C., & Midboe, A. M. (2015). Prevalence of mental health disorders among justice-involved veterans. Epidemiologic Reviews, 37(1), 163–176. https://doi.org/10.1093/epirev/mxu003
7 Saxon, A. J., Davis, T. M., Sloan, K. L., McKnight, K. M., McFall, M. E., & Kivlahan, D. R. (2001). Trauma, symptoms of posttraumatic stress disorder, and associated problems among incarcerated veterans. Psychiatric Services, 52(7), 959–964. https://doi.org/10.1176/appi.ps.52.7.959
8 Holliday, R., Holder, N., Smith, A. A., Desai, A., Hoffmire, C. A., … Monteith, L. L. (2023). Military sexual trauma among veterans using and not using VA justice-related programming: A national examination. Journal of Psychiatric Research, 164, 46-50. https://doi.org/10.1016/j.jpsychires.2023.05.067
9 Kimerling, R., Makin-Byrd, K., Louzon, S., Ignacio, R. V., & McCarthy, J. F. (2016). Military sexual trauma and suicide mortality. American Journal of Preventive Medicine, 50(6), 684–691. https://doi.org/10.1016/j.amepre.2015.10.019
10 Blodgett, J. C., Avoundjian, T., Finlay, A. K., Rosenthal, J., Asch, S. M., Maisel, N. C., & Midboe, A. M. (2015). Prevalence of mental health disorders among justice-involved veterans. Epidemiologic Reviews, 37(1), 163–176. https://doi.org/10.1093/epirev/mxu003
11 Holliday, R., Forster, J. E., Desai, A., Miller, C., Monteith, L. L., Schneiderman, A. I., & Hoffmire, C. A. (2021). Association of lifetime homelessness and justice involvement with psychiatric symptoms, suicidal ideation, and suicide attempt among post-9/11 veterans. Journal of Psychiatric Research, 144, 455–461. https://doi.org/10.1016/j.jpsychires.2021.11.007
12 Taylor, E. N., Timko, C., Nash, A., Owens, M. D., Harris, A. H. S., & Finlay, A. K. (2020). Posttraumatic stress disorder and justice involvement among military veterans: A systematic review and meta-analysis. Journal of Traumatic Stress, 33(5), 804–812. https://doi.org/10.1002/jts.22526
13 Jakupcak, M., Cook, J., Imel, Z., Fontana, A., Rosenheck, R., & McFall, M. (2009). Posttraumatic stress disorder as a risk factor for suicidal ideation in Iraq and Afghanistan War veterans. Journal of Traumatic Stress, 22(4), 303–306. https://doi.org/10.1002/jts.20423
14 Holliday, R., Kinney, A. R., Smith, A. A., Forster, J. E., Stimmel, M. A., Clark, S. C., Liu, S., Monteith, L. L., & Brenner, L. A. (2023). Suicide risk among veterans using VHA justice-involved services: A latent class analysis. BMC Psychiatry, 23(1), 235. https://doi.org/10.1186/s12888-023-04725-9
15 The 0.2% estimate is derived from: De Sousa, T., Andrichik, Al., Cuellar, M., Marson, J., Prestera, E., Rush, K., & Abt Associates. (2022). The 2022 annual homelessness assessment report (AHAR) to congress. The U.S. Department of Housing and Urban Development. https://www.huduser.gov/portal/sites/default/files/pdf/2022-ahar-part-1.pdf; The 1.7% estimate is derived from: Blackstock, O. J., Haskell, S. G., Brandt, C. A., & Desai, R. A. (2012). Gender and the use of Veterans Health Administration homeless services programs among Iraq/Afghanistan veterans. Medical Care, 50(4), 347-352. https://doi.org/10.1097/MLR.0b013e318245a738
16 Tsai, J., & Cao, X. (2019). Association between suicide attempts and homelessness in a population-based sample of US veterans and non-veterans. Journal of Epidemiology & Community Health, 73(4), 346–352. https://doi.org/10.1136/jech-2018-211065
17 Holliday, R., Forster, J. E., Desai, A., Miller, C., Monteith, L. L., Schneiderman, A. I., & Hoffmire, C. A. (2021). Association of lifetime homelessness and justice involvement with psychiatric symptoms, suicidal ideation, and suicide attempt among post-9/11 veterans. Journal of Psychiatric Research, 144, 455–461. https://doi.org/10.1016/j.jpsychires.2021.11.007
18 Bronson, J., Carson, A., Noonan, M., & Berzofsky, M. (2015). Veterans in prison and jail, 2011-12 (NCJ 249144). Bureau of Justice Statistics. https://www.bjs.gov/content/pub/pdf/vpj1112.pdf
19 Barr, N., Kintzle, S., Alday, E., & Castro, C. (2019). How does discharge status impact suicide risk in military veterans? Social Work in Mental Health, 17(1), 48–58. https://doi.org/10.1080/15332985.2018.1503214
20 Desai, A., Holliday, R., Borges, L. M., Blue-Howells, J., Clark, S., Stimmel, M., & Wortzel, H. S. (2021). Facilitating successful reentry among justice-involved veterans: The role of veteran and offender identity. Journal of Psychiatric Practice, 27(1), 52. https://doi.org/10.1097/PRA.0000000000000520
21 Centers for Disease Control and Prevention (2019). National Violent Death Reporting System (NVDRS) Query Page.https://www.cdc.gov/violenceprevention/datasources/nvdrs/index.html; Data on suicides in jails and prisons are drawn from: Office of Justice Programs. (2021, Oct 7). Press release. https://www.ojp.gov/sites/g/files/xyckuh241/files/archives/pressreleases/2021/nearly-fifth-state-and-federal-prisons-had-least-one-suicide-2019#nearly-a-fifth-of-state-and-federal-prisons-and-a-tenth-of-local
22 Jones, D., & Maynard, A. (2013). Suicide in recently released prisoners: A systematic review. Mental Health Practice, 17(3), 20-27. https://doi.org/10.7748/mhp2013.11.17.3.20.e846
23 Barry, L. C., Steffens, D. C., Covinsky, K. E., Conwell, Y., Li, Y., & Byers, A. L. (2018). Increased risk of suicide attempts and unintended death among those transitioning from prison to community in later life. The American Journal of Geriatric Psychiatry, 26(11), 1165–1174. https://doi.org/10.1016/j.jagp.2018.07.004
24 Finlay, A. K., Stimmel, M., Blue-Howells, J., Rosenthal, J., McGuire, J., Binswanger, I., Smelson, D., Harris, A. H. S., Frayne, S. M., Bowe, T., & Timko, C. (2017). Use of Veterans Health Administration mental health and substance use disorder treatment after exiting prison: The health care for reentry veterans program. Administration and Policy in Mental Health, 44(2), 177–187. https://doi.org/10.1007/s10488-015-0708-z
25 The regulation preventing VA care in correctional settings can be found in Medical benefits package, 38 CFR § 17.38(c)(5): https://www.law.cornell.edu/cfr/text/38/17.38, and was motivated by the VA’s desire to avoid duplication of care, given that prisons and jails are obligated to provide health care.
Ryan Holliday, Ph.D., is a Clinical Research Psychologist and Assistant Professor at the University of Colorado Anschutz Medical Campus.
Suggested citation: Holliday, R. (2023). Suicide among justice-involved veterans: Understanding risk and meeting needs. Council on Criminal Justice. https://counciloncj.org/suicide-among-justice-involved-veterans-understanding-risk-and-meeting-needs/
