A massive study of post-9/11 service members show that troops at the highest risk for suicide are those who serve less than a full enlistment and, in particular, those who leave after less than a year — personnel whose discharges may be related to mental health issues but normally are ineligible for Veterans Affairs Department health care.
The study, conducted by the Defense Department's National Center for Telehealth and Technology, or T2, found that among the 3.9 million troops who served from 2001 to 2007, the suicide rate for those in the military less than 12 months was 2.5 times that of troops who completed enlistments or obligations.
While the rate among personnel who stayed on active duty was 15 suicides per every 100,000 troops, the average rate for those with less than four years of service was 44 per 100,000. The rate for those who served less than a year was 48 per 100,000.
The difference is significant, said Phillip Carter, a senior fellow at the Center for a New American Security, because many of these service members received discharges that make them ineligible for veterans' health care benefits.
"We have a high-risk population that we actively deny care and services to," Carter said.
The study, which appeared April 1 online in JAMA Psychiatry, found that of 3,945,099 personnel in the study, 31,962 people died, with 5,041 documented suicides.
Of those, 1,080 had served less than four years.
Among troops who served fewer than a career of 20 years and died by suicide, 662 received honorable discharges; 403 received discharges that were "not honorable," and another 380 received "uncharacterized discharges," meaning they left service with less than 180 days remaining on their enlistments but did not have disciplinary problems.
Another 312 suicides were among those whose discharge status was "unknown" or not applicable, according to the study.
For those who received "bad paper" — other-than-honorable, bad-conduct or dishonorable discharges — accessing VA health care is challenging.
Under VA policy, veterans who served less than two years qualify for benefits and care for service-connected conditions, as do those who received honorable or general discharges are eligible.
But for those who served other than honorably or left the military with certain bad-conduct discharges, eligibility is less clear.
By law, troops who receive a bad-conduct or dishonorable discharge following a general court-martial conviction are ineligible. For most others, the VA can make a "character of service determination" to figure out whether a veteran may be eligible.
Service members can apply to the VA for such a review, but fewer than 10 percent do, according to Bradford Adams, staff attorney at the San Francisco-based veterans advocacy group Swords to Plowshares.
Of those requests, the VA has rejected 65 percent since Sept. 11, 2011, Adams said.
"The ball is in the VA's court. They have the authority and the discretion to decide who is going to be cared for and who isn't. A lot of people outside and even inside the VA think the department's hands are tied … and that's not the case," Adams said.
From Oct. 1, 1999, to Sept. 30, 2013, the services dismissed more than 145,000 troops with less than honorable discharges, including 19,054 bad-conduct discharges, 125,204 other-than-honorable discharges and 1,467 dishonorable discharges, according to Pentagon data.
It is not known how many of these discharges are linked to mental health conditions tied to military service, including post-traumatic stress disorder or combat-related depression.
But a 2010 study by the Naval Health Research Center found that combat-deployed Marines with a diagnosis of PTSD were 11 times more likely to engage in serious misconduct than combat Marines without a psychiatric diagnosis.
With the elevated likelihood of having a service-related mental health condition and being unable to access VA care, these former troops often turn to community nonprofits for help, use emergency room services at higher rates, and are more likely to end up running afoul of the law, becoming homeless, or, as noted by the T2 study, dying, Carter said.
"This has tremendous social costs," Carter said.
The coordinator can make referrals to VA care for those who qualify and can locate resources for those who don't, such as community programs and free counseling services from organizations like Give An Hour.
They also may be able to receive some counseling services at VA Vet Centers.
"We are really committed to serving all veterans and all who have served in the military," said Caitlin Thompson, VA suicide prevention deputy director.
Studies have indicated that veterans who are able to access VA care have lower rates of suicide. In a report released in 2014 by VA, the overall suicide rate for veterans who receive health services at VA has slowly decreased in the past several years, while the rate for those not enrolled has increased.
"VA care works," Adams said. "If these veterans are not in the VA system of care, they are in the emergency rooms, they are in lockup."
Defense Department officials said they are reviewing the study closely as part of an ongoing program review of suicide prevention initiatives.
"Suicide is complex, and the department conducts research efforts like this one to better inform and strengthen our prevention efforts," said DoD spokeswoman Laura Seal.
An earlier version of a veterans suicide prevention bill signed into law in February would have required DoD to review discharges or separations of former service members but the provision did not make it into the final version of the bill.
Former Defense Secretary Chuck Hagel last September ordered the Pentagon to allow former service members to petition for changes to their discharges if they had unrecognized PTSD at the time of their discharge.
The order, geared mainly to Vietnam veterans who received less-than-honorable discharges, actually allows any former service member with PTSD to file upgrade requests.
Study author Mark Reger, T2 deputy director, said his research suggests that suicide prevention programs targeted at those who leave military service early could curb suicides.
"Additional research is needed to clarify what the circumstances are surrounding early discharges and how these factors may be related to suicide," Reger and his fellow researchers wrote.
Adams, whose organization works to help veterans and former troops without veteran status, said he hopes the study "starts a dialogue" about these service members.
The former Army civil affairs officer added that while the services need to be able to discharge personnel for misconduct to ensure a ready force, the VA has the power to decide whether troubled former troops get care.
"What I remember from deployment is, if people on your team are struggling, it didn't matter why they were struggling. You supported them. ... We still need to care for these people," he said.
Patricia Kime is a senior writer covering military and veterans health care, medicine and personnel issues.