Issue Brief: Veteran Suicide in New York State January 2020 Introduction Suicide is the tenth leading cause of death in the United States.1 It affects all demographic groups, and our nation’s veterans are particularly at risk. While making up 7.9% of the U.S. adult population, veterans accounted for 13.5% of all deaths by suicide among the adult population in 2017. 2 The same year, a total of 6,139 veterans died by suicide across the country.3 At the national level, suicide is a worsening problem for both veterans and civilians. The suicide rate of the overall U.S. population increased from 14.7 per 100,000 people in 2005 to 18.1 in 2017, an increase of 23.1%. 4 The veteran suicide rate increased by 29.7% over the same time period (from 23.9 per 100,000 to 31.0).5 The negative impacts of suicide extend beyond the lost years of life for the people who died. There is a large emotional toll on surviving family members and friends, who face an elevated risk of developing major depression, post-traumatic stress disorder, and suicidal ideation and behavior.6,7 Work, neighborhood, and faith communities also feel the impact of a suicide; on average, a single suicide affects 135 people.8 Exacerbating the emotional consequences of a suicide, many families also face economic hardship after losing current and future income. These economic tolls also extend to the larger economy and medical system.9 There is no single cause for suicide; it is associated with an array of individual and environmental risk factors. Mental health disorders like depression and post-traumatic stress disorder, which disproportionately impact veterans, increase risk of suicide. 10,11,12 Substance use disorders increase suicide risk as well.13,14 Many of the environmental risk factors for suicide—including economic instability, unemployment, unstable housing, and access to firearms—are more prevalent among veterans.15,16,17,18 While there is no universal prevention strategy, research shows that suicide is a preventable public health problem.19 In 2017, New York was home to approximately 700,000 veterans, the sixth largest population of veterans in the country. 20 Although New York has one of the lowest rates of veteran suicide in the country, 136 veterans in the State died by suicide in 2017. This issue brief presents how New York’s veteran suicide rate compares to the rest of the country, examines how veteran suicide rates are changing in New York over time, and explores how State policies might influence veteran suicide rates. Issue Brief: Veteran Suicide in New York State 2 Veteran Suicide in New York State VETERAN SUICIDE RATES ARE LOWER IN NEW YORK THAN THE REST OF THE NATION In the last 10 years, New York has consistently ranked among the 10 states with the lowest veteran suicide rates. 21 New York had the second-lowest veteran suicide rate nationally in 2017 (17.5 per 100,000, compared with the national veteran suicide rate of 31.0 per 100,000) (see Exhibit 1). 22 Hawaii was the only state with a lower rate (16.8 per 100,000). 23 The state with the highest rate was Wyoming (62.8 per 100,000). E X H I B I T 1. Veteran Suicide Rates are Lower in New York than the Rest of the Nation 31.3 42.0 57.0 27.1 25.6 42.1 28.8 33.8 . 49.3 41.2 62.8 28.9 17.5 . 36.8 32.0 30.7 20.3 18.5 31.3 26.7 28.0 32.0 19.7 29.2 53.2 21.4 41.9 36.9 41.5 19.9 35.9 35.1 22.2 35.8 22.8 28.1 32.6 29.1 43.5 44.9 43.0 29.9 29.2 33.3 27.9 31.3 32.5 39.1 33.6 16.8 * Veteran suicide rate (per 100,000) 10 20 30 40 50 60 2017 Veteran Suicide Rate N.Y. 17.5 per 100,000 U.S. 31 per 100,000 Data Source: U.S. Department of Veterans Affairs. “2019 National Veteran Suicide Prevention Annual Report: State Data Appendix.” https://www. mentalhealth.va.gov/docs/data-sheets/2017/2005-2017_State_Data_Appendix.xlsx. 2017 data shown. *Rates calculated from suicide counts lower than 20 are considered unreliable. Issue Brief: Veteran Suicide in New York State 3 Veteran Suicide in New York State (continued) Veteran suicide rates are affected by the demographic makeup of the veteran population. New York’s veteran population is older than the national average. In 2017, about 54.4% of New York’s veterans were ages 65 and over, compared to 47.1% of veterans nationwide. 24 Older veterans have the lowest rates of suicide both in New York and across the country. 25 Therefore, New York’s older veteran population is likely a contributor to New York’s lower veteran suicide rate. However, even after adjusting for age, New York’s veteran suicide rate is statistically significantly lower than the national average. 26 NEW YORK VETERANS ARE DYING BY SUICIDE AT HIGHER RATES THAN THE OVERALL NEW YORK POPULATION New York State has a lower rate of veteran suicide than most other states. However, veterans in New York die by suicide at a much higher rate than the overall State population (see Exhibit 2). The disparity between veteran and overall population suicide rates is consistent between New York and the nation as a whole. E X H I B I T 2 . Veterans Die by Suicide at Higher Rates than the Overall Population 35 Veterans Overall Population 31.0 30 Veterans die by 25 suicide at 1.71 times the rate of Suicide Rate (per 100,000) overall U.S. 20 population 17.5 18.1 15 Veterans die by suicide at 1.67 10.5 10 times the rate of overall New York population 5 0 New York U.S. Data Source: U.S. Department of Veterans Affairs. “2019 National Veteran Suicide Prevention Annual Report: State Data Appendix.” https://www. mentalhealth.va.gov/docs/data-sheets/2017/2005-2017_State_Data_Appendix.xlsx. 2017 data shown. Issue Brief: Veteran Suicide in New York State 4 Veteran Suicide in New York State (continued) RATES OF VETERAN SUICIDE VARY DRAMATICALLY BY COUNTY There is substantial variation in veteran suicide rates between counties in New York (see Exhibit 3). From 2015 to 2017, Livingston, Columbia, and Wyoming counties experienced the highest rates of veteran suicide (82.0, 81.1, and 70.2 per 100,000, respectively). The largest number of veterans died by suicide in Erie and Suffolk counties over the same time period (43 and 40 veterans, respectively). Erie and Suffolk counties also have the largest veteran population in the State. 27 E X H I B I T 3 . Veteran Suicide Rates Vary Dramatically by County 31.3 36.5 30.6 39.6 40.6 57.2 57.8 33.5 49.0 13.2 33.5 13.7 36.5 20.1 14.2 25.3 8.3 22.1 15.0 11.3 19.7 0 28.5 37.5 14.0 24.5 25.0 70.2 82.0 25.7 36.3 32.9 30.3 0 24.2 39.5 24.6 62.4 14.7 33.2 21.9 36.0 81.1 35.6 18.2 15.6 24.7 48.9 21.9 59.8 29.0 18.9 30.3 15.7 21.8 16.4 17.1 19.5 17.0 18.9 15.3 11.3 Veteran suicide rate (per 100,000) 0 10 20 30 40 50 60 70 80 90 Data Source: Numerator of rates from New York State Department of Health. New York State Health Connector. “Suicide and Self Harm Dashboard.” https://nyshc.health.ny.gov/web/nyapd/suicides-in-new-york. Denominator of rates from U.S. Department of Veterans Affairs. National Center for Veterans Analysis and Statistics. “Table 9L: VetPop2016 County-Level Veteran Population by State, Age Group, Gender, 2015–2045.” https://www. va.gov/vetdata/veteran_population.asp. Rates are calculated over the three-year period: 2015–2017. Note: Data on number of suicides are not shown in Exhibit 3. Issue Brief: Veteran Suicide in New York State 5 Veteran Suicide in New York State (continued) NEW YORK VETERAN SUICIDE RATES ARE DECLINING From 2005 to 2017, national veteran suicide rates generally increased. Over the same period, New York’s veteran suicide rate experienced growth, and then a subsequent decline (see Exhibit 4). In both New York and the nation, veteran suicide rates generally increased from 2005 to 2011. The national rate increased 15.9% (from 23.9 per 100,000 to 27.7), while New York’s rate increased 67.2% (from 13.7 per 100,000 to 22.9). Suicide rates for the overall population also generally increased over this time period in both New York and the nation. Trends in the New York and national veteran suicide rates diverged after 2011. From 2011 to 2017, the national rate increased an additional 11.9% (from 27.7 per 100,000 to 31.0), while New York’s rate decreased 23.6% (from 22.9 per 100,000 to 17.5). Suicide rates for the overall population continued to increase nationally over this period, but decreased marginally in New York. E X H I B I T 4 . Since 2011, New York's Veteran Suicide Rate Generally Declined, While the Nation's Continued to Rise 35 31.0 30.3 30 28.6 27.7 27.3 Suicide Rate (per 100,000) 25.3 25 22.9 23.9 20.2 20 18.7 18.2 18.1 15.6 17.5 17.3 14.7 16.5 15 16.2 15.5 14.9 13.7 10.6 10.7 10.5 10.4 10 9.2 9.0 U.S. Veterans U.S. Overall 8.2 New York Veterans New York Overall 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Data Source: U.S. Department of Veterans Affairs. “2019 National Veteran Suicide Prevention Annual Report: State Data Appendix.” https://www. mentalhealth.va.gov/docs/data-sheets/2017/2005-2017_State_Data_Appendix.xlsx. Issue Brief: Veteran Suicide in New York State 6 Veteran Suicide in New York State (continued) SUICIDE RATES ARE RISING AMONG YOUNG VETERANS Although veteran suicide rates in New York are declining overall, this trend is not true for all veteran subgroups. One particularly concerning trend is an increasing rate of suicide among the youngest veterans in New York. Between 2005 and 2017, the suicide rate for New York veterans ages 18 to 34 years old more than doubled (from 12.8 per 100,000 to 27.7) (see Exhibit 5). This group had the highest veteran suicide rates in the State in 2017; all other age groups experienced an increase and subsequent decrease in suicide rates. Across the country, young veterans also have the highest rates of suicide of all veteran age groups as of 2017, and these rates have been increasing. 28 E X H I B I T 5 . The Suicide Rate for Young Veterans in New York State Grew More than Any Other Age Group Between 2005 and 2017 35 33.5 2005 2011 2017 30 27.7 Suicide Rate (per 100,000) 24.3 24.1 25 19.3 19.0 20 15.5 15.3 15 13.6 13.1 13.1 12.8 10 5 0 18–34 35–54 55–74 75+ Veteran Age Group Data Source: U.S. Department of Veterans Affairs. “2019 National Veteran Suicide Prevention Annual Report: State Data Appendix.” https://www. mentalhealth.va.gov/docs/data-sheets/2017/2005-2017_State_Data_Appendix.xlsx. Although suicide is a devastating event at any age, suicide among younger veterans results in the greatest number of years of life lost. The impact of young veteran suicide is likely to grow as additional military personnel from this age group return from post-9/11 deployment. Issue Brief: Veteran Suicide in New York State 7 Veteran Suicide in New York State (continued) GUN CONTROL EFFORTS MAY HAVE CONTRIBUTED TO LOWER SUICIDE RATES IN NEW YORK To prevent veteran suicide, it is imperative to understand the factors that drive it. No single factor causes or prevents suicide. Research demonstrates that a complex mix of individual and environmental risk factors contribute to suicide rates. 29,30 These include, but are not limited to, demographics, economic stability, mental health, substance use, and firearm access. More research is needed to determine how these factors may have contributed to the recent declining trend in veteran suicide rates in New York. Below we discuss one potential factor in relation to firearms. 85% of those who use firearms as a method of suicide die, compared with 5% of those who used other methods of suicide. Firearms are the single most common method of suicide among veterans. They are also the most lethal: 85% of those who use firearms as a method of suicide die, compared with 5% of those who used other methods of suicide.31 Veterans are more likely than the overall population to use firearms as a method of suicide. In 2017, about 69.4% of veteran suicides nationwide were by firearm, compared to about half of suicides among the overall population.32 These percentages are much lower in New York; fewer than half of veteran suicides in 2017 were by firearm, compared with about one-quarter of suicides among the overall population (see Exhibit 6).33 E X H I B I T 6 . In New York State in 2017, Firearms Were Used in: 45.6% of veteran suicides 25.7% of suicides among the overall population Data Source: U.S. Department of Veterans Affairs. 2017 Veteran Suicide Data Sheet. “New York.” https://www.mentalhealth.va.gov/docs/data-sheets/2017/New_York_Veteran_Suicide_Data_Sheet_2017.pdf Strong gun control legislation has been found to be correlated with lower suicide rates. For example, one study found that the five states with the lowest gun ownership rates also had the Issue Brief: Veteran Suicide in New York State 8 Veteran Suicide in New York State (continued) lowest rates of firearm suicide among white men.34 These five states, which include New York, also are consistently ranked as the states with the strongest gun control laws in the country.35 It is not certain whether gun control legislation impacts veteran suicide rates more than the suicide rates of the overall population. However, because more veterans nationwide own a gun than civilians (44.9% versus 20.0%), it is plausible that such legislation may have a greater impact on veterans.36 New York significantly strengthened its gun control legislation in 2013 through the passage of the Secure Ammunition and Firearms Enforcement (SAFE) Act.37 This legislation may have since contributed to a decline in the State’s veteran suicide rates. In recent years, State data show that both the veteran and overall population have generally become less likely to use a firearm as a method of suicide (see Exhibit 7). E X H I B I T 7 . The Share of Suicides that Involve a Firearm is Decreasing Over Time in New York 70% 64.3 Proportion of Suicides that Inolved Firearm 60% 57.8 57.7 52.8 55.4 51.1 50.5 50% 51.6 50.2 46.7 45.6 47.5 46.5 40% 38.7 31.8 29.8 30.4 30% 31.3 30.4 27.7 30.0 30.3 25.5 29.5 25.7 28.3 20% Veterans Overall Population 10% 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Data Source: U.S. Department of Veterans Affairs. “2019 National Veteran Suicide Prevention Annual Report: State Data Appendix.” https://www. mentalhealth.va.gov/docs/data-sheets/2017/2005-2017_State_Data_Appendix.xlsx. Issue Brief: Veteran Suicide in New York State 9 Conclusion New York veterans are dying by suicide at rates higher than the overall population in the State. However, New York consistently ranks among the states with the lowest rates of veteran suicide. More research is needed to better understand the reasons for lower rates in New York and the variation across counties, which may inform the direction of future interventions in both New York and the nation. New York recently enacted a package of gun control laws that may further help reduce suicide rates. These laws banned bump stocks, extended waiting periods for certain gun buyers, and authorized courts to confiscate guns from individuals deemed by family members and certain professionals to be a risk.38,39,40 It is important that New York also develop veteran-specific policies. Veterans face unique risk factors and barriers to care that require tailored prevention strategies. The Veterans Administration (VA) is helping to meet this challenge through its own suicide prevention strategy. This includes the VA’s suicide prevention clinical practice guidelines, post- deployment patient screenings, and the identification of high-risk patients through statistical modeling. 41 However, nearly 70% of New York veterans receive care outside of the VA, so it is critical that the State also expand services for veterans who receive care through community partners. 42 New York State is taking steps in this direction. On Veterans Day 2019, Governor Cuomo signed a package of bills that enhance veterans’ access to employment opportunities, increase access to paid leave, and provide assistance for discharge upgrades. 43 Governor Cuomo also recently signed legislation to direct veterans who have experienced sexual trauma toward treatment and counseling. 44 The New York State Suicide Prevention Task Force released its first report in 2019, with a special focus on veterans. 45 Most recently, in his 2020 State of the State, Governor Cuomo announced expanded efforts to prevent suicide among veterans, law enforcement, and first responders. 46 New York City Mayor de Blasio also recently announced an expansion of the City’s mental health services for veterans, including expanded peer support and mental health professional trainings. 47 New York must continue to develop veteran-specific policies to promote veteran health and reduce veteran suicides. Targeting these policies to counties with high counts or rates of veteran suicide may maximize their impact. Given the nuanced combinations of risk factors that drive suicide, there is no single prevention strategy to protect veterans’ lives. New York has proven to be a better environment for preventing veteran suicide than most. Still, the State must strive to become a safer place for its former service members. Issue Brief: Veteran Suicide in New York State 10 References 1. Centers for Disease Control and Prevention. WISQARS Leading Causes of Death Reports. 2017. https://webappa.cdc.gov/ sasweb/ncipc/leadcause.html 2. U.S. Department of Veterans Affairs. Office of Mental Health and Suicide Prevention. “2019 National Veteran Suicide Prevention Annual Report.” https://www.mentalhealth.va.gov/docs/data-sheets/2019/2019_National_Veteran_Suicide_Prevention_ Annual_Report_508.pdf 3. U.S. Department of Veterans Affairs. “2019 National Veteran Suicide Prevention Annual Report: State Data Appendix.” https:// www.mentalhealth.va.gov/docs/data-sheets/2017/2005-2017_State_Data_Appendix.xlsx 4. U.S. Department of Veterans Affairs. “2019 National Veteran Suicide Prevention Annual Report: State Data Appendix.” 5. Ibid. 6. Tal Young, Ilanit et al. “Suicide Bereavement and Complicated Grief.” Dialogues in Clinical Neuroscience vol. 14,2 (2012): 177-86. 7. Maple, Myfanwy, Julie Cerel, Rebecca Sanford, Tania Pearce, and Jack Jordan. “Is Exposure to Suicide Beyond Kin Associated with Risk for Suicidal Behavior? A Systematic Review of the Evidence.” Suicide and Life‐-Threatening Behavior 47, no. 4 (2017): 461-474. 8. Cerel, J., Brown, M.M., Maple, M., Singleton, M., van de Venne, J., Moore, M., and Flaherty, Cl. “How Many People are Exposed to Suicide? Not Six.” Suicide and Life-Threatening Behavior, 49(2) (2019): 529–534. 9. “Costs of Suicide.” Suicide Prevention Resource Center. https://www.sprc.org/about-suicide/costs 10. Ferrari, Alize J., Rosana E. Norman, Greg Freedman, Amanda J. Baxter, Jane E. Pirkis, Meredith G. Harris, Andrew Page et al. “The Burden Attributable to Mental and Substance Use Disorders as Risk Factors for Suicide: Findings from the Global Burden of Disease Study 2010.” PloS One 9, no. 4 (2014): e91936. 11. Gradus, Jaimie L. “PTSD and Death from Suicide.” PTSD Research Quarterly, 28(4). 2017. https://www.ptsd.va.gov/publications/ rq_docs/V28N4.pdf 12. Tanielian, Terri, Lisa H. Jaycox, Terry L. Schell, Grant N. Marshall, M. Audrey Burnam, Christine Eibner, Benjamin Karney, Lisa S. Meredith, Jeanne S. Ringel, and Mary E. Vaiana. “Invisible Wounds: Mental Health and Cognitive Care Needs of America’s Returning Veterans.” Santa Monica, CA: RAND Corporation, 2008. https://www.rand.org/pubs/research_briefs/RB9336.html 13. Ferrari, Norman, Freedman, Baxter, Pirkis, Harris, Page et al. “The Burden Attributable to Mental and Substance Use Disorders as Risk Factors for Suicide: Findings from the Global Burden of Disease Study 2010.” 14. U.S. Department of Veterans Affairs and U.S. Department of Defense. “VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide: Guideline Summary.” May 2019. https://www.healthquality.va.gov/guidelines/MH/ srb/VADoDSuicideRiskFullCPGFinal5088212019.pdf 15. American Public Health Association. “Suicide Prevention.” https://www.apha.org/-/media/files/pdf/topics/suicide_prevention. ashx?la=en&hash=4F53FEBF4FF35D9A73D38F4950C91C20F65C6DFB 16. Loughran, David S. “Why Is Veteran Unemployment So High?” Santa Monica, CA: RAND Corporation, 2014. https://www.rand. org/pubs/research_reports/RR284.html. 17. Tsai, Jack, and Robert A. Rosenheck. “Risk Factors for Homelessness Among US Veterans.” Epidemiologic Reviews 37, no. 1 (2015): 177-195. 18. Cleveland, Emily C., Deborah Azrael, Joseph A. Simonetti, and Matthew Miller. “Firearm Ownership Among American Veterans: Findings from the 2015 National Firearm Survey.” Injury Epidemiology 4, no. 1 (2017): 33. 19. Centers for Disease Control and Prevention. “Preventing Suicide: A Technical Package of Policy, Programs, and Practices.” 2017. https://www.cdc.gov/violenceprevention/pdf/suicideTechnicalPackage.pdf 20. U.S. Census Bureau, 2013-2017 American Community Survey 5-Year Estimates, Table S2101. http://factfinder.census.gov. 21. U.S. Department of Veterans Affairs. “2019 National Veteran Suicide Prevention Annual Report: State Data Appendix.” 22. Ibid. 23. Due to Hawaii’s low number of veteran suicides in 2017, this rate is considered unreliable. See U.S. Department of Veterans Affairs. “2019 National Veteran Suicide Prevention Annual Report: State Data Appendix.” 24. U.S. Department of Veterans Affairs. 2017 State Data Sheets. “New York.” https://www.va.gov/vetdata/docs/SpecialReports/ State_Summaries_New_York.pdf Issue Brief: Veteran Suicide in New York State 11 References (continued) 25. U.S. Department of Veterans Affairs. “2019 National Veteran Suicide Prevention Annual Report: State Data Appendix.” 26. U.S. Department of Veterans Affairs. 2017 Veteran Suicide Data Sheet. “New York.” 27. U.S. Department of Veterans Affairs, National Center for Veterans Analysis and Statistics, Table 9L: VetPop2016 County-Level Veteran Population by State, Age Group, Gender, 2015-2045. https://www.va.gov/vetdata/veteran_population.asp 28. U.S. Department of Veterans Affairs. Office of Mental Health and Suicide Prevention. “VA National Suicide Data Report 2005–2016.” September 2018. https://www.mentalhealth.va.gov/docs/data-sheets/OMHSP_National_Suicide_Data_ Report_2005-2016_508.pdf 29. Borges, Guilherme et al. “Twelve-Month Prevalence of and Risk Factors for Suicide Attempts in the World Health Organization World Mental Health Surveys.” The Journal of Clinical Psychiatry vol. 71,12 (2010): 1617-28. doi:10.4088/JCP.08m04967blu 30. U.S. Department of Veterans Affairs and U.S. Department of Defense. “VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide: Guideline Summary.” 31. Case fatality rates calculated using Table 1. See Miller M, Azrael D, Barber C. “Suicide Mortality in the United States: The Importance of Attending to Method in Understanding Population-Level Disparities in the Burden of suicide.” Annual Review of Public Health. 2012; 33: 393–408. 32. U.S. Department of Veterans Affairs. “2019 National Veteran Suicide Prevention Annual Report: State Data Appendix.” 33. Ibid. 34. Riddell, Corinne A., Sam Harper, Magdalena Cerda, and Jay S. Kaufman, “Comparison of Rates of Firearm and Nonfirearm Homicide and Suicide in Black and White Non-Hispanic Men, by U.S. State,” Annals of Internal Medicine 168 no. 10 (2018). 35. Giffords Law Center to Prevent Gun Violence. Annual Gun Law Scorecard. https://lawcenter.giffords.org/scorecard/ 36. Cleveland, Emily C., Deborah Azrael, Joseph A. Simonetti, and Matthew Miller. “Firearm Ownership Among American Veterans: Findings from the 2015 National Firearm Survey.” Injury Epidemiology 4, no. 1 (2017): 33. 37. S.2230. 2013 Reg. Sess. (NY 2013). 38. S02448. 2019 Reg. Sess. (NY 2019). 39. S02374. 2019 Reg. Sess. (NY 2019). 40. S02451. 2019 Reg. Sess. (NY 2019). 41. “Communities United for a Suicide Free New York. New York State Suicide Prevention Task Force Report.” April 2019. https:// omh.ny.gov/omhweb/resources/publications/suicide-prevention-task-force-report.pdf 42. U.S. Census Bureau. ACS 5-Year Estimates - Public Use Microdata Sample (2017). https://data.census.gov/mdat/?#/search?ds=A CSPUMS5Y2017&cv=MIL&rv=HINS6,HICOV&nv=ucgid&wt=PWGTP&g=0400000US36 43. New York State Office of the Governor. “Governor Cuomo Signs Package of Bills Enhancing Services and Bolstering Protections for New York Veterans.” November 11, 2019. https://www.governor.ny.gov/news/governor-cuomo-signs-package-bills- enhancing-services-and-bolstering-protections-new-york 44. S.5006-A. 2019 Reg. Sess. (NY 2019). 45. New York State Office of the Governor. “Governor Cuomo Announces Release of First Suicide Prevention Task Force Report.” April 22, 2019. https://www.governor.ny.gov/news/governor-cuomo-announces-release-first-suicide-prevention-task-force- report 46. Governor Andrew M. Cuomo, “Making Progress Happen: 2020 State of the State.” January 8, 2020; 232–233. https://www. governor.ny.gov/sites/governor.ny.gov/files/atoms/files/2020StateoftheStateBook.pdf 47. New York City Office of the Mayor. “Mayor de Blasio Announces Major Expansion of Mental Health Services, Additional Programs for City Veterans at Veterans Day Breakfast.” November 11, 2019. https://www1.nyc.gov/office-of-the-mayor/news/532-19/ mayor-de-blasio-major-expansion-mental-health-services-additional-programs-city#/0 Issue Brief: Veteran Suicide in New York State 12 VOICE: FAX: MAIL: WEB: 212-664-7656 646-421-6029 1385 Broadway, www.nyshealth.org 23rd Floor New York, NY 10018 Improving the state of New York’s health Endnotes 1 Centers for Disease Control and Prevention. WISQARS Leading Causes of Death Reports. 2017. https:// webappa.cdc.gov/sasweb/ncipc/leadcause.html 2 U.S. Department of Veterans Affairs. Office of Mental Health and Suicide Prevention. “2019 National Veteran Suicide Prevention Annual Report.” https://www.mentalhealth.va.gov/docs/data-sheets/2019/2019_Na- tional_Veteran_Suicide_Prevention_Annual_Report_508.pdf. 3 U.S. Department of Veterans Affairs. “2019 National Veteran Suicide Prevention Annual Report: State Data Appendix.” https://www.mentalhealth.va.gov/docs/data-sheets/2017/2005-2017_State_Data_Appendix. xlsx 4 U.S. Department of Veterans Affairs. “2019 National Veteran Suicide Prevention Annual Report: State Data Appendix.” 5 Ibid. 6 Tal Young, Ilanit et al. “Suicide Bereavement and Complicated Grief.” Dialogues in Clinical Neuroscience vol. 14,2 (2012): 177-86. 7 Maple, Myfanwy, Julie Cerel, Rebecca Sanford, Tania Pearce, and Jack Jordan. “Is Exposure to Suicide Beyond Kin Associated with Risk for Suicidal Behavior? A Systematic Review of the Evidence.” Suicide and Life‐ Threatening Behavior 47, no. 4 (2017): 461-474. 8 Cerel, J., Brown, M.M., Maple, M., Singleton, M., van de Venne, J., Moore, M., and Flaherty, Cl. “How Many People are Exposed to Suicide? Not Six.” Suicide and Life Threatening Behavior, 49(2) (2019): 529–534. 9 “Costs of Suicide.” Suicide Prevention Resource Center. https://www.sprc.org/about-suicide/costs 10 Ferrari, Alize J., Rosana E. Norman, Greg Freedman, Amanda J. Baxter, Jane E. Pirkis, Meredith G. Harris, Andrew Page et al. “The Burden Attributable to Mental and Substance Use Disorders as Risk Factors for Suicide: Findings from the Global Burden of Disease Study 2010.” PloS One 9, no. 4 (2014): e91936. 11 Gradus, Jaimie L. “PTSD and Death from Suicide.” PTSD Research Quarterly, 28(4). 2017. https://www. ptsd.va.gov/publications/rq_docs/V28N4.pdf 12 Tanielian, Terri, Lisa H. Jaycox, Terry L. Schell, Grant N. Marshall, M. Audrey Burnam, Christine Eibner, Benjamin Karney, Lisa S. Meredith, Jeanne S. Ringel, and Mary E. Vaiana. “Invisible Wounds: Mental Health and Cognitive Care Needs of America’s Returning Veterans.” Santa Monica, CA: RAND Corporation, 2008. https:// www.rand.org/pubs/research_briefs/RB9336.html. 13 Ferrari, Norman, Freedman, Baxter, Pirkis, Harris, Page et al. “The Burden Attributable to Mental and Substance Use Disorders as Risk Factors for Suicide: Findings from the Global Burden of Disease Study 2010.”  14 U.S. Department of Veterans Affairs and U.S. Department of Defense. “VA/DoD Clinical Practice Guide- line for Assessment and Management of Patients at Risk for Suicide: Guideline Summary.” May 2019. https:// www.healthquality.va.gov/guidelines/MH/srb/VADoDSuicideRiskFullCPGFinal5088212019.pdf VOICE: FAX: MAIL: WEB: 212-664-7656 646-421-6029 1385 Broadway, www.nyshealth.org 23rd Floor 15 American Public Health Association. “Suicide Prevention.” https://www.apha.org/-/media/files/pdf/top- New York, NY 10018 ics/suicide_prevention.ashx?la=en&hash=4F53FEBF4FF35D9A73D38F4950C91C20F65C6DFB Improving the state of New York’s health