Addressing a major risk factor in suicide — particularly among veterans — will require doctors to confront a subject too many feel ill-equipped to discuss.
Army friendships often last a lifetime. Bonds forged in the fires of training and mission have a way of holding strong through the years that follow in civilian life. The path that Jason Theis ’20 (HS, psychiatry) followed after discharge has taken him through college at the University of Maryland and then medical school at Johns Hopkins.
One of his Army buddies landed on a path with more ups and downs. The two met while working in military intelligence. Theis raves about that friend’s quick wit, toughness and athletic prowess. But his personality had a way of putting him at odds with the bureaucratic ways of intelligence work.
His friend landed back in civilian life with a less than honorable discharge, which meant no GI Bill and limited access to social services provided to veterans. He struggled with alcohol use. A night of excess landed him in jail. He was left wondering what the future might hold. He used a firearm to end his life.
Man With a Mission
Theis knew before this tragedy that suicides were on the rise among veterans of the war on terror. He’d seen the viral social media campaign that had thousands of folks on Facebook and Instagram doing 22 pushups for 22 straight days, raising awareness of 22 veteran suicides a day.
Numbers are one thing. The loss of a friendship that should have lasted a lifetime is another. It helped fuel Theis’ interest in psychiatry. It inspired his decision to devote a student research project to the topic of veteran suicides. That project evolved into an award-winning paper published last spring (2021) in Military Medicine.
“What I found is that little has been done in the way of rigorous research about the most common method of veteran suicides, and that is the use of firearms,” he says. “That’s where my journey into this really started to take off.”
The science is especially thin when measured against the scope of the problem. In 2017 alone, Theis reports, 4,200 veterans killed themselves with guns. By itself, that number nearly equals the total of U.S. military deaths recorded in Iraq since operations there began in 2003. His paper strives to serve as a clarion call for more research, laying out priority data that need gathering and potential interventions that need evaluating.
The paper also points to distressing trends on the clinical side. Even though firearms rank by an overwhelming margin as the leading suicide mechanism among veterans, clinicians rarely raise the topic of gun access with patients, even those who might be at risk for suicide. For some practitioners, the reluctance is rooted in the polarizing politics of gun safety. For others, it stems from a vaguer discomfort, a feeling that they know too little about the workings of guns and the culture of gun ownership to offer worthwhile advice.
“I had classmates in medical school who were terrified of the topic because they’d never been around guns in their lives,” Theis says. “Others were curious.” A gun owner himself, Theis is now trying to step into that void by giving presentations to clinicians on the topic and offering strategies for overcoming that unfamiliarity.
“Jason’s drive is rooted in his experiences,” says Katherine Hoops, a pediatric intensive care physician with a research specialty in gun violence. She is one of Theis’ mentors and was among his co-authors on the Military Medicine paper. “He’s one of those people for whom mission, passion, purpose and profession all intersect. He is committed to making a difference in the lives of veterans and military families, and I know he will do great work.”
Worlds of Pain
Theis has a harried look about him while power walking into the cafeteria at The Johns Hopkins Hospital. He’d squeezed this meeting into a jam-packed summertime orientation week for his residency in the Department of Psychiatry and Behavioral Sciences.
But he warms quickly to the conversation, charting his course in life through a series of happenstance encounters. The first dated to his junior year in high school in Grand Ledge, Michigan. He picked up the family phone one day. A stranger asked for his older sister. She wasn’t home.
“This guy was pretty slick” as a military recruiter, Theis recalls with a smile.
The recruiter moved right along to the new prospect: “Oh, I see. Well, tell me, man, when are you graduating?”
Theis didn’t have a plan for life after high school. He was a lousy student, near the bottom of his class. He hadn’t latched on to any career interests, though he did feel a duty to serve. This phone call came at a time when the events of 9/11 were still fresh.
“I felt like it was a way of doing something meaningful,” he says. He credits that decision with pushing him out of his comfort zone and toward a more genuine search for purpose in his life choices.
Early in basic training, Theis broke his foot. His recovery was imperfect, leaving him with lingering pain when jogging. Two years later, while stationed at Maryland’s Fort Meade, his primary care physician referred him to an orthopedic surgeon at the Walter Reed National Military Medical Center.
Psychiatry resident Jason Theis aims to give health providers the tools they need to communicate more comfortably about firearm use. Photos by Howard Korn
“Have you ever been there? It’s something I’ll never forget,” Theis says. “This was during the peak of the surge, and going to an orthopedic clinic at Walter Reed meant you were in the company of patients suffering from the full range of injury blast wounds. You could see the anxiety in the faces. You could get this sense for how dramatically their lives have changed.”
Theis felt guilty, being in such company over a smidgeon of foot pain. It didn’t help when that surgeon looked at his X-ray and muttered sarcastically, “Are you serious?” For emphasis, he added a disbelieving curse word between you and serious.
“I got where he was coming from,” Theis says. “Did my case rise to the level where I should take the time of someone at Walter Reed? But at the same time, I’m still a patient, aren’t I?”
Theis eventually re-upped for a second stint in the Army. A reenlistment bonus gave him the chance to test his academic mettle with a free semester at the University of Maryland. His first-ever biology class came as a revelation. “Something clicked during that class,” he says. “I was never a strong student before, but I enjoyed studying this time.”
Back on duty, Theis trained for a coming deployment as a team leader in a tactical signals intelligence unit. When those orders came in, he landed in the Sadr City neighborhood of East Baghdad embedded with a cavalry unit. His team operated out of what soldiers dubbed the “old MOD,” shorthand for a former Iraqi Ministry of Defense compound.
The infrastructure of the surrounding neighborhood was in tatters because of the war. That and rampant looting had nearby hospitals operating on life support, if at all. The only option open to civilians with serious medical problems was to seek help from the foreign medical teams stationed at the old MOD. Watching those families troop into the base with sick and injured loved ones, Theis found himself transported back to his day at Walter Reed.
“Here I am, a world away and in this entirely different culture, and these people had the same looks of anxiety and struggle in their faces as the ones I’d seen at Walter Reed,” Theis says. “It was in that moment that I said to myself, ‘Medicine is the path I should be on.’”
Sounding the Alarm
During medical school at John Hopkins, Theis took an additional year to pursue a master’s degree from the Bloomberg School of Public Health. In Public Policy class, he chose veteran suicide as his focus in an assignment on the broader topic of “firearms violence.”
Surprised to find quality research in short supply, he sought help at the Johns Hopkins Center for Gun Violence Prevention and Policy, peppering faculty member Jon Vernick with questions about that research void and what might help get it filled.
“Jon took me on a meet-and-greet walk down the hallway,” Theis says. Along the way he met Katherine Hoops and Cassandra Crifasi, center faculty members he would soon be working with to design a study focus.
“The plan we came up with was this: ‘Let’s dial it back to basic epidemiology,’” Theis says.
Digging through three decades of journal citations, he located 279 articles that touched on veteran suicide by firearms. Most were editorials or commentaries. In the end, fewer than 70 had the combination of focus and rigor needed for inclusion. Even those were a mishmosh.
Theis then dove into those Epidemiology 101 questions. Is suicide more frequent among veterans — if so, by how much? Are suicidal veterans more likely to choose firearms as a weapon? The numbers delivered resounding yeses on both fronts.
In the 20 years since 9/11, more than 7,000 U.S. soldiers, sailors and marines have been killed overseas while engaged in the War on Terror. In that same span, more than 30,000 U.S. veterans and active-duty personnel from those wars alone have died by suicide. Two-thirds of those suicides involved firearms.
The alarming numbers keep piling up. Veterans account for 5 percent of the U.S. population but 16 percent of annual suicides. Adjusting for age and gender, the veteran suicide rate is 27.7 per 100,000, which is 1.5 times higher than the general population. In addition, veterans are more likely to own guns — and then more likely to choose them in attempting suicide.
Theis puts the numbers in perspective this way: “We have the Vietnam wall in Washington, D.C. that honors the Americans killed in Vietnam. If we took an 11-year span, from 2005 to 2016, the number of fatal suicides by firearms among all veterans would have about the same number of names as that wall. But the problem is still hiding under the radar in medicine, and in the public eye, too.”
Earlier this year, Theis’ paper won top honors from the Maryland Psychiatric Society as the Resident-Fellow Paper of the Year.
Daunting Holes in the Data
Digging deeper into that literature, Theis had his eyes on two key issues, predictive tools and potential interventions, but the material was too thin to be of much help on either front.
Most studies lumped findings under the broad rubric of “veteran,” without differentiating among categories within that population — branch of service, length of service, discharge status and combat exposure among them. Are veterans who attempt suicide with a firearm more likely to have been on the battlefield? Are they more likely to have killed an enemy soldier or seen a friend die? Or, perhaps, will something more unexpected turn out to be a key variable? Attempts to answer these questions remain few and far between.
“Breaking that data down into those kinds of details, that needs to be a top research priority going forward because it would help to risk-stratify patients in the clinic,” Theis says.
The challenges with intervention possibilities are even more daunting. Another of Theis’ co-authors, Johns Hopkins psychiatrist Paul Nestadt, points out that it’s notoriously difficult to pinpoint which patients are at risk for suicide. People who kill themselves in the end tend to deny along the way that they’ve had suicidal thoughts. Even prior attempts aren’t really predictive — the bulk of suicides are committed by people with no history of those attempts.
While the raw prevalence numbers laid out in Theis’ research are eye-popping, they aren’t dramatic on a population level. “Despite it being a big problem, this is a relatively rare phenomenon, statistically,” Theis says. “The annual numbers we’re talking are 30 to 35 per 100,000 population, and these rates vary substantially by geography.”
The result is a bit of a conundrum. Some factors than can be linked with an increased risk of suicide turn out to be not very helpful at predicting “imminent suicide risk.” That risk is tied in with the epidemiologic concepts of positive and negative predictive values. As an example, Theis points to the presence of “relationship stressors.” Countless veterans go through rough spots in marriages and relationships, but the vast majority in that group don’t end their lives, let alone use a firearm to do so. But after-the-fact numbers tallied among suicide victims on this front are striking: Relationship stressors are nearly universal in their histories.
“There are tons of challenges like that in studying this,” Theis says. He takes encouragement from the fact that a number of new papers have appeared over the past 18 months — the literature finally seems to be expanding at a promising rate. At the Veterans Administration, identifying risk factors through new models that aim to better predict that “imminent” risk is an active area of research.
Raising the Topic
Throughout his research journey, theis experienced complications tied up with the passions of modern-day politics. In reaching out to veterans’ organizations, he ran into resistance from both the left and right. Some of these folks suspected that talk about the role of firearms in an epidemic of suicides would lead inevitably to calls for stricter gun safety laws. A gun owner himself, Theis didn’t get it.
“Some people have an unhealthy obsession with firearms and take efforts to study firearms from a public health standpoint as an attempt to infringe on ownership rights,” he says. “What it comes down to is this is a public health issue that has become entrenched in politics. At the same time, though, we know the majority of gun owners agree that certain measures that keep people who are at risk safe are appropriate.”
But the challenges aren’t just political: Most clinicians don’t feel qualified to talk with patients about firearms. Many physicians don’t own guns themselves. They may not even know anyone who does. Often, they regard gun ownership with a vague sense of disapproval.
In his research, Theis highlights the way these factors manifest in a reluctance by clinicians to even talk with patients about the topic of guns. One study found that just 15 percent of veteran patients with a positive suicide risk assessment were screened for access to firearms. Another found that only a quarter of patients seen in Veterans Health Administration settings were ever asked about firearms.
Theis has had several opportunities in recent months to talk with medical students and fellow clinicians on this front. He urges colleagues to move beyond the notion that they need deep expertise before they raise the issue with patients.
“You can choose to let yourself be scared by the fact that you don’t even know what a ‘magazine’ is, but you can also choose instead to be humble in front of your patient,” he says. “You could just say, ‘Hey, I’m worried that you’re at risk for suicide, especially with a firearm in the home,’ especially when emotional distress and substance use are involved. You can just ask the patient, ‘Have you thought about how you might reduce that risk?’”
By asking such open-ended questions in a respectful tone, clinicians can avoid coming across as overly didactic or authoritarian.
“Better yet,” he adds, “that approach opens up opportunities for your patients to teach you about something you don’t understand.” He urges medical students and physicians to think about veterans as a population where issues of cultural competency can be every bit as important as they are with members of ethnic, immigrant, religious and other groups.
“I’ve seen Jason talk to medical students about his experiences, and his passion for helping his brothers from back in the service is just amazing,” Nestadt says. “He has this gift for connecting with people, for engaging them in this topic and getting them excited about the possibilities for making a difference.”
Theis read at the start of his research about Emmy Betz ’05, an emergency medicine physician at the University of Colorado who launched a creative campaign to bolster cultural competency among physicians by taking them on field trips to shooting ranges. The goal: to meet gun owners in a collegial setting and gain a sense of the excitement and skill involved in their avocation.
Theis isn’t sure what, precisely, his own next step will be, but he seems confident that veteran suicide is a subject that he’s not finished with yet. That news comes as music to the ears of his mentor Katherine Hoops.
“Jason has a very successful career ahead of him,” she says. “He is growing not only as a consummate clinician who will provide compassionate and skillful care to his patients but also as a productive public health researcher who will improve care on a much broader scale.”