988 A graphic with a USA suicide prevention phone number

Veteran Suicide Prevention Revealed: A Critical Examination and Call for Reform

In a recent development, the Veterans Affairs Office of Inspector General (OIG) has released a deeply concerning report shedding light on the shortcomings in the prevention of veteran suicides. The report is centered around a tragic incident in 2021 when a suicidal veteran reached out to the Veterans Crisis Line, only to take their own life minutes after the interaction. This incident has sparked a nationwide call for reform within the system.

Subscribe to our weekly newsletter and stay up to date.

The Veterans Crisis Line, available 24/7 through telephone, text messages, and online chat, played a pivotal role in this tragic event. The distressed individual engaged in a 75-minute text conversation with a crisis line staff member, culminating in their devastating decision to end their life merely 10 minutes after the last message was exchanged.

During a Senate Veterans Affairs Committee hearing, Louisiana Senator Bill Cassidy expressed his deep concern about the OIG report, deeming it “incredibly damning.” The report also highlighted issues in the aftermath of the veteran’s suicide, including allegations of potential interference with the OIG’s investigative work.

Matthew Miller, the Executive Director for Suicide Prevention at the Veterans Health Administration, addressed lawmakers during the hearing, emphasizing the significant progress made on eight out of the 11 recommendations outlined in the OIG report. Miller stressed the urgent need for improvement, stating, “We’re better than what was depicted in that report, and we have to do better.”

The veteran at the center of this tragedy, aged in their 30s, had a history of post-traumatic stress disorder, depression, alcohol use disorder, and suicidal behavior. On that fateful night, they reached out to the crisis line in a desperate attempt to prevent self-harm, revealing that they had both the means and the location to commit suicide. They even hinted at the possibility of becoming intoxicated enough to carry out their plan.

Despite these known risk factors, the OIG report revealed that the crisis line worker failed to escalate the situation by transitioning the text conversation to a phone call, contacting third-party rescue personnel, or confirming the intervention of a family member in the patient’s efforts to prevent suicide. Tragically, the patient’s last outgoing text message to the crisis line was sent at 11:02 p.m., while the last response from the staffer was around 11:29 p.m., with the note that the patient had remained on the line until the call ended normally. The patient took their life at 11:40 p.m.

The following day, the suicide prevention program case manager contacted the sheriff’s department to request a welfare check, only then discovering the patient’s tragic death by suicide.

This incident underscores the persistent and alarming issue of veteran suicides. According to the latest VA figures, there were approximately 17 veteran suicides per day in 2020, a rate significantly higher than that of the general U.S. adult population. This gap has varied over the years, from 12% to as wide as 66% higher over the last couple of decades. In 2020, veterans committed suicide at a staggering 57% higher rate than nonveteran adults.

Cole Lyle, a former Marine and advocate for veterans with Mission Roll Call, points out systemic issues within the VA’s approach to suicide prevention. He argues that the system is too reactionary, advocating for increased outreach and funding for local organizations to address veterans’ crises at an earlier stage.

Lyle acknowledges that the Veterans Crisis Line has had success stories but insists that improvements are urgently needed. He states, “This is an unacceptable example of a lack of empathy and accountability, and we certainly need to do better.”

In light of this heart-wrenching incident and the broader context of veteran suicide, it is clear that a comprehensive reform of suicide prevention strategies is essential. It is a collective responsibility to ensure that our veterans receive the support and care they need during their most vulnerable moments.

Similar Posts


  1. The government doesn’t care about veteran suicide and is fueling it. They seem to only care about illegals and Ukraine . The IG seems to be part of the problem. They do a report no accountability and bonus paid. IG targets a vet they will medically make sure your druged up , manufacture evidence and destroy your life. Amazing how the government protects itself

  2. One of the hardest parts of overcoming this disability is that the Vet will parlay the idea for years on end. The PTSD side develops over those years until it becomes an unbearable condition. In 5-10 years the lifestyle is remodeled to deal with the stress and anxiety that PTSD causes and a normal lifestyle fades and is forgotten.
    Living in rehabilitation centers for 60-120-180 days would go a long way to help these Vets overcome the worst of their symptoms and start living a normal and more balanced lifestyle. The military taught us to put everything on the back burner, to bury the issues, and put the mission first often ahead of the mental health of the person. Depending on the severity, a program to help Vets overcome the effects of military service would dictate how long the Vet would remain in the program.

  3. Like Representative Bob Filner told CBS News about the 11,210 VETERAN SUICIDES the Cheif of VA Mental hid from Congress back in 2008, “This is a crime against our Nation…against our Nation’s Veterans!”

  4. I have used the VA Crisis Line many times and overall I would say the counselors have had empathy and listened and talked with me up to and hour and half or more. There have been occasions where I have called and got what I call a script reader with no real empathy just focused on getting their simplistic questions answered and rushing you off the line. I also have worked in Mental Health myself for many years so I know what I am talking about. What I do is say I’m not suicidal and call right back to get a different counselor and it usually works but have noticed on weekends the counselors don’t seem as good. I tell them regularly that they have helped me and more than several counselors I’ve used through the VA Community Care. Believe me I am critical of the VA healthcare system on many points but the VA Crisis Line and the VA Washington Hotline have been professional the majority of times.

    The VA crisis counselors often ask if you want to do a SPC consult (Suicidal Prevention Coordinator) and I have but at best I get nice social worker call me but nothing beyond that. I ‘ve asked them to escalate an issue that is making me extremely frustrated but have just got empty promises with no follow up. Many times I haven’t even received a call or I’ll get someone call and leave a message that is basically a script telling you how to call the VA crisis line which seems ignorant as they wouldn’t be calling me if I didn’t know how to call them.

    NEVER has my Mental Health Team been put into the loop which would seem a no brainer and only requires a direct message in their messaging system. Not once has anyone from my Mental Health Team called me to check on me or even message me in HealthEVet. This would seem to be the best thing to do as they are treating you and know what you are dealing with. Our Mental Health Department is like a revolving door where good Psychiatrists get frustrated with this grossly ineffective system. We get Travel Contract Psychiatrists on the regular and I had to go an Act of Congress to get a permanent Psychiatrist. They are so understaffed that the psychiatrist think that all they have to do is your scheduled appointments and get antagonistic if you expect them to treat you.

    I keep hearing this marketing spin that the VA gives specialty care for things like PTSD. Wow that’s news to me and I am 100% P&T with PTSD. It’s more like telephone call drive through appointments. I does force you to take care of yourself because you know you won’t get much from them. Even Community Care Therapists need some quality control but they are definitely better than the one Psychologist I talked to at the VA who was behind this big old school computer monitor asking questions in monotone and clickyity clacking on their keyboard. At least through Community Care I have choices and I scout them out. Someone else needs to administer the VA even Triwest could do it and let us choose our own providers not the privitization plan of the Koch brothers but one designed with the input of real Veterans that use VA Healthcare.

  5. All this shit will unfortunately just cause the VA to get more intrusive into people’s lives… hate to tell you. Fourth Amendment already eroded so I’d just go ahead and assume that if you dial that line, they’re gonna take over your device basically. That and you might as well call police because they’ll be called automatically. Big proponent of euthanasia in place of all the bullshit and games. Sad when the consequences of “thoughts of self harm” are worse than the actual act of suicide.

  6. Being a combat veteran, with PTSD, I believe we all at some point in our lives we contemplate suicide, some do it others do not. I have considered this many times. I also believe that if a Veteran has issues that give rise to this consideration they will act upon it PERIOD! if that is their choice, no intervention, no conversation, no anything with alter that decision because that person has come to a point where that action is the only viable one to their issues. I also have found that these hotlines, these VA EXPERTS (has been wanabees) the VA employees for these lines are useless as are the behavioral clinics and their so called staff personnel. The conduct of the VA operation and its absurd drug distribution for PTSD etc only help the VA not the veteran.
    I SAY THIS FROM MY PRACTICAL EXPERIENCE WITH THE VETERANS ADMINISTRATION AND THEIR INTERACTION WITH MYSELF AND MY SITUATIONS. As the saying goes if you have not walked in my moccasins then you do not know what one is saying or thinking, so shut your mouth!. Then we have the oxymoron situation , where is the unanimity of a veteran to speak with someone on these hot lines, it they track your telephone number, now who you are, where you live etc, to me that sucks and defeats the program.
    The single most reason for veteran suicide is the VA itself, that is our government and its actions and lack of responsibility to the US Constitution and the American Bill of Rights that we veterans fought and died for theses entities trample on them hourly.

Comments are closed.