Assessment of Suicidal Intent in Self-directed Violence and Subsequent Care Received Among Military Veterans: A National Study of Gender Differences


This study sought to understand whether female veteran self-directed violence (SDV) events were dis-proportionality classified as ‘undetermined’ versus ‘suicide attempt’ when compared to male veteran SDV events. Data from the Veterans Health Administration was used to identify 55,878 veterans with at least 1 “undetermined” SDV or nonfatal “suicide attempts” occurring between January 1, 2013 to December 31, 2018. Analysis of the data found that female veterans were disproportionately more likely than male veterans to have SDV events classified as “undetermined”.


Background: The Veterans Health Administration's system for documenting self-directed violence (SDV) requires that clinicians make a determination of the suicidal intent of the behavior (ie, "undetermined" intent vs. "suicide attempt") which contributes to the enhanced care offered. Past studies suggest clinicians' judgment of suicide risk is impacted by patient demographics regardless of clinical presentation. As women are less likely to die by suicide than men, women's SDV may be taken less seriously; they may be more likely to have their SDV classified as "undetermined" than men, which may impact the care received. Objectives: This study examines whether women veterans' SDV is disproportionately classified as "undetermined" suicidal intent versus "suicide attempt" as compared with men veterans, and how one's classification and gender modifies the care received. Research design: This was an observational, retrospective study of data from Veterans Health Administration administrative databases. We included all veterans with documented nonfatal "undetermined" SDV events and "suicide attempts" between 2013 and 2018 (N=55,878). Objectives were evaluated using mixed-effects logistic regression models. Results: Women veterans were disproportionately more likely than men veterans to have SDV classified as "undetermined" (odds ratio=1.17; 95% confidence interval, 1.08-1.27). Veterans who received an "undetermined" classification were significantly less likely to receive enhanced care. However, this relationship was not moderated by gender. Conclusions: Gender may impact clinicians' determinations of intent of SDV, but more research is needed on the extent of classification biases and to understand causes. Further, classification of intent is critical, as there is a strong relationship between classification and enhanced care.

Full Reference

Chen, Jason I. PhD*,†; Cameron, David C. MPH*; Laliberte, Avery Z. BA*,†; Hooker, Elizabeth R. MPH*; Niederhausen, Meike PhD*,†,‡; Denneson, Lauren M. PhD*,† Assessment of Suicidal Intent in Self-directed Violence and Subsequent Care Received Among Military Veterans, Medical Care: February 2021 - Volume 59 - Issue - p S17-S22 doi: 10.1097/MLR.0000000000001455