Traumatic brain injuries (TBIs) are a significant risk factor for firearm suicides among veterans. To date, over 400,000 veterans have sustained these injuries while deployed in support of post-9/11 conflicts. Most TBIs are the result of an overpressure (or blast overpressure, above normal atmospheric pressure) caused by explosive devices. Recent research and reporting indicate that the number of service members and veterans with TBIs may be even higher than previously estimated given new diagnostic developments and understandings of exposures to blast overpressure during military training exercises, including firing mortars and tanks or breaching doors.
TBI symptoms can be chronic and wide-ranging, including headaches, visual impairment, short-term memory loss, diminished executive functioning, tinnitus, and mood disturbances such as anger, impulsivity, and irritability. These “invisible” injuries are often overlooked, as affected service members and veterans appear “normal.” However, many have reported that chronic TBI symptoms severely impact their quality of life, sometimes leading to suicidal thoughts and behaviors. One combat veteran who participated in a research study my team and I conducted explained, “…I was going to kill myself if I didn’t get better, the symptoms are exhausting, and the guilt and shame are unbearable after angry outbursts.”
Research demonstrates that service members with a TBI are less likely to store their firearm(s) securely compared to other service members without a TBI, and veterans are twice as likely to die by suicide, predominately with a firearm. Despite these troubling statistics and the chronic nature of TBI symptoms, there are only 12 dedicated TBI clinics across the world serving the tens of thousands of service members with TBI; 4,800 of whom were injured in the first quarter of 2024, alone. In addition, executive branch-level TBI and mental health task forces to provide targeted action plans and hold the Department of Defense (DoD) and Veterans’ Affairs (VA) accountable for the care of post-9/11 veterans were discontinued with the new administration in 2016. Consequently, major gaps in TBI care have persisted for service members and veterans under the respective oversight of the DoD and VA. Just last year, in 2023, the DoD Inspector General (IG) outlined several issues with the DoD’s handling of TBIs. The IG reported that Military Health System providers frequently failed to identify or assess patients with TBIs, were inconsistent in the management of TBI symptoms and return-to-duty protocols, and lacked a streamlined approach for documenting and tracking TBIs. These findings highlight the need for accountability once again.
Research demonstrates that service members with a TBI are less likely to store their firearm(s) securely compared to other service members without a TBI, and veterans are twice as likely to die by suicide, predominately with a firearm.
The IG report did not identify a crucial piece of the puzzle—the military entitlement that officially documents the combat injury and frequently triggers care—the Purple Heart. The Purple Heart is the only official recognition given for injuries sustained in combat; to be entitled to this recognition, service members must meet the eligibility criteria that was established in the 1960s. Concussion injuries (i.e., TBIs) caused by the result of enemy generated explosions were identified as one of the eligible injuries prior to 2001. However, during the first eleven years of the of post-9/11 conflicts (2001-2012), military leaders regularly denied the Purple Heart entitlement to potentially tens of thousands of eligible service members. This likely occurred because the protocols to identify, document, and treat TBIs did not exist during that time period. Protocols to award Purple Hearts were only implemented in combat zones in 2012 after years of whistleblowing by service members and their families and investigative journalists sounding the alarm. Still, retroactive Purple Hearts were difficult to obtain, an issue which persists to this day for many combat veterans (i.e., service members and veterans who served on combat deployments) because the DoD shapes the application criteria around each new iteration of policy changes, placing those injured prior to the most recent policy implementation at a disadvantage. As some combat veterans say, “the DoD just keeps moving the goalpost.” Combat veterans are most commonly denied the Purple Heart because they cannot meet current requirements to produce documentation of their TBI(s) from the medic or medical officer who treated them overseas, potentially 20 years (or more) prior. These denials are happening despite an abundance of other supporting evidence, including TBI diagnoses from licensed physicians, at least two sworn statements from eye witnesses, and a combat action badge (another type of award only given after enemy engagement) detailing the event that caused the injury.
Failing to officially recognize veterans’ combat injuries through awarding the Purple Heart has serious implications. My earlier research on this issue found that army combat veterans who did not receive or were denied the Purple Heart for their combat-related TBI had a 38% higher suicide risk compared to those who did receive one. The Purple Heart not only acknowledges and validates invisible injuries, but also serves as a pathway to receiving TBI care. Without this recognition, veterans feel left behind, unseen, and experience difficulty accessing necessary care. The cumulative effects of these feelings and experiences lead to perceived institutional betrayal, which was identified as another risk factor for suicide in the study. Moreover, the lack of accountability by dedicated executive branch-level task forces and the DoD’s mismanagement of the screening, identification, and treatment of TBIs for the past two decades—the signature injuries of the post-9/11 conflicts—may explain, in part, why military suicide rates have been rising for nearly two decades.
A Way Forward
Historical mistrust and low or inconsistent VA utilization have been a concern for years because veterans receiving care from civilian healthcare providers are often not screened for military-related exposures or firearm access, despite calls to increase such evaluations –further overlooking those at the highest risk for suicide. However, there is a glimmer of hope through two recent efforts to improve the relationship between veterans and the VA: 1) The passing of the PACT Act, which addresses care for the often-elusive symptoms related to burn pit exposures and 2) the Biden-Harris campaign to increase VA enrollment and expand VA eligibility through public education and direct outreach to veterans. These initiatives led to over 185,000 veterans enrolling in the VA in two years, enabling more veterans to receive care for their symptoms and subsequently be exposed to the firearm suicide prevention initiatives within the VA. Given the success of this model to address burn pit exposures, this should be replicated with blast overpressure exposures (TBIs) with the expectation that a public health outreach of the same magnitude and intentionality could yield comparable results.
Furthermore, this year, US Senators Warren and Ernst named military TBIs as a priority issue and co-sponsored the bipartisan Blast Overpressure Safety Act that was added as an amendment to this year’s National Defense Authorization Act (NDAA). This legislation, which I helped draft language for with Dr. Kate Rocklein and Frank Larkin, aims to address many of the deficiencies in TBI identification and care highlighted by the DoD Inspector General: mandating care for veterans with chronic TBI symptoms, the tracking of blast overpressure exposures, and optimizing care delivery and prevention strategies. It also requires disclosure of the number of service members and veterans with TBIs who were punished, forced out of the military, or died by suicide to improve transparency and accountability. Additionally, I helped draft language for an NDAA amendment requiring the DoD to explain why Purple Heart entitlements were denied to combat veterans with TBIs and develop a streamlined process for awarding this entitlement. As we work to address the underlying issues contributing to suicide risk within the military population, we must urgently identify and implement strategies that promote secure firearm storage to prevent further loss.
Conclusion
Veterans’ Day serves as a powerful reminder of the sacrifices made by those who have served. As we honor veterans, it is crucial to recognize that many are fighting silent battles while serving or long after their service has ended. TBIs, though invisible, have lasting impacts on the lives of service members, veterans, and their families. By bringing these injuries back into the light, we can take meaningful steps toward healing.
ABOUT THE AUTHOR
Jayna Moceri-Brooks is a clinical assistant professor at New York University’s Rory Meyers College of Nursing and a member of the Regional Gun Violence Research Consortium.