A Veterans Day Salute: Lessons From 1918 and 2026 for Psychiatrists

This Veterans Day, Psychiatric Times honors those who have served with the latest research and reflections on a personal encounter with war.

The men and women who serve do so with great challenges and sacrifices and, as a field, psychiatry has endeavored to provide the needed support. That drive to support these individuals is often personal. A diary kept by the grandmother of Editor in Chief John J. Miller, MD, describes her husband, a World War I soldier, who came home “afraid of a sudden noise.”

More than a century later, the share of US veterans reporting recent suicidal ideation rose nearly 50% between 2019-2020 and 2025-2026, according to a nationally representative survey.¹ Three other 2026 studies tie military toxic exposures to posttraumatic stress disorder (PTSD), depression, and suicidal thoughts,²^,³ and show that rural veterans with serious mental illness (SMI) receive less Veterans Health Administration (VHA) mental health care than urban peers.⁴

Suicidal Ideation Is Up Nearly 50%, and Many Veterans Are Not in Treatment

More than 1 in 8 US veterans reported suicidal ideation in the past 2 weeks, and fewer than 2 in 5 of those with past-year ideation were receiving mental health treatment, according to researchers from the National Center for PTSD and Y Yale School of Medicine. The team analyzed the 2025 to 2026 wave of the National Health and Resilience in Veterans Study, a nationally representative web-based survey of 2636 veterans conducted between December 16, 2025, and January 12, 2026.¹

In that sample, the prevalence of past 2-week suicidal ideation was 13.4%, compared with 9.0% in the 2019 to 2020 wave (P < .001), a 49% increase. Past 2-week ideation was measured with item 9 of the 9-item Patient Health Questionnaire (PHQ-9). Lifetime suicide planning (8.0% vs 7.3%) and suicide attempts (4.9% vs 3.9%) were similar to prior estimates. The authors estimated these figures correspond to approximately 2.3 to 2.4 million veterans with past 2-week or past-year suicidal ideation.

Risk was concentrated among younger and female veterans. Past-year suicidal ideation was reported by 29.9% of veterans aged 18 to 44 years, compared with 7.6% of those aged 65 years or older. Female veterans reported higher rates of lifetime suicide planning (17.1% vs 6.8%) and attempts (11.1% vs 4.1%) than male veterans, and had greater adjusted odds of a lifetime attempt (OR, 2.32; 95% CI, 1.41-3.83). Functional disability accounted for the largest share of explained variance in suicidal ideation, followed by lifetime major depressive disorder (MDD; OR for past 2-week ideation, 2.22; 95% CI, 1.63-3.02) and lifetime PTSD (OR, 1.53; 95% CI, 1.09-2.13). Adverse childhood experiences accounted for the largest share of explained variance in suicide attempts (53.6%).

Among veterans with past-year suicidal ideation, only 38.1% were currently receiving mental health treatment. More specifically, 53.8% of veterans who used the VA as their primary source of health care were receiving mental health treatment, compared with 25.8% among those who did not. The authors noted that the cross-sectional design precludes causal inference and that all measures were self-reported.

“These findings suggest that suicidal ideation has increased among US veterans over the past 5 years, whereas suicidal planning and attempts have not, underscoring the need to strengthen early intervention, treatment engagement, and targeted prevention efforts,” the authors wrote.¹

Toxin Exposures Linked to PTSD and Suicidal Thoughts and Behaviors

Two additional studies found that exposure to service-related toxins was associated with PTSD and suicidal thoughts and behaviors.

Drawing on the aforementioned 2025 to 2026 survey wave, the same research group published a cross-sectional analysis. In that analysis, 623 veterans (26.2%) reported burn pit exposure only and 266 (8.2%) reported Agent Orange exposure; 76.9% of the Agent Orange group also reported burn pit exposure.² Psychiatric outcomes were based on positive screens from self-report measures of toxin exposure.

After adjustment for sociodemographic, military, and trauma characteristics, Agent Orange exposure was associated with greater odds of screening positive for current PTSD (OR, 3.47; 95% CI, 1.79-6.73), as was burn pit exposure (OR, 1.88; 95% CI, 1.30-2.72). Burn pit exposure was nominally associated with suicidal ideation (OR, 1.44; 95% CI, 1.06-1.97), but that association did not remain significant after false discovery rate correction.

Among 817 burn pit–exposed veterans who reported how often they were exposed, greater frequency was associated with progressively higher odds of screening positive for PTSD (OR, 1.44; 95% CI, 1.17-1.78), MDD (OR, 1.34; 95% CI, 1.10-1.63), alcohol use disorder (OR, 1.35; 95% CI, 1.10-1.67), and suicidal ideation (OR, 1.29; 95% CI, 1.06-1.58). The predicted probability of screening positive for PTSD rose from 0.10 among veterans exposed rarely to 0.33 among those exposed every day; for suicidal ideation, it rose from 0.15 to 0.31. The authors described these dose-response associations as particularly notable, while noting reliance on self-report and the cross-sectional design as potential limitations.

Under the Agent Orange Act of 1991 and the Promise to Address Comprehensive Toxics (PACT) Act of 2022, the US Department of Veterans Affairs recognizes exposure to Agent Orange and to toxins from open-air burn pits as presumptively service related. Nationally representative data on the psychiatric correlates of these exposures have been limited.²

“Toxic exposures may also serve as markers of deployment to high-risk operational environments characterized by persistent stress, and the observed dose-response associations may reflect cumulative effects of prolonged exposure,” the authors wrote. They added, “The current findings suggest that assessment of toxic exposures may help identify veterans at elevated risk for PTSD, MDD, AUD [alcohol use disorder], and SI [suicidal ideation], and support continued monitoring of physical health outcome

s among exposed veterans.”

Meanwhile, a larger observational cohort study that included data from 248,926 veterans enrolled in the Million Veteran Program found exposures were likewise associated with suicidal thoughts and behaviors.³

In the study, participants self-reported exposure to 9 toxins, including Agent Orange, chemical/biological weapons, anthrax vaccine, solvents/fuels, lead, pesticides, and open-air burn pits. Subsequent health records were used to identify suicidal thoughts and behaviors.

Veterans with more toxic exposures were more likely to have suicidal thoughts and behaviors (OR, 1.17; 95% CI, 1.16-1.18; P < .001). The association was comparable (ORs ranging from 1.11 to 1.19) across the program’s major service cohorts: pre-Vietnam, Vietnam, post-Vietnam, Gulf War, and post-9/11. PTSD and depressive symptoms accounted for the association.

“Findings suggest that providers working with veterans who report toxic exposure might benefit from also screening for STBs [suicidal thoughts and behaviors],” the investigators wrote. They call for research on whether toxic exposure interacts with genetic vulnerability and on how exposure might raise risk.³

Rural Veterans With SMI Use Less VA Mental Health Care, Despite Greater Need

Veterans with serious mental illness in rural areas are less likely than peers in urban areas to use VHA mental health care, according to a retrospective cohort analysis published in The Journal of Rural Health.

Researchers examined 387,477 veterans with SMI who received VHA care from fiscal years 2018 to 2022, 28% of whom were rural, and assessed their mental health care use in fiscal year 2023.⁴ Rural veterans with SMI more often had comorbid anxiety and PTSD than urban veterans, although effect sizes were small.

Rural veterans with SMI had 38% lower odds of receiving intensive SMI care, 15% lower odds of a video-to-home telehealth mental health visit, 13% lower odds of any outpatient mental health encounter, and 10% lower odds of multidisciplinary care. All differences remained after adjustment for key demographic and clinical factors.

The authors cite individual, institutional, and program-level barriers, including long travel distances, intensive SMI programs concentrated at urban facilities, and limited broadband access and digital literacy. The analysis captured only VHA-delivered care, and rural veterans may be more likely to use VA-purchased community care under the MISSION Act, which could partially explain the gap.

“These findings demonstrate stark differences in use of VHA mental health care for rural Veterans with SMI that span different types of care, providers and treatment modalities,” the authors wrote. They added, “Tailored interventions, especially for rural Veterans with SMI, are needed that simultaneously address technology-based barriers associated with rurality and SMI diagnosis.”⁴

“The Man Who Came Home”: A Family’s Record From 1918

In reflecting on the importance of making psychiatric care available to veterans, Miller highlighted the experiences of his grandfather and shared excerpts from the diaries of his grandparents. His grandfather, John A. Miller, served with the Third Division of the American Expeditionary Forces in World War I.

In an entry dated September 11, 1918, he described a heavy barrage that opened at 1 AM and the casualties that followed:

“We were all kind of nervous at first but this gradually wore off. Patients began coming in and we were rushed to death, working day and night. Stories came from the front of different attacks. Lots of gassed. We gave our beds up to patients and slept on ground.”

His grandmother, Harriett V. Miller, later wrote about the man who returned home:

“The boy who went away was so calm, sunny and sure that everything nice was just around the next corner, and the man who came home to me, uncertain, afraid of a sudden noise and timid of the dark in a building. So many days under fire without relief and exposure had left their tragic mark.”

Her account predates the formal recognition of PTSD in the diagnostic nomenclature by more than 6 decades, Miller noted. He pointed to Trauma and Recovery, by psychiatrist Judith Herman, MD. In it, she described World War II as the point when it was recognized that any soldier could break down under fire, and that psychiatric casualties rose with the severity of combat. Yet shortly after that war, “the lasting effects of war trauma were once again forgotten.”⁵

Honoring Service in the Clinic

Taken together, these studies remind clinicians of several important points when caring for veterans:

• Suicidal ideation is rising, and risk is not evenly distributed. Recent suicidal ideation among veterans rose nearly 50% in 5 years. Younger and female veterans carry disproportionate risk, and the authors underscore the importance of suicide risk assessment and monitoring in these groups.¹
• Many veterans at risk are not in treatment. Fewer than half of veterans with past-year suicidal ideation were receiving current mental health treatment. The share was lowest among those who get their care outside the VA (25.8% vs 53.8%). There is a need for continued outreach to at-risk veterans both within and outside the VA system.¹
• Exposure history belongs in the assessment, including how often. Asking about toxic exposures may help identify veterans at elevated risk for PTSD, depression, alcohol use disorder, and suicidal ideation. Risk rose with the frequency of burn pit exposure.^2,3
• Access gaps persist for rural veterans with SMI. Rural veterans with SMI were less likely than urban peers to receive intensive SMI care, telehealth, outpatient, or multidisciplinary mental health care. Individualized support, education, efforts to address technology barriers, and expanded telehealth options may enhance access.⁴

To all who have served, and to the clinicians who care for them: Thank you.

References

1. Fischer IC, Nichter B, Na PJ, et al. Suicidal thoughts, behaviors, and mental health treatment use in US military veterans. JAMA Netw Open. 2026;9(7):e2624114.
2. Fischer IC, Na PJ, Pietrzak RH. Military-related toxic exposures and mental and physical health in US veterans. JAMA Netw Open. 2026;9(8):e2628803.
3. Bourassa KJ, Stephenson M, Dennis PA, et al. Toxic exposure and rates of suicidal thoughts and behaviors among US military veterans. Psychiatry Res. 2026;362:117172.
4. Caloudas AB, Amspoker AB, Smith A, et al. Rural-urban differences in use of mental health care for serious mental illness at the Veterans Health Administration: a retrospective cohort analysis. J Rural Health. 2026;42(2):e70173.
5. Herman JL. Trauma and Recovery. Basic Books; 1992.