Abstract
IMPORTANCE: Suicide risk may be elevated among individuals who separate from military service with a character of discharge or service that was not honorable (ie, dishonorable, bad conduct, other than honorable, general, or uncharacterized), but a comprehensive evaluation of this possibility has not been previously published. OBJECTIVE: To examine suicide mortality by character of discharge compared with individuals who received an honorable discharge and the full veteran population recently separated from service. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included all individuals who separated from the active component of the US military between January 1, 2002, and December 31, 2021. Data were obtained from the US Department of Veterans Affairs/Department of Defense Mortality Data Repository. Suicide rates for each character of discharge were compared with those among individuals receiving an honorable discharge and the full veteran population recently separated from service. Analyses were conducted between December 21, 2023, and June 1, 2024. EXPOSURE: Character of discharge assigned at separation from the active component of military service. MAIN OUTCOMES AND MEASURES: Crude suicide rates up to 5 years after separation were examined. Age-standardized rate ratios were used for comparisons within the cohort between strata. Age-standardized mortality ratios (SMRs) were used to compare suicide mortality by character of discharge with the full separation cohort and within specific military service branches. RESULTS: Among 3 627 653 individuals (mean [SD] age at separation, 28.4 [8.6] years; 83% men), 5599 deaths by suicide occurred during the study period. All character of discharge groups had significantly higher suicide rates than the honorable group, with standardized rate ratios ranging from 1.91 (95% CI, 1.69-2.17) for uncharacterized to 2.77 (95% CI, 2.52-3.05) for general. Veterans who received an honorable discharge were less likely to die by suicide than the overall cohort population (SMR, 0.82 [95% CI, 0.79-0.85]), while veterans with all other characters of discharge were more likely to die by suicide, with SMRs ranging from 1.23 (95% CI, 1.15-1.31) for uncharacterized to 1.84 (95% CI, 1.72-1.97) for general. Common demographic risk factors for suicide (eg, age, race) were replicated within character groups in most cases. CONCLUSIONS AND RELEVANCE: In this cohort study, individuals who did not receive an honorable character of discharge were at significantly higher risk of suicide compared with veterans who received an honorable discharge and the veteran population recently separated from service. These findings suggest that character of discharge may be a helpful risk factor to consider for ongoing suicide prevention efforts.