Mortality Data Reveals How US Service Members and Veterans Died in 21st Century

US service members and veterans were less likely to die than the general population from most causes of death over a 17-year period, a population-based, prospective analysis found. But there was a glaring exception: suicide by firearm.

Among 201,618 subjects tracked from 2001 to 2018 by the Millennium Cohort Study, the overall death rate was less than half that of a comparable group of US adults (standardized mortality ratios [SMR], 0.44), reported Edward J. Boyko, MD, MPH, staff physician with the Veterans Affairs (VA) Puget Sound Health Care System and professor of medicine at the University of Washington, Seattle, and colleagues in BMC Public Health. However, suicides by firearm—while rare—were more common overall (SMR, 1.42), among military men only (SMR, 1.33), and among military women only (SMR, 2.83) than civilians. 

The findings about the overall death rate may reflect the better health of those who join the military and have access to health care during and after service, Boyko told Federal Practitioner. The suicide data may reflect higher access to firearms, he said, although “more research is needed to identify what types of military exposures or physical and mental health predictors are associated with increased mortality risk due to suicide.”

The ongoing Millennium Cohort Study began in 2001 to track the health of military personnel over time. The study has spawned > 180 reports “used to inform and guide policy, guidelines, and health promotion efforts within the military and VA,” Boyko said. “As the Millennium Cohort Study approaches its 25-year anniversary, it seemed like an ideal time to assess mortality, especially cause-specific mortality, as a way to measure the impact of military service on long-term health.”

The analysis tracks 4 panels of subjects enrolled at various times between 2001 and 2013. Of the 201,619 participants, 3018 (1.5%) died by 2018. Of the 198,01 nondeceased participants, 69.2% were male; 8.1% were born before 1960, 16.1% were born from 1960 to 1969, 24.4% were born from 1970 to 1979, and 51.5% were born in or after 1980. The racial/ethnic makeup was 72.7% non-Hispanic White, 12.2% non-Hispanic Black, 7.9% Hispanic, and 7.1% other. Two-thirds (66.4%) were active duty, and 33.6% were in the Reserve or National Guard.

Of the 3018 deceased participants, 81.2% were male. In terms of birth year, 32.4% were born before 1960, 22.1% were born from 1960 to 1969, 18.2% were born from 1970 to 1979, and 27.3% were born in or after 1980. The racial/ethnic makeup was 77.7% non-Hispanic White, 11.9% non-Hispanic Black, 5.5% Hispanic, and 4.9% other. About half (51.0%) were active duty, and 49.0% were in the Reserve or National Guard.

Most deaths were due to natural causes (57.0%), followed by accident (20.1%), suicide (17.1%), operations of war (3.0%), homicide (2.1%), and other causes (1.2%). The new report noted that the Millennium Cohort Study and other research have identified a “healthy soldier effect, in which military populations tend to be healthier than the general US population.”

Boyko explained that “the fitness requirements for joining the military may favor the selection of healthier individuals from the general population. Another benefit of military service is free access to health care, especially among those on active duty, as well as eligibility for VA health care and other benefits after leaving service. This would allow for greater access to preventive care and treatments, as well as routine screening for health conditions such as cancer, diabetes, or cardiovascular disease.”

Overall suicide rates were higher among female subjects than among civilians (SMR, 1.65), but no statistically significant difference was seen in men (SMR, 0.96) or across all participants (SMR, 1.03). Regarding the large gaps in firearm suicide rates in military subjects vs civilians, Boyko said, “accessibility and familiarity with firearms, a highly lethal means of suicide, may be driving the elevated risk of suicide by firearms … prior research has found that unsecure firearms storage—such as unlocked, loaded firearms—increases the risk of suicide by firearms.”

Rachel Sayko Adams, PhD, MPH, a research associate professor with the Department of Health Law, Policy and Management at Boston University School of Public Health, is familiar with the study findings. Adams, a principal investigator at the VA Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention, told Federal Practitioner that “efforts to further develop suicide prevention programs that consider the unique needs and preferences of female service members and veterans are critical to prevent future suicide mortality in this population.”

Adams added: “Just because service members and veterans have a lower all-cause mortality rate compared to the general US population, we should not assume that they are universally low risk or that we can reduce our public health prevention efforts targeting this population.”

Boyko highlighted KeepItSecure.net, which “helps veterans and service members protect themselves and their families by making it easier to store firearms securely during stressful or high-risk periods.” The site offers practical, judgment-free guidance with powerful storytelling and public outreach, with clear, actionable steps—such as using a cable gun lock or lockbox—to lower suicide risk long before a crisis occurs. The VA, Boyko said, provides free cable gun locks nationwide.

The Millennium Cohort Study is funded by the Department of Veterans Affairs and Department of Defense Military Operational Medicine Research Program and Defense Health Program. The report authors and Adams have no disclosures.