Military combat veterans constitute a large population in which standard practices of suicide risk assessment and prevention may not apply [Reference Rice and Sher8]. Studies suggest that military veterans may differ from their civilian peers in their risk responsiveness to established clinical factors [Reference Rice and Sher8]. Veterans are additionally exposed to stressors to which civilians remain naïve. Identification and clinical responsiveness to these factors can save lives [Reference Bryan, Cukrowicz, West and Morrow1].

The act of killing in combat is one such stressor which recent research suggests may raise suicide risk. Combat killing is a prevalent act; contemporary estimates in Iraq war veterans range from 32 to 40% [Reference Maguen, Lucenko, Reger, Gahm, Litz and Seal4]. An increased risk was first identified among Vietnam veterans who expressed guilt over killing [Reference Fontana, Rosenheck and Brett2]. Killing irrespective of guilt was subsequently found to be associated with Post-Traumatic Stress Disorder (PTSD) symptoms, a well-known risk factor for suicidality [3,4]. This association held after controlling for the effect of witnessing another's act of killing [Reference VanWinkle and Martin9]. A direct association with suicidal ideation has now been found [Reference Maguen, Luxton, Skopp, Gahm, Reger, Metzler and Marmar5] and confirmed to be significant independent of comorbid disorders and adjusted levels of combat exposure [Reference Maguen, Metzler, Bosch, Marmar, Knight and Neylan6]. As suicidal ideation and suicide attempts are both strong independent risk factors for completed suicide [Reference Rice and Sher8], these data strongly suggest that killing in combat increases the risk of completed suicide.

Nearly all healthcare providers care for military veterans: Worldwide, the vast majority veterans receive their care outside of veteran-specialized healthcare systems [Reference Rice and Sher8]. When concern for suicidality arises, all providers should inquire into veteran status and tailor risk assessment practices accordingly. Though controversy remains whether veterans as a group are at an increased risk of suicide as compared to their civilian peers [Reference Miller, Barber, Young, Azrael, Mukamal and Lawler7], certain risk factors within this group are better established [Reference Rice and Sher8]. A history of combat killing is both prevalent and readily identifiable. Incorporating this risk factor into standard suicide risk assessment practices in veterans appears empirically prudent.

Asking about a history of killing in combat provides the attentive clinician a window into the experiential content of combat narratives. Additional suicide risk factors may be spontaneously revealed within these narratives, such as re-experiencing symptoms or guilt. Discussion may serve as a seamless and less stigmatized entry to the identification of clinical disorders such as depression or PTSD. Attention to a history of killing in combat develops and enriches our healthcare for these deserving individuals.