Suicide Prevention in the US Military

Suicide prevention is a significant issue in the US military, with the loss of current service members and veterans a significant public and social health cost. There have been a variety of theories on the causes of the increase in military suicides, which has been termed an “epidemic.” (Pilkington, 2013)

Model of Suicidal Behaviour

A model of suicide behaviour is used to understand the factors that may lead to suicide for a specific population. One model that applies well to explaining military suicides is called the Interpersonal Theory of Suicide (van Orden et al., 2010). This model states that three elements need to be present for a person to become suicidal:

1. Thwarted belongingness
2. Perceived burdensome
3. Acquired capability

Thwarted belonging can occur when a returning service member loses the esprit de corps that characterized their military service, and a large part of their social support. This is especially true if a veteran is disabled.

Perceived burdensomeness can occur when a service member with a disability or mental health issues finds themselves unable to function independently. This may be a particularly difficult adjustment for someone who was used to feeling in control and being independent.

Finally, acquired capability involves fearlessness and experience with physical injury that reduces a suicidal person’s ability to resist suicide. Military members have virtually all acquired the capability for suicide via combat experience and other exposure in their careers.

Prevalence of Suicide in Servicemembers and Veterans

For many years, the military had a comparable or slightly lower rate of suicide than the general population (Armed Forces Health Surveillance Center, 2012) but recent trends have had suicide rates increase significantly (Department of Veterans Affairs, 2010).

Kaplan, McFarland, Huguet & Newsom (2012) note that while the existing research has been mixed on the exact nature of the suicide rate increase, it is definitely elevated. Further research will need to be conducted to determine the exact causes.

Causes of Military Suicide

There are a number of suspected causes of the increase in suicidal behaviour in soldiers since 2006 identified by Hyman, Ireland, Frost & Cottrell (2012) include:

• Presence of a mental health diagnosis
• Having been on deployment
• Taking anti-depressants
• Taking sleep medications (which were associated with more deployments)

They note that the impact of these on the suicide rate was strongest in National Guard and Army Reserve members and interestingly, quite weak in the Marine Corps. This suggests that perhaps the esprit de corps that is present in the Marines helps to buffer against the negative elements of mental health issues. The lowered suicide rate in Marine Corps members was present despite the fact that Marines were less likely to have protective factors like spouses and children.

As well, Alexander, Reger, Smolenski & Fullerton (2014) in their pilot study using the Department of Defense Suicide Event Report (DoDSER) to collect data on suicide deaths (and matched “control” soldiers who did not die by suicide) found events like “recent failed intimate relationships, outpatient mental health history, mood disorder diagnosis, substance abuse history, and prior self-injury” linked to suicide, all of which fit in one of the three categories of the Interpersonal Theory of Suicide.

Suicide Awareness in the Marine Corps

MCRP611C Combat Stress, the 2000 Marine Corps combat stress control manual includes a section on suicide awareness. In addition to listing common signs of suicide and preparatory behaviour such as:

• Believes he or she is in a hopeless situation
• Appears depressed, sad, tearful; may have changes in patterns of sleep and/or appetite
• May talk about or actually threaten suicide, or may talk about death and dying in a way that strikes the listener as odd
• May give away possessions

It also includes the acronym AID LIFE:

• Ask: “Are you thinking about hurting yourself?”
• I Intervene immediately.
• D Do not keep a secret concerning a person at risk.
• L Locate help (NCO, chaplain, corpsman, doctor, nurse, friend, family, crisis line, hospital emergency room).
• I Inform your chain of command of the situation.
• F Find someone to say with the person. Do not leave the person alone.
• E Expedite! Get help immediately. A suicidal person needs the immediate attention of helpers.

Role of Chaplains in Army Suicide Prevention

Army Chaplains provide primary spiritual care to soldiers (Zeiger, 2009) but are also considered the “gatekeepers” who most non-commissioned officers, enlisted leaders in the military, refer soldiers to when they find out they’re suicidal. (Ramchand, Ayer, Geyer & Kofner, 2015) Chaplains are afforded confidentiality like attorneys or therapists and this makes them attractive as first-level referrals.

Ramchand et. al. (2012) also found that a majority (54%) of Chaplains and Chaplain’s Assistants had received some kind of mental health training, but that they their suicide prevention knowledge was lacking and had difficulty intervening because of the stigma of mental health treatment.

Means Restriction

Counselling on access to lethal means (CALM) is one approach that has been proven to reduce suicide rates in the civilian population. CALM refers to the techniques used to limit or disable access to suicide plans, such as removing firearms from the home or locking up prescription medication that a person could use to suicide with.

Hoyt & Duffy (2015) provide a number of approaches for limiting means, including providing space on base for a soldier’s private weapons during a suicidal crisis, emphasize weapon safety (e.g. locking up of firearms) to reduce impulsive use, and engaging the entire chain of command on when means restriction is necessary.

Post Traumatic Stress Disorder

Much has been made of the influence of post-traumatic stress disorder on the suicide rate. Research indicates that both PTSD and traumatic brain injury independently increase the suicide rate. (Barnes, Walter & Chard, 2012) however virtually all mental health issues increase the suicide rate (Harris & Barraclough, 1997) with depression being more important than PTSD in the suicide rate.

Interventions to Reduce Military Suicide

Zamorski (2011) reviews a variety of interventions that have shown evidence or potential in reducing suicide risk in soldiers, though from a Canadian context. Some of these are listed below:

• Treatment of underlying mental health issues
• Screening for depression
• Training of gatekeepers to ask about suicide
• Systematic followup for suicide attempters and high risk patients
• Counselling and restriction of access to lethal means
• Resilience training
• Systematic monitoring and quality improvement of mental health

Zamorski notes Knox et. al.’s (2003) study of a comprehensive suicide prevention program that included many of the above interventions. Over a 6 year span, the suicide rate declined 33% as a result of the implementation of these techniques.

Bibliography

Alexander, C.L., Reger, M.A., Smolenski, D.J. & Fullerton, N.R. (2014) Comparing U.S. Army Suicide Cases to a Control Sample: Initial Data and Methodological Lessons. Military Medicine. 179. 10:1062

Armed Forces Health Surveillance Center. (2012) Deaths by Suicide While on Active Duty, Active and Reserve Components, U.S. Armed Forces, 1998-2011. Medical Surveillance Monthly Report. 19(6)

Department of Veteran Affairs. (2012) Suicide Data Report. Kemp, J., Bossarte, R.

Harris, E.C., Barraclough, B. (1997) Suicide as an outcome for mental disorders. A meta-analysis. British Journal of Psychiatry. 170:205-28

Hoyt, T. & Duffy, V. (2015) Implementing Firearms Restriction for Preventing U.S. Army Suicide. Military Psychology. 27(6) 384-390 DOI: 10.1037/mil0000093

Hyman, J., Ireland, R., Frost, L., & Cottrell, L. (2012). Suicide Incidence and Risk Factors in an Active Duty US Military Population. American Journal Of Public Health, 102(S1), S138-S146. doi:10.2105/AJPH.2011.300484

Kaplan, M.S., McFarland, H., Huguet, N. & Newsom, J.T. (2012) Estimating the Risk of Suicide Among US Veterans: How Should We Proceed From Here?. American Journal of Public Health. 102(S1)

Knox, K.L., Litts, D.A., Talcott, G.W., Feig, J.C. & Caine, E.D. (2003). Risk of suicide and related adverse outcomes after exposure to a suicide prevention programme in the US Air Force: Cohort study. British Medical Journal, 327, 1376.

Pilkington, E. (2012) “US military struggling to stop suicide epidemic among war veterans”. The Guardian. Accessed electronically on Dec 27 2015 from http://www.theguardian.com/world/2013/feb/01/us-military-suicide-epidemic-veteran

Ramchand, R., Ayer, L., Geyer, L., & Kofner A. (2015) Army Chaplains’ Perceptions About Identifying, Intervening, and Referring Soldiers at Risk of Suicide. Spirituality in Clinical Practice. 2(1) 36-47

United States Marine Corps. (2000) MCRP611C Combat Stress. Accessed electronically on Dec 27 2015 from http://www.au.af.mil/au/awc/awcgate/usmc/mcrp611c.pdf

Van Orden, K.A., Witte, T.K., Cukrowicz, K.C., Braithwaite, S., Selby, E.A., & Joiner, T.E. (2010) The Interpersonal Theory of Suicide. Psychology Review. 117(2)575-600 doi: 10.1037/a0018697

Zamorski, M.A. (2011) Suicide prevention in military organizations. International Review of Psychiatry. (23)173-180

Zeiger, H. (2009) Why Does the U.S. Military Have Chaplains?. Pepperdine Policy Review. Accessed electronically on Dec 27 2015 from http://publicpolicy.pepperdine.edu/academics/research/policy-review/2009v2/why-does-us-military-have-chaplains.htm