Multiple Stressors Up Suicide Risk Among Military Personnel

BOSTON – Both veterans and active-duty military are at significantly greater risk for suicide than is the general population, underscoring the critical need for identification of suicidal thoughts and prevention of suicidal actions, said clinicians who specialize in the mental health needs of current and former armed service members.

Of the 30,000-32,000 Americans annually who commit suicide, about one in five is a veteran – an average of 18 veteran suicides a day, according to the National Violent Death Reporting System of the Centers for Disease Control and Prevention.

From 1950 through 2005, despite four wars, seven recessions, and unprecedented advances in the diagnosis and treatment of mental illness, the overall American suicide rate has not changed, said Dr. Janet Kemp, Veterans Affairs national mental health director for suicide prevention at the VA Office of Mental Health in Washington.

"It’s not that people haven’t been paying attention to it, but to be perfectly honest, we’re not that far ahead in our ability to change the problem," she said at a symposium on the complexities and challenges of posttraumatic stress disorder (PTSD) and traumatic brain injury.

For active duty military, particularly those who are deployed to combat zones, a combination of "rage, guilt, and despair" and ready access to firearms can be a deadly combination, added Col. John Bradley, a physician who serves as chair of Integrated Health Services in the department of psychiatry at Walter Reed Army Medical Center, Washington, D.C.

"It’s not simply exposure to bad things, but it’s the emotional response to those things that really creates the distress for our returning veterans, and in particular, anger and survivor’s guilt are important themes," Dr. Bradley said.

Younger Vets, Women at Higher Risk

CDC data from 2008, the latest year available, suggest that younger veterans (aged 20-29 years), those 39 and older, and women vets are increased risk for suicide, compared with other veterans, although information on trends is hard to come by, Dr. Kemp noted.

Three of the most significant risk factors for suicide are PTSD, depression, and sleep disorders, Col. Bradley said. He cited a 2004 study of soldiers and Marines returning from combat in Iraq or Afghanistan that found that PTSD symptoms ranged from 9.5% among those with low levels of combat experience, to 18.5% among those with high levels of combat exposure. Rates of depression were 5.2% and 7.9%, respectively, and more than one-fourth of service members returning from war zones reported sleep problems: 25.6% and 37.2%, respectively (N. Engl. J. Med. 2004;351:13-22).

Additionally, the prevalence of PTSD and other mental health problems has been shown to increase during the first year after the end of a combat deployment, with PTSD levels increasing from 5% from 12.9% 3 months after deployment (during Operation Iraqi Freedom) to 17% at year, depression levels increasing from 7.9 to 12%, and anxiety rising from 7.9% to 11.5% (Arch. Gen. Psychiatry 2010;67:614-23).

Department of Defense studies have found that the rate of suicides among active duty military have begun to approximate those of the general public, Col. Bradley said.

"We used to believe that we were afforded some protection by our increased selection criteria for becoming a service member, access to health care, health and fitness, wellness, unit cohesion, etc., but now our rates are no better, and we have to ask the question ‘why?’ "

Data from the Post-Deployment Health Assessment, a universal screening instrument for returning service members, show that 25% of those who went on to commit suicide endorsed one of two depression items (hopelessness, loss of interest), 26% endorsed one of four PTSD items (nightmares, avoiding situations/thoughts, constantly on guard, and numb or detached), but only about 2% had reported suicidal thoughts. About 6% said they had sought mental health care in the past month, and 11% said they had been referred for mental health care.

Gunshot wounds are by far the most significant cause of death (from about 56% to 70%), followed by hanging/asphyxiation (18-20%), and drug, poisoning/carbon monoxide, exsanguination, or other causes (all below 10%).

Risk factors

The best predictor of a suicide attempt is presence of a current suicide plan or past attempt, the latter of which is associated with 100-fold risk for a second attempt within a year, but predictive ability is generally poor, Dr. Bradley said.

Other significant risk factors include:

• Family history of suicide.

• Family history of child maltreatment.

• History of mental disorders (particularly depression), alcohol, or substance abuse.

• Feelings of hopelessness or isolation from others.

• Impulsive or aggressive tendencies.

• Cultural and religious beliefs regarding acceptability of suicide.

• Local epidemics of suicide.

• Barriers to mental health treatment access.

• Loss (relational, social, work, or financial).

• Physical illness.

• Easy access to lethal methods (guns, knives, etc.).

• Unwillingness to seek help because of stigma attached to mental health/substance abuse or suicidal thoughts.

Prevention Recommendations

Col. Bradley served on a Defense Department suicide prevention task force that recommended key strategies to prevent suicide in the armed services in four domains:

• Organization and leadership.

• Wellness enhancement and training.

• Access to and delivery of high-quality care.

• Surveillance, investigations, and research.

"During our 19 site visits with military families at different installations across all four services, families and troops told us again and again and again that the major stressor in their lives is the repeated deployments and the lack of quality dwell time that they have in between those deployments to be able to reintegrate, reestablish a baseline, reestablish a support system in order to be successful," Col. Bradley said.

The task force recommended enhancing well-being, mental fitness, life skills, and resiliency of service members and families with programs such as financial management training, marriage and family relationship counseling, anger management, and conflict resolution skills.

Service members and their families also should have ready access to high quality behavioral health care, with continuity of care to ensure timely provision of services and seamless management. The task forces also called for standardized crisis intervention services and hotlines across all branches of the military.

Assessment and Management

The clinician should assess the degree of risk – acute or imminent – and ask the patient about current stressors and potential vulnerabilities over the long term. Col. Bradley and his colleagues employ the SAD PERSONS suicide assessment scale and the Beck Scale for Suicidal Ideation for evaluating patients.

Managing at-risk patients might include stabilizing medical conditions, taking steps to ensure the safety of both the patient and the clinician, and ruling out intoxication or withdrawal as possible causes of suicidal statements or actions. However, even retracted suicidal statements must still be evaluated, Dr. Bradley cautioned.

Treatment options include hospitalizing or committing to a care facility patients at imminent risk, although evidence to support this practice is limited. There is better evidence for suicide-specific therapies, psychosocial support, and medical therapies such as flupenthixol, clozapine, or electroconvulsive therapy.

Col. Bradley emphasized that there is no evidence to support the use of a "suicide contract," in which the clinician elicits a promise from the patient that he/she will not commit suicide.

"The only thing a suicide contract does is make a malpractice lawyer salivate when you’re being taken to court," he said.

The ongoing Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is the largest study of suicide and mental health among military personnel ever undertaken. It is designed to identify modifiable risk and protective factors related to mental health and suicide and will support the Army’s ongoing efforts to prevent suicide and improve soldiers’ overall well-being.

Data were presented at a symposium supported by the Home Base Program, a joint project of the Red Sox Foundation and Massachusetts General Hospital. Neither Dr. Kemp nor Col. Bradley had relevant financial disclosures.

BOSTON – Both veterans and active-duty military are at significantly greater risk for suicide than is the general population, underscoring the critical need for identification of suicidal thoughts and prevention of suicidal actions, said clinicians who specialize in the mental health needs of current and former armed service members.

Of the 30,000-32,000 Americans annually who commit suicide, about one in five is a veteran – an average of 18 veteran suicides a day, according to the National Violent Death Reporting System of the Centers for Disease Control and Prevention.

From 1950 through 2005, despite four wars, seven recessions, and unprecedented advances in the diagnosis and treatment of mental illness, the overall American suicide rate has not changed, said Dr. Janet Kemp, Veterans Affairs national mental health director for suicide prevention at the VA Office of Mental Health in Washington.

"It’s not that people haven’t been paying attention to it, but to be perfectly honest, we’re not that far ahead in our ability to change the problem," she said at a symposium on the complexities and challenges of posttraumatic stress disorder (PTSD) and traumatic brain injury.

For active duty military, particularly those who are deployed to combat zones, a combination of "rage, guilt, and despair" and ready access to firearms can be a deadly combination, added Col. John Bradley, a physician who serves as chair of Integrated Health Services in the department of psychiatry at Walter Reed Army Medical Center, Washington, D.C.

"It’s not simply exposure to bad things, but it’s the emotional response to those things that really creates the distress for our returning veterans, and in particular, anger and survivor’s guilt are important themes," Dr. Bradley said.

Younger Vets, Women at Higher Risk

CDC data from 2008, the latest year available, suggest that younger veterans (aged 20-29 years), those 39 and older, and women vets are increased risk for suicide, compared with other veterans, although information on trends is hard to come by, Dr. Kemp noted.

Three of the most significant risk factors for suicide are PTSD, depression, and sleep disorders, Col. Bradley said. He cited a 2004 study of soldiers and Marines returning from combat in Iraq or Afghanistan that found that PTSD symptoms ranged from 9.5% among those with low levels of combat experience, to 18.5% among those with high levels of combat exposure. Rates of depression were 5.2% and 7.9%, respectively, and more than one-fourth of service members returning from war zones reported sleep problems: 25.6% and 37.2%, respectively (N. Engl. J. Med. 2004;351:13-22).

Additionally, the prevalence of PTSD and other mental health problems has been shown to increase during the first year after the end of a combat deployment, with PTSD levels increasing from 5% from 12.9% 3 months after deployment (during Operation Iraqi Freedom) to 17% at year, depression levels increasing from 7.9 to 12%, and anxiety rising from 7.9% to 11.5% (Arch. Gen. Psychiatry 2010;67:614-23).

Department of Defense studies have found that the rate of suicides among active duty military have begun to approximate those of the general public, Col. Bradley said.

"We used to believe that we were afforded some protection by our increased selection criteria for becoming a service member, access to health care, health and fitness, wellness, unit cohesion, etc., but now our rates are no better, and we have to ask the question ‘why?’ "

Data from the Post-Deployment Health Assessment, a universal screening instrument for returning service members, show that 25% of those who went on to commit suicide endorsed one of two depression items (hopelessness, loss of interest), 26% endorsed one of four PTSD items (nightmares, avoiding situations/thoughts, constantly on guard, and numb or detached), but only about 2% had reported suicidal thoughts. About 6% said they had sought mental health care in the past month, and 11% said they had been referred for mental health care.

Gunshot wounds are by far the most significant cause of death (from about 56% to 70%), followed by hanging/asphyxiation (18-20%), and drug, poisoning/carbon monoxide, exsanguination, or other causes (all below 10%).

Risk factors

The best predictor of a suicide attempt is presence of a current suicide plan or past attempt, the latter of which is associated with 100-fold risk for a second attempt within a year, but predictive ability is generally poor, Dr. Bradley said.

Other significant risk factors include:

• Family history of suicide.

• Family history of child maltreatment.

• History of mental disorders (particularly depression), alcohol, or substance abuse.

• Feelings of hopelessness or isolation from others.

• Impulsive or aggressive tendencies.

• Cultural and religious beliefs regarding acceptability of suicide.

• Local epidemics of suicide.

• Barriers to mental health treatment access.

• Loss (relational, social, work, or financial).

• Physical illness.

• Easy access to lethal methods (guns, knives, etc.).

• Unwillingness to seek help because of stigma attached to mental health/substance abuse or suicidal thoughts.

Prevention Recommendations

Col. Bradley served on a Defense Department suicide prevention task force that recommended key strategies to prevent suicide in the armed services in four domains:

• Organization and leadership.

• Wellness enhancement and training.

• Access to and delivery of high-quality care.

• Surveillance, investigations, and research.

"During our 19 site visits with military families at different installations across all four services, families and troops told us again and again and again that the major stressor in their lives is the repeated deployments and the lack of quality dwell time that they have in between those deployments to be able to reintegrate, reestablish a baseline, reestablish a support system in order to be successful," Col. Bradley said.

The task force recommended enhancing well-being, mental fitness, life skills, and resiliency of service members and families with programs such as financial management training, marriage and family relationship counseling, anger management, and conflict resolution skills.

Service members and their families also should have ready access to high quality behavioral health care, with continuity of care to ensure timely provision of services and seamless management. The task forces also called for standardized crisis intervention services and hotlines across all branches of the military.

Assessment and Management

The clinician should assess the degree of risk – acute or imminent – and ask the patient about current stressors and potential vulnerabilities over the long term. Col. Bradley and his colleagues employ the SAD PERSONS suicide assessment scale and the Beck Scale for Suicidal Ideation for evaluating patients.

Managing at-risk patients might include stabilizing medical conditions, taking steps to ensure the safety of both the patient and the clinician, and ruling out intoxication or withdrawal as possible causes of suicidal statements or actions. However, even retracted suicidal statements must still be evaluated, Dr. Bradley cautioned.

Treatment options include hospitalizing or committing to a care facility patients at imminent risk, although evidence to support this practice is limited. There is better evidence for suicide-specific therapies, psychosocial support, and medical therapies such as flupenthixol, clozapine, or electroconvulsive therapy.

Col. Bradley emphasized that there is no evidence to support the use of a "suicide contract," in which the clinician elicits a promise from the patient that he/she will not commit suicide.

"The only thing a suicide contract does is make a malpractice lawyer salivate when you’re being taken to court," he said.

The ongoing Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is the largest study of suicide and mental health among military personnel ever undertaken. It is designed to identify modifiable risk and protective factors related to mental health and suicide and will support the Army’s ongoing efforts to prevent suicide and improve soldiers’ overall well-being.

Data were presented at a symposium supported by the Home Base Program, a joint project of the Red Sox Foundation and Massachusetts General Hospital. Neither Dr. Kemp nor Col. Bradley had relevant financial disclosures.

BOSTON – Both veterans and active-duty military are at significantly greater risk for suicide than is the general population, underscoring the critical need for identification of suicidal thoughts and prevention of suicidal actions, said clinicians who specialize in the mental health needs of current and former armed service members.

Of the 30,000-32,000 Americans annually who commit suicide, about one in five is a veteran – an average of 18 veteran suicides a day, according to the National Violent Death Reporting System of the Centers for Disease Control and Prevention.

From 1950 through 2005, despite four wars, seven recessions, and unprecedented advances in the diagnosis and treatment of mental illness, the overall American suicide rate has not changed, said Dr. Janet Kemp, Veterans Affairs national mental health director for suicide prevention at the VA Office of Mental Health in Washington.

"It’s not that people haven’t been paying attention to it, but to be perfectly honest, we’re not that far ahead in our ability to change the problem," she said at a symposium on the complexities and challenges of posttraumatic stress disorder (PTSD) and traumatic brain injury.

For active duty military, particularly those who are deployed to combat zones, a combination of "rage, guilt, and despair" and ready access to firearms can be a deadly combination, added Col. John Bradley, a physician who serves as chair of Integrated Health Services in the department of psychiatry at Walter Reed Army Medical Center, Washington, D.C.

"It’s not simply exposure to bad things, but it’s the emotional response to those things that really creates the distress for our returning veterans, and in particular, anger and survivor’s guilt are important themes," Dr. Bradley said.

Younger Vets, Women at Higher Risk

CDC data from 2008, the latest year available, suggest that younger veterans (aged 20-29 years), those 39 and older, and women vets are increased risk for suicide, compared with other veterans, although information on trends is hard to come by, Dr. Kemp noted.

Three of the most significant risk factors for suicide are PTSD, depression, and sleep disorders, Col. Bradley said. He cited a 2004 study of soldiers and Marines returning from combat in Iraq or Afghanistan that found that PTSD symptoms ranged from 9.5% among those with low levels of combat experience, to 18.5% among those with high levels of combat exposure. Rates of depression were 5.2% and 7.9%, respectively, and more than one-fourth of service members returning from war zones reported sleep problems: 25.6% and 37.2%, respectively (N. Engl. J. Med. 2004;351:13-22).

Additionally, the prevalence of PTSD and other mental health problems has been shown to increase during the first year after the end of a combat deployment, with PTSD levels increasing from 5% from 12.9% 3 months after deployment (during Operation Iraqi Freedom) to 17% at year, depression levels increasing from 7.9 to 12%, and anxiety rising from 7.9% to 11.5% (Arch. Gen. Psychiatry 2010;67:614-23).

Department of Defense studies have found that the rate of suicides among active duty military have begun to approximate those of the general public, Col. Bradley said.

"We used to believe that we were afforded some protection by our increased selection criteria for becoming a service member, access to health care, health and fitness, wellness, unit cohesion, etc., but now our rates are no better, and we have to ask the question ‘why?’ "

Data from the Post-Deployment Health Assessment, a universal screening instrument for returning service members, show that 25% of those who went on to commit suicide endorsed one of two depression items (hopelessness, loss of interest), 26% endorsed one of four PTSD items (nightmares, avoiding situations/thoughts, constantly on guard, and numb or detached), but only about 2% had reported suicidal thoughts. About 6% said they had sought mental health care in the past month, and 11% said they had been referred for mental health care.

Gunshot wounds are by far the most significant cause of death (from about 56% to 70%), followed by hanging/asphyxiation (18-20%), and drug, poisoning/carbon monoxide, exsanguination, or other causes (all below 10%).

Risk factors

The best predictor of a suicide attempt is presence of a current suicide plan or past attempt, the latter of which is associated with 100-fold risk for a second attempt within a year, but predictive ability is generally poor, Dr. Bradley said.

Other significant risk factors include:

• Family history of suicide.

• Family history of child maltreatment.

• History of mental disorders (particularly depression), alcohol, or substance abuse.

• Feelings of hopelessness or isolation from others.

• Impulsive or aggressive tendencies.

• Cultural and religious beliefs regarding acceptability of suicide.

• Local epidemics of suicide.

• Barriers to mental health treatment access.

• Loss (relational, social, work, or financial).

• Physical illness.

• Easy access to lethal methods (guns, knives, etc.).

• Unwillingness to seek help because of stigma attached to mental health/substance abuse or suicidal thoughts.

Prevention Recommendations

Col. Bradley served on a Defense Department suicide prevention task force that recommended key strategies to prevent suicide in the armed services in four domains:

• Organization and leadership.

• Wellness enhancement and training.

• Access to and delivery of high-quality care.

• Surveillance, investigations, and research.

"During our 19 site visits with military families at different installations across all four services, families and troops told us again and again and again that the major stressor in their lives is the repeated deployments and the lack of quality dwell time that they have in between those deployments to be able to reintegrate, reestablish a baseline, reestablish a support system in order to be successful," Col. Bradley said.

The task force recommended enhancing well-being, mental fitness, life skills, and resiliency of service members and families with programs such as financial management training, marriage and family relationship counseling, anger management, and conflict resolution skills.

Service members and their families also should have ready access to high quality behavioral health care, with continuity of care to ensure timely provision of services and seamless management. The task forces also called for standardized crisis intervention services and hotlines across all branches of the military.

Assessment and Management

The clinician should assess the degree of risk – acute or imminent – and ask the patient about current stressors and potential vulnerabilities over the long term. Col. Bradley and his colleagues employ the SAD PERSONS suicide assessment scale and the Beck Scale for Suicidal Ideation for evaluating patients.

Managing at-risk patients might include stabilizing medical conditions, taking steps to ensure the safety of both the patient and the clinician, and ruling out intoxication or withdrawal as possible causes of suicidal statements or actions. However, even retracted suicidal statements must still be evaluated, Dr. Bradley cautioned.

Treatment options include hospitalizing or committing to a care facility patients at imminent risk, although evidence to support this practice is limited. There is better evidence for suicide-specific therapies, psychosocial support, and medical therapies such as flupenthixol, clozapine, or electroconvulsive therapy.

Col. Bradley emphasized that there is no evidence to support the use of a "suicide contract," in which the clinician elicits a promise from the patient that he/she will not commit suicide.

"The only thing a suicide contract does is make a malpractice lawyer salivate when you’re being taken to court," he said.

The ongoing Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is the largest study of suicide and mental health among military personnel ever undertaken. It is designed to identify modifiable risk and protective factors related to mental health and suicide and will support the Army’s ongoing efforts to prevent suicide and improve soldiers’ overall well-being.

Data were presented at a symposium supported by the Home Base Program, a joint project of the Red Sox Foundation and Massachusetts General Hospital. Neither Dr. Kemp nor Col. Bradley had relevant financial disclosures.