SUICIDE AND THE UNITED STATES ARMY: Perspectives From the Former Psychiatry Consultant to the Army Surgeon General
by Col (Ret) Elspeth Cameron Ritchie
The DANA Foundation, Jan. 25, 2012
Editor’s note: The suicide rate of active-duty soldiers doubled between 2003 and 2010. In response, the Department of Defense and the United States Army improved their data collection methods to better understand the causes of military suicides. As retired colonel Dr. Elspeth Cameron Ritchie writes, unit history and the accumulation of stressors—from relationship problems to chronic pain—are significant suicide risk factors among soldiers. But, she argues, Army officials must use this knowledge to design more-effective strategies for suicide reduction, including limiting access to weapons, especially post-deployment, and better connecting soldiers with their communities.
Headlines in late 2011 lauded the end of combat operations in Iraq, celebrating the thousands of troops who are finally able to return home from the “sandbox.” But tens of thousands remain in Afghanistan, and will be there for an undetermined length of time. While homecoming for some soldiers, sailors, marines, and airmen may be imminent, reintegration into family and civilian life after deployment is filled with challenges. Hundreds of thousands of troops have so-called “invisible wounds of war,” post-traumatic stress disorder and mild traumatic brain injury. And the suicide rate has climbed steadily since the war in Iraq began.
The rate of suicide in the United States Army active-duty force remained relatively stable from 1990 to 2003, hovering at about 10 per 100,000 per year. This is approximately half the civilian rate. But in 2004 it began to rise, and from 2003 to 2010 the suicide rate for this group doubled, to about 21 per 100,000. Then the rate finally began to level off among active-duty soldiers, but it continued to rise among National Guard soldiers, although it remained relatively stable for those in the Navy and Air Force.
The rate of suicide remains twice as high as it was before the wars in Iraq and Afghanistan, so high that some have described the current situation as an epidemic. The increased rate commanded the attention of the highest military officers from all the branches of the service and the Department of Defense (DoD), and for the last five years or so, several ongoing, high-profile efforts have been made to better understand what may underlie these alarming statistics, and to determine how to prevent further suicides.
In the last three years, the Department of the Army and the Department of Defense each created task forces charged with the singular mission of better understanding the precipitants of military suicide—especially those that may be unique to this particular population. The task forces have looked at multiple issues, including mental health and medical care, screening, and personnel selection.
The two reports published by the task forces contain several hundred recommendations, including better military-wide education about the realities of suicide, standardized treatment protocols for at-risk soldiers, and expanded primary health screenings that will include behavioral health assessments. In addition, the Army and the National Institute of Mental Health (NIMH) are cosponsoring an ongoing $50 million study known as the Army Study to Assess Risk and Resilience in Servicemembers, or STARRS.
The ultimate goal of this study is to develop data-driven methods for mitigating or preventing suicidal behaviors and improving the overall mental health and behavioral functioning of soldiers during and after their Army service. But even as the military moves vigorously to implement key recommendations, including better education and training in the armed forces from the leadership down, the suicide rate remains stubbornly high.
Sources of Data
The Army has assembled some very good data on completed suicides from the last 10 years, partially in result of a change in its data-collection practices. The use of the routine “psychological autopsy” ended in 2001. The psychological autopsy was a long narrative seeking to describe the motivation for suicide in the deceased. Now formal psychological autopsies are mandated only when the cause of the death is undetermined.
The Army Suicide Event Report, or ASER, replaced the psychological autopsy. Implementation of the ASER, which began in 2003, gradually grew more robust, collecting data not only about the manner of death but also about events and factors thought to be involved with the suicide. ASERs have been performed for all active-duty soldiers who died by suicide since about 2004. The ASER is a Web-based quantifiable instrument, with data fields including demographic and clinical information, as well as information about the cause and manner of death.
… reports are not routinely done for reserve soldiers. Most researchers believe that suicide is underreported in the reserves – Col (Ret) Elspeth Cameron Ritchie
Thus it is easy to sort the information in numerous ways. Data on all known active-duty Army suicides are entered into an automated system and published as a composite report. The ASER later expanded its scope to include suicides from all the services, and was re-named the DoD Suicide Event Report, or DODSER, implemented in 2005. Similar to the former composite ASER Report, data on all known active-duty suicides from all the services are entered into an automated system and published as a composite report.
Researchers from the Army’s Public Health Command published in 2011 the composite Army data from 2003 to 2009,6 and this article draws heavily upon those data. (The other services are not currently publishing their own individual composite reports.)
In addition, over the last 10 years, a number of epidemiological consultation teams (EPICONs) have conducted reviews at Army bases that have experienced high suicide or homicide rates. And staff assistance visits and other investigations have contributed to the search for information as to the causes of suicide.
Mental Health Advisory Teams (MHATs), led by Army researchers from the Walter Reed Army Institute of Research (WRAIR), have administered surveys in Iraq and Afghanistan roughly once a year. These anonymous surveys ask about depression and PTSD symptoms, as well as barriers to care. Several of them, especially the fifth one, MHAT V, looked very closely at suicides in the theater of war. I was part of a suicide assistance visit to Iraq in 2007, when the suicide rate there was peaking.
An important caveat is that less is known about suicides in the reserve components of the services. Only in the last few years has the Army been able to collect good data on Army reserve suicides, and they have not been systematically studied in the same way as active-duty data. ASER reports are not routinely done for reserve soldiers. Most researchers believe that suicide is underreported in the reserves.
Risk Factors for Suicide
For at least the last 20 years, the highest risk factors for committing suicide in the military were being young, white, and male. Of course, given that the vast majority of service members are young and male, those data points were not particular surprising. There have been relatively few completed suicides among women (usually two to three a year, although one year the number peaked at nine). Being Caucasian, rather than black or Hispanic, is also a risk factor.
Both old and new research has highlighted clear precipitants in the majority of military suicides, especially relationship breakups and getting in trouble at work. For years, about two-thirds of suicides appeared to be triggered by a breakup, and another third involved a humiliating event at work, threatening the job. In many cases, both factors are in play, so the percentages are not mutually exclusive.
Typically a humiliating event appears to trigger the self-destructive behavior. That event might include relationship difficulties with parents or members of the unit, not just with romantic partners.
A recently published article, which I coauthored, documents the data from known suicides in the Army from 2003 to 2009, which support the idea that military suicides are often relatively impulsive, again related to a psychosocial imminent stressor or stressors. The article also highlights the stress load, as defined by the accumulation of multiple stressors, including relationship breakups, job difficulties, and physical problems that many soldiers experience during their active-duty careers.
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