Soldier Suicide Rates Continue to Rise

Suicides among active-duty soldiers in the US Army reached a 28-year high in 2008, continuing a 4-year trend that has persisted despite ongoing military efforts to curb such deaths.

In the face of these grim statistics, Army leaders are redoubling their efforts to address this problem and have recruited scientists at the National Institute of Mental Health (NIMH) to probe the underlying causes of suicide in this population and identify effective interventions.

The annual number of suicides among soldiers on active duty in the Army, Army Reserve, and Army National Guard has risen steadily from 67 in 2004 to at least 128 in 2008. The 2008 figure is likely to top 140 because another 15 cases are under investigation; about 90% of such cases ultimately are ruled to be suicides, said Master Sergeant Marshall Bradshaw, program manager of the Army Suicide Prevention Program, according to a transcript from a January 29 roundtable discussion on the 2008 suicide rates. This revised total would raise the suicide rate among active-duty Army personnel to 20.2 per 100 000 in 2008, surpassing the suicide rate among civilians with similar demographics, which was 19.5 per 100 000 in 2005 (the most recent year for which data are available from the national Centers for Disease Control and Prevention [CDC]).

Suicides among non–active-duty Army Reserve and National Guard troops also have risen substantially since 2004, when 15 cases were confirmed. However, the number of suicides among these non–active-duty forces actually dropped from 61 in 2007 to 43 in 2008.

Suicide rates among veterans also have risen. In 2004, there were 35.4 suicides per 100 000 male users of Department of Veterans Affairs (VA) medical care and 12.3 suicides per 100 000 female users. These rates rose to 37.2 suicides per 100 000 for men and 13.6 suicides per 100 000 for women in VA care in 2005 (the latest data available), according to 2008 testimony before Congress by then-Secretary of Veterans Affairs James B. Peake, MD. These data were derived by cross-referencing the names of veterans receiving VA care with the CDC's National Death Index.

A 2008 analysis of the mental health care needs of service members and veterans, conducted by the nonprofit RAND Corporation, found that many troops returning from deployment have serious psychiatric conditions or injuries that may increase the risk of suicide (http://veterans.rand.org). Yet despite efforts by the military and the Veterans Health Administration to better identify and treat individuals with these conditions, gaps in care persist.

Nearly one-third of troops returning from military service in Iraq or Afghanistan have experienced a traumatic brain injury or meet criteria for major depression or posttraumatic stress disorder (PTSD), according to a RAND survey of about 2000 such individuals. But only about half of these individuals seek treatment, and of those who do, only about half receive care that is at least minimally adequate.

The analysis found that substantial barriers to care persist. Too few mental health care workers or long wait times, particularly at VA facilities, may prevent some people from getting care. Many respondents reported the fear that seeking mental health care would have negative consequences on their career or undermine their coworkers' trust.

The authors of the analysis recommended offering confidential care, with exceptions when a soldier poses a threat to himself or herself or others, to help overcome such concerns. Terri Tanielian, coauthor of the report and codirector of the RAND Center for Military Health Policy Research, explained that if confidential care were available, soldiers might seek help earlier, which may prevent poor outcomes, including suicides.

Even when individuals do receive help, it often does not meet criteria for adequate care. The RAND analysis recommended that the Department of Defense and the Veterans Health Administration enhance their efforts to promote high-quality mental health care.

Over the past few years, the US Department of Defense and the Veterans Health Administration have taken several steps to improve mental health services for personnel returning from deployments and for veterans. For example, both agencies have expanded screening and treatment for PTSD and depression in primary care settings (Kuehn BM. JAMA. 2008;299[16]:1885-1886). They also have launched efforts to reduce the stigma surrounding mental illness among service members and to promote mental as well as physical wellness. For example, in 2006, the Army launched the BATTLEMIND program, which offers soldiers predeployment training on skills for coping with battle and provides postdeployment training for service members and their spouses on readjusting after deployment.

During the January roundtable discussion, General Peter Chiarelli, vice chief of staff for the Army, announced that over the next several months the Army will redouble efforts to educate officers and soldiers about suicide and Army suicide-prevention programs, such as the “Ask, Care, and Escort” program, and to encourage those in need to seek help.

“We have to change our culture,” said Chiarelli, according to the roundtable transcript. “[I]n the services and in the Army in the past . . . people have feared to reach out because they thought that it might affect their career.”

In particular, many soldiers have been concerned that seeking mental health care would prevent them from getting security clearances necessary for advancement. Previously, security clearance questionnaires asked soldiers to report whether they had sought such care. However, Chiarelli said during the roundtable that the question has been changed. Soldiers do not have to report seeking such care under most circumstances, and indicating that they have sought care will not prevent them from obtaining clearances, he said.

Carolyn B. Robinowitz, MD, a former president of the American Psychiatric Association, acknowledged the efforts of military leadership to decrease stigma and improve care, but said that the message that it is okay to seek care may not be taking hold among the rank and file. She encouraged senior officers who have sought care for psychiatric problems to come forward with their stories, to demonstrate that treatment can help and does not preclude the possibility of advancement.

The precise reasons for the increase in suicides among members of the military in recent years are not clear. The ongoing conflicts in Iraq and Afghanistan have undoubtedly increased stress on military personnel and their families, and such stress is clearly a factor, Army officials acknowledged at the roundtable.

About two-thirds of the 446 soldiers who have committed suicide since 2005 have done so during a deployment or after returning from a deployment, and about one-third had never been deployed, according to statistics provided by the Army. More than half of the postdeployment suicides occurred more than a year after return from deployment, and the majority (78%) of those who committed suicide while deployed were on their first tour.

Robinowitz said it is not clear why so many young soldiers are taking their lives, but that it is likely that multiple factors are involved. She noted the concern of some clinicians about the effect of extended deployments of soldiers, who live under constant threat of guerilla attacks during their time in the theater. Some individuals may be more vulnerable to such stress. Family stress during long deployments or challenges of readjusting to life back at home may also increase a soldier's distress. In an effort to cope, some individuals may abuse alcohol or other drugs, a behavior that further increases their suicide risk.

To probe such factors, the Army entered into an agreement with the NIMH in October to collaborate on a 5-year, $50-million prospective study of suicidal thoughts and behavior among soldiers. The study will follow up men and women at various stages of service, including entry into the Army, through deployment and after return, and after separation from the service.

Robert K. Heinssen, PhD, chief of the adult treatment and preventive interventions branch of the NIMH, explained that the project will be modeled after the Framingham Heart Study, which followed a population over time to identify how a multitude of interrelated factors may contribute to or protect against cardiovascular disease. The Army study will also try to identify factors that—alone or in concert with other influences—may make individuals vulnerable to suicidal thoughts or behaviors. It will also try to tease out traits that may make individuals more resilient to stress. The ambitious study may also include genetic information and interpersonal factors and life events. Scientists also may try to gauge soldiers’ physiological responses to stress, for example, by measuring cortisol levels in saliva.

Because of the urgent nature of the problem, the NIMH and academic centers that are chosen to participate will quickly share relevant data with the Army. Participating scientists are expected to be agile enough to quickly identify trends in the data and pursue new lines of inquiry as needed. The data will also be used to design tests of potential interventions based on the evidence, although performing such tests is beyond the scope of the project. More details about the project are available at http://grants.nih.gov/grants/guide/rfa-files/RFA-MH-09-140.html.

Heinssen noted that while the Army's immediate concern is helping soldiers and their families, this study should contribute greatly to the overall understanding of suicide. He explained that the study will most likely be the largest examination of suicide ever conducted, and that conducting such a study outside the military may be impossible.

“The results from this study will have tremendous scientific and public health impact for the nation,” he said.