Good news in the battle against military suicide.

Abstract

Suicide among members of the military is a topic of current national importance.Historically, active-dutyU.S. Army soldiers had a lower rate of completed suicide than demographicallymatchedcivilians.However, as therate forcivilians has remained consistent, that for soldiers has escalated in the past decade. As a result, since 2008, the military rate has exceeded the civilian rate (1). This phenomenon has understandably led to a greatly increased emphasis on understanding suicide risk and protective factors among soldiers and to the search foreffectivepreventionprogramsandtreatmentmodels. For example, the Department of the Army and the National Institute of Mental Health have funded the large-scale Army Study To Assess Risk and Resilience in Servicemembers (Army STARRS) (2), which is beginning to yield valuable informationonrisk factors. Simultaneously, treatment researchers are investigating psychotherapeutic methods to reduce suicide ideationandattempts inbothactive-dutyandveteranhealthcare settings (3, 4). In the context of the need for effective treatment of suicidal military members, Rudd et al. (5), in their article published in this issue of the Journal, report on results of an intervention tailored to the demands of an active military setting that is based on the elements of treatment shown to be effectivewith other populations, brief cognitive-behavioral therapy (CBT). They randomly assigned 152 active-dutyArmy soldiers at high risk for suicide to treatment as usual or to treatment as usual plus brief CBT. Participating soldiers were recruited from inpatient and emergency department clinical settings; all of themhadeithera suicideattempt in thepastmonthor suicidal ideationwith intent todie in thepastweek.Treatment asusual could consist of psychotherapy, psychiatric medication, substance abuse treatment, or other support groups. Brief CBT consisted of 12 planned sessions on aweekly or biweekly basis, although there was flexibility in the actual duration of treatment depending on how well the participants mastered the skills that were covered. Assessments were conducted at baseline, and then at 3, 6, 12, 18, and 24 months after baseline, with the primary outcome consisting of the occurrence of suicide attempts over this 2-yearperiod.Results showedthat across all participants, there were 31 suicide attempts by 26 soldiers in the 2 years. Strikingly, those who received brief CBT along with treatment as usual were 60% less likely to make a suicide attempt than thosewho received treatment as usual alone (N58/76 in CBT [13.8%] compared with N518/76 in treatment as usual [40.2%]). The difference could not be attributed to group differences in dropout or in such baseline characteristics as previous suicide attempts or severity of depression. Soldiers participating inCBT also had fewer hospitalization days than those in treatment as usual alone. Despite the dramatic treatment differences for suicide attempts, there were no treatment group differences at any assessment point in current or worstpoint suicidal ideation, hopelessness, depression, anxiety, or posttraumatic symptoms. In other words, the treatment was highly specific in its impact on suicide attempts. The authors acknowledge limitations of the study, above all, the amount of missing data on self-reported hopelessness, depression, anxiety, and posttraumatic stress symptoms over time. However, suicide attempts were assessed by in-person or telephone interviews and therefore were less affected by missing data. A second limitation is that the sample was 88%male, indicating the need for further study of suicide prevention among female soldiers. This limitation has taken on more significance since the recent publication of initial findings from the Army STARRS project, showing that active-duty women had higher odds of making a suicide attempt than men (6). These findings are extremely good news in the search for solutions to what has been appropriately designated as the “vexing challenge” of increasedmilitary suicide rates (7). Are the results credible in the context of related research, and what can we learn from them about effective psychotherapy more generally? First, is it credible that a treatment can have major and specific impact on suicidal behavior without having differential impact on associated symptoms? This type of specificity of skills-based treatment models that address suicide risk is not without precedent. Dialectical-behavior therapy, which includes group-based skills training and individual psychotherapy, initially proved effective in comparison to treatment as usual in decreasing suicidal behavior without