Managing Acute Suicidal Ideation in a Forward Deployed Location in Afghanistan

Abstract

In 2010, 30 military service members committed suicide in deployed locations, 29 of which were in either Afghanistan or Iraq. There were an additional 46 suicide attempts by military personnel in deployed locations. Approximately 180,000 military personnel were deployed to Iraq and Afghanistan during 2010, which equates to a suicide rate of 16.8 per 100,000 in the deployed setting, higher than the reported overall suicide rate in the United States during the same year, 12.2 per 100,000. Managing acute suicidal ideation and behavior in the deployed setting can be a difficult task because of the nature of the environment, lack of resources, and a lack of evidence-based guidance on this topic. A call is received from a battlefield Commander or First Sergeant. They state, “PFC Snuffy told his squad leader that he was thinking about shooting himself with his M4 because he just found out his wife is cheating on him. What should we do?” The frequency that the above scenario, or variations of it, occurred during the authors’ recent deployment is the main reason that the subsequently described model was originally developed. Without it, we would have had to “reinvent the wheel” several times per week—not exactly an effective use of resources. This article outlines a practical approach for managing service members with acute suicidal ideation in a deployed setting, which was developed and used by the authors while deployed in 2012 to Forward Operating Base (FOB) Fenty’s Combat Stress Control (CSC) Clinic, located in eastern Afghanistan. The approach is based on the guidance provided by Army Field Manual 4-02.51, Combat and Operational Stress Control (COSC), specifically the concept of the Soldier Restoration. Our approach uses the COSC management principles of brevity, immediacy, contact, expectancy, proximity, and simplicity (BICEPS), which apply to all COSC interventions or activities throughout the theater, and the actions used for Combat and Operational Stress Reactions (COSR), commonly known as the 5 R’s: reassurance of normality, rest, replenish, restore confidence, and return to duty. One of the primary roles of the CSC Clinic is to assist battlefield Commanders with the management of safety concerns resulting from behavioral health issues among their service members. There is an emphasis on acute suicidal ideation. The model that will be discussed in this article will be referred to as “The Three Day Rule,” or “The Rule.” The origin of our model is a modification of the premise of COSC Soldier Restoration, typically a 1 to 3 day program where Soldiers with COSR receive treatment applied using BICEPS and the 5 R’s, briefly discussed earlier.