Preventing Suicides in US Service Members and Veterans

Abstract

BEFORE THE WARS IN IRAQ AND AFGHANISTAN, THE INcidence of suicide in active duty US service members was consistently 25% lower than that in civilians, attributable to “healthy-worker” effects from career selection factors and universal access to health care. Between 2005 and 2009, the incidence of suicide in Army and Marine personnel nearly doubled. From 2009 through the first half of 2012, the incidence of suicide among Army soldiers remained elevated (22 per 100 000 per year), with the number dying of suicide each year exceeding the number killed in action. High rates of suicide have also been reported for US veterans, although incidence studies in veteran populations have drawn conflicting conclusions. The pressing question is why suicides increased so markedly in soldiers and Marines, but not in Navy or Air Force personnel (or in civilians). An obvious answer would be repeated ground combat tours. However, to date no study has definitively confirmed an independent association with deployment variables. This may be due to confounding factors such as higher service attrition for personnel with deployment-related mental health problems (contributing to healthy-worker effects). The optimal way to study militaryspecific risk factors is to follow individuals longitudinally beyond the time of their service, an endeavor few research groups are able to undertake. Although longitudinal studies may eventually establish deployment associations, current evidence suggests that such associations are likely to be weak and not independent of well-established risk factors, especially underlying mental health problems. A logical explanation for the high suicide rates in soldiers and Marines is the cumulative strain from the protracted war effort, across both deployed and garrison environments, causing higher population prevalences of mental disorders. If this explanation is accurate, the most effective medical intervention strategies are those that facilitate access to effective treatment. Determining the value of intervention strategies requires reliable effectiveness measures. However, military and veteran suicide research is hampered by problems with determination of “veteran” status on surveillance records; misclassifications of the manner of death; lack of integration of data from the US Department of Defense (DOD), Department of Veterans Affairs (VA), and National Death Index; and wide rate variability in population subgroups. Pressures exist to rapidly implement multicomponent prevention programs. However, apparent program successes based on observational evidence (eg, Air Force effort in the 1990s) cannot be replicated without knowing which components contributed to effectiveness. As the war effort in Afghanistan draws down, caution is advised in attributing future reductions in suicide rates to specific programs. Attention must stay focused on the most promising suicide intervention strategies within the broad categories of screening, education, and treatment, considering also potential iatrogenic effects.