Several months ago a statement was released by the military that a 2-star General in the Army had taken his own life. Prior to his loss he had spoken with great concern about the incidence of suicides within the Armed Forces. His rank and stature make his suicide unique; however, his death also poignantly illustrates the complexity of the problem of suicide within the military and the need to find greater understanding about this phenomenon. Part of this understanding must come from a look at the personal narratives and beliefs that may contribute to suicides within the military.
In September 2015 The New York Times published an article by Dave Philipps1 that told the story of a Marine battalion that had lost 13 men to suicide since their return from combat in Afghanistan. I had that article laid out on my dining room table for over a week after its publication. I studied the photos and slowly read and reread the words—the story brought forth the pain and challenges that these men were facing. There seemed to be great isolation in their lives, and there was no escape from the struggle that followed their experiences in combat.
War and the multitude of experiences that come with it had eroded their view of self and the world in general. As the suicides marched through the battalion, the psychological strain experienced by the others increased. They became haunted by the past and present. Although many of them had engaged in psychological and psychiatric treatment, it was the rebuilding of the connection between those that remained that seemed to be most beneficial.
A surge of suicides
Suicide among active-duty personnel and veterans has become something of an epidemic. It has gripped the attention of military commanders and veteran advocacy groups, as well as clinicians and the general public. There was a time when the suicide rates in the military were far lower than in the general population. This was thought largely to be secondary to the innate social support that comes with military service, as well as the screening out of major mental illness. However, over the past decade and a half the rate has increased dramatically.
In several branches of the Armed Services the rate of suicide has surpassed that of the general population. The most recent publicly available suicide data from the Department of Defense demonstrate an overall unadjusted suicide rate of 19.9 per 100,000 Armed Services members, with the Army having the highest rate of 23.8 per 100,000.2 This is in contrast to the US national rate during the same year of 13 per 100,000.3
It would be logical to attribute the surge of suicides to the simultaneous prolonged engagement in combat operations, repeated deployments, and the stress that comes from this. Stories and anecdotes, such as the one from Dave Philipps in The New York Times,1 seem to support that idea. However, at least 2 relatively recent studies have failed to connect deployments to the risk of suicide: one published in 2013 in JAMA, the other in 2015 in JAMA Psychiatry. Their findings suggest that other factors are at play, including mental health conditions, substance use disorders, and early transition from the military.4,5
In contrast, an article published this year in Lancet Psychiatry notes an increased risk of suicide among those previously deployed in support of Operation Enduring Freedom/ Operation Iraqi Freedom.6 There was no increased risk of suicide during deployment or in the first quarter after deployment, but the risk of suicide increased as time went by after the return. Also confirmed was the increased risk in those with mental health conditions (except PTSD). The risk was especially prominent in persons with a history of self-inflicted injuries. An elevated risk was also seen in early separation from the military as well as sustained risk following separation.
Dr. Brown is currently a Fourth-Year Psychiatry Resident at the Naval Medical Center in San Diego, CA; he serves as the Chief Resident of the Consult/Liaison Service.
Dr. Brown reports no conflicts of interest concerning the subject matter of this article.
1. Philipps D. In unit stalked by suicide, veterans try to save one another. New York Times. September 19, 2015. https://www.nytimes.com/2015/09/20/us/marine-battalion-veterans-scarred-by-suicides-turn-to-one-another-for-help.html?_r=0. Accessed January 30, 2017.
2. Smolenski DJ, Reger MA, Bush NE, et al. Department of Defense Suicide Event Report (DoDSER): Calendar Year 2014 Annual Report. Washington, DC: US Department of Defense; 2014.
3. Curtin SC, Warner M, Hedegaard H. Increase in suicide in the United States, 1999-2014. NCHS Data Brief, no 241. Hyattsville, MD: National Center for Health Statistics; 2016.
4. LeardMann CA, Powell TM, Smith TC, et al. Risk factors associated with suicide in current and former US military personnel. JAMA. 2013;310:496-506.
5. Reger MA, Smolenski DJ, Skopp NA, et al. Risk of suicide among US military service members following Operation Enduring Freedom or Operation Iraqi Freedom deployment and separation from the US military. JAMA Psychiatry. 2015;72:561-569.
6. Shen YC, Cunha JM, Williams TV. Time-varying associations of suicide with deployments, mental health conditions, and stressful life events among current and former US military personnel: a retrospective multivariate analysis. Lancet Psychiatry. 2016;3:1039-1048.
7. Joiner TE Jr, Van Orden KA, Witte TK, Rudd MD. The Interpersonal Theory of Suicide: Guidance for Working With Suicidal Clients. Washington, DC: American Psychological Association; 2009.
8. Junger S. Tribe: On Homecoming and Belonging. New York: Twelve; 2016.
9. National Public Radio. Suicides Cast a Pall Over Marine Reunions. May 20, 2016. Accessed January 30, 2017. http://www.npr.org/2016/05/12/477758580/suicides-cast-a-pall-over-marine-reunions?utm_content=bufferafe27&utm_medium=social&utm_source=twitter.com&utm_campaign=buffer.
10. Johnson BD. Durkheim’s one cause of suicide. Am Sociol Rev. 1965;30:875-886.
11. Bryan AO, Bryan CJ, Morrow CE, et al. Moral injury, suicidal ideation, and suicide attempts in a military sample. Traumatol. 2014;20:154.