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It would be logical to attribute the surge of suicides in the military to simultaneous prolonged engagement in combat, repeated deployments, and attendant stress. But studies have failed to connect deployments to suicide risk.
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.
Despite the growing collection of suicide-related data, there is scant evidence that supports the effectiveness of suicide prevention programs within the Armed Forces. It is reasonable to believe that the ongoing epidemiological studies of suicide will help to define a construct to establish effective suicide prevention measures. In addition to the statistics, there are conceptual models and theories that warrant attention.
The Interpersonal Theory of Suicide has merit and importance within this population. It may provide a model to help clinicians better understand the risk of suicide among those who have served our country by lending a framework with which to explore the individual’s personal narrative.
The Interpersonal Theory of Suicide, developed by Thomas Joiner,7 asks “Why do people die by suicide?” and answers “Because they can, and because they want to.” The theory states that the desire to die by suicide emerges from a perception of burdensomeness and of failed belonging, and the capability to do so is acquired. If these domains are examined with the available military suicide data as well as with an eye to the experiences of service members, the significance of this theory becomes apparent.
Protective factors of belonging
A sense of belonging is an important force in our social, psychological, and emotional functioning. The military is a closed community of individuals with a common purpose and experience. It seems that military service on its own may provide members with a sense of belonging. Within the military there are individual units that provide an even greater and more defined sense of belonging.
Sebastian Junger’s8 recent book, Tribe: On Homecoming and Belonging, explores the sense of belonging within combat units. He argues that the intensity of shared objectives within combat ties individuals together in a very primal and natural way. This can be coupled with concrete data of reduced suicide risk during and immediately after deployment as evidence for the increased sense of belonging and the protective virtue of this.
Data also point to an increased risk of suicide with the passage of time after deployment, as well as with separation from the military. This may suggest that as units dissolve and people with the shared experiences withdraw, so does their sense of belonging. General Robert Neller, the commandant of the US Marine Corps, recently coordinated a reunion for an infantry unit that had become plagued by suicides in the years following their return from Afghanistan. When asked about this during an interview on National Public Radio, he stated, “. . . when units are together, that’s when they are the strongest.”9
The sense of belonging can also be extended to other recently described risk factors for suicide among service members: namely, the evidence that there is an increased risk among those whose service was ended early. It does not take much to imagine an individual who joins the military in search of belonging only to have this cut short with early separation from the military; consequently, he or she is never able to establish the esprit de corps that can come with successful service.
Durkheim believed that social integration, or the “common conscience” of a society, played a significant role in suicides.10 It was Durkheim’s assertion that groups with a “weak common conscience” had higher rates of suicide. This is an early concept that is in keeping with the idea of failed belonging and evidence of the importance of this particular theme within suicides.
Perception of burdensomeness
The perception of burdensomeness comes down to the idea that one’s death will lead to a benefit for others. This is likely most common in the form of such extreme self-loathing or guilt that one is led to believe that his mere existence is causing some level of perceived harm to others. The New York Times article described experiences during combat that left troops with great remorse and guilt-experiences that ingrained a sense of regret or betrayal.1 This is consistent with the described phenomenon of moral injury, which has been demonstrated to have a relationship to suicidality.11
On the other end of the spectrum is the individual who never deployed and was separated early from the military for disciplinary or other causes. In this scenario the individual may be left feeling like a failure in the eyes of his family or friends, which leads to the belief that he is bringing those people down in some way. This scenario might be consistent with the data on suicide that illustrate an increased risk of suicide in persons who never deployed and were separated relatively early in their military career. Even if the reason for early separation was a preexisting mental condition, this concept may still apply-a mental illness may increase the risk of suicide, but it is not the cause per se.
Some evidence suggests that combat and military training offers the necessary habituation to the fear of painful experiences in order to carry out a lethal act of self-harm. However, as many of the recent suicides in the military are among those who have never deployed or seen combat, engagement with an enemy cannot be the only source of acquired capability. At a minimum there are clear data that indicate that persons within the military with a history of self-inflicted wounds have a substantially greater risk of completing suicide.6
The identification of independent risk factors for suicide is important in bringing understanding to the phenomenon of suicide as well as in identifying individuals who may be at increased risk. In addition, conceptual models of suicide risk carry their own significance. People have stories and thoughts and emotions that build a concept of themselves and the world. The narratives that people build inform their decisions in life and in many cases inform their manner of death through suicide. The Interpersonal Theory of Suicide offers a framework to explore potential suicide risk, which may be especially helpful within the context of those who serve and have served in the military.
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.