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Article Excerpt
Suicide is a significant public health concern within the United States' military. Suicide may occur before, during, and after military deployment or service for a multitude of reasons that may or may not be directly related to deployment. Therefore, it is crucial that mental health counselors are trained to identify risk at an early stage so they can offer evidence-based practices to manage and reduce it. Enhanced understanding of the similarities and differences in suicide risk and protective factors for civilian and military individuals is crucial for counselors who work directly with Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) active-duty personnel, veterans, and family members. This review aims to educate counselors about the role of demographic, life event, psychopathology, and behavioral and psychological variables in exacerbating or alleviating the desire to die. The information presented is based on an electronic search of medical and psychological databases for terms related to suicide by military service members. Recommendations related to identification, prevention, and management of suicide risk in OEF/OIF service members and beneficiaries are presented.
Public Health Significance of Suicide
Suicide is a serious public health problem throughout the world. Globally it accounts for nearly half of all violence-related deaths (World Health Organization [WHO], 2006). In the United States (U.S.) suicide is the 11th leading cause of death, with about 30,000 deaths annually (Centers for Disease Control [CDC], 2007). Among those aged 15-24 suicide is the third leading cause of death, at a rate of 10.3 per 100,000 (U.S Department of Health and Human Services [DHHS], 2004). In the U.S. between 1999 and 2004, 54.6% of suicide deaths were attributed to firearms, 20.4% to suffocation, and 17.2% to poisoning (CDC). On average, more than 80 Americans die by suicide every day. Males are four times more likely to die by suicide than females (CDC, 2006). One common assumption for this disparity' is related to the method of suicide: males use firearms in 50-60% of cases (CDC, 2007).
The National Mental Health Association (2006) estimates that there are 500,000 nonfatal suicide events in the U.S. every year. In 2002 more than 90,000 hospitalizations and 324,000 emergency room evaluations were attributed to nonfatal suicide events (CDC, 2004). Moscicki (2001) found that 2-5% of the U.S. population has attempted suicide at some point. Of about 6,000 respondents aged 15-54 responding to the National Comorbidity Survey (NCS), 13.5% had experienced suicide ideation, 3.9% had engaged in some type of preparatory behavior, and 4.6% had attempted suicide (Kessler, Borges, & Walters, 1999). Suicide death and injuries in the U.S. are estimated to result in over $25 billion annually in direct costs and such indirect costs as lost productivity (CDC, 2006).
The U.S. active-duty military is comprised predominantly of young male adults; about 50% are aged 17-26 (Eaton, Messer, Wilson, & Hoge, 2006). According to CDC data (2004), suicide is the third leading cause of death among this age group generally. In the U.S. military, suicide has historically ranked as the second leading cause after accidents (Ritchie, Keppler, & Rothberg, 2003). In 2005, the reported Department of Defense (DoD) average suicide rate was 11.4 per 100,000 (ranging from 8.9 for the Air Force to 13.7 for the Army). Carr, Hoge, Gardner, and Potter (2004) suggested that correcting reporting and classification mistakes might increase suicide rates in the military by as much as 21%. To date, there are no reliable data on suicide attempts in the military. Recent findings from the Post-Deployment Health Assessment survey (Hoge, Auchterlonie, & Milliken, 2006) indicated that of 222,620 soldiers and Marines returning from Operation Iraqi Freedom (OIF), 1.1% (n = 2,411) reported "some" suicide ideation and 0.2% (n = 467) reported "a lot."
Purpose and Methodology of Current Review
The U.S. National Strategy for Suicide Prevention identifies suicide as a "public health problem that is preventable." One of its goals is the development and promotion of effective clinical and professional practices (U.S. Public Health Service [USPHS], 2001, p. 46). The DoD and the Department of Veterans Affairs (DVA) have demonstrated their commitment to preventing suicide by funding research on military suicide, setting up groups like the DoD Suicide Prevention and Risk Reduction Committee, and providing training, such as the Military Suicide Prevention Conference.
Enhanced understanding of the similarities and differences in suicide risk and protective factors for civilian and military individuals is crucial for mental health counselors who work directly with Operation Enduring Freedom (OEF) and OIF active-duty personnel, veterans, and family members. Our review of the literature highlights unique assessment and treatment implications that need to be carefully considered when working with these clients. Because suicide behavior may occur before, during, and after deployment or service for a multitude of reasons that may or may not be directly related to deployment, it is crucial that we as counselors identify the risks early and offer evidence-based practices to manage and reduce them.
This review is based on a search of the electronic databases of PsycINFO and PubMed for terms related to suicide in military service members. Various combinations of the following search terms were used: suicide, prevention, military, deployment, risk factors, protective factors, OEF/OIF. A review of the abstracts determined whether the queried articles were relevant. Government sites were also searched for documents related to specific subtopics. In some cases reference lists of articles were used to locate and verify source documents.
CIVILIAN RISK AND PROTECTIVE FACTORS FOR SUICIDE BEHAVIOR
Risk and protective factors identified for the civilian population will serve as a point of comparison for this review of the literature pertaining to the military. A risk factor is any hazard that increases the likelihood of suicide behavior. A protective factor in general reduces or prevents the likelihood of suicide behavior and at times may counteract the deleterious impact of risk factors (Substance Abuse and Mental Health Services Administration [SAMHSA], 1999).
Risk Factors
Demographic. Although the elderly account for about 10% of the U.S. population, they account for 20% of national suicide deaths (Hoyert, Arias, Smith, Murphy, & Kochanek, 2001). The highest suicide rate consists of men 75 and older (Pearson, Conwell, Lindesay, Takahashi, & Caine, 1997). While females attempt suicide more often than males, the aggregate U.S. suicide rate of females from 1999-2004 was about four times less than for males (CDC, 2007). Divorce, particularly for males, has long been considered a risk factor (Goldsmith, Pellmar, Kleinman & Bunney, 2002; Kposowa, 2000). White and American Indian/Alaska Native males and females have consistently (1950-2005) had the highest suicide rates of all races (DHHS, 2007).
Clinical Psychopathology. Although most individuals with a mental disorder do not engage in suicide behavior, the majority of those involved in suicide events have some clinical psychopathology. Overall, a mood disorder (particularly major depressive disorder) is antecedent to 30-90% of all suicide deaths (Arsenault-Lapierre, Kim, & Turecki, 2004; Isometsa, 2001; Rihmer, 2007). The second most often co-occurring mental disorder among those who die by suicide, present in 26-55% of deaths, is a substance-related disorder (Rihmer, 2007). Among drug-related suicide attempts by individuals 18 or older, 33.2% involve alcohol, 28.4% illicit drugs like cocaine or marijuana, 58.9% psychotropic medications, and 36% pain medications, such as opioids, nonsteroidal anti-inflammatory agents, and acetaminophen (SAMHSA, 2006). Cavanagh, Carson, Sharpe, and Lawrie (2003) found that comorbidity of mental disorder and substance disorders preceded deaths in significantly more suicide cases (38%) than nonsuicide controls (6%).
Behavioral and Psychological Features. Histories of suicide attempt or hospitalization, family history of suicide, impulsivity, hopelessness,...
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