Written in Collaboration with George Maliha and Anita Mathews
George Washington once said that "the willingness with which our young people are likely to serve in any war, no matter how justified, shall be directly proportional to how they perceive the Veterans of earlier wars were treated and appreciated by the nation." Indeed, America holds in high esteem our military members and veterans, honoring them for their service. This respect for the military -- as well as providing service members with benefits for housing, food, and health care -- is essential to maintaining morale as well as ensuring a stream of qualified recruits into the all-volunteer force.
However, there is a growing threat confronting our brave military men and women. Suicide rates among service members, which have reached a 30-year high, have become a significant public health crisis that must be addressed. While military service has historically been protective against suicide among active duty personnel, the dramatic rise in the suicide rate since 2005 among this population group indicates that this is no longer the case. On average, one suicide a day occurs in the military, and the number of service members who took their lives this year has surpassed the number killed in combat. There has been an 18 percent increase in suicide among active duty military members over the past year alone. Among men in the general population ages 17-60, suicide represents 7 percent of deaths but 20 percent of deaths among men of this age in the military. And while veterans represent 10 percent of the U.S. general population, 20 percent of suicides in America occur in this population group.
What are the reasons for this alarming increase in military suicides?
Unfortunately, despite years of study, the reasons for the rising suicide rates in the military are not fully understood. In 1985, I developed a model for understanding suicide in the general population as the result of a complex process by which protective factors -- treatment, counseling, social supports, and other elements -- are inhibited while promoting factors -- mental illness (including depression and post-traumatic stress disorder (PTSD)), substance and alcohol abuse, stress, battle injuries, marital problems, financial difficulties, a humiliating or very stressful life experience, access to a lethal method, and other influences -- are heightened (see Figure 1).
Figure 1. Promoting and Protective Factors for Suicide (Modified from Blumenthal, S. J. (ed), Suicide over the Life Cycle, American Psychiatric Press, Washington, D.C., 1990.)
Among soldiers in the military, a reported 20 percent had a history of substance abuse, 7 percent a history of major depression, 5 percent were suffering with PTSD, and 3 percent had a traumatic brain injury (TBI). According to the U.S. Department of Defense (DoD) and Centers for Disease Control and Prevention (CDC) statistics on suicides in the military:
- 95 percent of military suicides are among enlisted members.
- 95 percent are male.
- 83 percent of the suicides occurred in the U.S. and 10 percent in Iraq or Afghanistan.
- 80 percent are Caucasian.
- 41 percent had a recent outpatient behavioral health service.
- 38 percent had served in Afghanistan or Iraq.
- 47 percent are under the age of 25.
- 34 percent had communicated their suicide intent.
- 30 percent had a personal relationship difficulty in the previous month.
- 20 percent had been prescribed antidepressants.
- 14 percent had exhibited prior suicidal behavior.
- 11 percent had been in combat.
- 6 percent had seen someone killed in combat. Information from Time article, "The War On Suicide?" July 23, 2012
While researchers suggest that the stresses caused by deployments to Iraq or Afghanistan have contributed to increased risk, 90 percent of suicides occurred among troops who had no combat history -- and nearly one-third of suicides in the military occurred among those who had not deployed even once. While participating in a war can be a contributing factor, it may be the nature -- and not length -- of the conflict that is at issue. Indeed, recent research has shown that bomb blasts and multiple concussions (more common during the most recent wars) can lead to chronic traumatic encephalopathy (CTE), which may predispose soldiers to PTSD and depression -- increasing the risk of suicidal behavior. In fact, the blast generated by a single IED (more than 330 miles per hour) is sufficient to produce CTE in military personnel in the vicinity of the explosion as well. A high rate of PTSD and substance abuse as well as difficulties reintegrating into society may also contribute to suicidal thoughts and behavior. The lack of readily available mental health services for military members seeking help has also been cited as playing a role.
Special Issues for Women Soldiers
While civilian men have a four times higher suicide rate than women and 95 percent of military suicides are male, female veterans appear to be more than three times more likely to commit suicide than their civilian counterparts. The elevated suicide rate among service women as compared to females in the general population reflects some of the particular stresses of being a woman in the military, especially when deployed away from family members, including spouses and children as well as friends. Without the social support and connection to family (a protective factor against suicide among women in the general population), deployed women are disconnected from these protective connections. At the same time, women may be more isolated from their colleagues in the armed forces -- increasing their vulnerability -- by their smaller numbers, lower ranks, and weaker support networks for gender-specific issues.
And, while enhanced efforts are being made to prevent sexual harassment and assault in the armed services, a risk factor for PTSD and suicide, female service members are still targets. In 2010, an estimated 19,000 rapes and sexual assaults took place in the military. Indeed, 47 percent of female officers and 60 percent of enlisted women report being sexually harassed, and 29 percent of women reported that they were victims of sexual assault while in the service. Despite these alarming statistics, it is estimated that only 10 percent of these incidents are reported to military authorities, so many women suffer this invisible wound of military service alone. Women are often penalized for alleging sexual assault and, in the past, were required to report such attacks to their supervisors, who in some cases are the perpetrators of the rape or attack. These reports are alarming, especially considering that the armed services have had a "zero-tolerance" policy for such attacks for years. A number of female service members who were abused are now unemployed and continue to suffer from their physical and mental injuries, and a significant number of them do not receive adequate treatment. Some of these tragic cases have been chronicled in a recent film documentary, The Invisible War.
How can the military stem the surge of suicides?
The somewhat different constellation of risk factors for military suicides as compared to the general population challenges previous models and demands a re-examination of who is at high risk and what services are needed to effectively prevent these tragedies among current troops and veterans.
The Pentagon spends approximately $2 billion -- almost 4 percent of its $53 billion annual medical expenditures -- on mental health, and the U.S. Department of Veterans Affairs allocates $73 million of its $6.2 billion mental health budget on suicide prevention. But given the rise in emotional problems and traumatic brain injuries among service members and veterans, more funding is needed as well as an increase in mental health personnel. Additionally, innovative outreach initiatives are required that promote earlier detection of suicidal thoughts and behaviors in service members, and there is a need for new strategies to deliver effective care.
Fortunately, the U.S. government is intensifying its actions to identify, treat, and protect at-risk individuals and to engage in suicide prevention activities for soldiers, their families, and the general public. Two weeks ago, President Barack Obama issued a multi-faceted executive order to expand suicide prevention efforts. The VA will increase its crisis line capacity by 50 percent by the end of the year, boost the number of VA mental health providers, promote research on this public health problem, and address societal issues to prevent suicides among veterans. The Secretary of the U.S. Department of Health and Human Services, Kathleen Sebelius, also announced $55.6 million in new grants for suicide prevention programs at the national, state, campus, and community levels.
This week on World Suicide Prevention Day, Surgeon General Regina Benjamin and the National Action Alliance for Suicide Prevention, a network of 200 public and private sector organizations co-chaired by former Senator Gordon Smith and Army Secretary John McHugh, released a comprehensive national strategy and campaign for reducing the number of suicides in America through improved early detection and reaching out to those at risk. To achieve its goal of saving 20,000 lives in the next five years, the 2012 National Strategy for Suicide Prevention has four critical components:
- Create environments that foster healthy individuals and communities
- Enhance preventive services within clinical and community settings
- Increase availability of timely treatment and support
- Promote suicide prevention through research and evaluation
The strategy outlines specific ways by which health care systems, schools, community organizations, and families can participate in implementing each of these components, calling specifically on health care providers to set "zero suicides" as an aspirational goal. It also contains guidance for the media regarding how to report suicide in a culturally-competent manner. In fact, a critical element of the strategy's priorities is to change the way suicide is discussed in the public arena by reducing shame and promoting hope and resilience as part of prevention messages.
A number of actions are being taken to detect and prevent suicide among service members. First Lady Michelle Obama and Dr. Jill Biden have established the Joining Forces initiative to support the employment, education, and wellness needs of military families, placing a particular emphasis on psychological well-being. In a January 2011 report entitled "Strengthening Our Military Families," one of the four key objectives includes increasing access to behavioral health services and substance abuse treatment and recovery programs, as well as building awareness of the importance of "psychological fitness." The U.S. Department of Defense and the U.S. Department of Veterans Affairs are launching an outreach campaign with new public service announcements to combat the surge of suicides among service members.
To improve early detection of suicidal thoughts and behavior, troops returning home from deployments overseas are being administered questionnaires that help evaluate their mental and physical health, screening for those soldiers who require further evaluation and treatment. For those troops who have already left the service, the military has begun a review of mental health-related disabilities granted over the past decade to ensure veterans are being adequately compensated for their emotional injuries and have the financial resources for treatment. The armed forces are also working to reduce the stigma associated with seeking help for mental disorders by providing and expanding counseling services available at military and Veteran Affairs (VA) medical facilities.
Furthermore, while post-deployment questionnaires about mental health problems are useful, troops may be worried about being truthful about their feelings because of the stigma that has been associated with mental illness in the military, its impact on leave time away from bases, as well as the bearing of a diagnosis on future career prospects. Draper Laboratory, a non-profit research group based in Cambridge, Mass., recently launched a consortium to improve the identification of PTSD and treatment outcomes. The study is searching for biomarkers of PTSD based on imaging and/or chemical assays that if found may help reduce the stigma surrounding a diagnosis that at present relies upon subjective reports. Presently, in-person interviews, albeit more costly, are necessary in allowing health professionals to collect reliable information and conduct a more thorough mental health assessment. In fact, expanding such screenings to pre-deployment (as has been mandated since 1998) and even pre-enlistment would allow for better tracking of mental health issues among troops and facilitate identification of at-risk individuals for early intervention. Moreover, these screenings could also be used to identify and treat other conditions that increase the risk of suicide, such as substance/alcohol abuse and dependence -- 26 percent of military suicides are associated with substance abuse. Indeed, 11 percent of Iraq and Afghanistan War veterans in the VA system have received prescriptions for painkilling opioids for more than 20 consecutive days. Those suffering from PTSD were more than three times more likely to be prescribed these highly-addictive drugs. Of current service members, 25-35 percent of wounded soldiers are addicted to illegal or prescription drugs as they await their medical discharges -- and there is little evidence that this percentage decreases after they are discharged from the service. Health care professionals treating military personnel require training about the dangers of prescribing these medications long-term for troops. Moreover, another risk factor for suicide, alcohol abuse, remains at very high rates among this population and must be addressed.
To address sexual abuse and harassment toward women, the military has recently announced several new policies, including improved procedures for prosecuting sexual assault in the uniformed services, establishing a special victims unit, and removing responsibility for investigating these cases from local commanders who may have been the perpetrators. Additionally, new recruits are required to attend a briefing on the Defense Department's sexual assault prevention policy within two weeks of entering active duty. Indeed, the branches are now demonstrating commitment to cracking down on these attacks on women; the Air Force is currently investigating allegations of widespread abuse in its training facilities. Moreover, recently, the DoD announced the creation of an independent special victims unit -- within each branch -- devoted to investigating sexual crimes. Female and male soldiers should also have a streamlined process to report sexual harassment and assault as well as be provided with counseling services for their specific needs.
Suicide hotlines have been established by all military branches, the VA, and for the general public as well. The suicide hotline established by the federal government for the general public -- 1-800-273-TALK (8255) -- has a special extension for veterans, accessed by pressing #1. The president's executive order requires that the VA boost the capacity of this veterans' crisis line by 50 percent by the end of 2012 to ensure that no veteran experiencing a crisis has to wait more than 24 hours before being connected to a mental health professional. Initiatives are also underway to expand services through social media, chat forums (VeteransCrisisLine.net), and texting (838255). Studies have found that each media captures a different group of at-risk soldiers, ensuring that a source of help is available to individuals whenever and wherever they require it. The military is urging service members to look out for fellow soldiers and is trying to transform the environment into one that encourages soldiers to seek help and to be supported. The branches have also developed targeted approaches to this public health problem. The Army, for instance, has launched its "ACE" educational campaign, in which cards are distributed instructing soldiers to Ask, Care, and Escort, while the Air Force has formalized procedures to alert commanding officers of disciplinary actions against service members as these events can be a source of humiliation, triggering suicidal thoughts and behaviors in some of those being disciplined. Additionally, the Tragedy Assistance Program for Survivors (TAPS), a military family organization, is raising awareness about this public health problem in the uniformed services and demanding action now.
Additionally, ensuring a strong support network and providing multiple sources of help for service members is essential. Family, friends, and colleagues must be watchful. A suicidal individual almost always shows warning signs, such as talking about wanting to die or killing oneself, giving away prized possessions, looking for lethal means, talking about hopelessness or not having any reason to go on, or telling others they would be better off if he or she were not around. Commanding officers, colleagues, friends, and families have an important role to play. They must signal that mental illness is as serious and painful as other physical illnesses such as heart disease and diabetes and requires proper and comprehensive treatment. Indeed, according to the 2007 report of the Commission on Care for America's Returning Wounded Warriors, it was recommended that the military aggressively treat mental illness, yet adequate and timely mental services and interventions have not always been available. At the same time, officers must be able to discuss with their troops the possession of privately-owned weapons as access to a lethal weapon is a risk factor for suicide -- for both military personnel and civilians. Although some other nations have higher suicide rates, the United States is the only country in the world where guns are the leading method of suicide, so addressing ways to reduce the use of this method among at risk service members is critical.
Moreover, the Armed Forces should increase awareness among service people of its anonymous mental health hotlines, chat lines, and texting services as well as intensify its efforts to hire more mental health professionals -- vacancy rates have surpassed 20 percent at some VA hospitals and the army only has 20 percent of the psychiatrists it needs. Also, mechanisms must be put into place to connect veterans with mental health professionals in their communities as many will not get services through the VA system. Furthermore, as veterans -- especially those discharged in the last decade -- shamefully suffer from higher unemployment and homelessness rates than their civilian counterparts, a concerted effort must be made to ease their transition to civilian life. Hence, when service members begin contemplating discharge from the armed forces, to reduce another potential form of stress, financial planning and career placement services should be made available in addition to other support services. Already, job placement and training programs have shown success in helping service members about to be discharged for medical or documented psychological issues transition to civilian life. To provide new veterans with increased chances for employment, tax credits for employers hiring veterans have been instituted and should be extended. To further reduce financial strains, other tax mechanisms, such as rate reductions or tax credits for members of the uniformed services and veterans, should be explored.
Lastly, more research is needed on the risk factors for suicide in the military and for evaluating new approaches to prevention and intervention. Recently, a Defense Department panel heard testimony from family members of soldiers who had committed suicide during their military service. Their message: A comprehensive action plan to prevent suicide among service members and veterans is urgently needed to illuminate the specific risk factors and to develop effective interventions to address this public health problem, now and into the future.
Clearly, it is an unacceptable disservice to those who have courageously served this country for them to suffer alone. This nation has prided itself on treating its military and veterans with respect and care. However, as President John F. Kennedy once said, "As we express our gratitude, we must never forget that the highest appreciation is not to utter words, but to live by them." This week's release of a National Strategy for Suicide Prevention is an important step forward, but we must now invest the resources, develop innovative partnerships, and take the actions necessary across all sectors of society to prevent this silent wound of war and tragic loss of life among America's service men and women.
Need help? In the U.S., call 1-800-273-8255 for the National Suicide Prevention Lifeline.
Rear Admiral Susan Blumenthal, M.D., M.P.A. (ret.) is the Public Health Editor of the Huffington Post. She is also the Director of the Health and Medicine Program at the Center for the Study of the Presidency and Congress in Washington, D.C., a Clinical Professor at Georgetown and Tufts University Schools of Medicine, and Chair of the Global Health Program at the Meridian International Center. Dr. Blumenthal served for more than 20 years in senior health leadership positions in the Federal government in the Administrations of four U.S. Presidents, including as Assistant Surgeon General of the United States, the first Deputy Assistant Secretary of Women's Health, and as Senior Global Health Advisor in the US Department of Health and Human Services. She also served as a White House Advisor on Health. Prior to these positions, Dr. Blumenthal was Chief of the Behavioral Medicine and Basic Prevention Research Branch and Head of the Suicide Research Unit at the National Institutes of Mental Health and Chair of the Health and Behavior Coordinating Committee at the National Institute of Health. Admiral Blumenthal has received numerous awards including honorary doctorates and has been decorated with the highest medals of the US Public Health Service for her pioneering leadership and significant contributions to advancing health in the United States and worldwide. She is the author of many scientific publications and is the editor of the book, Suicide Across the Life Cycle. Named by the New York Times, the National Library of Medicine and the Medical Herald as one of the most influential women in medicine, Dr. Blumenthal is the recipient of the 2009 Health Leader of the Year Award from the Commissioned Officers Association and was named a Rock Star of Science by the Geoffrey Beene Foundation.
To learn more about Susan Blumenthal, M.D., visit 4globalhealth.org.
George Maliha is a senior at Princeton University, studying molecular biology and pursuing a certificate in public and international affairs from the Woodrow Wilson School. He serves as the editor for several Princeton publications. George served as a health policy intern at the Center for the Study of Presidency and Congress in Washington, D.C.
Anita Mathews is a recent graduate of Brown University with a major in neuroscience. She is currently a Health Policy Fellow at the Center for the Study of the Presidency and Congress in Washington, D.C and will attend medical school next year.
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