Interventions to Reduce The Risk of Soldiers’ Suicides and Their Consequences
In determining how to intervene to reduce the risk of suicides, the first goal is to understand the risks that cause suicides, or that at least make suicide more likely. These risk factors have been summarized as:
- The increase in fearlessness about death that derives from combat; interventions affecting this should address helplessness and loss of control;
- Immediate access to firearms or other tools for suicide; interventions to limit access to such weapons is probably not practical in a combat zone;
- Issues of insomnia, nightmares, or general agitation; interventions for these symptoms need to consider the combat-zone setting, thus sleeping medications can only be used with great care;
- A sense of not belonging to the group creates a limited social support network; interventions in these areas become impractical for the CSC to implement, but getting the entire unit involved may be helpful;
- Limited access to mental health services and psychiatric care; interventions in this area are challenging to change in a war zone.
With these and similar points in mind, a number of suicide intervention programs have been tried in the military. Several very recent studies have evaluated the success of these interventions.
One such program is the Air Force Suicide Prevention Program (AFSPP), which aspired to reduce both the mortality (deaths) and morbidity (injuries or illnesses) resulting from suicidal actions. As described in a study that considered its effectiveness medically, AFSPP is a program in which command leadership and social support were used to mediate suicide risk. The assumption behind this program is that those contemplating suicide and at risk for executing it display identifiable signs. Thus, group or command recognition of such signs can stimulate an early warning and thus head off the suicide attempt. Furthermore, the program attempts to remove the stigma from suicidal thoughts, thus enabling requests for assistance. This is accomplished through training to change the social norms of the military group to encourage individuals to seek help, acknowledges that the distress is normal under the prevailing circumstances, tries to improve personnel skills at coping with stress, and tries to remove any stigma from seeking mental health care. Other aspects of the program included attempts to reduce non-military symptoms including domestic violence or other anger management issues, substance abuse issues (including alcohol abuse), and depression. Key initiatives of this program, developed over the course of fifteen or more years, can be readily found online. Overall, once the program was implemented in 1997, the suicide rate in the Air Force dropped from a typical 3.0 per 100,000 to about 2.4 per 100,000, a modest but measurable improvement.
A similar version of the AFSPP was implement by the Army of Serbia and Montenegro in 2006, including both education and access to mental health services. The results from this intervention were that suicide rates dropped from a pre-intervention 13 per 100,000 to a post-intervention rate of 5 per 100,000.
Other services have also developed interventions. A suicide prevention program implemented in 1994 by the U. S. Army 25th Infantry Division (Light) was based on psychological autopsies of suicides between 1985 to 1993. The focus of this intervention was on education, including lectures from chaplains, lectures within training programs for both enlisted and command personnel, wallet-sized warning cards with symptoms and warning signs of suicide and emergency contact information for easy referral, crisis intervention meetings where symptoms were discovered, identification of individual soldiers as high-risk, placing them under special scrutiny by their commanders and both mental health care and social work care. The informal results of this program were that in two years the suicide rate had decreased to only 3 suicides in that time.
The U.S. Navy and Marine Corps undertook additional suicide training by adding a video on suicide awareness to the required annual training regimen. The Navy reported that suicide rates had dropped to 9.2 per 100,000 which was “the lowest rate in 10 years” (as of 2001) and the Marines had a suicide rate of 15.6 per 100,000.
A program instituted by a U.S. Army Infantry Division in 2007 implemented a complex suicide prevention program that addressed all stages of a soldier’s warfighting experience, including specific interventions for each of pre-deployment phase, a 15-month deployment phase, re-deployment, and reintegration back into U.S. society. Each of these phases had phase-specific programs for education, early identification of those at risk, and interventions in high-risk individuals. Rather than being a generic program applied to all, this program is tailored to the needs of the individual soldiers in this unit in each of those phases. Not only did this result in suicide rates substantially lower than those in other deployed units at the time, but it also seemed associated with a greater willingness to seek mental health services on the part of the soldiers. The program also put a premium on maintaining active monitoring of at-risk individuals as well as monitoring trends in individual units. Critical to this program’s success was in making mental health personnel available even to those soldiers in remote deployed areas, and in ensuring that all personnel at all levels knew that suicide prevention was a senior command priority. This program was based on the elements of the sexual assault victim advocate program, a successful program already familiar to commanders of all levels.
At the U.S. Naval Base in Okinawa, a small scale program involving 35 sailors was implemented in which sailors considered at risk were referred to Gamblers Anonymous program for 12 weeks, along with as-needed individual counseling. While 3 suicide attempts were made prior to the program, none were attempted once the program was implemented.
From a warfighter’s perspective, probably the greatest obstacle to success with the AFSPP and the other programs mentioned here is the continuing cultural stigma that is associated with mental health problems, a stigma that is prevalent in the general U.S. population and is especially so in the military world. This is a powerful influence on a soldier’s behavior, and one which keeps many from seeking help with their stressful situations. As noted in the study on AFSPP, the reluctance to seek psychiatric help with their combat stress can keep soldiers who are in deep mental pain from asking for help, to the extent that not only do those deployed to combat arenas experience triple the rate of PTSD, but those veterans with PTSD experienced an increased risk of suicide 30 years after leaving the military. Also, the study AFSPP noted that actual implementation of the program can vary dramatically based on the warfighting demands on the service, which reduces the available time and personnel needed to implement the program. In particular, in 2004,when wars were being fought at high levels in both Afghanistan and Iraq, the degree of implementation dropped and the number of suicides increased dramatically.
Several interventions in suicide prevention include mandatory antidepressant or other psychoactive medications. One problem with this approach to suicide prevention from the soldier’s perspective is that these medications frequently have side effects that are highly undesirable in a combat zone environment. In particular, psychoactive medications can cause problems including being “too mellow” and thus not alert enough to dangers in a war zone. On the flip side, the medication guide for many antidepressants notes that danger signs can include: thoughts of suicide or dying, attempts to commit suicide, worsening or new depression, worsening or new anxiety, increase in agitation, panic attacks, insomnia, worsening or new irritability, increased aggression, dangerous impulsivity, and mania, with many of these symptoms mirroring those of PTSD. Even worse, antidepressants have been documented as causing an increase in suicide, particularly in young adults between 18 and 24 years old —exactly the population of soldiers in deployed units. The efficacy of these medications in a war zone environment is questionable, and at least one researcher has concluded that it the increased use of these psychoactive drugs within deployed troops has itself caused much of the increase in suicides in this population. As a soldier, this insistence on medicating the troops is a very uncomfortable solution to a difficult problem.