2013 Issues   /   September 2013

Increasing Military Suicide Rates Unrelated to Deployment, Combat

USM By U.S. Medicine
September 4, 2013

By Brenda L. Mooney

Cynthia A. Leardman, MPH

SAN DIEGO, CA – Despite common misconceptions, increasing suicides by military servicemembers do not appear to be related to combat experience or deployment – or even multiple deployments, according to a new study.

Instead, the study published recently in the Journal of the American Medical Association found that mental health and substance abuse disorders,as well as being male, are the factors most strongly associated with military personnel taking their own lives. 1

Their research was the first to link service data with post-service follow-up on military personnel returning from deployment, the authors pointed out. Previous military suicide studies relied on case series and cross-sectional investigations.

“The results indicated that deployment was not associated with suicide. When we looked at mental health factors, we found that they were associated with suicide — this included manic depressive disorder and depression, as well as alcohol-related problems,” said lead author Cynthia A. LeardMann, MPH, of the Naval Health Research Center in San Diego.

Noting “quite a bit of speculation as to the cause” of the upswing in suicides, LeardMann pointed out that “our servicemembers face unique challenges, such as deployment, which some have assumed might be associated with the increased suicide rate.” That view, however, was not borne out by the study, she added.

The increased rate of suicide in the military “may largely be a product of an increased prevalence of mental disorders in this population, possibly resulting from indirect cumulative occupational stresses across both deployed and home-station environments over years of war,” the report suggested.

Click image to enlarge and for abbreviations key. For table source, see reference 1.

Background in the article said suicide rates among active-duty military personnel began to increase sharply in 2005 from a baseline rate of 10.3 to 11.3 per 100,000 persons to a rate of 16.3 per 100,000 persons in 2008, with the highest rates among Marine Corps and Army personnel — 19.9 and 19.3 per 100,000 persons, respectively. The authors added that suicide rates among those on active-duty status have stabilized since 2009 at about 18 per 100 000.

A report released last year by the Center for New American Security (CNAS) stated that, from 2005 to 2010, current and former servicemembers took their own lives at a rate of approximately one every 36 hours and, although only 1% of Americans have served in the military, former military personnel represent 20% of suicides in the United States.

For the recent suicide study, researchers used Millennium Cohort Study data for 2001, 2004 and 2007, tracking 151,568 current and former military personnel until the end of 2008. During that time, 83 study subjects committed suicide. Based on models adjusted for age and sex, the study determined that factors significantly associated with increased risk of suicide included male sex, depression, manic-depressive disorder, heavy or binge drinking and alcohol-related problems. On the other hand, the authors said they found that deployment-related factors — combat experience, cumulative days deployed, or number of deployments — were not associated with increased suicide risk in any of the models.

The strength of the association for factors most associated with suicide risk were:

  • Male sex (hazard ratio [HR], 2.14; 95% CI, 1.17-3.92; P = .01; attributable risk [AR], 3.5 cases/10,000 persons);
  • Depression (HR, 1.96; 95% CI, 1.05-3.64; P = .03; AR, 6.9/10,000 persons);
  • Manic-depressive disorder (HR, 4.35; 95% CI, 1.56-12.09; P = .005; AR, 35.6/10,000 persons), or
  • Alcohol-related problems (HR, 2.56; 95% CI, 1.56-4.18; P <.001; AR, 7.7/10,000 persons).

The authors said a nested, matched case-control analysis using 20:1 control participants per case confirmed those findings.

“These findings suggest that a way to potentially mitigate suicide risk is to focus on screening efforts as well as the quality of care for both mental health disorders as well as substance abuse disorders,” LeardMann said during an online interview made available by JAMA. She cautioned, however, that the study looked at the first years of an increasing trend and that further analysis is “needed to examine more recent data and confirm these findings.”

Army Col. Charles C. Engel, MD, MPH

An accompanying editorial from Army Col. Charles C. Engel, MD, MPH, of the Uniformed Services University of the Health Sciences in Bethesda, MD, pointed out that military suicides have been the “recent focus of controversy and misunderstanding” but that the new study offers “some potentially reassuring ways forward: the major modifiable mental health antecedents of military suicide — mood disorders and alcohol misuse — are mental disorders for which effective treatments exist.” 2

“Furthermore, evidence-based service delivery models, particularly those involving primary care, are well known, supported by randomized trial evidence of lasting improvements in suicidal ideation among patients with depression, and designed to overcome population stigma and barriers to care,” Engel emphasized.

He cautioned, however, that successfully implementing those models might require a cultural change to overcome “current overreliance on outdated combat and operational stress models of suicide prevention. Such success will also require addressing long-standing military ambivalence toward the medical model of mental illness — an ambivalence affecting servicemembers, military clinicians, and senior leaders alike.”

LeardMann also underscored the importance of the military continuing programs to help screen and treat mental illness and substance abuse — factors that can lead to increased suicide rates. Also important, she added, is examining “the effectiveness of these programs to help mitigate suicide risks.”

In addition to the Naval Health Research Center, LeardMann’s co-authors are from National University in San Diego, the Uniformed Services University of the Health Sciences in Bethesda, MD, the VAs Puget Sound Health Care System in Seattle, WA, Analytic Services Inc. in Arlington, VA, Loma Linda, CA, University, and Walter Reed Army Institute of Research in Silver Spring, MD.

1.    LeardMann CA, Powell TM, Smith TC, Bell MR, et. al. Risk Factors Associated With Suicide in Current and Former U.S. Military Personnel.  JAMA. 2013;310(5):496-506. doi:10.1001/jama.2013.65164.

2.    Engel CC. Suicide, Mental Disorders, and the US Military: Time to Focus on Mental Health Service Delivery.  JAMA. 2013;310(5):484-485. doi:10.1001/jama.2013.92420

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