Military Suicide: US Takes Aim at Its 'Toughest Enemy'

Deborah Brauser

September 26, 2012

Editor's note: The original  version of this article contained an error in the phone number for the National Suicide Prevention Lifeline. It has now been corrected. We apologize to our readers.

September 26, 2012 — With suicide rates by military personnel reaching all-time highs this summer and rates of psychiatric illnesses in this population — including posttraumatic stress disorder (PTSD) and severe depression — on the rise, clinicians, members of the US Congress, and even the President are taking action.

In August, the US Army confirmed that 26 active-duty soldiers and 12 reserve soldiers died by suicide in July, which is the highest number ever recorded in 1 month in this population. From January through July of this year, a total of 116 active-duty soldiers and 71 reservists are believed to have killed themselves, compared with 165 and 118, respectively, in all of 2011.

Soldiers return from a 7-month Operation Enduring Freedom deployment (AP Photo/Bob Jordan)

In response, President Obama signed an executive order on August 31 directing the US Department of Veterans Affairs (VA) to hire 1600 new mental health professionals and 800 peer-support counselors so that anyone in crisis can see someone within 24 hours. He is also setting up a task force to develop strategies for improving diagnosis and treatment of PTSD and traumatic brain injury (TBI).

In addition, the US Department of Defense (DoD) has created a "Real Warriors" campaign and Web site to offer support and to inspire these individuals to come forward for help.

"When men and women come home, they need to be able to get into a social life that they had before. And they are not mentally capable of doing it. They are not the same people; and they need to be able to get assistance to be able to assimilate back into normal society. We owe them that much," Representative Grace F. Napolitano (D-CA), cochair of the Congressional Mental Health Caucus, told Medscape Medical News.

"With rates of suicide, posttraumatic stress, and traumatic brain injury rising in recent years, we must ensure we are doing everything we can to treat these invisible wounds of war," added Rep Napolitano in a recent release.

Multiple Deployments

More than 2 million service members have been deployed to Iraq or Afghanistan since 2001, according to a White House release. And many of these individuals have been deployed multiple times.

The most common reason for hospitalization of Army personnel is now admission for some type of psychiatric illness, including PTSD, depression, other anxiety disorders, or substance abuse.

The US Army reports that approximately 15% of US infantry personnel experience some sort of PTSD symptoms post deployment. The most common reason for hospitalization of Army personnel is now admission for some type of psychiatric illness, including PTSD, depression, other anxiety disorders, or substance abuse.

Dr. Harry Croft

"My understanding is that never before in the history of modern American warfare have service men and women been deployed to the combat areas so many times. I've seen some deployed 4 and 5 times," Harry Croft, MD, a private practice psychiatrist in San Antonio, Texas, and medical director of the San Antonio Psychiatric Research Center, told Medscape Medical News.

"And the time at home, or dwell time, should be a lot longer than it is. Many of our service people serve for 12 to 18 months and then are home for 6 months, often worrying about or preparing for being redeployed. This can lead to emotional problems, which can often lead tragically to suicide," said Dr. Croft, who also served as a psychiatrist in the US Army Medical Corps from 1973 to 1976.

"Outdated" Approach to Substance Abuse

In a recent report released by the Institute of Medicine (IOM), Committee members analyzed policies and programs from the DoD for the prevention, screening, and treatment of substance use disorders for service members and their families — and found them to be lacking.

Recommendations for improvements from the IOM report include the following:

  • Because almost one half of active duty service members reported having participated in binge drinking in 2008, easy access to alcohol on military bases should be curbed;

  • Although the Army's Confidential Alcohol Treatment and Education Pilot is to be commended, such programs should be expanded;

  • The use of evidence-based programs and practices should be increased;

  • Access to care should be expanded because of "substantial unmet needs...as well as outdated policies and practices that serve as barriers to such care";

  • Treatment services need to be restructured "for the 21st century," including creating multidisciplinary teams and placing a greater emphasis on outpatient services, group therapy, and computerized cognitive-behavioral therapy.

Access to care should be expanded because of 'substantial unmet needs…as well as outdated policies and practices that serve as barriers to such care.' "

In addition, researchers from the University of Michigan Health System recently found a significant link between substance use disorders and increased risk for death in veterans with PTSD.

The study, which examined data on more than 270,000 VA patients with PTSD, also showed that having a substance use disorder was a stronger predictor of death for those who were younger than 45 years than for those who were older.

Toughest Enemy

Still, it is the sobering rates of military suicides that have grabbed the most recent attention.

A report released last December by the DoD estimates that 18 veterans die by suicide each day. And between 2005 and 2010, active service members took their own lives at an average rate of 1 every 36 hours.

Suicide is the toughest enemy I have faced in my 37 years in the Army. That said, I do believe suicide is preventable.

"Suicide is the toughest enemy I have faced in my 37 years in the Army," said General Lloyd J. Austin, vice chief of staff of the Army, in the August data report.

"That said, I do believe suicide is preventable. To combat it effectively will require sophisticated solutions aimed at helping individuals to build resiliency and strengthen their life coping skills," he added.

Last May, as part of Mental Health Awareness Month, Rep. Napolitano hosted several briefings for legislative staff in Washington, DC, about the mental health crisis in the military and programs that are being created to address these issues. One session introduced the Army's Comprehensive Soldier Fitness program, which is designed to reduce PTSD and other psychological issues by promoting mental resilience.

In addition, the 5-year Study to Assess Risk and Resilience in Service members (STARRS) is currently examining factors that may help protect soldiers' mental health and factors that put them at risk. It is scheduled to conclude at the end of 2014.

"Because promoting mental health and reducing suicide risk are important for all Americans, findings from Army STARRS will benefit soldiers as well as civilians," reports an Army release.

In an article published in the September issue of Mayo Clinic Proceedings, Timothy Lineberry, MD, a psychiatrist at the Mayo Clinic in Rochester, Minnesota, and a suicide expert for the Army, writes that military suicide has become "a major public health concern."

In the article, Dr. Lineberry suggests that greater use of gun locks and reduced access to other means of suicide, better monitoring for sleep disturbances, and improving primary care treatment of depression are all important steps to combat the trend.

He also recommends that opioids be prescribed under great care and that their use be closely monitored.

"Despite the anticipated end of large-scale military operations in Afghanistan and Iraq, the effects on the mental health of active-duty service members, reservists, and veterans is only beginning to be felt," said Dr. Lineberry.

"Moreover, the potential effect on service members of their war experiences may manifest indefinitely into the future in the form of emerging psychiatric illnesses."

The "Brain at War"

Troubling associations have also been found between behavioral and physical problems.

Researchers from the University of Pittsburgh Medical Center Sports Medicine Concussion Program announced in August at the Military Health System Research Symposium that residual symptoms of PTSD and concussions may be linked in military personnel who experience blast and/or blunt traumas.

Their study of more than 27,000 participants from the Army Special Operations Command showed that PTSD symptoms were found in 31% of the reported concussions from combination blast-blunt trauma, 23% were from blast trauma only, and 12% were from blunt trauma only.

Of the participants who had never been diagnosed with a concussion, only 6% experienced symptoms of PTSD.

Previous research has shown that combat-related behavioral problems affect women just as much as men — and sometimes even more. In fact, past studies have shown that women may actually be at greater risk of developing PTSD than men.

Women with PTSD may also experience faster aging at the cellular level and increased inflammation than men with PTSD.

In a presentation at the "Brain at War" conference in San Francisco this summer, Aoife O'Donovan, PhD, from the University of California–San Francisco and the Northern California Institute for Research and Education, presented preliminary study findings showing that women with PTSD may also experience faster aging at the cellular level and increased inflammation than men with PTSD.

Activation of immune system cells was greater in the 10 female participants with PTSD than in the 8 without PTSD. In addition, none of the men with PTSD showed immune activation differences compared with the men without PTSD.

A cell-signalling pathway thought to help control inflammation was "ramped up" in men with PTSD but "dampened down" in the women with PTSD, "leading us to question if there are specific mechanisms by which men but not women might be more protected from inflammation," said Dr. O'Donovan in a release.

Barriers to Care

With all of these recent studies and reports, better mental healthcare options are obviously needed for this population. However, worries about stigma, fear of a backlash from employers, and living in locations with few mental health resources can all be barriers to seeking care.

In a presentation at this year's American Psychiatric Association (APA) annual meeting, Major Gary H. Wynn, MD, research psychiatrist at the Center for Military Psychiatry and Neuroscience at the Walter Reed Army Institutes of Research in Silver Spring, Maryland, said that between 20% and 50% of soldiers who begin treatment for combat-related PTSD walk away before its completion.

He noted a study published in 2011 in Military Psychology that reported key reasons for this lack of follow-through often include mistrust of mental health clinicians, a belief that these types of problems can work themselves out on their own, and an overall belief that seeking treatment should be a last resort.

We've learned that keeping soldiers who are already enrolled in PTSD treatment from dropping out is the most important strategy for improving outcomes.

"We've learned that keeping soldiers who are already enrolled in PTSD treatment from dropping out is the most important strategy for improving outcomes. This requires better matching of evidence-based therapies with patient preferences to improve engagement and a patient's willingness to remain in care," said Major Wynn in a release.

But some barriers may actually push individuals to seek help. A study published in the September issue of Psychiatric Services examined 157 National Guard soldiers with PTSD returning from combat in Iraq.

Need for Outreach

The findings showed that stressors related to readjusting to civilian life, such as problems with marriage and employment, were strong drivers of care seeking — especially in older veterans. These stressors were also more predictive of treatment seeking than were levels of PTSD symptoms.

"Many of the vets I see do not, under their own volition and because of their symptoms, go for treatment. I'll often tell them, 'You've been suffering for years with these symptoms. Why didn't you go in sooner?' And usually it's because someone suggested they go. Often it's their spouse, or their kids, or their employer, or a judge," said Dr. Croft, who was not involved with the research.

"The fact that many vets don't seek treatment simply because of their symptoms, such as nightmares or flashbacks, is no big surprise to me. It isn't because of the impact of their symptoms on them personally but rather the impact on their relationships or legal issues," he said.

Interestingly, he noted that many vets do not recognize that something is really wrong.

"They just assume that this is how life is after you go to combat."

Rep. Napolitano agrees.

Rep. Grace Napolitano

"We put these people in harm's way," she said. "So I think it's up to us in this country to at least ensure that they get all the assistance needed to bring them back to society in a workable fashion."

In another study published in the same issue, data on more than 400,000 veterans with PTSD suggested that having a comorbid health condition also drove treatment seeking. These vets had 64% more visits than did vets with PTSD alone.

However, it also showed that vets living in rural communities had significantly fewer visits than those living in urban areas, emphasizing the need for increased outreach programs and telemental health services.

 

Reducing Stigma

One program that appears to be doing well is the Re-Engineering Systems of Primary Care Treatment in the Military (RESPECT-Mil). It has been implemented by the Army into approximately 90 clinics around the world so far. Through it, service members are screened and treated for PTSD or depression in a primary care setting.

RESPECT-Mil director Colonel Charles Engel, MD, MPH, director of the DoD Deployment Health Clinical Center at Walter Reed National Military Medical Center and senior scientist at the Center for the Study of Traumatic Stress, presented preliminary results of the program at this year's annual meeting of the APA.

Col. Charles Engel

"Most mental health services really are delivered by primary care and family doctors. These [clinicians] are who soldiers and their families go to see when they're not feeling well. And many mental health problems can manifest with physical symptoms," Col. Engel told Medscape Medical News.

Dr. Engel noted that military services may see approximately 10% to 15% of the active force for a visit over the course of a year. But in primary care, many people will make 3 to 5 visits a year for a variety of reasons.

According to a release, approximately 63,000 soldiers have been diagnosed with a previously unrecognized behavioral need since 2007. Program data showed that twice as many patients had a significant reduction in self-assessed PTSD severity scores in December 2010 as in August 2009.

The program's Web-based care management system automatically flags patient records when significant improvements are not seen after 8 weeks of treatment, allowing providers to adjust plans in a timely manner.

Making behavioral health screening as standard as a blood pressure check helps defuse any perceived stigma around seeking help.

"Making behavioral health screening as standard as a blood pressure check helps defuse any perceived stigma around seeking help. Early intervention ensures soldiers get effective help sooner while reducing the use of clinical services for related symptoms like back pain or accidents," said Col. Engel in the release.

"I think the bottom line is we're trying to create a caring system that makes best use of the money that the public has entrusted us with and at the same time is taking care of soldiers and their families to the best of our abilities. We see it as a sacred trust to meet their needs," he told Medscape Medical News.

Few Treatment Options

In July, the IOM released a report on PTSD treatment recommendations. The only medications that are currently recommended by the US Food and Drug Administration for treating PTSD are sertraline and paroxetine.

"I believe that with PTSD, medication alone usually doesn't have the very positive impact we would like for it to have. It requires, I believe, education, information, and buying into treatment. It needs to be psychotherapy as well as medication," said Dr. Croft.

However, he added that although these options may help some veterans, "a lot of others" are not being helped.

"So in the treatment realm, the cognitive-behavioral therapies, especially prolonged exposure and cognitive processing therapy, are being touted as the best evidence-based treatments. But many of the vets don't go or don't buy into these processes and stop going," he said.

"So we're looking for other therapies that may work: eye movement desensitization, hypnosis, and other talking therapies. And they're also looking for other medications, such as D-cycloserine, which is an old tuberculosis drug that may work on the glutamate system, and ketamine," said Dr. Croft.

Complementary and alternative treatments currently being explored to treat PTSD and TBI by some civilian and service clinicians include yoga, meditation, massage, acupuncture, and even service dogs.

I suspect that the more we look, the more we're likely to find something that might be much more effective than what we currently have. Do I think that these alternative therapies need to be researched? Absolutely...we need all the help we can get for these veterans.

"I suspect that the more we look, the more we're likely to find something that might be much more effective than what we currently have. Do I think that these alternative therapies need to be researched? Absolutely. Because we need all the help we can get for these veterans," said Dr. Croft.

The Army recently awarded a $3 million research and development grant to Michael J. Kubek, PhD, to assess the effects of a nasal spray containing thyrotropin-releasing hormone (TRH) in treating suicidal ideation.

Dr. Kubeck, an associate professor of anatomy and cell biology and of neurobiology at Indiana University School of Medicine in Indianapolis, has spent more than 30 years researching the neurochemical TRH. He and colleagues are working to develop a system that will deliver TRH or neuropeptides into the nasal cavity, which will then be dispersed into the brain over time.

Tip of the Iceberg

"I think it's important to realize just how many people are being affected," said Col. Engel. He noted that in addition to the 2 million service people who have now been deployed and brought back, each one has family members who have to deal with their own effects from these issues.

He added that President's Obama inititative to hire additional VA personnel isn't "the total solution."

"I'd argue that what we really need is a good system in place to improve access and continuity of care in addition to hiring the people to make it happen. Many people won't seek specialty care, even if it's there for them. So we need to create a system that essentially frontloads the healthcare system and enables their regular doctor to identify the people who are in the greatest need," he said.

Dr. Croft recommended that civilian clinicians educate themselves specifically about combat PTSD.

"Many of us were educated about single-event PTSD. A lot of the symptoms and stressors are the same, but there are some differences. And I think it's important we learn about the effects combat has on people, because we're just seeing the tip of the iceberg," he said.

In the next 5 years, we're expected to have a million more coming home from combat areas. But I would say: go ahead and assume that PTSD patients are already in your practice. You just may not know it yet.

"In the next 5 years, we're expected to have a million more coming home from combat areas. But I would say: go ahead and assume that PTSD patients are already in your practice. You just may not know it yet," said Dr. Croft.

National Suicide Prevention Lifeline: 1-800-273-TALK.

Major Wynn is coeditor of the recently published Clinical Manual for Management of PTSD. Dr. Croft is on Medscape's Committee for PTSD and is the author of the book, I Always Sit With My Back to the Wall.

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