Amid
growing alarm at the rate of suicide among members of the military and
confusion about possible causes, researchers reported on Monday that
most of the Army’s enlisted men and women with suicidal tendencies had
them before they enlisted, and that those at highest risk of making an
attempt often had a long history of impulsive anger.
The new research — contained in three papers posted online Monday by the journal JAMA Psychiatry
— found that about one in 10 soldiers qualified for a diagnosis of
“intermittent explosive disorder,” as it is known to psychiatrists —
more than five times the rate found in the general population. This
impulsive pattern, in combination with mood disorders and the stresses
of deployment, increased the likelihood of acting on suicidal urges.
The
new papers bring together five years of work by a coalition of
academic, government and military researchers, investigating hundreds of
suicides and surveying thousands of active soldiers in anonymous
questionnaires.
The
effort began in 2008, after the suicide rate among active soldiers rose
above the civilian rate among young healthy adults for the first time.
The wars in Iraq and Afghanistan have relied on an all-volunteer Army,
not a draft like previous wars, and many of today’s enlisted men and
women have deployed two, three, sometimes four times.
The
new reports provide the first glimpse at how changes in the makeup of
the fighting force and the increased demands of service have affected
the suicide rate. The annual soldier suicide rate more than doubled
between 2004 and 2009, to over 23 per 100,000. In that period, 569
soldier deaths were ruled suicides. Since then, the rate has begun to
fall back toward 20 per 100,000, the civilian rate in the same age
group.
“This
effort will do for suicide what the Framingham Heart Study did for
cardiology, provide for the first time a way to look at multiple factors
over a huge number of people,” said Dr. David Brent, a psychiatrist at
the University of Pittsburgh who was not involved in the research. The
results, he added, strongly suggest that “the baggage people bring with
them and often don’t disclose in order to get into armed services
presumably interacts with the stresses of deployment” to increase
vulnerability to suicide.
The
three reports do not settle whether so-called accession waivers, which
relax standards for new soldiers and which the Army has used to shore up
its ranks, increased the force’s vulnerability to suicide. One study,
an investigation of suicides and accidental deaths led by Michael
Schoenbaum of the National Institute of Mental Health, found a host of
risk factors many have suspected: demotions, a lower rank and previous
deployment among them. But looser standards for enlistment were not
correlated with increased suicides.
Overall,
the three reports sketch a portrait of suicide risk that in many
respects is like the civilian one. About 14 percent of the surveyed
soldiers said they had had suicidal thoughts, and 5 percent had made
plans at least once to take their lives — mirroring the rates among
civilian peers. About 2 percent had actually made an attempt. (The
attempt rate for civilians is actually twice as high, but soldiers’
attempts are more often lethal.)
About
a quarter of soldiers surveyed qualified for at least one current
psychiatric disorder, such as depression, anxiety or substance abuse.
That is roughly twice the rate among peers in the general population,
but only about half of those disorders developed after enlistment. The
biggest difference between soldiers and young adults in the civilian
population was in impulsive anger. The rate was more than 11 percent
among surveyed soldiers, and less than 2 percent among young civilians.
The anger issues predated enlistment about three-quarters of the time,
said Matthew Nock, a lead author on one of the papers and a psychologist
at Harvard.
“The
people at highest risk of making an attempt struggled with depression
and anxiety, or post-traumatic stress, in combination with impulsiveness
and aggression,” Dr. Nock said. “The former gets people thinking about
suicide, and the latter gets them to act on those thoughts.”
The
new findings present the military with a challenging question: How do
you identify people vulnerable to suicide without driving them
underground? More intensive scrutiny typically leads would-be recruits
to hide mental struggles. Some experts suggested that the services could
screen people after enlistment, to identify those who might be offered
additional support.
“A
small minority of soldiers are responsible for a disproportionate
amount of suicidal behavior,” wrote Dr. Matthew J. Friedman, of the
National Center for PTSD, in an editorial accompanying the three
reports. “Better identification of and intervention with the cohort are
likely to have the best payoff.”
These
experts also said that the military could invest in courses that shore
up mental toughness service-wide as a preventive measure. In 2009, the
Army invested in such a program for its 1.1 million members, but a
recent report concluded that the program had not been effective.
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