Better Recruit Screening Probably Won’t Solve Military Suicide Crisis

By Annette M. Boyle

Childhood, Pre-Military Events Strong Contributors

SALT LAKE CITY – The roots of the rising suicide rates in servicemembers and veterans reach back into childhood home environments and pre-military experiences, according to a quartet of recent reports.

Childhood trauma such as physical or sexual abuse, living with a mentally ill adult or a substance abuser and witnessing domestic violence increase the risk of suicide during and after service, as do suicide attempts prior to enlistment and sexual assault prior to and during service. As more evidence of pre-enlistment factors in suicide emerge, controversy over the need for mental health screening has also intensified.

In recent years, determining risk factors for suicide has been a high priority for the DoD. Suicide rates started rising in 2005 and, in 2011 and 2012, more servicemembers died by suicide than were killed those years in conflict in Iraq and Afghanistan.

In the Army, the suicide rate rose to 29.7 per 100,000 in 2012 for all soldiers and to 31.8 per 100,000 for male soldiers. That same year, the suicide rate in the Army National Guard reached 30.8 deaths per 100,000.

Across all services, the rate was 22.7 per 100,000 in 2012 and 19.1 in 2013. In the age-matched general population, the rate was 20.3 per 100,000 in 2010, the last year available, although that data also includes military figures.

“It’s very difficult to do direct comparisons of suicide rates between servicemembers or veterans and their civilian peers, because we do not have a way to separate those who have never served from those who have, so servicemembers/veterans are counted in both groups,” said Craig Bryan, PsyD, executive director of the National Center for Veteran Studies (NCVS) at the University of Utah. After adjusting for gender and age, “our best available information is that young servicemembers and veterans appear to have higher suicide rates than the U.S. population, but older servicemembers and veterans have equal or lower suicide rates.”

As the concern about suicides and mental health disabilities have grown over the past few years, fewer waivers for mental health have been granted for new recruits. A report from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) “recently found no relationship between medical waivers and suicide deaths. This was contrary to what most of us expected,” noted Bryan.

As a result, he questioned the efforts to require more stringent mental health exams, such as those currently working through Congress as part of the defense budget. “I do not think that policies related to disqualification criteria will have a notable effect on suicide rates,” he said.

Regardless of the success of the proposed bills, the new research provides greater insights into experiences that increase the risk of suicide in servicemembers.

Adverse Childhood Events

The classic story of a young man escaping a troubled home life by enlisting has a basis in truth — and significant repercussions for today’s military. Adverse childhood events (ACE) such as violence in the home, sexual abuse and living with someone who is mentally ill, alcoholic or incarcerated can result in post-traumatic stress disorder, substance abuse and attempted suicide in adults. A study in the September issue of JAMA Psychiatry found that men who reported a history of military service during the all-volunteer era experienced all 11 ACEs evaluated at significantly higher rates than men with no military service. Most notably, they reported more than twice the prevalence of sexual abuse compared to those who had never served. 1

The researchers drew on data from the 2010 Behavioral Risk Factor Surveillance System and telephone interviews with population-based samples of non-institutionalized adults from Jan. 1 through Dec. 31, 2010. Results from 60,598 participants were analyzed.

In addition to comparing those with and without military service histories, the study looked at differences between those who served while the draft was in effect and those who served in the volunteer forces. Men who served during the draft had no greater experience of ACE than men of similar age who were not drafted prior to 1973, although those who had military service reported less drug use at home than those who did not.

Women in both the draft and all-volunteer periods were more likely to have experienced physical or emotional abuse or have lived in homes with domestic violence or alcohol abuse than women who had not served in the military, according to the study.

Drilling down further, a detailed look at the impact of a specific ACE — harsh physical punishment or physical abuse by parents — on suicidal behavior among 12,567 Army National Guardsmen found that Guardsmen who had been abused reported three to eight times the rate of suicidal behavior compared to those who had not experienced severe physical punishment or abuse. “A child experiencing abuse has little opportunity to effectively cope when stressed, being in a powerless position with no recourse. This may lead to less ability to handle future stressful circumstances,” suggested lead researcher James Griffith, PhD, of the NCVS.

But not all traumatized children have critically impaired stress responses, Bryan told U.S. Medicine. “Although we know that childhood trauma is associated with increased risk for suicide attempts during military service, many more servicemembers who are trauma victims do not attempt suicide,” Bryan noted. As a result, screening for trauma at this point may disqualify many potential servicemembers who would never attempt suicide. “So until we know more about which trauma victims are at increased risk for suicide in the military, I’m not sure that making decisions based on knowledge of this background would be very useful,” he added.

Military Sexual Trauma

Military sexual trauma also significantly increased the risk of suicidal thoughts and behaviors, at least among men. Women who suffered military sexual assault were more likely to exhibit nonsuicidal self-injurious behaviors, according to a presentation at the August American Psychological Association (APA) convention. “Most survivors will not seek out treatment, and when they do, we need to make sure they receive the therapies that are most effective for sexual assault, such as prolonged exposure and cognitive processing therapy,” Bryan said.3

Also at the APA meeting, Bobbie Ray-Sannerud, PsyD, of the NCVS discussed the results of a study previously covered in U.S. Medicine that found 50% of active duty servicemembers or veterans who attempted suicide had thought about suicide and 25% had attempted suicide prior to joining the military.

The DoD currently screens recruits for previous suicide attempts, “but our methods are limited to self-report, which is highly vulnerable to response bias. In short, it’s very easy (and very understandable) for someone to conceal this history. Unfortunately, we do not have ‘better technology’ to identify increased risk without relying on self-report, although there are a number of efforts underway right now to address this limitation,” Bryan said.4

Regardless of contributing factors, brief cognitive behavioral therapy can reduce suicide attempts in military personnel by 60%, according to Bryan. NCVS and other organizations are evaluating additional strategies and interventions to prevent suicide attempts.

“We also need to develop strategies for identifying and helping military personnel and veterans who are not in mental health treatment, as the majority of suicides occur among those who are outside of the healthcare system,” he noted.

1 Blosnich JR, Dichter ME, Cerulli C, Batten SV, Bossarte RM. Disparities in adverse childhood experiences among individuals with a history of military service. JAMA Psychiatry. 2014 Sep 1;71(9):1041-8.

2 Griffith J. Prevalence of childhood abuse among Army National Guard Soldiers and its relationship to adult suicidal behavior. Presented at “Factors associated with suicide risk among military personnel and veterans.” Symposium 3161. 2014 American Psychological Association Convention.

3 Bryan CJ, Bryan AO, Clemans TA. Gender differences in the association of military sexual trauma with suicide risk. Presented at Factors associated with suicide risk among military personnel and veterans. Symposium 3161. 2014 American Psychological Association Convention.

4 Bryan CJ, Bryan AO, Ray-Sannerud BN, Etienne N, Morrow CE. Suicide attempts before joining the military increase risk for suicide attempts and severity of suicidal ideation among military personnel and veterans. Comprehensive Psychiatry. 2014 April;55(3):534-541.

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