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MILITARY PSYCHOLOGY, 24:488–512, 2012 ISSN: 0899-5605 print / 1532-7876 online DOI: 10.1080/08995605.2012.716269
Army Suicides: “Knowns” and an Interpretative Framework for Future
Directions
James Griffith U.S. Army National Guard, Baltimore, Maryland
Studies have yielded consistent variables associated with military suicides: age (17 to 30 years), gender (male), race (white), and previous mental health con- ditions. Military experience variables have shown little associations with suicide. Taken together, findings may be explained, in part, by age-specific psychosocial tasks (e.g., intimacy versus isolation and identity versus role confusion). Both relate directly to the extent that the individual is socially integrated—tasks health and medical research literature have described as increasingly more difficult for youth to effectively accomplish. Contextual circumstances, such as gender and race, appear to provide necessary supports to successfully accomplish these psychosocial tasks.
Since World War II, U.S. military suicide rates have been lower than age- matched civilian rates (Cassimatis & Rothberg, 1997). Additionally, during wartime suicide rates in the military have generally declined (Rothberg, Holloway, & Ursano, 1987). Yet, in 2004, when the U.S. was engaged in warfare in both Iraq and Afghanistan, military suicide rates were observed rising and, in 2008, surpassed the civilian age-adjusted rate (20 versus 19 per 100,000). See Figure 1.
This article not subject to U.S. copyright law. The findings and views presented here are solely those of the author and do not reflect the position
of any entity, public or private. Correspondence should be addressed to James Griffith, 10956 Bellehaven Boulevard, Damascus,
MD 20872. E-mail: [email protected]
ARMY SUICIDES 489
Rate per 100,000
CalendarYear
FIGURE 1 Civilian age-adjusted suicide rates compared to Army suicide rates: 1990 to 2010 (civilian rates after 2009 are not available). (color figure available online)
Initially, it was thought that service members who had experienced combat or had deployed multiple times experienced high levels of strain and distress. In fact, research had shown deployment experiences, such as the number and length of deployments, and occurrence of combat engagements, were associated with increased posttraumatic stress disorder (PTSD) and related symptoms (Mental Health Advisory Team studies (MHAT), 2008). The services having endured much of the ground combat operations in Iraq and in Afghanistan (the Army and Marine Corps) first showed increased suicide rates (see Figure 2). Rates for the Marine Corps and the Army first showed increases starting in 2001. Suicide rates for the Army climbed from about 13 per 100,000 in 2005 to about 20 in 2008 (Army Health Promotion, Risk Reduction, and Suicide Prevention Report, 2010)—higher than the most available suicide rate for age-matched civilian popu- lation, at about 19 per 100,000 (National Center for Health Statistics, 2012). Rates for the Army National Guard (ARNG) increased starting in 2006 and in 2010 (about 31 per 100,000) exceeded the Army (about 25 per 100,000) and the Army Reserve (about 23 per 100,000), as well as the most available civilian age-adjusted rate (about 19 per 100,000 in 2009).1
1It should be kept in mind that globally, from 1950 to 1995, there has been an increase of approx- imately 49% for suicide rates among males and 33% for suicide rates among females (Bertolote & Fleischmann, 2002). In 1998, the global rate among men aged 15 to 24 years was 19 per 100,000 and among men aged 25 to 34 years was 28 per 100,000. The Centers of Disease Control has released suicide rates for the U.S. only up to 2009.
490 GRIFFITH
Rate per 100,000
Calendar Year
FIGURE 2 Suicide rates for the Army (active component, Army National Guard [ARNG], and Army Reserve [USAR]): 2003 to 2010. (color figure available online)
THE “KNOWNS” OF ARMY SUICIDES
Since 2004, the ARNG has monitored suicides and their characteristics but did not begin in-depth analyses until 2010. Griffith (2012) performed a series of analyses of all ARNG suicides from calendar years 2007 through 2010 and a corresponding random sample of 1,000 nonsuicides drawn from each year’s ARNG population.2
2Suicide data were available starting in 2007, as data on suicides were first reliably recorded in this year. There were 60, 60, 62, and 112 suicides, respectively, for calendar years 2007, 2008, 2009, and 2010. After the death of a soldier, the unit to which the soldier was assigned performed pre- scribed procedures for investigation (Department of Army, 2006), usually in conjunction with local civil authorities, to determine the cause of death, and once confirmed they were called “confirmed suicides.” The analyses reported here represented all suicides from calendar years 2007 through 2010 and a corresponding random sample of 1,000 nonsuicides drawn from each year’s ARNG population. Suicide has a very low occurrence in the general and military populations. This situation is called “rare events data,” meaning that the binary dependent variable has thousands of times fewer events than zero or nonevents, and when used analytically, often results in underestimating the probability of rare events (King & Zeng, 2001). An efficient method for making valid inferences in this situation is a sampling
ARMY SUICIDES 491
There were two primary sources of data: the ARNG personnel system and the DA 15-6 (Department of Army, 2006). Information extracted from the ARNG personnel system included the following variables: age, gender, race, type of high school attainment, mental category or MCAT (based on the Armed Services Vocational Aptitude Battery or ASVAB), marital status, rank, prior service, years of service, military status (M-day or part-time versus full-time military service), military occupational specialty (MOS) (coded into combat arms versus others), in training, and ever deployed. The DA 15-6 (Department of Army, 2006) con- tained 37 lines of individual history, including circumstances surrounding the suicide, such as family problems (parent-child problems, partner problems, loss or recent death of a loved one), school problems (academic problems, dissatisfaction, drop-out), employment problems (dissatisfaction, uncertainty, unemployment), behavioral problems (spouse/child abuse, DUI/DWI), new life circumstances (unwanted pregnancy, newlywed, new parent, new employment, recent separa- tion or divorce), and mental health conditions (suicidal thoughts, suicide attempts, substance and/or alcohol abuse, evidence of anxiety or depression, physical health problems).
Analyses revealed that suicides in the ARNG were predominately male, young in age (17 to 24 years of age and 25 to 29 years of age), white, nonprior service, single, and M-day status (i.e., part-time rather than full-time military service). Suicides occurred primarily while the soldier was in civilian status, averaging about 80% during 2007–2009. The most common methods of suicide were gun- shot wounds and hanging. Griffith (2012) performed logistic regression analyses to determine the association of soldier characteristics with suicide. Previously described data elements were used simultaneously to predict suicide. Table 1 displays results of the logistic regression analysis.
With the data elements considered, largely personnel information, about 5% variation in suicide risk (having committed or not) was explained. Age, gen- der, and race accounted for over half (57.1%) of the explained variance, and an unknown “year effect” accounted for about one-quarter (24.5%) of the explained variance. Military-related variables (prior service, M-day, in-training, combat MOS, and having been deployed) added 14.3% to the explained variance. Variables associated with having committed suicide included: age, specifically 18–24 years (1.74 more likely than other age groups), and 25–29 years (1.43 more likely than other age groups), being male (3.05 more likely than females), and being white (1.85 more likely than other race groups). A strong year effect was
design in which all available events (suicides) are used and a fraction of nonevents (nonsuicides) (see Breslow, 1996; King & Zeng, 2001). Thus, the analytic sample for the present study consisted of (1) all suicides in each calendar year 2007 through 2010 and (2) a random sample of 1,000 Guard soldiers for each year.
492 GRIFFITH
TABLE 1 Logistic Regression Prediction of 2007–2010 Army National Guard (ARNG) Suicides Versus
Random Sample of Suicides by Soldier Characteristics (Adapted From Griffith, 2012)
Predictor Variable Likelihood Odds-Ratio
Predictive Power (% of total variance accounted for by set of predictors by row)
Aged 17–24 years 1.74∗∗ Aged 25–29 years 1.43∗ 6.1% Male 3.05∗∗∗ 30.6% White 1.85∗∗∗ 20.4% Single 0.78 2.1% Alternate high school degree 1.16 2.0% Prior service 1.03 M-day 1.28 12.2% In-training 0.68 Combat MOS 1.07 Deployed 0.86 2.1% Year 2007 0.54∗∗∗ Year 2008 0.54∗∗∗ Year 2009 0.57∗∗∗ 24.5%
Pseudo R squared .049 100.0% Wald Chi-squared (df = 14) 82.17∗∗∗
Note. The analytic sample used was the combined cases of 2007–2010 suicides plus random sample of 1,000 soldiers each Calendar Year (CY) for comparison (see Footnote 2 for explanation). Listwise deletion N = 4,288. MCAT was not entered due to officers not having scores, though results were much the same when MCAT was considered.
Odds-ratio is the amount of times the variable value (e.g., male) is more likely to commit suicide than the reference group (e.g., female), that is, males are 2.73 times more likely than females to commit suicide, and so on.
The nomenclatures for the variable abbreviations and coding for simple correlations are described below.
Alternative high school degree was “dummy coded” (1 = yes and 0 = no), indicating the categories: other nontraditional high school credential, other than Selected Reserve (SR) program, high school degree in 365 days, home study diploma, high school certificate of attendance, test-based equivalency diploma, overseas GED (General Educational Development), occupational program certificate, and correspondence school diploma.
MCAT is mental category as defined by scores on Armed Services Vocational Aptitude Battery; there are six mental categories from highest to lowest aptitude: Category I, II, IIIA, IIIB, IV, and V, and this was coded ordinally, ranging from 1 to 6.
Prior service was “dummy coded” (1 = yes and 0 = no), indicating the soldier has had previous military service other than first-time in the Guard.
M-day was “dummy coded” (1 = yes and 0 = no), indicating “mobilization day” asset, a reservist who serves only one weekend a month and 15 days annual training.
In-training was “dummy coded” (1 = yes and 0 = no), including training categories: in or awaiting warrant officer basic course, individual active duty training status, awaiting or in basic officer leader course, and in split phase training.
Combat MOS was “dummy coded” (1 = yes and 0 = no), including combat arms military occupa- tional specialties (MOS); for males, duty MOSs of 11, 13, 19, 21, 25, 31, 68, 79, 88, 89, and 91; and for females, duty MOSs of 15, 21, 25, 31, 68, and 92. These typically are MOSs involving combat knowledge and skill.
Deployed was “dummy coded” (1 = yes and 0 = no), indicating the soldier had been mobilized and served full-time in military service. ∗p < .05. ∗∗p < .01. ∗∗∗p< .001.
ARMY SUICIDES 493
evident for odd-ratios associated with the years. Fewer soldiers committed sui- cide in 2007, 2008, and 2009 (all odds-ratios were about 0.50) than in 2010 (the reference category).
Another aim of the ARNG analyses was to determine whether those who com- mitted suicide represented one homogenous group or multiple groups. Cluster analyses were performed using available variables, largely demographic char- acteristics. Agglomerative clustering suggested two clusters. A K-means cluster analysis was then performed to describe the two clusters. Table 2 displays differences in cluster variables between the two groups.
Members of the first group accounted for about one-third of the calendar year 2007–2010 suicides and tended to be older, male, white, married, more senior enlisted (SSG-SFC), prior service, more years of service, less likely M- day, less likely in training, and having been deployed. This group was labeled as “careerists.” Members of the second group accounted for about two-thirds of the calendar year 2007–2010 suicides and tended to be younger, male, white, single, privates and specialists (PFC-SPC), nonprior service, fewer years of service, more likely M-day, in training, and not having been deployed. This group was labeled as “first-termers.” A summary of the unit suicide incident report (“37-liner”) showed (though not always meeting traditional levels of statistical significance) differences in the circumstances surrounding suicide (see Table 3).
“Careerists” or members of the first cluster tended to have more prior suicide attempts, interpersonal (antisocial, partner) problems, PTSD and other illnesses, driving under the influence or driving while intoxicated (DUI/DWI), and access to firearms. “First-termers” or members of the second cluster tended to have more thoughts of suicide and isolation, and mood and anxiety problems. Members of both groups displayed past mental health problems, alcohol/substance abuse, and loss of significant other. Although not at traditional levels of statistical signifi- cance, the percentage of “first-termers” (young, white, male, etc.) increased from 57% of suicides in 2007 to 74% of suicides in 2010.
Active Component Army
Beginning in 2009, the U.S. Army Public Health Command conducted a series of in-depth analyses of suicides in the Army. The resulting reports provide descrip- tions of suicides and comparisons of suicides to nonsuicide samples. The studies relied on several archival data sources: the Army Behavioral Health Integrated Data Environment (ABHIDE); demographic and military information from the Department of Defense Manpower Data Center; behavioral health information and postdeployment health assessments and reassessments from the Armed Forces Health Surveillance Center; and information from Department of Defense Suicide Event Reports.
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496 GRIFFITH
Black, Gallaway, & Bell (2011) examined 872 Army suicides, which had occurred from 2001 to 2009. A nonsuicide comparison group was included for each year. Analysis revealed suicide rates in the Army more than doubled from 9 per 100,000 in 2001 to 22 per 100,000 in 2009. The 2009 rate exceeded the most available suicide rates for civilians (age-adjusted rate of 18 to 18.5 per 100,000 in 2006). Suicides were disproportionably males, Caucasians, younger in age (18 to 24 years) and having been previously deployed. Millikan, Spiess, Mitchell, Fulcher, & Watts (June 2011) and Millikan, Spiess, Mitchell, Watts, & Porter (October 2011) and authors of the U.S. Army Public Health Command report (2010) described the 20-year-old age group as having the highest suicide rate, with increased risk associated with ages under 35 years. The most com- mon methods of suicide were gunshot wounds and hanging (Black et al., 2011). Men were more likely to choose methods of gunshot, hanging, and asphyxiation, whereas women were more likely to choose drug overdoses.
Black et al. (2011) also reported that nearly one-half of suicides had prior mental health diagnoses, usually mood disorder, major depressive disorder, substance-related disorder, anxiety disorder other than PTSD, adjustment dis- order, and PTSD (U.S. Army Public Health Command, 2010; Milliken et al., October 2011). Civilian suicides also have been associated with co-occurring mental health disorders (Nock, Hwang, Sampson, & Kessler, 2010). In 2008, the suicide rate among soldiers with any mental health diagnosis was five times higher (73.5 per 100,000) than the rate among soldiers without a mental health diagnosis (14.8 per 100,000) (Black, Gallaway, Bell, & Ritchie, 2009). Suicide rates were highest among soldiers with an adjustment disorder diagnosis (263.3 per 100,000), anxiety disorder (except PTSD) (241.2 per 100,000), or substance abuse-related disorder (228.7 per 100,000). The elevated risk for suicide among soldiers with mental health diagnosis has increased steadily since 2004 and almost doubled for soldiers with mood disorders or adjustment disorders (Black et al., 2009; U.S. Army Public Health Command, 2010).
Findings showed suicides had previously detected mental health symptoms often indicated in the deployment and postdeployment assessments, yet few sol- diers had been referred to behavioral health care providers. An examination of suicides from 2006 to 2009 showed that about one-quarter of the suicides had reported at least one symptom on the Predeployment Health Assessment (PDHA), but only about 5% had been referred. Of the half of the suicides who reported depressive and PTSD symptoms on the Postdeployment Health Reassessment (PDHRA), only about 6% had been referred for follow-up care (U.S. Army Public Health Command, 2010). Noteworthy is that no suicides in 2010 had been referred for behavioral health conditions after completion of the PDHA, unlike previous years (2008–2009), and they represented a significant decrease from the 2008–2009 suicides. Additionally, a substantial proportion of suicides had received some form of mental health treatment in the past (U.S. Army Public
ARMY SUICIDES 497
Health Command, 2010). Overall, about 17% of suicide cases received inpatient care and 48% received outpatient care for mental health disorders. The percentage of suicides receiving care has increased steadily from 2003 to 2009, as well as the proportion under care within the 30 days preceding the suicide.
Both current and past interpersonal problems were evident among suicides (U.S. Army Public Health Command, 2010). Most suicides (79%) had stressful personal life circumstances. The most commonly cited personal life circumstances included relationship problems, job problems (both military and civilian), and physical health problems (Black et al., 2011; U.S. Army Public Health Command, 2010). More recent studies added legal problems and administrative actions against the soldier as additional stressful personal life circumstances (Millikan, Bell, Gallaway, Spiess, & Youmans, February 2011; June 2011; October 2011). Black and her colleagues also noted that “Almost one third had evidence of con- tributing factors from childhood or other time periods prior to the entry into the Army” (Black et al., 2011, p. 443). Millikan et al. (June 2011; October 2011) also noted that suicide cases prior to 2010 were more likely to have pre- service contributing factors such as childhood neglect and abuse or recent loss of family member or close friend. These latter findings, taken together, are consis- tent with common themes among research-based identified risk factors for suicide, including negative early life events, psychopathological conditions, experiencing stressful life events, social and interpersonal isolation and feelings of alienation, and method availability (Blumenthal & Kupfer, 1989).
An analysis of suicides committed from January 2004 to July 2009 showed associations of suicide rates with military occupational groups (U.S. Army Public Health Command, 2009). The highest rate (21.8 per 100,000) was found among the Maneuver, Fire, and Effect (MF&E) occupations. Within this occupational group, suicides having infantry military occupational specialties (MOSs) had the highest suicide rate (28.7 per 100,000), followed by chemical MOSs (25.3 per 100,000), armor MOSs (20.6 per 100,000), engineer MOSs (20.5 per 100,000), and military police MOSs (19.9 per 100,000). All other occupational groups fell below the Army average rate of 18.1 per 100,000. As noted by researchers, military occupational specialties having higher rates also had proportionally more soldiers at risk for suicide (young males). Indeed, recent analyses have shown that age, gender, and race largely accounted for differences in suicide rates by occupation (Millikan et al., February 2011; U.S. Army Public Health Command, 2010). Variations have also been observed from post to post, though not entirely consistent nor with clear-cut explanation. From 2003 to 2009, Forts Campbell and Stewart had significantly more suicides and Forts Bragg and Hood had fewer suicides than other posts (U.S. Army Public Health Command, 2009). However, from 2009 to 2010, suicides decreased at Forts Campbell and Stewart and Schofield Barracks and increased at Forts Hood, Carson, and Lewis (Millikan et al., June 2011).
498 GRIFFITH
Attempted Suicides
More recent reports (Millikan et al., February 2011; Millikan et al., June 2011) included analyses of those who attempted suicide from January 2005 to September 2010. Attempters were similar to suicide completers—predominately enlisted white males under 35 years. However, a larger proportion of attempted suicides than completed suicides were made by women (Millikan et al., February 2011). An earlier study (U.S. Army Public Health Command, 2010) reported attempters, compared to completers, were more likely to be young in age, female, single, junior enlisted, non-Caucasian, in the Army, and assigned to an instal- lation with a predominantly training mission. A larger proportion of attempters than completers had mental health diagnoses and had received treatment (Millikan et al., June 2011). Additionally, proportionally more attempters than completers received diagnoses of mood disorders, particularly major depressive disorder, depression not otherwise specified, anxiety disorders other than PTSD, and adjust- ment disorders. Attempters were also more likely than suicide cases to have had more than one mental health diagnosis. Attempters were also more likely to have a history of self-injury and more likely than suicide cases to be victims of abuse (U.S. Army Public Health Command, 2010). Methods of harm varied by whether the suicide was attempted or completed. Attempted suicides were more likely to choose drug or alcohol overdoses, followed by cutting. Completed suicides were more likely to choose gunshot wounds or hanging.
Summary Across Components
There are clear similarities in findings across the Army studies. First, the primary factors associated with suicide risk were: age (17–24 years; 25–29 years), gender (male), and race (white). Similar suicide factors such as age (young adults and seniors), gender (male), and race (non-Hispanic white) are found in the civilian population (Karch, Logan, & Patel, 2011; Kessler, Berglund, Borges, Nock, & Wang, 2005; Pagliaro, 1995). However, the relative association of these factors with suicide risk is not the same, as observed here and in the general literature. When examined together, research has shown gender and age has a greater association with suicide than race (Berman, Jobes, & Silverman, 2007). Second, findings revealed that many suicides had a pre-existing negative mental health condition, of which many had not been referred for treatment. Of those referred, many were not consistently treated and still others received no treatment. Third, suicides were often associated with concurrent interpersonal problems, such as relationship problems or loss of a significant other. Fourth, current suicide rates for Army service members were higher than those of the most available civilian rates (from 2009), though it is unclear whether suicide rates have risen in the civilian population in more recent years, as Centers for Disease Control suicide rates typically lag 3 years.
ARMY SUICIDES 499
The primary risk factors for suicide are then being young in age, male, and white, with behavioral health conditions, for the most part untreated, and early childhood trauma and abuse. Although the likelihood for such individuals to com- mit suicide is greater, not everyone having one or more of these risk factors will commit suicide. It is believed these factors combine with a unique set of concur- rent circumstances (largely yet to be identified) and can lead to suicide. In some analyses (Griffith, 2012), only 5 to 6% of the variance in having committed suicide can, at present, be explained. Additional research should be done to capture infor- mation and provide further explanatory variance. Table 4 provides a summary of findings for studies of suicides in the Army and ARNG.
AN INTERPRETATIVE FRAMEWORK
Research findings reporting on civilian suicides (Kessler et al., 2005) and on Army service members described here have shown three primary factors associated with being at risk for suicide: age (17–24 years and 25–29 years), race (white), and gen- der (male). Other variables, such as military occupational specialty, having been deployed, prior service, being in training, and so on, generally have shown little or no association with suicide. How then can these three consistent factors associated with suicide be reconciled within an interpretative framework? The extensive soci- ological literature on suicide suggests at-risk factors relate to age-specific tasks of identity and relationship development, contextualized by gender and race, to pro- vide this interpretive framework. Age necessitates age-specific tasks concerning development of self-identity and the quality of interpersonal relations. Race and gender define the context of coping. Race can determine the nature and amount of informal support available to the individual. Gender is associated with differences in the benefit of support, in addition to being socialized to be competitive and aggressive, and having familiarity and comfort with weapons of violence. Each aspect of this interpretation is further elaborated below.
Age
Suicides in the Army occur largely from 17 years of age through the mid-20s. This age span prescribes specific tasks for the individual, which defines who the individual is and how their identity relates to others. For individuals at this age, major tasks in their psychosocial development are (1) developing a coherent, pos- itive identity as opposed to being confused about self-identity; and (2) having intimate relationships as opposed to being isolated (Conner & Goldston, 2007; Duberstein et al., 2004; Erikson, 1968; Portes, Sandhu, & Longwell-Grice, 2002). According to Erikson (1968), in developing a positive identity, the individual first experiences life independently and organizes and gives meaning to experiences
TA B
LE 4
S um
m ar
y of
Fa ct
or s
A ss
oc ia
te d
W ith
S ui
ci de
Fr om
A rm
y N
at io
na lG
ua rd
(A R
N G
) an
d A
ct iv
e C
om po
ne nt
A rm
y A
na ly
se s
A rm
y N
at io
na lG
ua rd
(A R
N G
) A
ct iv
e C
om po
ne nt
A rm
y
Pr im
ar y
at -r
is k
fa ct
or s
Y ou
ng ag
e (1
7– 24
;2 5–
29 ye
ar s
ol d)
Y ou
ng ag
e (1
8– 24
ye ar
s in
ea rl
ie r
re po
rt s
an d
th en
ex pa
nd ed
to un
de r
35 ye
ar s
ol d;
20 ye
ar s
ha vi
ng hi
gh es
tr at
e) M
al e
M al
e W
hi te
N on
-H is
pa ni
c C
au ca
si an
,N at
iv e
A m
er ic
an .
B eh
av io
ra lh
ea lth
co nd
iti on
— pr
ed om
in at
el y,
m oo
d di
so rd
er ,
de pr
es si
on ,a
nd ad
ju st
m en
td is
or de
r, of
te n
no nr
ef er
re d
Sl ig
ht ly
re la
te d
to su
ic id
e M
ili ta
ry -r
el at
ed va
ri ab
le s
sh ow
lit tle
or no
re la
tio ns
hi p,
in cl
ud in
g ra
nk ,p
ri or
se rv
ic e,
m ili
ta ry
oc cu
pa tio
na ls
pe ci
al ty
(M O
S) ,h
av in
g be
en de
pl oy
ed ,n
um be
r of
to ur
s, nu
m be
r of
da ys
in ga
rr is
on pr
io r
to de
pl oy
m en
t
E ar
lie r
st ud
ie s
re po
rt ed
de pl
oy ed
st at
us w
as re
la te
d; la
te r
st ud
ie s
sh ow
ed m
ili ta
ry -r
el at
ed va
ri ab
le s
ha d
lit tle
or no
re la
tio ns
hi p,
su ch
as m
ili ta
ry oc
cu pa
tio na
ls pe
ci al
ty (M
O S)
,A rm
y Fu
nc tio
na l
G ro
up ,d
ep lo
ye d
U se
fu lfi
nd in
gs Tw
o gr
ou ps
of su
ic id
e: Y
ou ng
er gr
ou p
w ith
an xi
et y
an d
m oo
d pr
ob le
m s,
su ic
id e
id ea
tio ns
O ld
er gr
ou p
w ith
ch ro
ni c
he al
th an
d be
ha vi
or al
he al
th pr
ob le
m s
E vi
de nc
e of
cu rr
en ta
nd pa
st in
te rp
er so
na lp
ro bl
em s,
m os
tc om
m on
be in
g re
la tio
ns hi
p pr
ob le
m s
an d
m ili
ta ry
- or
w or
k- re
la te
d is
su es
, an
d ph
ys ic
al he
al th
A tte
m pt
er s
w er
e si
m ila
r to
su ic
id e
co m
pl et
er s—
pr ed
om in
at el
y en
lis te
d w
hi te
m en
un de
r 35
ye ar
s (M
ill ik
an et
al .,
O ct
ob er
20 11
) L
ar ge
r pr
op or
tio n
of at
te m
pt er
s th
an co
m pl
et er
s w
as w
om en
(M ill
ik an
et al
., Fe
br ua
ry ,2
01 1)
C om
pa re
d to
co m
pl et
er s,
at te
m pt
er s
w er
e yo
un ge
r an
d m
or e
lik el
y to
be fe
m al
e, si
ng le
,j un
io r
en lis
te d,
no n-
C au
ca si
an ,i
n th
e R
eg ul
ar A
rm y,
an d
as si
gn ed
to an
in st
al la
tio n
w ith
a tr
ai ni
ng m
is si
on (U
.S .A
rm y
Pu bl
ic H
ea lth
C om
m an
d, A
pr il
20 10
) Pr
op or
tio na
lly m
or e
at te
m pt
er s
th an
co m
pl et
er s
ha d
be ha
vi or
al he
al th
di ag
no se
s (m
oo d
di so
rd er
,m aj
or de
pr es
si on
,a nx
ie ty
di so
rd er
) So
m e
ev id
en ce
of be
in g
vi ct
im s
of ch
ild ab
us e
500
ARMY SUICIDES 501
by responding to questions about oneself in relation to the world, such as who am I? What is my relationship with others? What am I to do in life? In the second task, the individual forms significant and meaningful relationships with others, which reinforces self-identity, provides intimacy and love, and prevents feelings of isolation and loneliness.
Major suicide theorists Joiner, VanOrden, Witte, & Rudd (2009) and Durkheim (1897) have included in their theories of suicide the lack of self-identity in the context of others. Self-identity provides the individual with a sense of worth and meaning, characteristics often absent in suicides. Often, stressful circumstances and consequences make these tasks difficult, if not impossible, to accomplish adaptively. These circumstances might include: problems in personal relation- ships, past mental health problems, alcohol and substance abuse, job problems, suicide ideation, and feelings of loneliness. Army studies have shown many of these problems present among suicides. Indeed, recent research suggests increased adjustment issues are becoming more prevalent among adolescents and young adults. Medical and sociological research have suggested suicide may be shifting to younger age groups due to increases in drug and alcohol use and depression among youth (Capaldi & Stoolmiller, 1999; Conner & Goldston, 2007), as well as a shift in attitudinal and behavioral characteristics of recent generations known as “millennials” (Warner, 2010; Zemke, Raines, & Filipczak, 2000), and altered family structure (Stockard & O’Brien, 2002). Portes et al. (2002) have made connections between psychosocial developmental tasks and suicide, in particu- lar among adolescents and young adults. They cited studies showing connections between suicide attempts among adolescents and their experiences of high lev- els of stress, lack of family support, and identity problems (Grob, 1983; Wagner, Cole, & Schwartzman, 1995).
Very recent research has shown that childhood and early adolescent trauma predicted later young adulthood suicide behaviors—both as a main effect and interaction between these earlier experiences and current stressors. Pompili et al. (2011) reported that the presence of negative life events in adulthood and stress- ful events experienced during childhood and adolescence was associated with suicide. These earlier experiences also interacted with current stressful events. In fact, life events experienced within the last 6 months, in addition to com- bined effects of these events and past life events experienced between birth and age 15 years, were associated with suicide attempts. Studying suicides and ear- lier development, Seguin, Renaud, Lesage, Roberts, and Turecki (2011) described two developmental trajectories for suicide risk among individuals between 15 and 20 years. Both were defined by earlier stressful life events within a social con- text lacking support. Individuals in the first trajectory had severe developmental difficulties and a lack of adult protection, starting at a very early age, creat- ing mental health problems throughout the life. The second trajectory developed more slowly and was characterized by the presence of family tension and discord
502 GRIFFITH
and academic difficulties. Others also have observed developmental changes in personality functioning in multiple birth cohorts, in different Western nations, using both longitudinal and cross-sectional research designs (Caspi, Moffitt, & Thornton, 1976; Roberts, Caspi, & Moffitt, 2003).
Other studies evidence generational shifts in violence, psychopathology, and life values, possibly related to increased depression and suicidality among young adults. Stockard and O’Brien (2002) and O’Brien and Stockard (2006) exam- ined the distribution of suicide rates by age groups for birth cohorts 1930, 1965, and 2000. Over time, they observed that the age distributions of the suicide rates shifted such that in 2000 there were relatively more suicides committed by younger age groups (late teens to mid-20s) than in 1930 or 1965. They specu- lated that decreased social integration and regulation among more recent cohorts (i.e., increased cohort size and proportionally more disrupted families) were asso- ciated with these shifts in suicides and homicides. Studying large samples of American young adults, Twenge, Gentile, DeWall, Lacefield, and Schurtz (2010) reported significant increases (from 1938 to 2007 and from 1951 to 2002) in several forms of psychopathology. Current generations of young people scored about one standard deviation higher clinical scales of psychopathic deviation, paranoia, hypomania, and depression. In a more recent study, Twenge, Campbell, & Freeman (2012) reported shifts in life goals, concern for others, and civic ori- entation among large cohorts of American high school seniors (1976–2008 and 1966–2009). Compared to Baby Boomers (born 1946–1961) at the same age, GenX’ers (born 1962–1981) and Millennials (born after 1982) considered goals related to extrinsic values (money, image, fame) more important and those related to intrinsic values (self-acceptance, affiliation, community) less important.
Race
Race is likely associated with the nature and amount of informal support available to the individual, especially during stressful circumstances, to help augment the individual’s coping. Documented in the general literature is the extended support network afforded to African Americans (Early, 1992; Gibbs, 1997; Hetherington & Parke, 1975; Kubrin & Wadsworth, 2009; Lareau, 1987; Stack, 1974; Taylor, Chatters, Tucker, & Lewis, 1990). Thus, under stressful circumstances, whites would be expected to have more negative consequences than African Americans, due to the buffering effects of indigenous social supports (Cohen & Wills, 1985). Some have also described African Americans’ higher level of participation in religion, compared to whites’ generally lower level, as an additional inhibition against self-harm (Kubrin & Wadsworth, 2009). Others have also described the greater resiliency among African Americans in adapting to adverse life circum- stances, such as discrimination, unemployment, poverty, urban living, and the like (McIntosh & Santos, 1981; Seiden, 1981).
ARMY SUICIDES 503
Gender
Maris, Berman, & Silverman (2000) offered several reasons for the gender asso- ciation with suicide, including that males are more likely to engage in suicide-risk behaviors, such as alcohol abuse, access to firearms, and shame of failure. Males are also less likely to engage in protective behaviors, such as seeking help for problems, being aware of signs of personal distress, having flexible coping skills, and having developed social supports. Many of these associations are a result of different socialization patterns between males and females, in particular, inter- personal behaviors (Wilson, 1987). Males’ aggressiveness and competiveness, along with greater exposure, familiarity, and comfort with weapons often lead to their greater availability and less inhibition to use them for self-harm (Kubrin & Wadsworth, 2009). There is also evidence that women benefit more than men from social integration (Cohen, 2004; House, Landis, & Umberson, 1988), and with its absence men are more vulnerable to the negative effects of stressful circum- stances. This has been attributed to integration having higher costs for women— taking the responsibility for other network members (Kessler, McLoed, & Wethington, 1985) and being more sensitive to the quality and content of relation- ships (Coriell & Cohen, 1995)—all of which is not experienced by men. Hence, women may benefit more from higher quality relationships, whereas men do not.
INTERPRETATIVE FRAMEWORK AND PREVAILING ASSUMPTIONS
Recognition is given to the fact that the interpretative framework offered here is limited by the available data. To date, analyses have been largely retrospec- tive, relying on pre-existing personnel data. Thus, data on key constructs are absent, such as early developmental experiences (childhood abuse and trauma), later adolescent and early adulthood development of self-identity and interper- sonal relationships, experienced stressors, coping and availability of supports, and so on. Even so, findings described here lead to tentative conclusions regarding several prevailing assumptions about suicides in the military (see Table 5).
Military experience variables, in particular having been deployed, number and length of deployments, and so on, showed little to no association with suicide, and the military experience variables combined accounted for little explained variance in suicide. Findings also have shown that suicides are not one homogenous group. Suicides, at least those observed in the ARNG, rep- resented two demographically defined groups, each having somewhat unique circumstances.
The offered interpretative framework explained suicide as defined by age- specific tasks, made more difficult for some soldiers to successfully accomplish than others. Some have described these difficulties in terms of earlier adverse life
504 GRIFFITH
TABLE 5 Prevailing Assumptions of Suicide in the Military
Prevailing Assumption Evidence
War and associated stressors cause suicide. Unlikely Suicide is worsened by deployments. Unlikely Suicide is worsened by poor unit leadership, administration. Can assist in identification and
referral Suicides represent one homogenous, monolithic group of
individuals. Unlikely
Suicides in the military relate to selection mechanisms at accessioning.
Likely
Suicide is a behavior existing at the end of a continuum—it is a continuous phenomenon (as opposed to a being discrete phenomenon and affecting a very special group).
Coping likely defined by early experiences
Suicide in the military can be explained by prevailing theories of suicide.
To some extent
Suicide is a phenomenon that can be affected by broad policy. Suicide theories explain suicide in such a way to provide
broad level policies. That is, clinically based theories are applicable to the issue of suicide at a broad, macro level.
Likely identification and referral; not broad-based preventive measures
experiences, which defined particular paths or trajectories of unsuccessful cop- ing (Pompili et al., 2011; Seguin et al., 2011). Within the interpretive framework, race and gender define the amount of available social support and integration, both of which are important to consider when coping with stressful life events. Indeed, several theories of suicide have emphasized the importance of social con- text in suicide (Durkheim, 1897; Joiner et al., 2009). Thus, it seems unlikely that poor unit administration or leadership is associated with the primary causes of suicide. This is not to say that unit administration and leadership are not associ- ated with distress experienced by soldiers. Positive effects of leadership on soldier well-being, particularly reducing the negative effects of stressors on individuals, is evident in the military and health literature (Griffith & West, 2010; MHAT, 2009; Solomon, Mukilincer, & Hobfoll, 1986). Rather, important age-specific tasks relate to suicide, and thus, greater sensitivity should be shown toward how the individual is resolving these tasks, particularly if they not effectively negotiated, such as confused self-identity and being isolated. Life events associated with stress and strain should be mitigated to the extent possible, allowing positive self- identity and development of interpersonal relationships. To the extent possible, informal supports should be available and offered to the individual. Knowing the availability of weapons of violence, specifically firearms, to males, is crucial in suicide management, and how best to inhibit their immediate access for potential self-harm (Ramchand, Acosta, Burns, Jayjox, & Pernin, 2011).
ARMY SUICIDES 505
The offered interpretative framework offers several policy implications. First, broad-based preventive measures, such as resiliency training, will likely have little effect on preventing suicide. The perspective taken here implies that suicide has early etiology (i.e., childhood abuse and trauma) and likely defined structure (i.e., psychosocial tasks defined by age). Accordingly, the second policy implication is that potential suicides should be identified for formal assessment and treat- ment. Third, there should be a well-defined protocol for what soldiers, leaders, and family members do when they identify potential at-risk individuals. Fourth, there should be a system in place to provide identified potential suicides consis- tent mental health treatment. At present, ARNG soldiers, not on active duty status, must rely on their private health care insurance. Nearly all suicides in the ARNG occurred during civilian or nonduty status.
IMPLICATIONS FOR PRACTICE, RESEARCH, AND THEORY
In the context of this interpretive framework, the Army suicide study findings offer implications for practice, research design and analyses, and theory.
Practical Implications
Findings imply that more frequent, reliable methods to screen soldiers for sui- cide behaviors are needed. At present, screening methods to assess psychological adjustment have not had consistent administration, scoring, or follow-up pro- cedures. The initial induction interview conducted by medical personnel at the military entry processing station (MEPS) consists of a few open-ended questions, not having standard scoring and criteria for referral. Similarly, soldiers respond to questions about stress levels, suicide ideation, and substance abuse during the PDHA and PDHRA, but again, scoring and criteria for referral have not been stan- dardized. These assessments do not appear to be effective in identifying solders at risk for suicide. Additional effective assessments with greater measurement preci- sion are needed to detect soldiers at risk for suicide. A possible screener for those already in the military is the Predeployment Mental Health Screening Questions (Warner, Appenzeller, Parker, Warner, & Hoge, 2011), which screens those at risk for mental health problems prior to deployment.
Nearly one-half of all suicides in the Army analyses had mental health conditions preceding suicide. Of those, only a few received any treatment, with the majority receiving no formal assessment or treatment. There is a clear need for more determined referral and follow-up of soldiers who are screened for being at risk for suicide. This includes a designated person responsible for referral and follow-up and a mechanism whereby at-risk individuals can receive med- ical treatment. Follow-up for reservists inevitably will include medical care in
506 GRIFFITH
civilian status; thus reservists must rely on private health insurance. During the Gulf War, evident was that many soldiers, especially young soldiers, did not have basic health and dental insurance (Allen, 1992).
The current Army suicide prevention programs (ACE education programs) are directed primarily at those who might recognize suicide intentions in others and not in themselves. Little education and training has been directed at soldiers potentially at risk. Training should be developed explicitly for soldiers who are at risk for suicide. Training would better inform soldiers of events that may cause distress, or stressors (such as “Dear John” letters), possible psychological and behavioral reactions (strain), and other more adaptive responses. Chosen meth- ods of suicide also have implications for future education and training. Most who committed suicide use firearms. More thought should be given to devel- oping education and training for soldiers on the proper handling and storage of personally owned firearms, in particular, for family members to recognize when firearms need to be removed from soldiers at risk. Research has also shown that the availability of firearms to those contemplating suicide is a major determinant for follow-through (Kubrin & Wadsworth, 2009). Mann et al. (2005) suggested greater “means restriction” as a preventive strategy. Indeed, research on the avail- ability of firearms (“opportunity hypothesis”) supports the idea that restriction would reduce suicide (see also the recent RAND report, Ramchand et al., 2011).
Research Implications
Discrepancies in suicide counts and rates may be a result of differences in proce- dures defining conditions surrounding suicides (Rosenberg et al., 1988). Future studies should improve on issues relating to the measurement and analysis of suicides. Standard definitions of suicide, including universal procedures for inves- tigating possible suicides, should be developed and uniformly implemented across the services. Consideration should be given to developing gradations of sui- cide, such as having attempted, having considered (suicide ideation), and so on. The importance of this distinction is illustrated by the fact that women are far more likely to attempt suicide than men, yet far less likely to succeed (Centers for Disease Control and Prevention, 2009), and thus, women and men may be considered equally at risk. Thought should be given to whether these condi- tions represent different continua or types or whether these conditions represent different quantities of self-destructive intentions on the same continuum.
The incidence of suicide should go beyond raw counts per service. Rates should consider the raw occurrence of the events divided by the “eligible” individuals who might experience the event. Thus, mathematically, rates consider character- istics known about a small suicide population in relation to the occurrence of individuals having such characteristics overall. Overall rates and rates for specific segments of the population for a given time period (e.g., calendar year) provide
ARMY SUICIDES 507
a means to know comparative risk for suicide at one point in time (e.g., being young versus white, etc.) for the military overall as well as by service compo- nent. Such rates also allow tracking of suicide risk for specific segments of the population across time. Documenting rates each year and across years shows changes in risk factors, which can be related to other phenomena and thus imply underlying causative factors of suicide. Also, while tracking annual prevalence rates of suicides overall for the population and subpopulation is informative, this approach likely obscures important and subtle changes in behavioral health over time. Studies of birth cohorts have observed variations in the prevalence of vio- lent behavior, psychopathology, and values (O’Brien & Stockard, 2006; Stockard & O’Brien, 2002; Twenge et al., 2010; 2012). These findings imply that studies ought to track such rates by birth cohorts, in addition to the oral tracking of preva- lence rates. Finally, rates allow comparison to civilian risk rates to discern military risk relative to civilian risk. Error bands for rates are appropriate and necessary. Suicide counts are typically low and vary by year, greatly affecting rate calcu- lations. One method to derive error bands is the quotient of the rate divided by incident count (see http://www.health.state.ny.us/diseases/chronic/ratesmall.htm). When one or both rates in comparison rate are less than 100 incidences, confi- dence interval calculations are handled differently (see http://www.nyhealth.gov/ statistics/chac/chai/docs/table1.htm).
Future study designs should also include at a minimum cases of nonsuicides that occur during the same time period as the suicide cases. Comparison of sui- cides to nonsuicides is somewhat problematic in that suicides have very low occurrence in the general and military populations. This situation is called “rare events data,” meaning that the binary dependent variable has thousands of times fewer events than zero or nonevents and, when used analytically, often results in underestimating the probability of rare events (King & Zeng, 2001). An efficient method for making valid inferences in this situation is a sampling design in which all available events (suicides) are used and a fraction of nonevents (nonsuicides) (see Breslow, 1996; King & Zeng, 2001).
To date, suicide analyses have generally described the composition of the sui- cide population and examined rates of subpopulations defined by demographic or military-related variables. Conspicuously absent in Army suicide studies are analyses that include examining all variables simultaneously to examine each variable’s association with suicide as well as associations between variables. Future studies should consider multivariate analyses, both descriptive and pre- dictive models. Descriptive multivariate models can be useful when examining the extent to which suicides can be described as occurring as one homogenous group, or two groups with similar within-group characteristics, but differences in between-group characteristics. Such descriptions go beyond simple similarities and differences among suicide groups. Analyses can suggest different detection and treatment methods, as described earlier for careerists and first-termers.
508 GRIFFITH
Predictive or discriminatory, multivariate approaches are useful in specify- ing how much variance in the outcome of interest—suicide—can currently be explained by the existing data elements. Multivariate analyses can also deter- mine which of several variables account for most of the explained variance. And finally, multivariate analyses can easily accommodate interaction terms to assess the effects of combinations of variables associated with suicide. For example, future analyses should continue examining interactions among predictor or risk variables to see whether groups (e.g., young men, combat arms specialty, deploy- ment experiences) are more susceptible to conditions making them greater risks for suicide (Millikan et al., June, 2011).
Because age is consistently associated with suicides, future studies should examine unique aspects of age or generational cohorts. Zemke et al. (2000) have described various attributes of several American generations and their implica- tions for the workplace. Soldiers born between 1982 and 2002 are members of the “millennial generation.” This generation has been described as having several strengths, such as collective action, optimism, tenacity, heroic spirit, multitasking capabilities, and technological savvy. This generation has also been described as having liabilities, including the need for supervision and structure and the inability to handle difficult situations and people. Some have even suggested that develop- mental history has fostered them to be “profoundly narcissistic,” in persistent need of praise to enhance an over-evaluated sense of self-esteem, difficult to manage in work settings, wearing casual attire, using iPods, and unable to take criticism (Warner, 2010). Indeed, there is some evidence that cohorts differ in suicide rates related to measures of social integration and regulation (O’Brien & Stockard, 2006), and such possibilities should be considered in future study designs.
Theoretical Implications
Age, gender, and race accounted for one-half to two-thirds of the explained vari- ance in the ARNG studies. Military experience variables, in particular those associated with war (deployment, military occupational specialty), accounted for little variance in suicide. Noteworthy also is that nearly all of the ARNG suicides occurred in civilian, not military status. Future studies should strive to gather information relative to these demographic characteristics that would lead to a better understanding of underlying processes of suicide. For example, it has been suggested here that the common thread among age, gender, and race is social integration or, more accurately, lack thereof, while trying to accomplish basic age- dependent life tasks. This preliminary explanation is consistent with several major theories of suicide involving social relationships. This speculation argues for more information on early teen experiences (e.g., Pompili et al., 2011).
Findings also question whether suicides occur on the same continuum as individuals who are distressed by life circumstances and develop physical and
ARMY SUICIDES 509
mental health problems. Many of the suicide cases in Army analyses have behavioral and mental health conditions, which—on the face of it—are very different than those having problems in daily living (U.S. Army Public Health Command, 2010; Griffith, 2012). Additionally, many suicides were associated with earlier, childhood abuses (Black et al., 2011; Millikan et al., June 2011). Very recent research has shown childhood and early adolescent trauma, which here it was argued exacerbates age-specific developmental tasks, predicted later young adulthood suicide behaviors—both as a main effect and interaction effect between these earlier experiences and current stressors (Pompili et al., 2011). Consistent with this proposal, Seguin et al. (2011) have observed that suicides take on two trajectories depending on childhood and early adolescent difficulties. Evident from the discussion here, the proposed integrative framework implies several useful directions for practice, for research design and analyses, and for theory.
ACKNOWLEDGMENT
Special thanks are extended to Courtney West, who carefully copyedited the manuscript before submission.
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