Suicide is a growing public health crisis. According to the Centers for Disease Control and Prevention, the suicide rate in the U. S. increased 24 percent — from 10.5 to 13 suicides per 100,000 population — between 1999 and 2014, with the pace increasing after 2006. In 2014, suicide was the 10th leading cause of death in the U.S. And no group of people is suffering more than military veterans.
The U.S. Department of Veterans Affairs released a sobering report in August 2016. After analyzing more than 50 million veteran suicide records between 2001 and 2014, the VA’s Office of Suicide Prevention found that the risk for suicide among veterans when compared to civilian adults has increased.
There were about 11 suicides per 100,000 in Army active-duty between 2001 and 2004, after the Iraq invasion, says Dr. Gregory Fricchione, associate chief of psychiatry at Massachusetts General Hospital and professor of psychiatry at Harvard Medical School. That number more than doubled over the next five years, and it has remained fairly constant since then, at about 24 to 25 per 100,000 per year, which is nearly 25 percent higher than the general population of the same age and gender.
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This is in stark contrast to previous time periods, says Dr. Robert Ursano, director of the Center for the Study of Traumatic Stress at the Uniformed Services University of the Health Sciences. “It is important to remember that suicide rates in the Army were about half those in the civil population prior to that [time period],” he says. “Being in the Army was generally protective of suicide.” He notes that the military provides full and meaningful employment and generous health care benefits, both of which greatly lower the risk of suicide.
Is depression behind this troubling change? Perhaps. “It’s estimated that up to 14 percent of service members experience depression after deployment,” Fricchione says. “However, this number may be even higher because some service members don’t seek care for their condition.” Ursano says there are two different risks at play — suicidal ideation, which means contemplating suicide, and actually committing the act. He says that research has linked depression to ideation rather clearly. “But depression is not a good predictor of suicide per se,” he says. “Anxiety is more likely to predict an actual suicide.” That makes screening more problematic. “The questions for family members, primary care physicians and mental health providers are all different. Each is looking at a different part of the elephant.”
Finding Answers in the STARRS
Ursano is one of the principal investigators in the Army’s Study to Assess Risk and Resilience in Servicemembers, more easily called the Army STARRS project. Funded by the U.S. Department of Defense, this massive and important project, which started in 2015 and runs to 2020, is intended to provide practical information on how to reduce risk and build resilience for suicide prevention and other mental and behavioral health issues affecting military personnel.
The project has already “knocked down some myths,” Ursano says. For one, suicide is not explained by increased deployment. In fact, one study of more than 975,000 enlisted soldiers found the highest risk was among those who never deployed, and those soldiers were at greatest risk during their second month of service.
A better predictor of suicide, it seems, is if one member of a unit attempts it, then others are more likely to follow suit. The greater the number of previous suicide attempts in the unit, the greater the individual risk for other soldiers in the unit, another STARRS study found. The characteristics of the unit — leadership style and quality, social support, group cohesion and the presence of bullying or hazing — may be the factors behind the likelihood of suicide attempts in the unit, Ursano says. “For example, strong unit cohesion has been associated with reduced distress, increased resilience, and positive states of mind.”
Where does depression fit in? It is certainly a risk factor, he says, but just one in a toxic mixture of factors, including military demotion, a history of criminal or family violence and post-traumatic stress disorder, that contribute in unknown ways. “There are lots of little explanations, instead of one big one,” Ursano says. “I wish we had a better answer.”
[Read: What Are the Risk Factors for Depression?]
Searching for Better Predictions and Treatments
The STARRS project and new programs popping up around the country may be where better answers take shape. The Army using artificial intelligence and data analytics to develop machine-learning algorithms to predict suicide and suicide attempts, he says. “It’s called ‘concentration risk strategy,’ and the Army is leading the way on this.” This strategy is used to predict rare events, like airplane crashes. “When you are trying to identify a needle in a haystack, this is like trying to shrink the haystack,” he says. “The VA also has an algorithm for this, which shows that it can be done — you can find where the risk is highest.”
The challenge then becomes lowering the risk for those few in a large population. Medicine does this all the time; Ursano compares giving a cholesterol-lowering statin to many people at risk for cardiovascular disease, even though only a small number of those people will ever actually develop the disease. “The problem is, in mental health we don’t have a statin for suicide,” he says. “We are moving farther along in predicting suicide and attempts, and we have to move just as far along with treatments.”
The military is studying new interventions, both with psychotherapy and pharmacology, “but there is no new silver bullet out there,” Ursano says. Fricchione adds that military patients with psychiatric disorders “have a multitude of variables that need management and monitoring. Psychological trauma is clinically difficult to manage in primary care even when it does not involve military combat experience.”
Fortunately, he says, strides are being made in the therapy of PTSD, depression and related health issues like substance abuse. And intensive outpatient programs are being developed at places like UCLA, Rush University, Emory University and in Boston, where Fricchione serves as interim chief medical officer at Home Base, a Red Sox Foundation and Massachusetts General Hospital Program.
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“These programs provide individualized care that is tailored to each wounded veteran and family member,” Fricchione says, and ensure that veterans will not be denied access to care due to their geographic location or inability to pay. The treatment programs integrate behavioral health care, rehabilitative medicine, wellness, nutrition, mindfulness training and family support, he says. Home Base recently initiated a two-week intensive clinical program for veterans who live too far away to access care regularly. Patients receive nearly a year’s worth of therapy and support in two weeks, along with basic food, lodging and transportation expenses.
While veterans stand to gain the most from all of this, STARRS and these other programs will eventually help civilians as well. “The hope is that these findings will inform suicide risk and prevention for the entire nation,” Ursano says.
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Depression’s Role in Increased Suicides in Military originally appeared on usnews.com
