Psychiatric Annals

Military Psychiatry 

Suicide in the United States Military

Joseph M Rothberg, PhD; Robert J Ursano, MD; Harry C Holloway, MD

Abstract

Suicide attempts and suicide are a continuing problem in the military, where suicide is the third leading cause of death. A recent survey of the admissions to the psychiatric service at the Walter Reed Army Medical Center revealed that about one third had significant suicidal ideation or behavior.1 Unfortunately, other data on suicide attempts are not available from military statistics although information on completed suicides is systematically recorded. The recent increase in the suicide rate of young white males in the United States, that segment of society which provides the predominant source of manpower for the military, is of concern. The rate has increased about threefold from the mid-1950s to the present, 6.2/100,000 in 1955 to 21.4/100,000 in 1980 for 15 to 24 year old white males.

The individuals who commit suicide while in the military can be characterized by their demographics (age, race, sex) and other attributes (eg, marital status) at the time of death just as is done for any other human death. There are also risk factors specific to individuals in the military. The study of suicide in the military provides an opportunity to examine the effects of social structure upon the distribution of suicides.

Further, by examining the circumstances of suicidal behavior in the social structure, something may be learned about the interaction of environmental, demographic, and psychological factors in the causation of suicide. No comparable population shares the military service members' history as young professionals "employed" in an institution who meet minimum physical, medical, and mental competency levels. participate in an ongoing regimen of physical and intellectual training, and are immunized, fed, clothed, housed, and provided with comprehensive health care. The military is unique because, by law and regulation, it functions in loco parentis with a commander explicitly charged with the well-being and health of the personnel under his command. These attributes as well as the traditions and other shared aspects of the life of a soldier, sailor, airman, or marine make the United States military a distinct community. Suicide and suicide attempts carry unique visibility and organizational impact in this community.

CRUDE RATE

The crude suicide rate (ie, number of suicides divided by the number in the population) for the Department of Defense (DOD) averaged 10.9 per 100,000 over the three-year span from 1982 through 1984.2 By individual service, the rates per 100,000 were 10.9 for the Army, 11.0 for the Navy, 1 3.9 for the Marine Corps,and 9.9 for the Air Force. As the third ranking cause of death in the DOD, suicide ranks behind only motor vehicles and heart problems. For comparison, in the United States, the crude suicide rate was 11.9 in 1980 where it was the seventh ranking cause of death. Gunshot and small arms were the mode of suicide in 60% of active duty military personnel in 1982 to 1984. This fraction is essentially the same as the 57.3% for the United States in 1980.3 Membership in the military does not radically influence the choice of the mode of suicide. In the army, the rate of suicide by day of week and by month of year is different from that observed in national suicide statistics.4 This suggests that the structure of military life influences the way suicidal behavior is manifest. Studies are underway to examine some of the dynamics of military life that may influence these rates.

HISTORICAL TRENDS

The suicide rate for males in the United States army decreased from 1911 to 1984 (Figure). During the two world wars, the rates decreased strikingly. Those dips also delimit periods of successively lower suicide rates. Suicide was second only to…

Suicide attempts and suicide are a continuing problem in the military, where suicide is the third leading cause of death. A recent survey of the admissions to the psychiatric service at the Walter Reed Army Medical Center revealed that about one third had significant suicidal ideation or behavior.1 Unfortunately, other data on suicide attempts are not available from military statistics although information on completed suicides is systematically recorded. The recent increase in the suicide rate of young white males in the United States, that segment of society which provides the predominant source of manpower for the military, is of concern. The rate has increased about threefold from the mid-1950s to the present, 6.2/100,000 in 1955 to 21.4/100,000 in 1980 for 15 to 24 year old white males.

The individuals who commit suicide while in the military can be characterized by their demographics (age, race, sex) and other attributes (eg, marital status) at the time of death just as is done for any other human death. There are also risk factors specific to individuals in the military. The study of suicide in the military provides an opportunity to examine the effects of social structure upon the distribution of suicides.

Further, by examining the circumstances of suicidal behavior in the social structure, something may be learned about the interaction of environmental, demographic, and psychological factors in the causation of suicide. No comparable population shares the military service members' history as young professionals "employed" in an institution who meet minimum physical, medical, and mental competency levels. participate in an ongoing regimen of physical and intellectual training, and are immunized, fed, clothed, housed, and provided with comprehensive health care. The military is unique because, by law and regulation, it functions in loco parentis with a commander explicitly charged with the well-being and health of the personnel under his command. These attributes as well as the traditions and other shared aspects of the life of a soldier, sailor, airman, or marine make the United States military a distinct community. Suicide and suicide attempts carry unique visibility and organizational impact in this community.

CRUDE RATE

The crude suicide rate (ie, number of suicides divided by the number in the population) for the Department of Defense (DOD) averaged 10.9 per 100,000 over the three-year span from 1982 through 1984.2 By individual service, the rates per 100,000 were 10.9 for the Army, 11.0 for the Navy, 1 3.9 for the Marine Corps,and 9.9 for the Air Force. As the third ranking cause of death in the DOD, suicide ranks behind only motor vehicles and heart problems. For comparison, in the United States, the crude suicide rate was 11.9 in 1980 where it was the seventh ranking cause of death. Gunshot and small arms were the mode of suicide in 60% of active duty military personnel in 1982 to 1984. This fraction is essentially the same as the 57.3% for the United States in 1980.3 Membership in the military does not radically influence the choice of the mode of suicide. In the army, the rate of suicide by day of week and by month of year is different from that observed in national suicide statistics.4 This suggests that the structure of military life influences the way suicidal behavior is manifest. Studies are underway to examine some of the dynamics of military life that may influence these rates.

HISTORICAL TRENDS

The suicide rate for males in the United States army decreased from 1911 to 1984 (Figure). During the two world wars, the rates decreased strikingly. Those dips also delimit periods of successively lower suicide rates. Suicide was second only to motor vehicle accidents as the reason for death in the US army in the years before WW II. The fighting in Korea did not have as evident an effect on the army-wide suicide rate as did the two world wars. No data are available for 1958 through 1975 so the effect of Vietnam on the suicide rate is unknown.

During the last century suicide in the military was notoriously higher than in civilian life.5 Army suicides for matched age groups of males had become less frequent in the military than in the civilian population in the 1950s.6 The data for the Air Force for the years 1958 through 1964 show a rate of 11.9 per 100,000 with a general decreasing trend.7 These data indicate that suicide occurs with less frequency in Air Force men than among men in the general population even when age is considered. For 1966 through 1977, Navy and Marine Corps had rates of 7.2 for the Navy and 15.2 for the Marines.8 The lower age-specific rates for males in the military compared to the general population was also found in a recent analysis.2

FIGURESuicide Rate per 100,000 United States Army Males, All Ages, All Races, 1911-1984

FIGURE

Suicide Rate per 100,000 United States Army Males, All Ages, All Races, 1911-1984

DEMOGRAPHICS AND OTHER RISK FACTORS

Youth is a risk factor for suicide in the military (Table). Each ten-year age interval (except for the 55 and over interval) has a lower rate in the DOD than in the civilian community when race and sex are controlled. The ratio of suicide rates for whites and blacks is about 2:1 in the civilian community and about 1.5:1 in the DOD. The ratio of male to female suicide rates is over 3:1 in the US population and lower (about 1.5:1) in the DOD. For the males, the under 25 age group had a rate about three quarters of the VS rate while the over 25 age group had a rate about half of the US rate. This relation was observed in both white and black males. In contrast, for both white and black females, the average suicide rate is greater for the DOD than the US in each age category. This important difference requires further study.

The suicide rate for separated or divorced soldiers is seven times higher than for married soldiers,9 a finding similar to that in civilian populations.10 Measures of suicide rates by length of service in the military show two periods of increased risk, the first few months of service and the last few years before retirement. These are periods of high stress related to transitions into and out of the community - periods of psychosocial transition. The risk factors and protective factors are probably not the same in the young person with adaptational problems as opposed to the middle-aged person anticipating retirement. Divorce, entering the service, retirement, or involvement in a legal action likely to change the status of the military member are likewise periods of particular clinical concern. Given that suicidal response to a loss may be impulsive, prevention will be unlikely for such episodes of suicidal behavior. One area in which active intervention may reduce suicide is in those soldiers facing a loss of status secondary to legal action because the military system is clearly aware of the action that is putting them at risk. Individuals who are caught in the breakup of love relationships through divorce or separation may be much more difficult for the military to identify. It is anticipated that individuals who are found to be HTLV-III positive may be faced with the precipitous loss of socially supporting and loving relationships. If past experience is any guide, this group will be at exceptionally high risk for suicide. They should be the subject of special attention to prevent an increase in suicides.

Table

TABLEComparison of Suicide Rates per 100,000 in the Military and General US Population

TABLE

Comparison of Suicide Rates per 100,000 in the Military and General US Population

Military service in itself, apparently, does not carry an extra risk for suicide. The Veterans Administration (VA) health care system has a suicide rate only one fifth of the US rate." The protective effect observed in this patient population does not generalize to all veterans as evidenced by a population-based analysis of the 1960 male veteran suicides in Texas which found no overall difference in the suicide rate compared with the general population of the same age and sex.12 Taken together, these studies suggest that military service is not a risk factor for suicide and that those veterans who commit suicide are greatly underrepresented in the VA system.

Hospitalization for mental illness is a risk factor of varying intensity for suicide among veterans, active duty military, and civilians. The 24-year mortality follow-up experience of World War II army veterans who received disability separations for "psychoneurosis" in 1944 showed a 20% excess mortality over the period 1946 to 1969 with increased risk of death from alcoholism, suicide, and homicide.13 The presence of prior psychiatric illness in veterans was associated with a ninefold increase in the suicide rate.12 In an analysis of the records of all suicides in the naval service between July 1965 and fanuary 1972, the rate of suicide for psychiatric patients after discharge from major Navy hospitals was 195/100,000 per year (calculated to be an 18-fold elevation over the naval service rate) and 37 per 100,000 (a fourfold increase) while hospitalized.14 For civilian mental patients, a fivefold increase in the suicide rate compared to the general population has been reported while hospitalized or within one year of discharge during 1960 to 1970.15 The additional contribution of current and prior military service to the increased risk for suicide subsequent to mental disease remains an open question. The role of alcoholism and other substance abuse in military suicide is unknown.

CONCLUSION

The risk factors for suicide in the military (divorce, separation, retirement, and mental disease hospitalization) are similar to those in the civilian community. However, in contrast to the civilian community, the youthful component accounts for more suicides in the military. Rates for suicide in age-race matched males are lower in the DOD than in civilian communities. For females, however, the rates are higher. The factors involved in the military-civilian differences in the age-race-sex specific suicide rates as well as the factors contributing to the variation in suicide rate between the services are areas of future study.

REFERENCES

1. Amen DG: Suicidal Behavior as a Targeted Event: Ideas for Evaluating the Need for Hospitalization. Walter Reed Army Medical Center, Washington. DC. 1984.

2. Redman RA, Walter L| Jr: Suicide Among Active Duty Military Personnel. Office of the Secretary of Defense for Health Affairs. Washington. DC, 1985.

3. Centers for Disease Control: Suicide - United States. 1970-1980. MMWR 1985; 34:353-357.

4. Rothberg |M: Cycles of suicide. Proceed" ings of the 29th Conference on the Design of Experiments in Army Research, Development and Testing 1984; pp 157-165. Army Research Office.

5. Durkheim E: Suicide: A Study in Sociology. Spaulding |A. Simpson G (trans). New York, The Free Press. 1951.

6. Yessler P: Suicide in the military, in Rcsnick HLP (ed): Suicidal Behavior. Boston, Little Brown & Co. 1968, pp 241-254.

7. Eggerslen PF. Goldstein SM: Suicide by Air Force personnel 1958 to 1964. Milit Med 1968: 133:26-68.

8. Chaffee RB: Completed Suicide in the Navy and Marine Corp. Naval Research Center. San Diego, CA, 1982.

9. RothberglM, Rock NL, Iones FD: Suicide in the United States army personnel, 1981-1982. Milit Med 1984; 149:537-541.

10. Jacobson GF: Portuges SH: Relation of marital separation and divorce to suicide: A report. Suicide Life Threat Behav 1978; 8:217-224.

11. Baker JE: Monitoring of suicidal behavior among patients in the VA health care system. Psychiatric Annals 1984; 14:272-275.

12. Pokorny AD: Suicide in war veterans: Rates and methods. J New Ment Dis 1967; 144:224-229.

13. Keehn RJ, Goldberg ID1 Beebe GW: Twenty-four year mortality follow-up of Artny veterans with disability separations for psychoneurosis in 1944. Psvchosom Med 1974; 36:27-46.

14. Scbuddi MA. Gunderson EKE: Suicide in the naval service. Am / Psychiatry 1974; 151:1328-1331.

15. Slettcn IW. Brown ML, Evenson RC, et al: Suicide in mental hospital patients. Diseases of the Nervous System 1972; 33:328-334.

TABLE

Comparison of Suicide Rates per 100,000 in the Military and General US Population

10.3928/0048-5713-19870801-10

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