Magazine article Clinical Psychiatry News

Fink! Still at Large: A Recent Report on Suicide in the U.S. Army Shows That Suicidal Behaviors Are More Common among Young, Unmarried Soldiers. What Factors Might Make Young People More Vulnerable?

Magazine article Clinical Psychiatry News

Fink! Still at Large: A Recent Report on Suicide in the U.S. Army Shows That Suicidal Behaviors Are More Common among Young, Unmarried Soldiers. What Factors Might Make Young People More Vulnerable?

Article excerpt

When the Army released its report, newspapers across the country (and perhaps around the world) ran headlines like this: "More U.S. Soldiers Committed Suicide in 2007 Than at Any Time Since the First Gulf War." For those of us who tend to the mental health of others, these suicides are particularly tragic.

We are sending young people to war at a time in their lives when, developmentally, they want to be autonomous. The majority of these young people--most of whom are men--have never witnessed death before, certainly not to the extent that they see it while in combat.

We can only speculate about the underlying reasons for their decisions to take their lives. One factor could be the extended amount of time in which they are deployed. Our volunteer Army needs manpower, and we do not have a plethora of men and women waiting in the wings to fight. One major supposition about the suicides is that they could be related to these redeployments. The Army's data show that 7% of the soldiers who either had completed or attempted suicide last year had a history of multiple deployments to Iraq or Afghanistan. It must be very disheartening to wait for the day when you expect to be sent home to your family--and then find out that you have to return to active duty in a month.

These young men are dispatched to a land that is foreign and hostile. The justifications for the war have been ambiguous at best, and this probably has made it difficult for some soldiers--particularly the younger ones--to develop the kind of patriotism that their grandfathers had during World War II.

When today's soldiers arrive in the theater, many see their buddies get killed, and they have no recourse--other than to get angry or to get out. And this desire to get out can lead to suicide. After all, a soldier cannot just announce to his sergeant that he is leaving.

So, one of the causes of suicide might be survivor guilt. This phenomenon has been written about extensively and was eloquently portrayed by Rod Steiger in "The Pawnbroker," a powerful 1965 film about the inner life of a Jewish pawnbroker and concentration camp survivor. When someone you care for dies, the question often becomes: Why him and not me? Certainly, the pain prompting such a question is palpable in the armed services, where the soldier has spent months in close quarters with, and often developed close emotional ties to, his comrades.

The Army has developed an exquisite data system--the Army Suicide Event Report (ASER)--aimed at recording suicidal events. In the report, the Army has been very careful to record whether the suicide occurred during the soldier's deployment or after the return home. For many, the realities of their lives at home might have been drab, compared with the constant state of tension and excitement of war. Life events such as broken love affairs, unhappy marriages, and other issues on the home front can overwhelm and depress anyone.

We know that depression is almost always a factor in suicide, as it was with these young people. Although the Army lists depression as making up only 10% of the motivators, it also lists depressive symptoms such as hopelessness (11%), emotional relief (11%) and avoidance or escape (8%), so one could conclude that a large number of those soldiers were depressed when they took their lives.

The record shows that 30% of the suicide victims had used alcohol or drugs during the event. When they eliminated the responders who listed "I don't know," the percentage went up to 46. A significant number had told people of their intent to take their lives, and that should have been enough to alert coworkers and families of real danger. We must help people become more responsive to the potential of suicide.

The psychiatric literature on suicide both in adults and children is robust. Many young soldiers are still children in many ways. About 40% of those who died had been separated or were having relationship issues at the time of the suicide.

We are cognizant that people who commit suicide often are impulsive and see no other way out of their psychological pain. Often, that pain is guilt. I have already mentioned survivor guilt. But war gives people many opportunities to feel guilty: They are involved with killing unarmed or innocent civilians, they have contributed to the death of a colleague, their hatred for an officer or fellow soldier is very high, or their hatred for war makes them feel unpatriotic, "unAmerican," or just bad for being in the wrong place at the wrong time.

Discouragement often leads soldiers to feel hopeless with no sense of the future of their own ambitions once they get out. If this person has a deep sense that he or she is going to die, pushing things along might not seem very frightening.

Most people I have interviewed who have made a serious attempt to die see no reason to go on. Life is meaningless to them. In recent years, I have noticed that most of these suicidal people have histories of enormous abuse, having been repeatedly trained to believe that they are worthless.

The statistics on existing mental illness in both completions and attempts is significant in the ASER. Among those who successfully killed themselves, 24% had been diagnosed with a mood disorder and 20% had been diagnosed with an anxiety disorder. In the latter group, 7% had posttraumatic stress disorder (PTSD) and 18% had a history of substance abuse.

It is interesting to note that "combat fatigue" was used as a diagnosis during World War II to patch the guy up and send him back into battle. Combat fatigue was the precursor of PTSD, and perhaps the Army is doing the same thing for young people who develop PTSD while deployed. Those in charge of the war and in need of troops seem to have little regard for individual men and women, and instead keep their eyes on the target--which is fighting the war.

Whether or not a suicide occurs depends on a great deal of emotional vulnerability, and throughout this column, I have been referring to varying levels of vulnerability in some men and women who kill themselves. Even such a "minor" factor as the presence and availability of guns needs to be considered. According to ASER, "firearms were the most common method of completed suicide, and overdoses and cutting were the most common methods of self-harm not resulting in death."

In addition, there is the sense of humiliation that some soldiers might feel when someone suggests a visit to a professional. The seeking out of professional help might result in the soldier's losing a great deal of status and stature among his comrades and superiors. A person who is supposed to be a "man," a "fighter," a "protector of his country," should not be seen as having a mental illness or emotional disturbance.

If he becomes depressed during his tour of duty, his efforts not to reveal his ambivalence, sadness, tears, or other signs of the illness might increase his stress level to the point where he is driven to thoughts of suicide or action.

Other important vulnerabilities include prior mental problems, low self-esteem, and an inability to take the kind of criticism and pressures that sergeants are reputed to provide.

In addition, mental problems or other is sues in the soldier's home life might be major contributors to the development of depressive symptoms and, ultimately, to suicide.

This has become such important sequelae of war, because it's sad enough that we take young people out of the normal course of their lives and send them to hostile foreign territory to risk their lives. When the soldier takes his own life, it is often incomprehensible to civilians, because few people in the country stop to think about the kinds of stressors that would lead a soldier to kill himself.

In the ASER report, there is a category related to the soldiers' experiences in direct combat--such as seeing casualties, being injured, witnessing killing, seeing dead bodies, and having killed others--which might be very disturbing to the young person. Even if they know that "war is hell," such experiences can be devastating to a sensitive "kid" whose life experience might not even include the loss of a grandparent.

No one knows how these events are processed in the mind. I've discussed a few ways these issues might be handled by the soldier, including survivor guilt and depression. But in truth, we don't know, and in the Army, this is the way war goes. There is no way to determine by looking at a person how he is feeling. I certainly wish we could!

All of the usual indicators of lethality must be applied to these young men. For example, 10% of those in the 2007 ASER report had a family member who had completed a suicide. We don't know how many of them had tried suicide before, but we must pay more attention to factors that might indicate danger.

The abuse history of the completers and attempters is also interesting. Many had been victims of physical and/or sexual abuse as children. Other important historical information includes excessive debt or bankruptcy (9%), job problems (22%), and poor performance evaluations (9%).

All of us who are involved with delinquent and criminal systems know of cases of "suicide by cop." This occurs when a person points a gun at a police officer, who then shoots him. After the death of the victim, it is discovered that the gun was not loaded. In some cases, no gun was ever found.

We will never know how many heroes in Iraq and Afghanistan put themselves in the line of fire purposely to die bravely instead of putting an end to their own lives. This is one of the great unknowns in the area of soldier suicides.

For young people who oppose the war and find themselves killing others, it might be too overwhelming, and they might find that this method is easier and more socially acceptable than suicide.

We are involved in a terrible war, and we can only hope that it will be over soon. In the meantime, each week 5-10 American soldiers die exclusive of suicide. We as a nation must grieve for these destroyed lives and families.

In addition to more than 4,000 dead soldiers, there are 30,000 seriously wounded young people, and that does not include thousands of kids who come home with severe PTSD.

The high suicide rate is truly a disgrace. We should try to figure out how to screen young people before they are taken into the armed forces and undergo the horrors of war.

According to the Army Suicide Event Report for 2007, 24% of those who successfully killed themselves had been diagnosed with a mood disorder.

DR. FINK is a consultant and psychiatrist in Bala Cynwyd, pa., and professor of psychiatry at Temple University in Philadelphia. He can be reached at cpnews@elsevier.com.

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