The steady annual increase in the number of military suicides following the U.S.-led invasions of Iraq and Afghanistan is often assumed to be caused by the trauma of combat.
But a Department of Defense study published last week in the Journal of the American Medical Association concluded, from a study of 83 cases, that the leading causes of suicide among service members between 2001 and 2007 were mental-health problems and alcohol abuse – tracking with trends in the wider civilian population, where suicide rates also rose sharply between 1999 and 2010.
Still, a top former general and advocate for veteran support is wary of downplaying the link between combat trauma and suicide.
Military suicides have continued to escalate each year since the period covered by the research published last week, prompting the Pentagon last year to describe the problem as an “epidemic." The Department of Veterans Affairs reported in February that 22 veterans commit suicide every day, compared with 18 per day in 2007. And last year, more active duty soldiers took their own lives than were killed in combat, according to the Associated Press.
The new research, however, reiterated what military mental health researchers have long maintained—that suicide among servicemen and women is not typically related to traumatic experience in war zones or to post-traumatic stress disorder. More than half of the suicides analyzed in the JAMA study had never been deployed to a war zone. In fact, the researchers say, the strongest suicide risk factors among military personnel are the same as those in the wider population—alcohol abuse, depression and bipolar disorder, and gender. (Men are more likely than women are to commit suicide.)
But retired Army Gen. Peter Chiarelli believes the study failed to draw the connection between post-traumatic stress disorder (PTSD) and the escalation of suicide-risk factors such as alcohol abuse. Chiarelli, now CEO of the Seattle-based mental health research organization One Mind for Research and a champion of efforts to address suicides in the military, believes that combat trauma fuels the factors that can trigger suicide.
"I have issue with the study because with post-traumatic stress, one of the symptoms of PTSD is self-medication, and self-medication with alcohol," he told Al Jazeera in a telephone interview.
"For a group of professionals to say this is substance abuse-related and not due to PTSD is, in my opinion, not understanding that you have many kids out there, many soldiers, who do not get the help they need, and they self-medicate with alcohol."
The study published in JAMA concluded that "unique stressors, such as combat incidents" were not significant factors in triggering suicide in most of the 83 cases it had investigated.
"The findings from this study do not support an association between deployment or combat with suicide, rather they are consistent with previous research indicating that mental health problems increase suicide risk," the authors wrote.
Their study involved analyzing 83 suicide cases among 150,000 servicemen and women who had regularly self-reported their health conditions as part of the Pentagon’s Millennium Cohort Study, accounting statistically for variations in age, gender, mental health status and deployment-related factors.
"We really found nothing that was military-specific that was related to suicide deaths," said Cynthia LeardMann, epidemiologist with the Naval Health Research Center and one of the lead authors of the study.
The study’s principal researcher, Dr. Nancy Crum-Cianflone of the Deployment Health Research Department at the Naval Health Research Center, said further research was required, particularly in light of the even sharper rise in military suicides in the years after those covered by her team’s research. “When you become a veteran, do you have specific risk factors? Maybe those risk factors won’t be seen for many years over time,” she said.
Rajeev Ramchand, a senior behavioral and social scientist at the RAND Corporation co-author of "The War Within: Preventing Suicide in the U.S. Military," calls the JAMA study "hugely informative" and "a great step forward." But, he added, "I don't think it's the last word."
The research "seems to suggest that the phenomenon we're seeing is not unique to the military," he said, noting similar trends in the civilian population. The Centers for Disease Control and Prevention reported in June that suicide rates among middle-aged Americans had risen by nearly 30% between 1999 and 2010.
"We have seen an increase in suicide rates in the middle-aged male population," said Ramchand. "A lot more needs to go into isolating these stressors and the contribution that deployment contributes.”
LeardMann acknowledged that the JAMA study had not investigated the links drawn by Chiarelli between combat deployments and suicide-trigger problems such as alcohol abuse and depression. But researchers noted that of the suicides covered in the study, 58 percent had never been deployed. More recently, a DOD report found that around 53 percent of the personnel who had committed suicide in 2011—the latest year for which accurate data is available—had never deployed to Iraq or Afghanistan. And only 15 percent of that year's total had actually been exposed to combat.
The Pentagon, also, has been inclined to support the view that suicide among service personnel tends to be triggered by factors not specific to the military. "We're dealing with broader societal issues," then Defense Secretary Leon Panetta suggested last summer in a speech at the DOD and VA's annual conference about suicide prevention. "Substance abuse, financial distress and relationship problems—the risk factors for suicide—also reflect problems … that will endure beyond war."
Others are more inclined to focus on preventive care.
"I wouldn't rule out that PTSD is a risk factor for suicide in the military. It doesn’t show up as one when we adjust for other factors," says Dr. Charles Engel, director DOD's Deployment Health Clinical Center at Walter Reed National Military Medical Center, who wrote an editorial in JAMA that ran alongside the study. "I don't think anyone's trying to diminish the importance of PTSD. It may well mean that depression and alcohol issues may be downstream effects of PTSD."
Engel called for greater focus on mental-health treatment, noting that military personnel often “have mixed feelings about mental health care" because of a continued stigma attached to seeking psychiatric or psychological care. A recent survey from the Iraq and Afghanistan Veterans Association (IAVA) found that 30 percent of respondents had considered suicide, and 43 percent said they didn’t seek care for mental health issues fearing that doing so would have a negative impact on their career.
The Tragedy Assistance Program for Survivors (TAPS), an advocacy organization that supports those who have lost family members or friends to combat-related deaths, released a statement saying that the results from the JAMA study were unsurprising, given the fact that "many service members are afraid to seek help when they need it."
That's why Chiarelli has pushed for the American Psychological Association to drop the "D" in PTSD because, as he says, "there's a certain portion of the population, when you’re between 18 and 25 years old—or even older—they don't want to go to a doctor and be told that they have a disorder. So they go self-medicate."
He says the Army, in particular, has made huge strides in addressing depression and suicide risk by screening for mental health in primary care doctor visits, who can then refer a patient to a specialist, so "you don’t have to tell your first sergeant that you’re going to see the psychiatrist."
But whatever the cause, and no matter how much mental health screening the military implements, the retired general says, more mental health research needs to understand the biological basis of mental illnesses, rather than just relying on patients’ self-reported answers to diagnostic questions. That way, he says, perhaps biomarkers for PTSD and other mental illnesses can provide a clearer diagnosis, in the way physical illness is diagnosed via a scan or blood test.
"This isn't just a soldier problem. This is a national problem, an American problem, a world problem," Chiarelli said. "It's not just service members. We have a huge problem as a society, as a world society, with suicide."