Responding to the Army Suicide Epidemic: How to Regain the Healthy Soldier Effect
By: MAJ Jake Conrad
In the past five years, the Army has lost ten times more soldiers to suicide than were lost to combat.[1,2] Today, the Service’s Active Duty (AD) suicide rate is two and a half times as high as it was in 2001, twice as high as the general population rate, and trending in the wrong direction.[3, 4] With respect to suicide, the Army has lost the “healthy soldier effect,” the label applied when the Army enjoyed better health outcomes than the general population during the second half of the 20th century.[5, 6] If the AD Army suicide rate had remained on par with that of the general population since 2005, 700 fewer soldiers would have been lost to suicide.
In one form or another, suicide has touched everyone in uniform. Throughout my service, I have witnessed its effects firsthand. Last year, in choosing a graduate school Capstone Project, I sought to explore a personal and meaningful issue connected to my profession. I chose the Army suicide epidemic. It quickly became apparent that this is a complex problem with no straightforward solution. The following is a condensed version of my final project. In sharing, I hope to highlight the significant impacts of suicide on the force, shed light on causal contributors, and propose some suggestions to the difficult question: “what should we do?”
The Rise in Army Suicides
Suicide is the second leading cause of death among military personnel.[7] Since 2006, 4,231 AD service members have taken their own lives. This amounts to more casualties from suicide than from the past 15 years of combat in the wars in Iraq and Afghanistan.[8] Sadly, the Army is infamous for leading the military branches in suicide incidence. In five of the past six years, the AD Army led all component services in suicide rates, exceeding the total active military average by twenty percent.[9] In 2018, the Army suffered its worst year on record since 1938 with 29.9 deaths per 100k service members.[10]
Generally, the Army population is not comparable with the larger population of the US. Meaningful comparison requires adjustments for demographic differences such as age, sex, and ethnicity. Such adjustment leads some to conclude that today’s incidence of suicide in the Army is no worse than it is in America generally.[11] However, the standard demographic adjustment of Army suicide incidence fails to account for sociocultural factors. Military service provides benefits such as guaranteed housing and employment, as well as access to quality medical care and education services. Moreover, throughout the second half of the 20th century, Army soldiers had an unadjusted suicide rate comparable to or below that of the general population.[12] This phenomenon has been termed the “healthy soldier effect.” It proposes that soldiers have lower all-cause mortality rates than the general population due to initial screenings, physical health standards, and access to quality medical care.[13]
It is in the context of the healthy soldier effect, then, that we must make sense of the drastic increase in the Army suicide rate since 2000. The upward trend began in 2005 after the start of Operation Iraqi Freedom and continued as the wars in the Middle East proceeded.[14] In 2004, the AD Army had a suicide rate of 10 per 100k service members. By 2012, this rate had nearly tripled.[15] Since then, the suicide rate among AD Army soldiers has risen to double that of the general population. It is true that the suicide rate for the US generally has increased over the past two decades. From 2001 to 2018, the general population suicide rate increased 33%.[16] But during the same period, the AD Army suicide rate increased 244%.[17] Since 2005, losing the healthy soldier effect meant 700 additional service member deaths by suicide.[18]
The Department of Defense (DoD) and Army responded to the increased incidence of suicide by expanding suicide prevention research, policies, and programs. In 2011, the DoD launched the Defense Suicide Prevention Office (DSPO). The DSPO is responsible for advocacy, program oversight, and policy for suicide prevention, intervention, and postvention for DoD service members, civilians, and their families. The DoD also began funding suicide prevention research with relevance to military personnel. In 2014, over 61 studies were funded, costing more than $100 million. That same year, the Army allocated $65 million to fund The Army Study to Assess Risk and Resilience in Servicemembers (STARRS).[19] Yet despite spending hundreds of millions of dollars, the Army suicide rate increased.[20] The Service has yet to curb the epidemic.
Why Should We Care?
The toll of suicide for the Army as an institution charged with defending the nation is extremely high. The epidemic incurs significant fiscal, emotional, and readiness costs on the force. The fiscal impact of one civilian suicide in the US is $1.3 million.[21] Using this metric, suicides since 2018 have cost the military more than a billion dollars. That is enough money to field 80 Apache Attack Helicopters or 170 Abrams Tanks. Of course, the cost to the military is higher. This figure does not consider a suicide’s impact on mission readiness, unit cohesion, and public perception. The Army is structured to promote tight-knit relationships at the small unit level. Comradery is ingrained in soldiers during basic training where trainees must depend on their assigned “battle buddy” to succeed. This is reinforced again in the operational environment as soldiers routinely trust peers and leadership with their lives. As a result of these close bonds, the mental health of soldiers is adversely affected by the death and injury of other unit members. We know a soldier is at a higher risk of suicide if there were previous suicide attempts in that soldier’s unit.[22,23] And as military service becomes associated with suicide, recruitment is affected. Recently, the Army has struggled to enlist new members, barely meeting its 2019 goals, and failing to meet its 2018 goals. Americans become more reluctant to join an all-volunteer force when veterans and soldiers are at higher risk.[24]
Every suicide is also a human tragedy. The epidemic continues to claim victims, regardless of background, rank, or position. Each casualty possesses a unique story and leaves behind loved ones wracked with pain and guilt. In 2016, Major General John Rossi was two days away from pinning on his third star and assuming a prestigious command position. Overwhelmed by his responsibilities and plagued with self-doubt, he went home and hanged himself. In 2017, 21-year-old Private Nicole Burnham arrived at her first Army duty station in South Korea. Six months later, after a series of failures by her commanding officers, she took her own life. Army Chief of Staff General James McConville has declared that people are his number one priority.[25] For the Army to honor this commitment to its people, it must do more to prevent the tragic and unnecessary loss of human life that each suicide is.
Suicide Etiology
Suicide is as old as humanity. It has claimed warriors (Ajax), writers (Hemingway), celebrities (Robin Williams) and scientists (Alan Turing). Yet its etiology remains elusive. Today, there are two primary approaches to explaining suicide–the sociological approach and the psychological approach.
Sociologists tend to think suicide is the result of an imbalance between the social forces of integration and moral regulation. Emile Durkheim described suicide as a social phenomenon, rather than an individual neurosis. It results when society fails to integrate some of the individuals comprising it.[26] This theory gained prominence in the early 20th century but has fallen out of favor with psychologists due to weaknesses with respect to identifying the specific individuals at risk of suicide. Although Durkheim’s approach is a poor predictor of individual behavior, it can help us identify causal factors attributable to a community or an organization, such as the Army.[27]
Psychologists tend to see suicide as the result of a complex combination of factors that lead to feelings of hopelessness and burdensomeness combined with a capability to act.[28] Research has attempted to identify these correlates, terming them “risk factors” due to their presence being associated with an individual’s increased risk of suicide. Some prominent risk factors are mental illness, social isolation, criminal or legal problems, and substance abuse disorders. The treatment approach flowing out of this explanation tries to reduce suicide by identifying and addressing the risk factors.[29]
The literature explaining the loss of the healthy soldier effect identifies two sociological factors as root causes and two psychological factors as contributing causes. These are categorized below and explained in further detail in the following sections.
Sociological Root Cause:
· The Army is enlisting more high-risk individuals
· The Army has created conditions that increase the risk of suicide
Psychological Contributors:
· The Army fails to identify those most at risk
· The Army employs ineffective prevention strategies
The Army is Enlisting More High-Risk Individuals
Over the past two decades, there has been a steady increase in the suicide rate among the total US population. This highlights a growing suicide crisis in the US, and the military may be importing these effects.[30] In the mid-2000s, the Army relaxed recruiting standards to meet force requirements brought on by the wars in Iraq and Afghanistan. The Service increased waivers for high school diplomas, aptitude tests, and criminal and medical problems.[31] During this period, first term soldiers accounted for a majority of the Service’s suicide attempts. The Army also retained over 25 thousand soldiers who did not meet requirements to remain in service.[32] In 2017, when faced with similar obligations, the Army once again reduced enlistment standards.[33] Lowering standards to meet recruitment goals diminishes the healthy soldier effect by increasing the proportion of individuals possessing suicide risk factors within the force.
The Army has Created Conditions that Increase Suicide Incidence
Social integration plays an essential role in mental health, while social isolation is associated with negative health outcomes including increased mortality. The structure of an individual’s social relationships shapes his or her ability to be happy and healthy.[34] Over the past two decades, two factors have worsened the Army’s ability to achieve social integration. The rise of communications technology and the deployment operations tempo.
Ninety-seven percent of US young adults report social media use, up from 12% in 2005. Although the goal of social media platforms is to connect with others, it often has the opposite effect. Social media use positively correlates with social isolation and negatively correlates with emotional support.[35] Social integration is not optional in Army basic training. For 22 weeks, recruits are isolated from all else, forced to rely on their drill instructors and one another. If an individual refuses to integrate, they do not graduate. However, the regular Army is not akin to basic training. Once recruits complete training, they are transferred to one of many bases across the country and granted a sizable amount of autonomy. Typically, they are separated by hundreds of miles from former emotional and social support networks. In the past, this facilitated a rapid social integration within the new community. However, technological advances, such as social media and cell phones, allow soldiers to maintain continuous ties with family, friends, and homeplaces. As a result, soldiers may be less likely to integrate locally.[36] This is worsened by the frequent changes of location that accompany military service. On average, every two years, individual social networks are uprooted, and soldiers must restart the social integration process.[37]
Deployment operations tempo refers to the rapid movement of Army units in and out of theaters of war and preparatory training centers. Since the wars in Iraq and Afghanistan began, soldiers have routinely deployed to the Middle East, some as often as every other year. When not deployed, they often worked long, intense hours, preparing and training for the next deployment.[38] From 2001 to 2015, the Army deployed over 1.3 million soldiers to the Middle East, totaling 1.3 million troop-years of deployed service. The Army has provided 58% of the total deployments since 2001, with the Navy and Air Force tied for second place at 15%. In 2015, among soldiers who had deployed, the cumulative average time deployed was 18 months.[39] Since then, force requirements in the Middle East have decreased, although the Army’s obligations elsewhere have not. Multiple deployments, long deployments, and shortened time between deployments are risk factors for suicide.[40] Following an extended absence, individuals find it difficult to socially reintegrate. A rapid reintegration period followed by an immediate training cycle for another deployment exacerbates the problem. Oftentimes, soldiers are not given a chance to fully reset before occupational demands separate them, once again, from social support systems.[41]
The Army Fails to Identify Those Most at Risk
There are significant barriers to treatment and identification of mental health disorders within the Army. Ninety to ninety-five percent of suicide victims in the US general population have a diagnosable mental disorder at the time of their death.[42] These disorders are increasing in frequency among the general population with mental illness manifesting in one out of every five adults. The issue is not improving with the next generation as nearly ten percent of youth suffer from major depression, a rate that has doubled within the past five years.[43] The Army is reporting similar trends. The prevalence of mental health disorders among soldiers has doubled in the past decade. The Army also has a much higher rate when compared to sister Services. [44]
Eighty percent of military suicide victims were previously diagnosed with a mental health disorder, and the largest factor differentiating successful suicides from ideations is the presence of these disorders.[45] Many service members with mental health disorders are not actively seeking treatment. Studies have estimated that only one out of every five soldiers with a diagnosed disorder receives mental healthcare.[46] This indicates that mental health treatment barriers are a major public health concern in the Army.[47] These barriers can be categorized as structural or attitudinal. Structural barriers include financial constraints or difficulty attending appointments. Attitudinal constraints include perceived stigma, negative views towards mental health professionals, or a desire to handle the issue personally. Most soldiers report not seeking treatment due to attitudinal constraints. The most frequent reason is a desire to handle the issue personally, followed by perceived ineffectiveness, stigma, and embarrassment. Additionally, it is likely that many soldiers have undetected mental health conditions. These conditions may be overlooked due to a lack of perceived need for treatment, unreported symptoms, or inadequate mental health screenings. This is attributable to poor mental health knowledge among the force and a culture that does not incentivize honest symptom reporting.[48] The high rate of suicide within the Army is at least partially explained by the high proportion of untreated and undetected mental health conditions within the ranks.
The Army Employs Ineffective Prevention Strategies
The DoD and the Army have devoted hundreds of millions of dollars to suicide prevention research and program implementation. Researchers have attempted to identify military specific risk factors—generating over 24 hypotheses—and associated these with the increase in Army suicides. Subsequent strategies have focused on identifying individuals with associated risk factors and intervening.[49] Some of these even relate to the Army’s own internal suicide prevention efforts.[50] Despite these efforts, the Army suicide rate has not meaningfully decreased since 2003. This indicates that the current strategies are ineffective. This is not surprising because using individual risk factors to predict future suicidal behaviors is only slightly more accurate than a coin toss. Despite the investment, our predictive ability has not improved across more than fifty years of research.[51]
Interventions fail for numerous reasons. The Army has a perceived tendency to “medicalize” prevention efforts.[52] This suggests that the Service addresses suicidal thoughts and behaviors by inadvertently isolating soldiers and using pharmaceuticals as a first option in treatment. While soldiers must receive proper and adequate care, removing them from the operational environment and placing them in the medical system could trigger elevated stress and reduce their sense of belongingness. This action may also exacerbate the stigma associated with mental health conditions, leading to further isolation of the soldier within his or her units. For these reasons, soldiers may avoid seeking help and resist medical interventions.[53] Army mental health professionals tend to use medication as a first preference in treatment due to ease of access and a lack of viable alternatives. This approach can backfire as behavioral health misdiagnosis occurs often,[54] and improperly prescribed medication may slow recovery or cause irreversible adverse effects.[55]
| Offered explanations for Army suicide increases | ||
| Mental Health Issues | Genetic predisposition | Risk taking behavior |
| Combat and Deployments | Poor physical health | Adverse childhoods |
| Isolation | Grief and moral injury | Inadequate social support |
| Loss of purpose | Expertise in weaponry | Chronic pain |
| Sexual Assault / Harassment | Mandatory suicide training | Legal problems |
| Failed relationships | Weak moral character | Desert heat |
| Contagion from exposure | Disruption in energy fields | Underdeveloped neocortex |
| Traumatic Brain Injuries | Inadequate nutrition | Financial difficulties |
What Now?
The rise in the Army suicide rate is hard to explain in a way that points to an obvious remedy. Since suicide is preventable, inaction is not an option.[56] Today’s elevated Army suicide rate is a drain on readiness, a human tragedy, and a test of whether the Army will be true to its values. The Service must strive to regain the healthy soldier effect. The question is how should the Army do so.
Assessment for All
In 2020, following reports of increased military suicides, the General Officer in charge of the Army Training and Doctrine Command suggested that all soldiers be required to see a behavioral health professional annually. “Just like we have to go see the dentist, we all ought to see the behavioral health specialists once a year.”[57] The Assessment for All option would incorporate mandatory behavioral health assessments as an Army-wide medical readiness task. Assessments would be conducted face to face with a certified mental health professional. Completion would be tracked in the Army’s medical readiness system and required to maintain status on Active Duty. This approach would tackle three key issues regarding suicide prevention within the force. First, it would improve the identification of those at risk of suicidal thoughts and behaviors. Behavioral health clinicians would be put in position to assess soldier well-being and, if necessary, to intervene. Second, it would improve service member awareness of the mental health resources available through the military health system. All soldiers would be assigned a behavioral healthcare provider, promoting relationships between service members and clinicians, and allowing soldiers to know where to seek personal assistance or help for others. Third, it would combat the stigma regarding mental health conditions and care in the Army. If everyone is required to see a behavioral health specialist, individuals will be less reluctant to seek help. This policy may catalyze a cultural shift, promoting an Army that is more accepting and aware of mental health challenges.
Machine Learning
Machine Learning represents a leap forward in how computers process information. This groundbreaking technology is being applied to suicide prevention efforts. By analyzing patient data, suicide prediction algorithms identify individuals who are at risk of suicidal thoughts and behaviors. Data are drawn from internet content, mobile use, social media accounts, audio recordings, written documents, biological data, and electronic medical records.[58] Machine learning suicide prevention technology can be used in tandem with clinical care providers, or standalone. If implemented correctly, this technology could access biological data, electronic medical records, personnel information, training records, and military pay information. It has the potential to be applied to the entire AD Army population and updated in real time. If a soldier is identified as high risk, the chain of command could be notified, and the soldier flagged to follow up with an assessment with a mental health care professional.
Tougher Standards
The primary purpose of physical and mental standards in the military is to select candidates best suited to the demands of military service. In the Army, basic fitness standards are meant to promote the readiness of the force. Despite these requirements, the Service provides physical, mental, and criminal waivers for approximately 10% of the recruited population with 10% of all waivers relating to mental health conditions.[59] Waivers are provided due to the fact that every individual’s circumstances are unique, and often the Army’s black and white regulations do not account for these extraordinary situations. In addition, waivers may be granted to ensure the Service is able to meet recruiting requirements. By granting waivers for individuals suffering from mental health conditions, the Army incorporates a population that is at increased risk of suicide. Individuals with diagnosed mental health conditions are four times more likely to commit suicide than the general population.[60] If the Service no longer accepted waivers for individuals suffering disqualifying mental health conditions, regardless of the circumstances, it could reduce the population of Soldiers at highest risk.
Conclusion
Command Sergeant Major (CSM) James McGuffey enlisted in the Army following the September 11th terrorist attacks. As a Soldier, he demonstrated an aptitude for service, progressing through the ranks quickly and joining the elite 75th Ranger Regiment. But at the very same time CSM McGuffey was excelling professionally, he was suffering from depression and anxiety. These conditions were exacerbated by routine deployments and multiple failed marriages. Unwilling to seek help due to stigma and career concerns, CSM McGuffey soldiered on—through years of stress, trauma, and thoughts of self-harm. On the exterior, he was a confident and competent soldier. But on the interior, and hence unbeknownst to his peers and superiors, he was moving toward crisis.
That is how, at the age of thirty, James McGuffey found himself lying in bed with a pistol in his mouth. Moments from pulling the trigger, his mother called. James is confident that he would not be here today if it were not for his mother’s phone call.[61]
CSM McGuffey was saved, but not by the Army. Too many Soldiers’ lives end in tragedy—without a suicide epidemic. Since 2005, 1,994 AD Soldiers have committed suicide. In each instance, opportunities to save a fellow soldier were missed. Too often, nobody called.
The Army requires every Soldier to pledge to “never accept defeat” and “never leave a fallen comrade.” It does so because the bedrock of the Army is its people. Yet we somehow arrived at a point in time when the institution seems resigned to the scourge of suicide in its ranks. It does not have to be this way. During the twentieth century, it was not this way. The less than one percent of all citizens who raise their right hands and swear an oath to support and defend our nation deserve better. The Army owes itself better.
Jake Conrad is an active duty Army Armor officer serving as a Joint Chiefs of Staff Intern at the Pentagon.
Endnotes
[1] DoD Under Secretary of Defense for Personnel and Readiness, “Annual Suicide Report CY 2018.” DSPO (2019).
[2] Blum, David. “American War and Military Operations Casualties.” Congressional Research Service (2020): 44-45
[3] Lineberry, T. “Suicide in the US Army.” Mayo Clinic (2012): 872.
[4] National Institute of Mental Health, “Suicide Statistics.” NIMH, January 2021, https://www.nimh.nih.gov/health/statistics/suicide.shtml.
[5] McLaughlin, R. “An evaluation of the effect of military service on mortality: quantifying the healthy soldier effect.” Annals of epidemiology 18, no. 12 (2008): 928-936.
[6] Bollinger, M.”Erosion of the healthy soldier effect in veterans of US military service in Iraq and Afghanistan.” Population health metrics 13, no. 1 (2015): 1-12.
[7] Suicide is the tenth leading cause of death in the US. In 2018, 48,344 Americans died by suicide and there were an estimated 1.4 million attempts. NIMH, “Suicide Statistics.”
[8] Mann, C. “Trends in Active-Duty Military Deaths Since 2006.” Congressional Research Service (2020).
[9] DoD Under Secretary of Defense for Personnel and Readiness. “Annual Suicide Report CY 2018.”
[10] Smith, J. “A historical examination of military records of US Army suicide, 1819 to 2017.” JAMA network open 2, no. 12 (2019)
[11] DoD Under Secretary of Defense for Personnel and Readiness. “Annual Suicide Report CY 2018.”
[12] Ibid.
[13] Waller, M. “Changes over time in the” healthy soldier effect”,” Population Health Metrics 9, no. 1 (2011): 1-9.
[14] Smith, Jeffrey Allen, “A historical examination of military records of US Army suicide, 1819 to 2017.”
[15] Lineberry, Timothy, “Suicide in the US Army.”
[16] NIMH, “Suicide Statistics.”
[17] DoD Under Secretary of Defense for Personnel and Readiness, “Annual Suicide Report CY 2019.” DSPO (2020).
[18] Resulted deaths were computed by contrasting the Army suicide rate with the general population rate in Figure 2 for CY 2005 – 2019.
[19] Ramchand, R. “Developing a research strategy for suicide prevention in the Department of Defense: Status of current research, prioritizing areas of need, and recommendations for moving forward.” Rand health quarterly 4, no. 3 (2014).
[20] DoD Under Secretary of Defense for Personnel and Readiness. “Annual Suicide Report CY 2018”
[21] Shepard, D. “Suicide and Suicidal Attempts in the United States: Costs and Policy Implications.” Suicide and Life-Threatening Behavior (2015): 46(3).
[22] Ursano, R. “Risk of Suicide Attempt Among Soldiers in Army Units with a History of Suicide Attempts.” JAMA Psychiatry 74(9) (2017): 924-931.
[23] Long, J. “Why the Army Missed Its Recruitment Goals.” Modern War Institute (February, 2019) retrieved from https://mwi.usma.edu/not-economy-army-missed-recruitment-goals.
[24] Harrell, M. “Losing the Battle: The Challenge of Military Suicide.” Center for a New American Security, October 2011, retrieved from http://ncdsv.org/images/CNAS_LosingTheBattleTheChallengeOfMilitarySuicide10-2011.pdf.
[25] Army News Release. “McConville confirmed as CoS ‘people’ to be his top priority.” U.S. Army (October, 2019) retrieved from https://www.army.mil/article/222341/mcconvilleconfirmedpeopletobehistoppriority
[26] Taylor, S. Durkheim and the Study of Suicide. Macmillan International Higher Education, 1982.
[27] Selvin, H.C. Durkheim’s Suicide: further thoughts on a methodological classic. 1965.
[28] Wolfe-Clark, A. “Integrating two theoretical models to understand and prevent military and veteran suicide.” Armed Forces & Society 43, no. 3 (2017): 478-499.
[29] Nock, M. “Risk factors for the transition from suicide ideation to suicide attempt: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).” Journal of abnormal psychology 127, no. 2 (2018): 139.
[30] Case, A., and Angus D. Deaths of Despair and the Future of Capitalism. Princeton University Press, 2020.
[31] Inskeep, S. “Army Documents Show Lower Recruiting Standards.” NPR (2008), retrieved from https://www.npr.org/templates/story/story.php?storyId=89702118
[32] Chiarelli, P.W. Army health promotion risk reduction suicide prevention report 2010. Diane Publishing, 2010.
[33] Woody, C. “The Army is changing its standards to get more recruits.” Business Insider (2017), retrieved from https://www.businessinsider.com/army-changing-recruiting-standards-to-attract-more-soldiers-2017-10.
[34] Mueller, A. “Adolescents under pressure: A new Durkheimian framework for understanding adolescent suicide in a cohesive community.” American sociological review 81, no. 5 (2016): 877-899.
[35] Whaite, E. “Social media use, personality characteristics, and social isolation among young adults in the United States.” Personality and Individual Differences 124 (2018): 45-50.
[36] Ibid.
[37] Stewart, D. “Longer Time Between Moves Related to Higher Satisfaction and retention.” United States General Accounting Office (2001): 1-35.
[38] Ritchie, E. “Suicide and the United States army: perspectives from the former psychiatry consultant to the army surgeon general.” In Cerebrum: the Dana forum on brain science, vol. 2012, pp. 1-1. 2012.
[39] Wenger, J. Examination of recent deployment experience across the services and components. Rand Arroyo Center (2018): 1-50.
[40] Gilman, S. “Sociodemographic and career history predictors of suicide mortality in the United States Army 2004–2009.” Psychological medicine 44, no. 12 (2014): 2579.
[41] Ritchie, E. “Suicide and the United States army: perspectives from the former psychiatry consultant to the army surgeon general.” In Cerebrum: the Dana forum on brain science, vol. 2012, pp. 1-1. 2012.
[42] Hawton, K. 2000. Suicide and violence. The international handbook of suicide and attempted suicide, pp.437-456.
[43] Reinert, M. “2021: The State of Mental Health in America.” Mental Health America (2020).
[44] Military Data Repository. “Prevalence of Mental Health Conditions Among AD SMs from 2005-2017.” MDR, April 2009, retrieved from https://www.pdhealth.mil/research-analytics/psychological-health-numbers/mental-health-disorder-prevalence-and-incidence
[45] Nock, M. “Psychological autopsy study comparing suicide decedents, suicide ideators, and propensity score matched controls: Results from the study to assess risk and resilience in service members (Army STARRS).” Psychological medicine 47, no. 15 (2017): 2663.
[46] Colpe, L. “Mental health treatment among soldiers with current mental disorders in the Army Study to Assess Risk and Resilience in Service Members (Army STARRS).” Military medicine 180, no. 10 (2015): 1041-1051.
[47] Naifeh, J. “Barriers to initiating and continuing mental health treatment among soldiers in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).” Military medicine 181, no. 9 (2016): 1021-1032.
[48] Ursano, R. “Risk factors associated with attempted suicide among US Army soldiers without a history of mental health diagnosis.” JAMA psychiatry 75, no. 10 (2018): 1022-1032.
[49] Bryan, C. “Suicide prevention in the military: A mechanistic perspective.” Current opinion in psychology 22 (2018): 27-32.
[50] Castro, C. “Suicides in the military: The post-modern combat veteran and the Hemingway effect.” Current psychiatry reports 16, no. 8 (2014): 460.
[51] Suicide involves an intricate combination of specific factors and proving causality is difficult. Researchers must draw qualitative data from suicide incidence within the population and the combination of the low suicide rate and on self-reporting makes this problematic.
Franklin, J. “Risk factors for suicidal thoughts and behaviors: a meta-analysis of 50 years of research.” Psychological bulletin, 143(2), p.187.
[52] Army Forces Health Surveillance Center. “Death by suicide while on active duty, active and reserve components” US Armed Forces, 2000-2011, 7.
[53] US Department of the Army “Army Gold Book” HQDA (February, 2011), 13.
[54] Baker, C. “Forensic Validity of a PTSD Diagnosis” Department of Veterans Affairs, National Center for PTSD, December 2011, retrieved from http://www.ptsd.va.gov/professional/pages/forensic-validity-ptsd.asp
[55] Caplan, P. When Johnny and Jane come marching home: How all of us can help veterans. MIT press, 2011.
[56] DoD Under Secretary of Defense for Personnel and Readiness. “Annual Suicide Report CY 2018.”
[57] Cox, M. “General’s Proposal to Curb Suicide: Require Every Soldier to Visit Behavioral Health” Military News (September, 2020) retrieved from https://www.military.com/daily-news/2020/09/29/generals-proposal-curb-suicide-require-every-soldier-visit-behavioral-health.html
[58] Heller, D. “How Artificial Intelligence will save lives in the 21st century” FSU News (February, 2017) retrieved from https://news.fsu.edu/news/health-medicine/2017/02/28/how-artificial-intelligence-save-lives-21st-century/
[59] Brook, T. “Army Issues Waivers To More than 1,000 Recruits for Bipolar, Depression, and Self-Mutilation” USA Today (April, 2018) retrieved from https://www.usatoday.com/story/army-issues-waivers-1-000-recruits-history-bipolar-depression-self-mutilation
[60] Dutta, Rina, et al. “Reassessing long-term risk of suicide after a first episode of psychosis.” The Lancet 381 (2013): S37.
[61] Britzky, H. “This Soldier Almost Died By Suicide. Now He’s Telling His Story” Task and Purpose (March, 2021) retrieved from https://taskandpurpose.com/news/army-suicide-prevention-soldiers-veterans/