Examining of the Psychosocial Predictors of Suicide among Active Duty Servicemen and Veterans

Outline of Chapter Two 

Psychological Problems of Veterans and Military Personnel 

This section is the first one in the literature review, since mental health problems are one of the most common reasons for committing suicides by current service members as well as veterans (Castro & Kintzle, 2014; Armenta et al., 2018). The section is aimed to discuss how severe stressful situations that occur in the conditions of performing tasks in the military arena provoke the appearance of various mental disorders. One of the most dangerous mental issues is post-traumatic stress disorder, which includes a series of triggers that cause the veteran and service members to experience bouts of an obsessive state, intense experiences, and hysteria (Wolfe-Clark & Bryan, 2016). Besides, mental health diagnostics, serotonin reuptake inhibitors, poor sleep, decline, ranks, enlightenment, and separation or divorces have been associated with suicide (Hyman, Ireland, Frost & Cottrell, 2012; Sher, Braquehais & Casas, 2012). 

The Most Common Mental Diseases among the Military and Veterans 

Post-traumatic stress disorder 

Depression 

Causes of Mental Problems 

1.2.1. Combat Exposure 

1.2.2. Places and number of deployments 

1.3. The Manifestation of Mental Illness in the Military and Veterans 

1.3.1. Characteristics of the behavior of military and veterans in public places 

1.3.2. Triggers of mental deterioration 

Discussion for Section 

References for Section: 

Armenta, R., Rush, T., LeardMann, C., Millegan, J., Cooper, A., & Hoge, C. (2018). Factors associated with persistent posttraumatic stress disorder among U.S. military service members and veterans.  BMC Psychiatry ,  18 (1). doi: 10.1186/s12888-018-1590-5 

Castro, C. A. & Kintzle, S. (2014). Suicides in the Military: the post-modern combat veteran and the Hemingway effect. Current Psychiatry Reports , 16 (8), 460, doi: 10.1007/s11920-014-0460-1 

Hyman, J., Ireland, R., Frost, L., & Cottrell, L. (2012). Suicide Incidence and Risk Factors in an Active Duty US Military Population.  American Journal of Public Health ,  102 (S1), S138-S146. doi: 10.2105/ajph.2011.300484 

Pickett, T., Rothman, D, Crawford, E. F., Brancu, M., Fairbank, J. A., & Kudler, H. S. (2015). Mental health among military personnel and veterans. North Carolina Medical Journal, 276 (5), 299-306 DOI: 10.18043/ncm.76.5.299 

Sher, L., Braquehais, M., & Casas, M. (2012). Posttraumatic stress disorder, depression, and suicide in veterans.  Cleveland Clinic Journal of Medicine ,  79 (2), 92-97. doi: 10.3949/ccjm.79a.11069 

Start, A., Allard, Y., Adler, A., & Toblin, R. (2018). Predicting suicide ideation in the military: The independent role of aggression.  Suicide and Life-Threatening Behavior . doi: 10.1111/sltb.12445 

Wolfe-Clark, A., & Bryan, C. (2016). Integrating Two Theoretical Models to Understand and Prevent Military and Veteran Suicide.  Armed Forces & Society ,  43 (3), 478-499. doi: 10.1177/0095327x16646645 

The Relationship of Mental Problems and Suicidal Tendencies 

This section has intent at studying the literature on the causal and hereditary relationship between the presence of mental problems and the appearance of suicidal tendencies. Logan, Fowler, Patel, and Holland (2016) have stated that suicide among military personnel and veterans remains a public health problem. There is an assumption that the military population will have a lower suicide rate compared to the civilian population due to medical and psychological examinations when they enter the service, free access to mental health care, increased job security compared to civilian colleagues, and place a support network in the form of teams (Reimann & Mazuchowski, 2018). However, military personnel also face unique stress factors, such as deployment and frequent movement, which may affect their suicide risk (Reimann & Mazuchowski, 2018). Mental health and intimate partner problems are used to be ordinary provocative circumstances (Gros et al., 2018). 

2.1. The Role of Mental Illness in Committing Suicide 

2.1.1. Mental illness as the root cause of suicide 

2.1.2. Mental illness as a minor factor 

2.2. Lack of Psychological Help as a Trigger to Suicide 

2.2.1. Problems in the provision of psychological assistance to current military and veterans 

2.2.2. Social stigmatization as a consequence of visits to psychological care centers by service members 

Discussion for Section 

References for Section: 

Cohen, G., Fink, D., Sampson, L., & Galea, S. (2015). Mental Health among Reserve Component Military Service Members and Veterans.  Epidemiologic Reviews ,  37 (1), 7-22. doi: 10.1093/epirev/mxu007 

Gros, D., Allan, N., Silva, C., Lancaster, C., Conner, K., & Stecker, T. (2018). Relations between thwarted belongingness, perceived burdensomeness, and history of suicide attempts and readiness for mental health treatment in high-risk veterans, reserves, and active duty service members.  Military Behavioral Health , 1-8. doi: 10.1080/21635781.2018.1486760 

Hester, R. (2017). Lack of access to mental health services contributing to the high suicide rates among veterans.  International Journal of Mental Health Systems ,  11 (1). doi: 10.1186/s13033-017-0154-2 

Hom, M., Stanley, I., Gutierrez, P., & Joiner, T. (2017). Exploring the association between exposure to suicide and suicide risk among military service members and veterans.  Journal of Affective Disorders ,  207 , 327-335. DOI: 10.1016/j.jad.2016.09.043 

Logan, J. E., Fowler, K. A., Patel, N. P., & Holland, K. M. (2016). Suicide among military personnel and veterans aged 18-35 years by the county-16 states.  American Journal of Preventive Medicine, 51( 5 Suppl 3), 197-208. doi: 10.1016/j.amepre.2016.06.001 

Nock, M., Ursano, R., Heeringa, S., Stein, M., Jain, S., & Raman, R. et al. (2015). Mental Disorders, Comorbidity, and Pre-enlistment Suicidal Behavior Among New Soldiers in the U.S. Army: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).  Suicide and Life-Threatening Behavior ,  45 (5), 588-599. doi: 10.1111/sltb.12153 

Reiman, C., & Mazuchowski, E. L. (2018). Suicide rates among active duty service members compared with civilian counterparts, 2005-2014. Military Medicine, 183 (1), 396-402. https://doi.org/10.1093/milmed/usx209. https://academic.oup.com/milmed/article/183/suppl_1/396/4959986 

Ways and Means of Suicide among the Militaries 

This section focuses on how and by what the military commits suicide. For the beginning, Anglemyer and the co-authors have found out the role of firearms in suicides of current service members (Anglemyer et al., 2016). Indeed, from 2006 to 2011, the highest rates of suicides were among military personnel (Anglemyer et al., 2016). Among the whole amount of suicides with the known causes, more than half of the cases are connected to firearms (Hyman et al., 2012; Anglemyer et al., 2016). In this regard, there is an in-depth connection between access to guns and other fire weapons and the possibility of suicide. Moreover, there is a high connection between the location of military service and the number of suicides (Reger et al., 2015; Bryan, 2015). The critical circumstances, which have to be considered, contains differences in the type of military service, place of deployment, and combat traumas (Reger et al., 2015). 

3.1. The Common Means of Suicide among Veterans and Current Service Members 

3.1.1. Firearms as a mean of suicide 

3.1.2. Overdose of pills 

3.2. Relationship between Access to Firearms and Suicide 

3.2.1. Comparison of suicide statistics of military and civilians 

3.2.2. The presence of weapons as the cause of suicide 

Discussion for Section 

References for Section: 

Anglemyer, A., Miller , M. L., Buttrey, S., & Whitaker, L. (2016). Suicide rates and methods in active duty military personnel, 2005 to 2011: A cohort study. Annals of Internal Medicine, 165, 167–174. doi: 10.7326/M15-2785 

Bryan, C. J. (2015). On deployment and military suicide risk.  JAMA Psychiatry, 72 (9), 949–950. Doi:10.1001/jamapsychiatry.2015.0671 

Cleveland, E., Azrael, D., Simonetti, J., & Miller, M. (2017). Firearm ownership among American veterans: findings from the 2015 National Firearm Survey.  Injury Epidemiology ,  4 (1). doi: 10.1186/s40621-017-0130-y 

Hyman, J., Ireland, R., Frost, L., & Cottrell, L. (2012). Suicide Incidence and Risk Factors in an Active Duty US Military Population.  American Journal of Public Health ,  102 (S1), S138-S146. doi: 10.2105/ajph.2011.300484 

Logan, J. E., Fowler, K. A., Patel, N. P., & Holland, K. M. (2016). Suicide among military personnel and veterans aged 18-35 years by the county-16 states.  American Journal of Preventive Medicine, 51( 5 Suppl 3), 197-208. doi: 10.1016/j.amepre.2016.06.001 

Mann, J. J., & Gibbons, R. D. (2015). Guns and suicide. American Journal of Psychiatry, 170 (9), 939-942. doi/pdf/10.1176/appi.ajp.2013.13060818 

Reger, M. A, Smolenski, D. J., Skopp, N. A., Metzger, M. J., Kang, H. A., Bullman, T. M., Gahm, G. A. (2015). Risk of suicide among us military service members following operation enduring freedom or operation Iraqi freedom deployment and separation from the US military. JAMA Psychiatry, 72 (6), 561-569. doi:10.1001/jamapsychiatry.2014.3195 

Eliminating the Problem of Suicides among Militaries 

This section aims to review the surveys and other literature on the topic of current suicide prevention programs. Such programs rethink prevention as a promotion of psychological health and general quality of life in society rather than prevention of death from suicide (Bryan et al., 2012; Schoenbaum et al., 2014). Such a strategy involves the integration of programs into the existing structure, rather than using isolated psychiatric clinics similar to the current system of psychiatric care among the general population (Bryan et al., 2012). This approach is identical to the public health approach to promoting healthy habits in order to maintain a healthy community, and not just to respond to existing problems (Bryan et al., 2012). It includes practices related to physical health and social connection in addition to psychological well-being and refers to the concept of promoting overall "mental fitness" ( Casey , 2011; Bryan et al., 2012). Also, current programs have focused on power approaches that encompass military identity and integrate psychological skills into everyday military culture (Bryan et al., 2012). It represents a fundamental shift from previous military suicide prevention programs, highlighting risk factors associated with military values and lifestyles, as well as warning signs of impending suicidal behavior (Wolfe-Clark & Bryan, 2016). Thus, this approach aims to capitalize on the strengths of the armed forces and integrate strategies into day-to-day operations, rather than focusing primarily on eliminating potential weaknesses (Sherman, Larsen & Borden, 2015). 

4.1. Analysis of Suicide as a Social Action 

4.1.1. Time frames of suicide among veterans and current service members 

4.1.2. Family as a preventive factor in suicidal tendencies 

4.2. Public Programs for Veterans and Current Militaries 

4.2.1. Government programs 

4.2.2. Promotion of the need for psychological treatment 

Discussion for Section 

References for Section: 

Alexander, C., Reger, M., Smolenski, D., & Fullerton, N. (2014). Comparing U.S. Army Suicide Cases to a Control Sample: Initial Data and Methodological Lessons.  Military Medicine ,  179 (10), 1062-1066. doi: 10.7205/milmed-d-13-00574 

Bryan, C., Jennings, K., Jobes, D., & Bradley, J. (2012). Understanding and Preventing Military Suicide.  Archives of Suicide Research ,  16 (2), 95-110. doi: 10.1080/13811118.2012.667321 

Casey Jr, G. W. (2011). Comprehensive soldier fitness: A vision for psychological resilience in the US Army.  American Psychologist ,  66 (1), 1-3. 

Kashiwa, A., Sweetman, M., & Helgeson, L. (2017). Occupational Therapy and Veteran Suicide: A Call to Action.  American Journal of Occupational Therapy ,  71 (5), 7105100010p1. doi: 10.5014/ajot.2017.023358 

Pickett, T., Rothman, D, Crawford, E. F., Brancu, M., Fairbank, J. A., & Kudler, H. S. (2015). Mental health among military personnel and veterans. North Carolina Medical Journal, 276 (5), 299-306 DOI: 10.18043/ncm.76.5.299 

Sherman, M., Larsen, J., & Borden, L. (2015). Broadening the focus in supporting reintegrating Iraq and Afghanistan veterans: Six key domains of functioning.  Professional Psychology: Research and Practice ,  46 (5), 355-365. doi: 10.1037/pro0000043 

Wolfe-Clark, A., & Bryan, C. (2016). Integrating Two Theoretical Models to Understand and Prevent Military and Veteran Suicide.  Armed Forces & Society ,  43 (3), 478-499. doi: 10.1177/0095327x16646645 

Section 5. Progress in Solving the Problem 

This section is intended to describe the literature connected to the progress in solving the problem of the increase the number of suicides among the military population. In this respect, Stanley (2018) has argued that suicide is a significant problem in the whole sphere of healthcare, and in recent years it has become an increasingly severe issue among military personnel (Stanley et al., 2018). Moreover, the suicide rate of the US Army for the first time in many decades has exceeded this figure for the general population (Nock et al., 2013). Suicide is difficult to detect, predict, and prevent due to a variety of factors, such as its low base rate, associated stigma and the motivation to hide suicidal thoughts or behavior among people, who have them (Nock et al., 2013). During recent years, a great progress has been made in understanding the risk factors and protective factors for suicidal behavior, conceptualizing it to achieve positive results, and developing methods to overcome some of the significant obstacles faced by scientific and clinical efforts in this region. According to Villatte and co-authors (2015), suicidal behavior in the past is one of the most potent and consistent predictors of possible suicide and can be especially noticeable in military suicide (Nock et al., 2014; Villatte et al., 2015). The measurements of prevention of the suicides require good assessment strategies that collect accurate data on risk factors and protection, qualified clinicians, who can focus directly on suicide as a problem to be treated, and policies based on the best available empirical data (Bryan et al., 2012). Treatment of suicidal susceptibility contributes to the formation of a culture, in which participation in the treatment of suicide among current and former military personnel is seen as a sign of endurance, dedication and courage. 

5 .1. Detection of Suicidal Behavior 

5 .1.1. Triggers of suicidal behavior 

5 .1.2. Signs of suicidal behavior 

5.2. Prevention of Suicides among Militaries 

5.2.1. Urgent care methods 

5.2.2. Long-term care strategies 

5.3. Dynamics of Providing Assistance to Veterans and Current Service Members 

5.3.1. Dynamics of attendance of psychological assistance centers 

5.3.2. Attitude of veterans and current military personnel to psychological assistance centers 

Discussion for Section 

References for Section: 

Bryan, C. J., Rudd, M. D., Wertenberger, E., Etienne, N., Ray-Sannerud, B., & Morrow, C. E. (2014). Improving the detection and prediction of suicidal behavior among military personnel by measuring suicidal beliefs: an evaluation of the Suicide Cognitions Scale. Journal of Affective Disorder , 159 , 15–22. doi:10.1016/j.jad.2014.02.021. 

Bryan, C., Jennings, K., Jobes, D., & Bradley, J. (2012). Understanding and Preventing Military Suicide.  Archives of Suicide Research ,  16 (2), 95-110. doi: 10.1080/13811118.2012.667321 

Bryan, C., Jennings, K., Jobes, D., & Bradley, J. (2012). Understanding and Preventing Military Suicide.  Archives of Suicide Research ,  16 (2), 95-110. doi: 10.1080/13811118.2012.667321 

Harrison, M., Vargo, T., Camit, C., Agrawal, V., Gramling, L., & Sanghvi, R. et al. (2017). Suicide Prevention and Psychological Resilience for Military and Veterans.  Oxford Handbooks Online . doi: 10.1093/oxfordhb/9780199935291.013.37 

Nock, M. K., Deming, C. A., Fullerton, C. S., Gilman, S. E., Goldenberg, M., Kessler, R. C.,… Ursano, R. J. (2013). Suicide among soldiers: a review of psychosocial risk and protective factors. Psychiatry , 76 (2), 97-125. DOI: 10.1521/psyc.2013.76.2.97 

Nock, M., Stein, M., Heeringa, S., Ursano, R., Colpe, L., & Fullerton, C. et al. (2014). Prevalence and Correlates of Suicidal Behavior among Soldiers.  JAMA Psychiatry ,  71 (5), 514-522. doi: 10.1001/jamapsychiatry.2014.30 

Sharp, M., Fear, N., Rona, R., Wessely, S., Greenberg, N., Jones, N., & Goodwin, L. (2015). Stigma as a Barrier to Seeking Health Care among Military Personnel With Mental Health Problems.  Epidemiologic Reviews ,  37 (1), 144-162. doi: 10.1093/epirev/mxu012 

Stanley, I. H., Buckman- Schmitt, J. M., Chu, C., Rogers, M. L., Gai, A. R., Wagner, R. K., Guiterrez, P. M., & Joiner, T. E. (2018). The military suicide research consortium common data elements: An examination of measurement invariance across current service members and veterans. Assessment . https://doi.org/10.1177%2F1073191118777635 

Villatte, J. L., O'Connor, S. S., Leitner, R., Kerbrat, A. H., Johnson, L. L., & Gutierrez, P. M. (2015). Suicide attempt characteristics among veterans and active-duty service members receiving mental health services: A pooled data analysis.  Military Behavioral Health, 3 (4), 316-327.