Preventing Suicide in the U.S. Military

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November 14, 2012

Commander Steven Bartell, CHC, USNDefense Suicide Prevention Office

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Suicide: A National Problem

• Suicide is a problem afflicting the civilian and military population alike.

1. Heart disease2. Cancer3. Lower respiratory diseases4. Stroke5. Accidents6. Alzheimer's disease7. Diabetes8. Flu&Pneumonia9. Kidney disease10. Suicide

Accidents Suicide Homicide Neoplasm Flu/Pneumonia0

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10

15

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25

30

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25-34

15-24

Leading Causes of Death: U.S. General Population (Ages 15-34)

Suicide deaths per 100,000 people

1. Accidents2. Suicide 3. Neoplasms 4. Circulatory system diseases 5. Homicide

Leading Causes of Non-Combat Deaths: U.S. Military

Leading Causes of Death: U.S. General Population (All Ages)

*For the general population, suicide is the:•2nd leading cause of death for those 25-34•3rd leading cause of death for those 15-24

*For the military, suicide is the:• 2nd leading cause of death for all ages

Source: CDC (Figures for general population are for 2009, figures for military are for 2001-2008)

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Suicide Trends in the Military

• The suicide rate for active duty Service members in the Department of Defense increased from 2001 to 2009. Though essentially level in 2010 and 2011, rates are predicted to increase again in 2012.

• The increase can be attributed to many factors. These include occupational, financial, social, emotional, physical, mental, environmental and spiritual stressors.

Source: Mortality Surveillance Division, Armed Forces Medical Examiner

Suicide Rate in the Services

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 20110

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10.3 10.511 11.4 11.3

13.113.8

16.1

18.317.7 17.5Suicide deaths per 100,000 people

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How DoD is Responding

• Approximately 900 Service activities and several policy changes have been executed to build resiliency, reduce stress and prevent suicides.

Developing a Wide Array of Initiatives

• Each Service has a full-time Suicide Prevention Program Manager who leads the Service’s efforts on behalf of Service senior leaders and has a formal suicide prevention program.

Designating Suicide Prevention Leaders

• While recognizing that suicide prevention efforts must be taken as part of a comprehensive effort to address various high-risk behaviors, each Service is taking actions to address drug and alcohol abuse, safety violations and criminal activity.

Addressing Related Factors

• Each Service branch has developed stigma reduction programs, along with a suicide prevention campaign that shares the same general guidance for Service members: • Recognize a distressed Service member• Temporarily care for the individual in crisis• Escort the warfighter to a professional mental health provider

Implementing Stigma Reduction Efforts

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How DoD is Responding

• While these suicide prevention efforts are continuing, DoD has also begun work to more effectively standardize, streamline, evaluate and communicate these initiatives.

• The Defense Suicide Prevention Office (DSPO) is leading this DoD-wide effort, working with the Services to promote help-seeking, resilience, and Total Force Fitness throughout the military.

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Evaluate

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Overarching DoD Strategy

Defense Suicide Prevention Office

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Total Force Fitness

• DoD has developed numerous initiatives to foster Total Force Fitness among those in the military.

• Total Force Fitness elevates fitness of the mind to fitness of the body.

Total Force Fitness strengthens the readiness, resilience and well-being of each member of the Armed Forces.

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How to Identify Suicidal Behavior: Immediate Signs

• You can spot immediate warning signs that a Service member may soon be planning to take their own life. Key indicators include that the Service member is: o Talking about or making plans to take their own lifeo Putting their personal affairs in ordero Giving away their personal possessionso Obsessing about death – sad music/poetryo Abusing drugs or alcohol o Acquiring or obtaining access to lethal means (prescription drugs, weapons, etc.)o Engaging in other out-of-the-ordinary risk-taking behavior

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How to Identify Risk Factors for Suicide

• Service members may be predisposed to taking their own life if they have:

o A previous history

o Medical problems

o Psychological problems

o Legal and discipline problems

o A negative command climate

o Changes in personality or behavior

o Financial problems

o Occupational problems

“Every suicide is as different and as unique as the people themselves. And the reality is there is no one reason a person decides to commit suicide. That decision reflects a complex combination of factors and events….” – General Peter Chiarelli, Vice Chief of Staff, Army, in testimony before the House Armed Services Committee, 29 July 2009

One of the main reasons that many Service members do not come forward when they need help is because of the stigma associated with doing this.

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Protective Factors

• Protective factors can help a Service member foster resistance, build resilience and maintain readiness.

• Protective factors include:o Total Force Fitnesso Sense of purposeo Sense of belongingo Loving relationshipso Stable environmento Respected and valuedo Participation in relaxation, hobbies and recreationo Spirituality, faith, forgiveness, positive sense of values, beliefs and ethicso Problem-solving & goal-oriented skillso Regular sleeping, eating and exercise

• It is important to be able to identify protective factors in order to gauge someone’s resilience and susceptibility to suicide.

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Asking About Suicide

• You should not be afraid to ask a Service member questions about suicidal thoughts or plans they may have.

• What are some common fears that people have about asking about suicide?

• Language to use:

o Are you feeling suicidal?o Do you feel like killing yourself? o Are you planning to kill yourself? What are your plans? o Do you have any firearms/knives? If so, how can we keep you and your

family safe from them?o Have you tried to kill yourself in the past? o What are your reasons for living? Let’s think through some reasons for

living. (To assess protective factors.)

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Key Resources

• If you find that someone is in crisis, you need to be able to provide information on how and where Service members and their families can find professional help. Ensure them that crisis assistance is readily available both by phone and online:o Military Crisis Line: (800) 273-8255, Press 1, or www.militarycrisisline.net o Military OneSource: (800) 342-9647 or www.militaryonesource.mil

• Additional resources at DoD include:o Suicide Prevention and Risk Reduction Committee

Visit www.suicideoutreach.org o Defense Centers of Excellence

Dial (866) 966-1020, 24 hours a day, 7 days a week Visit www.dcoe.health.mil

o Real Warriors Campaign Visit www.realwarriors.net

o Service-Specific Suicide Prevention Programs Air Force: www.af.mil/suicideprevention.asp Army: www.preventsuicide.army.mil Marine Corps: www.usmc-mccs.org/suicideprevent/index.cfm Navy: www.suicide.navy.mil National Guard and Reserve: www.vets4warriors.com

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Questions & Answers

Final Thoughts

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Point of Contact

Commander Steven Bartell, CHC, USNDefense Suicide Prevention Office

(703) 588-0501, steven.bartell@osd.mil

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EXTRA SLIDES

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Risk Factor: “The Stigma”

• One of the main reasons that many Service members do not come forward when they need behavioral health assistance is because of the stigma.

• They fear discriminatory and humiliating treatment that includes:o Insultso Loss of respecto Fewer responsibilities giveno Reduced prospects to advance their career

• You should encourage help-seeking behavior, normalizing the care of the “hidden wounds” incurred by Service members. Remind Service members that it takes strength to ask for help.

“We have three goals. Prevention, intervention and help-seeking behavior. Prevent it before it happens, intervene to stop it from happening and get people to seek help without fear of stigma or retribution.”– Navy Secretary Ray Mabus in discussing suicide prevention and sexual assault in 2011

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Risk Factor: PTSD

• Posttraumatic stress disorder (PTSD): A mental health condition that is triggered by experiencing, witnessing or perceiving a traumatic event.

• Symptoms can include:o Reliving the event or frightening elements of it (nightmares, flashbacks,

intrusive thoughts)o Avoidance of memories, places and social situations that are reminiscent

of the evento Emotional numbingo Hypervigilance

• PTSD symptoms can get worse or last for months or even years.

• Research indicates that when untreated, PTSD greatly increases the risk of suicidal behavior.

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Risk Factor: PTSD (continued)

• PTSD has been proven to be a significant problem for warriors in conflicts in Afghanistan and Iraq, especially for those exposed to sustained ground combat.

• It is important to recognize those who might suffer from PTSD and refer them to professionals specializing in this area.

• The main treatments for people with PTSD are counseling (known as “talk” therapy or psychotherapy), medications or both.

• Through group therapy, Service members can talk about their trauma or learn skills to manage PTSD symptoms (depending on the group’s focus).

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Protective Factors: Partners in Care

Partners in Care (PIC) connects Service members, Veterans, and their families to local faith-based communities, promoting

resiliency by offering hope and providing care• Military Service members, Veterans, and their families are integrated in local

communities in every state across our country

• Local faith communities can bring hope, offer support and continuity of spiritual care to increase resiliency in times of war and peace

• Diverse, pluralistic, inter-faith network of participating faith communities

• Voluntary involvement

• Memorandum of Understanding required

• Support is offered free of charge

• Support is provided according to the ability and resource availability of the participating community

• Support is offered equally to all referred, regardless of religious affiliation

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Protective Factors: Spirituality

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Postvention

• A RCC might be called upon to react appropriately to a suicide.• Called “postvention,” this activity of support takes place in the immediate

aftermath of a suicide and can reduce the possibility of additional suicides.• Postvention:

o Helps survivors cope with griefo Prevents additional suicideso Encourages help-seeking behavioro Promotes resiliency, hope and healing

• Suicide is preventable, and postvention is prevention.

Postvention: The provision of crisis intervention, support and assistance for those affected by a completed suicide.

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Scenario 1: What Would You Do?

Questions: What immediate signs, if any, suggest that the Lieutenant Colonel was in danger of

taking his life? What risk factors did he have? What could have been a protective factor for him? What general course of action would you as an RCC have taken were you to have

met with him?

Scenario: A married Lieutenant Colonel in his early fifties had deployed several times and experienced multiple concussions and head trauma. He suffered from traumatic brain injury, sleeping problems and dementia. He was assigned to a Warrior Transition Unit (WTU) and prescribed multiple medications. The day he died, he went to a bible study class and then went to the emergency room seeking treatment to alleviate his headaches and pain. He was given a 30 tablet refill of Ambien (sleep medication). After the ER visit, he went to his car, drank four 50ml bottles of rum and ingested the entire prescription. His suicide note indicated that he could no longer stand the headaches and pain.

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Scenario 2: What Would You Do?

Questions:• What immediate signs, if any, suggest that the Staff Sergeant may be in danger of

taking his life?• What risk factors does he have?• What may be a protective factor?• What general course of action would you have taken were you to have met with him

as an RCC?

Scenario: A Staff Sergeant had a hard childhood. His father was in and out of jail and both parents used illegal drugs. When he joined the Army, he thought he had finally escaped his background. He was promoted through the ranks and was well respected by his leadership. He helped to emancipate his sister, with whom he is very close, and was paying for her college. Following a very violent improvised explosive device (IED) attack, he started having difficulty sleeping and was waking up with nightmares. Shortly after deploying, his parents stole his identity and incurred a large debt in his name.