Suicide in the Army: A Review of Current Information

Military Medicine, Jul 2005 by Allen, John P, Cross, Gerald, Swanner, Jerry

This article summarizes findings on demographic factors, distal risk factors, and proximal risk factors for suicide and reports recent data on suicide by Army personnel. In addition, the article offers recommendations to reduce the risk of suicide and suicide attempt in the Armed Services and suggests possible directions for future research on suicide in the military.

Introduction

The United States ranks well below many industrialized countries in prevalence of suicide. Suicide is, however, the 11th leading cause of death in this country and accounts for ~30,000 deaths per year (10.7 deaths per 100,000 people). Suicide is responsible for approximately the same number of deaths per year in this country as diabetes mellitus or homicide. In the United States, more people kill themselves than are killed by others (29,350 confirmed suicides vs. 16,765 homicides).1

Demographic Correlates of Suicide

Several demographic factors have been associated with suicide, including gender, age, ethnicity, marital status, and region of the country. The now-complex and voluminous body of epidemiological research on suicide was incisively reviewed by Moscicki,2 and several of her observations are summarized as follows: (1) The most consistent demographic correlate of suicide is gender. Men are more than four times as likely as women to commit suicide. (2) Although suicide rates have been declining over the past 40 years for most segments of the population, the age group of 18 to 30 years is a striking exception. Among young adults, the rate is actually rising. ' For individuals 15 to 24 years of age, suicide now ranks as the third leading cause of death.2 Because it occurs even at young ages, suicide is responsible for a disproportionately large number of years of life lost. (3) Among Caucasian male individuals, the rate of suicide increases dramatically from approximately the mid-60s onward. For African American male subjects, the rate peaks in the early 20s and then seems to decline and stabilize. Suicide risk among female subjects does not appear to show a clear relationship with age. (4) The prevalence of suicide by Caucasian individuals exceeds that of African American individuals. Hispanic subjects are least likely to commit suicide. American Indian and Alaskan Native groups have the highest rates among ethnic groups for which data are available. Suicide rates for African American and Caucasian subjects are much lower for married people than for those divorced or widowed. (5) Suicide tends to be more frequent in the western part of the United States than in the eastern part. Firearms are the most common means of committing suicide for both genders, with hanging and medication overdoses also being often used.

In reviewing studies examining the possible role of religion in suicide, Koenig et al.3 drew two general conclusions. Rates of suicide tend to be lower among individuals who belong to conservative Protestant denominations or who are Muslims than among those who profess other religions or have no religious affiliation. Across sects, active religious involvement reduces suicide risk.

Distal Risk Factors for Suicide

Risk factors for suicide may be distinguished as "distal" or "proximal." Distal factors are longstanding and enhance vulnerability to suicide.4 Proximal factors are more immediate and influence the particular timing for a suicide attempt. Proximal factors build on distal factors.

Not surprisingly, a past suicide attempt is a particularly potent distal risk factor, and it has been estimated that there is one completed suicide per 18 attempts.5 Thirty to 40% of those who commit suicide have engaged in earlier attempts.6

Psychiatric conditions are also important distal factors. Approximately 90% of those who commit suicide suffer at least one diagnosable psychiatric condition.2 Although the role of depression in suicide is most frequently considered, the contribution of alcohol dependence/chronic heavy alcohol consumption to suicide is substantial as well. In an 8-year longitudinal study, suicide was found to be 5.4 times as common for health maintenance organization enrollees who averaged six drinks per day than for those who abstained or consumed alcohol at only low levels.7

Among individuals dependent on alcohol, suicide vulnerability is related to the severity and duration of alcoholism, social isolation, and concurrent depression.8 Alcoholic individuals who have made suicide attempts seem to differ from those who have not on the basis of many of the same risk factors as among nonalcoholic individuals, including being more likely to be male, being more depressed, and having fewer friends or other sources of social support.9 Recent loss and unemployment have been particularly associated with suicide risk among younger alcoholics, whereas medical illness and depression are more typical precipitants among older alcoholics.10

The greater the number of risk factors, the greater is the likelihood of suicide among alcoholics.11 The lifetime risk for suicide among alcoholics is 60 to 120 times that of members of the general population.8 Between 3%8 and 7 of alcoholics ultimately commit suicide, and 20% of the nation's suicides are by alcoholics. With ongoing abstinence, the risk of suicide among recovering alcoholics progressively diminishes.13,14