“Doctors used to call it “shell shock,” “soldier’s heart,” or “nostalgia.” Soldiers would shake uncontrollably, experience heart palpitations, or go blind after witnessing trauma on the battlefield. From as far back as ancient Greece, history reveals the psychological toll of war on soldiers. (Baran, 2010).
In the United States, combat fatigue was coined to describe the mental health issues of soldiers that had returned from Vietnam. Common experiences among veterans were an inability to concentrate, insomnia, nightmares, restlessness, and impatience with almost any job or course of study, as well as alienation, depression, mistrust and expectation of betrayal. About 15 percent of American soldiers who served in Vietnam were still suffering from war-related mental health issues fifteen years after the war, according to a government-funded report published in 1990. (Baran, 2010). In 1980, Vietnam veterans pushed for legislation and acceptance in the medical and psychology fields concerning combat fatigue. Later that year, Post Traumatic Stress Disorder was recognized by practitioners and was returned back to the DSM as a mental health issue. Experts believed that up to 30% of Vietnam veterans were facing mental health issues and PTSD. (Baran, 2010) It is estimated that since the Vietnam War has ended, approximately 150,000 veterans have committed suicide. The landscape of the United States was changed on the morning of September 11, 2001. In response to the attack, in October 2001 active duty soldiers were deployed to Afghanistan and Operation Enduring Freedom (OEF) was launched. By January 2002, more than 30,000 military personnel from active duty and reserves were involved in the conflict. In March 2003, military personnel were deployed to Iraq, with the aid of Great Britain, in support of Operation Iraqi Freedom (OIF).
As of the end of 2013, the United States had deployed more than 2,000,000 military personnel, and many of them completing multiple deployments. As the conflicts progressed, so did the means in which troops were being injured and killed. Troops were sustaining injuries due to Improvised Explosive Devices (IED’s). Explosive devices were placed along well travelled roadways of the troops, where they would detonate either causing blast injuries or shrapnel injuries from the debris. Due to the increase of both IED’s and Vehicle Borne Improvised Explosive Devices (VBIED), there was a spike in upper torso injuries that had not been seen in any other conflict the US had been involved in. From this, trauma specialists on the front lines were dealing with a new injury, Traumatic Brain Injuries (TBI). TBI’s occur when there is sudden trauma to the head, either by a blow or jolt, causing damage to the brain. TBI’s are very common, they are usually termed as a concussion and approximately 1.4 million individuals sustain one a year. During the 10 years of conflict it was estimated that approximately 14-20% of the 2,000,000 troops deployed, had sustained a TBI.
Due to the results, TBI’s and PTSD were deemed the “signature wounds” of OIF and OEF (Burke, Degenffe and Olney, 2009). Most TBI’s in everyday life are results of traffic accidents, falls, and sports related injuries, but in the war zone, it was generally a result of explosive blasts. Generally, these injuries are “mild” (brief changes in mental status or consciousness) to “severe” (extended period of changes in mental status or prolonged unconsciousness). It is estimated that approximately 80% of TBI cases are considered “mild” where people would exhibit confusion, dazed, headaches, dizziness and cognitive changes. Eventually, with proper treatment, most individuals return back to “normal” within 3-6 months. (VA 2014) Due to the improper handling of TBI’s and troops at the beginning of OIF and OEF, many soldiers suffered repeated TBI’s before they had completely healed. It is this group that concerns medical practitioners, because coupled with PTSD, other mental health issues and the physical changes, these service members are at risk. My research questions seek to answer the following: if service members had deployed and completed multiple deployments, are they at greater risk for committing suicide compared to their counterparts who had not deployed? If due to the increase of exposure in the area of combat operation and likelihood of service members receiving a TBI, does that increase the likelihood of suicide and are they at greatest risk if it is combined with PTSD? Finally, if service members receive treatment or counselling for the mental health issues, does it reduce the likelihood of suicide?
In a 10 year period of OIF and OEF, the use of IED’s were responsible for almost two thirds of service members wounded or killed in action. Due to advancement in initial trauma care and personal protective equipment, approximately nine out of ten US servicemen and women survived their wounds. Because of the use of IED’s and declining mortality rate, service members were being exposed to repeated bouts of ground combat. More than 793,000 service members have had multiple deployments, increasing their risk of TBI’s and PTSD (Wall 2012). In Wall’s research of the VHA database system and a checklist of required categories, she determined that veterans from OIF/OEF returning with PTSD was initially reported at a similar rate as that of the Vietnam veterans, 17% respectively. Although there is no data on TBI’s from the Vietnam veterans era, for OIF/OEF veterans, TBI’s were reported as 19% initially, but by 2012, those numbers jumped to 41%. At the end of her research, she stated that PTSD rates had climbed to as high as 79% and TBI rates of 41%, dependent on reporting criteria. Wall also stated that service members who had both PTSD and TBI was reported to be as high as 26%. However, it is not uncommon for service members to return home with some level of PTSD, it is the veterans at the far end that are at risk for suicide (Wall 2012).
In 2006, Karen Eaton, Stephen Messer, Abigial Wilson and Charles Hoge published an article comparing suicide rates of the civilian population and U.S. Military. Their research covered from 1990-2000 of all four military branches and U.S. mortality rates as published. They concluded that prior to OIF/OEF, Military rates were approx. 20% lower than the civilian rate. They specifically looked at the male population of 17-26 yr olds, because on the civilian side, they were the most at risk group. Research concluded that the military male was less likely to commit suicide than their civilian counterpart. They contributed these findings to full-time employment and access to comprehensive health care. However, as veterans returned from deployment and were either discharged due to medical problems or their contract expired, these members were placed into the at-risk group, causing suicide rates to steadily climb from 2002-2006. As the wars continued, it was estimated that the increase in suicide rates among service members and veterans had increased 66% (Bossarte, Knox, Piegari, Altieri, Kemp and Katz, 2012).
It was asserted that combat experiences might serve as a mechanism for increasing suicide risk, and that combat left service members with the acquired capability for suicide. As the war continued, the risk for suicide amongst service members increased. This was especially true in the group of males between ages 17-26, they were twice as likely to commit suicide as the civilian males. During peacetime, the military’s suicide rate is lower than the rest of the population, but due to increasing deployment rotations and grueling ground combat, it suggests that this exposes the veterans and service members to factors that would lead them to commit suicide (Bryan, Cukrowicz, West and Morrow, 2010). In the article “Combat experience and the acquired capability for suicide,” the authors assert that the increase in deployments, potential for traumas that result in TBI’s and PTSD, and the basic military experience, causes the development of the “acquired capability for suicide.” They believed this to be true due to the increase in violent behaviors (Bryan, Cukrowicz, West and Morrow, 2010).
In 2008, the Veterans Health Administration, completed an intensive study of their database concerning service members. As of October 2007, there had been approx. 1.64 million service members deployed in support of OIF/OEF. It was estimated that approx. 300,000 individuals suffer from PTSD and approx. 320,000 had experienced at least one minor TBI. Of those reporting probable TBI’s, approx. 57% had not received treatment, and this was primarily found in the Reserve Components due to their discharge from active duty, condition not initially reported until the Post-Deployment Health Reassessment (PDHRA) 90 days post deployment and lack of VA’s or health care providers. It was assumed that the individuals on active duty, had received treatment due to the battery of tests and post-deployment debriefings that they receive versus that of the Reserves (Rand Study, 2008).
Methodology and Data Used
For my research, I utilized database searches for hard data from the Annual Department of Defense Suicide Event Report (DoDSER 2008-2011) and Veterans Health Administration. Although, both had information on suicide trends of the last 11 years of war, it wasn’t until 2008, when they began tracking PTSD and mental health disorders in relation to suicides on active duty. In 2010 they started tracking comorbidity of TBI and PTSD and its’ relation to suicide amongst reserve and active duty personnel. During the early part of the war, service members (SMs) returning home were often misdiagnosed with other Mood Disorders (anxiety, depression, bipolar) versus PTSD, this was due to both the VHA and DoD’s unwillingness to accept that war was having a lasting effect on our SM’s. Also, without a diagnosis of PTSD, it would absolve the DoD and VHA of future care.
Below is the information from both the CDC (civilian suicide rate) and DoD and VHA concerning the suicide rates per 100,000 from 2001-2012. The civilian suicide rate is lower than what has been published originally because the suicides of veterans had been removed from the total numbers. As one can see, military personnel are at higher risk for committing suicide against the rest of the population. Overall, the most at risk group is military veterans and this is more than likely due to improper handling of health issues (RAND 2008). Although the VHA and DoD commissioned the RAND Study in 2008, it is still unknown of this group, how many had been diagnosed with PTSD and TBI. The rate of suicides have increased amongst veterans over the last 5 years and approx. half are over the age of 50.
The DoD is broken down into 4 branches of service, the Army, Air Force, Navy and Marine Corp. The below information shows the total amount of suicides from 2008-2012 broken down by branch and partial reporting of 2013. Each year the Army has had the highest amount of suicides. This could be explained with 2 points, one, the Army is the largest branch and two, and their deployment lengths were 18 months in combat from 2002 until 2008 and from 2008 until current, deployment lengths were reduced to 12 months. In the 11 years of war, the Army, to include the Reserves and National Guard, carried the burden of service members (SM’s) deployed. Both the Navy and Marine Corp have 6 month rotations in combat and the Air Force had a 3-6 month rotation.
As the war lingered on, the rates of TBI’s and diagnosis of PTSD increased, so did personnel suffering from them increase. In the chart below, I analyzed data from the DoDSER and on average, half of the SM’s that committed suicide had had at least one deployment overseas to combat. From the total amount of suicides, 19%-30% had been diagnosed with PTSD. However, an additional 30%-42% had been diagnosed with a Mood Disorder and it is unknown if it was an accurate diagnosis or a misdiagnosis. Additionally, there were 56 SM’s in 2010 and 68 in 2011, that had been diagnosed with PTSD, and 53 and 63 SM’s had been diagnosed with TBI’s that committed suicide. One drawback of the research is, without the raw data I am unable to tell if the SM’s who deployed were also the SM’s who were diagnosed with both PTSD and TBI. At a glance, it appears that of the approximate 50% of the SM’s who deployed that committed suicide almost half of them had been diagnosed with PTSD and from there, half had been diagnosed with TBI’s.
Additionally, it would appear that SM’s that had incurred a TBI and PTSD, does increase their risk of committing suicide. But until further research and availability of the raw data is made available, one cannot answer that correctly, it would be an educated guess at best. I also considered using regression analysis for the above graph, but there was not enough data to show an accurate pattern as well as not having access to the raw data.
Based upon information, there appears that there is no relationship between deploying to combat and staying stateside and the risk for suicide among military personnel. However due to the increase in veteran suicides, one would have to look at the raw data to analyze whether those individuals had been in combat and if there were any diagnosis of PTSD and TBI. Also, without the raw data from the DoD, one cannot say for certain if the comorbidity of PTSD and TBI increases the risk of suicide as well as receiving treatment for those conditions immediately. It would appear on face value that those identified with PTSD and TBI are at greater risk for suicide especially if proper treatment isn’t rendered and this is due to the SM’s compromised state. It wasn’t until 2008 that the DoD and VHA recognized PTSD and the possible relation to the increase in suicides amongst active duty and veterans. In conclusion, I cannot disprove my initial questions about comorbidity and treatment without further investigation and access to the original data. Lastly, it appears that going to combat may not have an impact on a SM’s decision to commit suicide.
http://www.t2.health.mil/programs/dodser, 2008, 2009, 2010, 2011. http://minnesota.publicradio.org/projects/2010/02/beyond-deployment/ptsd-timeline/index.shtml. Feb 2010, Madelaine Baran http://www.ptsd.va.gov/public/problems/traumatic_brain_injury_and_ptsd.asp, January 2014 http://veteransandptsd.com/PTSD-statistics.html, Rand Study, 2008 Ashley, V., Honzel, N., Larsen, J., Justus, T., & Swick, D. (2013). Attentional bias for trauma-related words: exaggerated emotional Stroop effect in Afghanistan and Iraq war veterans with PTSD. BMC Psychiatry, 13, 86. Barnes, S. M., Walter, K. H., & Chard, K. M. (2012). Does a history of mild traumatic brain injury increase suicide risk in veterans with PTSD?. Rehabilitation Psychology, 57(1), 18-26. doi:10.1037/a0027007 Belik, S. , Stein, M. , Asmundson, G. , & Sareen, J. (2009). Relation between traumatic events and suicide attempts in canadian military personnel. Canadian Journal of Psychiatry. Revue Canadienne De Psychiatrie, 54(2), 93-104 Belik, S. , Stein, M. , Asmundson, G. , & Sareen, J. (2010). Are canadian soldiers more likely to have suicidal ideation and suicide attempts than canadian civilians?. American Journal of Epidemiology, 172(11), 1250-1258. Benda, B. (2005). Gender differences in predictors of suicidal thoughts and attempts among homeless veterans that abuse substances. Suicide & Life-threatening Behavior, 35(1), 106-116. Bossarte, R. , Knox, K. , Piegari, R. , Altieri, J. , Kemp, J. , et al. (2012). Prevalence and characteristics of suicide ideation and attempts among active military and veteran participants in a national health survey. American Journal of Public Health, 102 Suppl 1(Supplement 1), S38-S40. Brenner, Lisa A., Betthauser, Lisa M., Homaifar, Beeta Y, Villarreal, Edgar, Harwood, Jeri E.F., Staves, Pamela J., Huggins,
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