• Impulsive or aggressive tendencies.
• Cultural and religious beliefs regarding acceptability of suicide.
• Local epidemics of suicide.
• Barriers to mental health treatment access.
• Loss (relational, social, work, or financial).
• Physical illness.
• Easy access to lethal methods (guns, knives, etc.).
• Unwillingness to seek help because of stigma attached to mental health/substance abuse or suicidal thoughts.
Prevention Recommendations
Col. Bradley served on a Defense Department suicide prevention task force that recommended key strategies to prevent suicide in the armed services in four domains:
• Organization and leadership.
• Wellness enhancement and training.
• Access to and delivery of high-quality care.
• Surveillance, investigations, and research.
"During our 19 site visits with military families at different installations across all four services, families and troops told us again and again and again that the major stressor in their lives is the repeated deployments and the lack of quality dwell time that they have in between those deployments to be able to reintegrate, reestablish a baseline, reestablish a support system in order to be successful," Col. Bradley said.
The task force recommended enhancing well-being, mental fitness, life skills, and resiliency of service members and families with programs such as financial management training, marriage and family relationship counseling, anger management, and conflict resolution skills.
Service members and their families also should have ready access to high quality behavioral health care, with continuity of care to ensure timely provision of services and seamless management. The task forces also called for standardized crisis intervention services and hotlines across all branches of the military.
Assessment and Management
The clinician should assess the degree of risk – acute or imminent – and ask the patient about current stressors and potential vulnerabilities over the long term. Col. Bradley and his colleagues employ the SAD PERSONS suicide assessment scale and the Beck Scale for Suicidal Ideation for evaluating patients.
Managing at-risk patients might include stabilizing medical conditions, taking steps to ensure the safety of both the patient and the clinician, and ruling out intoxication or withdrawal as possible causes of suicidal statements or actions. However, even retracted suicidal statements must still be evaluated, Dr. Bradley cautioned.
Treatment options include hospitalizing or committing to a care facility patients at imminent risk, although evidence to support this practice is limited. There is better evidence for suicide-specific therapies, psychosocial support, and medical therapies such as flupenthixol, clozapine, or electroconvulsive therapy.
Col. Bradley emphasized that there is no evidence to support the use of a "suicide contract," in which the clinician elicits a promise from the patient that he/she will not commit suicide.
"The only thing a suicide contract does is make a malpractice lawyer salivate when you’re being taken to court," he said.
The ongoing Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is the largest study of suicide and mental health among military personnel ever undertaken. It is designed to identify modifiable risk and protective factors related to mental health and suicide and will support the Army’s ongoing efforts to prevent suicide and improve soldiers’ overall well-being.
Data were presented at a symposium supported by the Home Base Program, a joint project of the Red Sox Foundation and Massachusetts General Hospital. Neither Dr. Kemp nor Col. Bradley had relevant financial disclosures.