Ebook: Lowering Suicide Risk in Returning Troops

This Advanced Research Workshop (ARW), “Wounds of War: Lowering Suicide Risk in Returning Troops,” was convened to discuss the topic of increased suicide risk in service men and women around the world. Research has shown that those who have served in both combat missions and peacekeeping operations are at an increased risk for suicide. Research suggests that this may result from their “wounds of war”. Some wounds may be more “invisible”; such as depression, posttraumatic stress disorder, and chronic pain, while others are more visibly apparent; such as physical disabilities. Whatever the wound, however, it seems they may all lead to an increased risk of suicide.

During this workshop, we discussed many aspects of military suicide and how to more effectively deal with this issue. Specifically, some of the questions addressed were:

1. How do we detect those who are vulnerable to increased suicide risk, possibly due to a combination of genetics and past environmental insults?

2. How do we most appropriately assess for increased risk?

3. Once detected, how do we help to decrease that risk?

4. Are there pre-deployment training methods we can employ to help “inoculate” individuals against increased risk?

5. Are there in-theater and post-deployment methods most appropriate for dealing with this risk?

Through this workshop, we have come closer to understanding what programs are already in place in various countries for detection, assessment, prevention, and treatment. We have begun to learn from these existing plans and can start to formulate a more common set of best practices and guidelines which can be implemented throughout organizations in all our countries; having as our common goal to always seek to serve our service members more effectively.

This Advanced Research Workshop has given participants an opportunity to foster essential international collaborative research on military suicide, a common and disabling consequence of war, terrorism, and natural disasters. As a result, it represents an important landmark in efforts to help soldiers and civilians of NATO and partner nations become more resilient in the face of international conflict.

This publication, which contains full papers focused on the key presentations during the workshop, acts as the permanent record of this event; a tangible documentation of the ideas that formed the basis of discussion and collaboration at the workshop. This text is organized to mirror the program from the event so as to provide an overview of the ideas of presenters and participants in the ARW.

Financial support for the workshop was provided by several sponsors. Great thanks to the primary funder, the NATO Security through Science Programme. In addition, we would like to acknowledge the generous contributions of the Telemedicine and Advanced Technology Research Center (TATRC) of the U.S. Army, as well as the Austrian Ministry of Defence (MoD).

The workshop was organized and this accompanying publication was compiled and edited jointly by the Interactive Media Institute, San Diego, California, USA and Interactive Media Institute-Europe (IMI-E), Brussels, Belgium. Professor Brenda K. Wiederhold, program co-chair, conceived the overall design of the workshop and recruited co-chairs Professor Dragica Kozarić Kovačić, of the University Hospital Dubrava in Zagreb, Croatia, and Professor Kresimir Cosic, of University of Zagreb and the Croatian Parliament to help with the event. With the assistance of her co-chairs, Dr. Wiederhold selected and invited the majority of the speakers and participants, and conference coordinators Ruth Kogen, MFA and Magda Horodyska, M.S. organized logistics including registration, travel, lodging and meals, assembling of workshop materials, and other arrangements for the ARW. Professor Dragica Kozarić Kovačić and Professor Cosic extended invitations to several distinguished international speakers, further improving the quality of the workshop. Mag. Christian Marolt uncovered the beautiful Austrian location where the event took place and Astrid Mentzik was responsible for the artistic design of all event-related materials. Sinisa Popovic, Faculty of Electrical Engineering and Computing, University of Zagreb, served as the event's photographer. Ms. Kogen along with McKinley Tolliver reviewed the conference program and full manuscripts, helping with editing and assembly of this and other associated texts.

Suicide is a major social and public health problem, one of the leading causes of death, a major complication of different psychiatric disorders that can evoke great suffering in patients and their families, and places a financial burden on society as a whole. Suicidal behavior and suicide are frequently associated with various psychiatric disorders and personality traits. However, most psychiatric patients never attempt suicide, indicating that aside from psychiatric diagnoses, other socio-cultural, environmental, biological and genetic factors are important risk factors for suicide. The biological and genetic contributions to suicide are still not completely understood, and the heterogeneity of the underlying neurobiology makes such investigations particularly difficult. Molecular basis of suicidal behavior is assumed to involve the changes in different neurotransmitter and neuroendocrine systems (primarily in the serotonergic and noradrenergic systems, the activity of the hypothalamic-pituitary-adrenal axis (HPA). Therefore, research on suicide, which is the major and the most dramatic consequence of suicidal behavior, should be linked to biological characteristics of suicidal behavior, to find biomarkers that might predict suicidal behavior, in order to prevent suicide.

In order to reveal biological correlates of suicidal behavior, we have to study three major fronto-limbic circuits: 1) orbitomedial prefrontal-limbic (OM PFC-L), 2) precingulate prefrontal-limbic (PC PFC-L), and 3) dorsomedial-dorsoanterolateral (DL PFC-L) limbic circuit. Limbic structures form the limbic lobe, which includes the limbic cortex (cingulate cortex and hippocampal formation) and subcortical structures (amygdala, nucleus accumbens septi, septal nuclei, hypothalamus and limbic midbrain area). The nuclei with identified neurotransmitter systems in the limbic midbrain area (LMA) project directly on three frontal cortical circuits and serve as major modulatory systems: serotoninergic (5-HT), noradrenergic (NA), and dopaminergic (DA) system.

The neural pathways (structural wiring) of fronto-limbic (FC-L) cortical systems connect amygdala - orbitofrontal cortex, dorsomedial thalamic nucleus - dorsolateral prefrontal cortex, prefrontal cortex - nucleus accumbens, precingulate cortex - subcortical limbic nuclei, and numerous cortico-cortical pathways, which interconnect OM, PC and DL prefrontal cortices and establish bilateral connections with limbic cingulate and hippocampal formation cortices.

For each of the fronto-limbic circuits, certain prominent functions have been proposed; OM PFC-L is essential for decision-making and impulse control. Consecutively, fine abnormalities of function of this system are one of the neural substrates for suicidal “diathesis.” These abnormalities were documented in neuroimaging studies in individuals who attempted suicide and in postmortem studies in people who committed suicide. The abnormalities may involve different levels of circuitry: principal neurons, interneurons, afferent pathways, synapses, and receptors. It is generally accepted that a decrease in serotonin transporter binding is one of the most prominent and most constant findings in people who have committed suicide. However, the principal abnormality lies in the frontolimbic circuit, which is under the influence of the 5-HT system. The abnormalities of DL PFC-L are less well documented, but we believe that this circuit plays a role in suicidal behavior because it is necessary for conscious representation of suicidal ideation. For proper diagnostic assessment of underlying psychiatric disorders and suicidal behavior, it is necessary to obtain the following “neurobiologically”-relevant data: imaging on a high-resolution device with 3D morphometry and volumetry, tractography, MR spectroscopy, SPECT, and, in advanced clinical centers, functional MRI and pharmacogenomic screening. The plasticity of frontolimbic circuits is present throughout life. The structural plasticity of pathways is present only during prenatal and early postnatal life; the plasticity of synapses lasts at least until the third decade of life, while plasticity of the receptors lasts throughout life. The MR imaging and pharmacogenomic parameters may serve as useful indicators for detection of vulnerable individuals who have an increased risk of suicide in addition to principal mental disorder.

Using this neurobiologically-based approach we hope to succeed in lowering suicide risk.

Untreated mental illness is an enormous problem in civilian and military populations. This paper reviews the literature on 1) methods and controversy related to defining the need for mental health treatment at a population level, 2) studies examining the relationship between mental disorder diagnoses and self-perceived need for mental health treatment, and 3) studies examining attitudes and barriers toward mental health care. Similar to civilian populations, the few studies in military samples have found that the majority of soldiers meeting criteria for a mental disorder do not receive mental health treatment or perceive a need for treatment. Attitudinal barriers (e.g., I would be seen as weak; a wish to solve the problem on their own) are more commonly endorsed than structural barriers (e.g., cost of services) toward seeking mental health care. Implications for future research and interventions are discussed.

The Mental Health Advisory Team (MHAT) IV was established by the Office of the U.S. Army Surgeon General at the request of the Commanding General, Multi-National Force-Iraq (MNF-I). The mission of MHAT IV was to (a) assess Soldier and Marine mental health and wellbeing, (b) examine the delivery of behavioral health care in Operation Iraqi Freedom (OIF), and (c) provide recommendations for sustainment and improvement to command. Part of the MHAT IV mission was to review the status of the theater's suicide prevention and surveillance programs, including an analysis of completed suicides. The MHAT IV assessed the mental health of the deployed force from August 28, 2006 to October 3, 2006. Recommendations are based on findings from anonymous Soldier (N = 1,320) and Marine (N = 447) surveys, and on behavioral health, primary care, and unit ministry team surveys; focus group interviews with Soldiers and Marines, as well as interviews and focus groups with Army and Navy behavioral health personnel; various secondary sources; and personal observations by team members.

Suicide is one of top ten causes of death in most countries, and it has large impact both on families of victims and their environment. Suicide rate in Europe is 17.5 per 100,000 people and various activities from WHO and other organizations are underway with the goal of reducing suicide rates. Different underlying factors can contribute to suicide, and risk factors include both genetic and environmental factors, as well as probable existence of independent inheritance of a predisposition to suicidal behavior. In this paper we review actual epidemiological data on suicide behavior in Europe and Croatia, novel approaches and theories on suicidal behavior, and present our experiences in the diagnostic process. Some predictors of suicidality from our previous studies in PTSD patients are indicated. We reveal an integrative diagnostic model for PTSD and suicidality, based on integration of psychiatric, psychological, and biological markers. Preliminary algorithms for predicting suicidal behavior using data mining methods are shown, and some important variables are indicated. Further studies with larger numbers of patients and more parameters are needed for future development of this multidisciplinary approach to the assessment of suicidal behavior.

Intense multi-factorial stresses faced by participants in combat operations may cause high levels of psychological suffering that may progress to serious mental disorders or even suicide. Therefore, the impact of stress and mental disorders on modern military is analyzed, including the role and importance of military training and leadership in protecting warfighters from devastating combat-related psychological disorders. Mental health indicators and stress-related impact factors, extended with known risk and protective factors for suicide, lead to a comprehensive mental health profile. In order to address the issues of psychological suffering and potential suicide of warfighters, the need for an interdisciplinary approach and joint institutional efforts has been stressed. Finally, an integrated strategy of suicide risk detection and prevention is proposed, based on longitudinal acquisition of an extended vector of comprehensive mental health indicators and appropriate probabilistic analyses. Regressive analysis of the individuals' databases is the starting point for identification of various psychological disorders, degraded operational performance, and potential suicide risk.

In spite of the fact that the suicide rate in Lithuania decreased during the past years, it is still one of the highest in Europe. 1 to 1.5 thousand people commit suicide in Lithuania every year. In 2006, the suicide rate was 30.9 per 100,000 people. Men commit 84% of all suicides. The number of male suicides is six times higher than that of female suicides. Men of average age living in rural areas have the highest risk of suicide. The ratio of attempted suicides to committed suicides is 10:1. Official data on suicide in the Lithuanian Armed Forces has existed since 1993. There have been few suicide cases in the Lithuanian Armed Forces since then. The amount of suicides are spread nearly equally among conscripts, officers, and non-commissioned officers. The suicide rate ranged from 0.15 to 0.34 per 1,000 servicemen for several years. Since 2004, the rate remains more or less level and does not exceed 0.2 per 1,000 servicemen. There is a need for suicide prevention measures, both in the country and in the Armed Forces, in spite of the fact that suicide rates in the military are not as high as in the civilian population. Suicide prevention measures should be applied not only to conscripts but to military professionals as well as officers and non-commissioned officers who are deployed. Scientific research findings [1] have shown an above average prevalence of suicidal behavior among servicemen, a low level of knowledge about suicide, inappropriate attitudes toward suicide, and a positive view on suicide prevention in the military, which became the background for the Program of Psychological support in the Lithuanian Armed Forces. The Program, with a wide spectrum of prevention measures, include: training, education, psychological support for servicemen and their families, additional care of personnel with psychological problems, and/or the risk of suicide, and monitoring of servicemen's psychological wellbeing, is in progress. The efficiency of this program is now being assessed. Since 2006, incident handling for service personnel by psychological support professionals has been organized not only in Lithuania but in the mission area as well. The concept of psychological support for service personnel and their families across the deployment cycle was validated and is now being successfully implemented.

The annual report of the United States (U.S.) Army Suicide Event Report (ASER) allows for detailed Army-wide statistical reports on suicide events, including attempts and completions. The report submitted as of March 1^st 2007 provided statistics for Calendar Year (CY) 2006 indicating a suicide rate of 16.91 (per 100,000) for the overall Army-Active Component only – the highest they have been since 1991. Historically, the U.S. Army annual average is 12 suicides per 100,000 Soldiers.

Data from ASER note the most frequently reported stressors included failed or failing relationships (especially marriage) followed by legal problems, work-related problems, and excessive debt. In addition, almost two-thirds of suicide completions had a history of at least one deployment to Iraq or Afghanistan; however, multiple deployments were relatively rare among those with suicide behaviors. The data also noted almost a third of completed suicides occurred in a deployed environment.

For this reason, the Department of the Army (DA), the Office of the Surgeon General (OTSG), Behavioral Health Proponency Office, Walter Reed Army Institute for Research (WRAIR), U.S. Army Center for Health Promotion and Preventive Medicine (CHPPM), U.S. Army Medical Department Center & School (AMEDDC&S), Battlemind Training Office (BTO), U.S. Army Medical Command (MEDCOM), the Suicide Prevention Office (SPO), the Chaplain Corps, and the U.S. Army Training and Doctrine Command (TRADOC) have collaborated to conduct ongoing research and training and policy development and implementation regarding suicide prevention in the U.S. Army.

The development of the Battlemind Training System serves as a collaborative effort at building Soldier resiliency through all phases of the deployment cycle, life cycle, and support cycle of military service. Battlemind may be defined as a Soldier's inner strength to face adversity and fear in combat with confidence and resolution; the will to persevere and win. Battlemind skill developed through military training serves as the cornerstone for resiliency of the American Soldier on and off the battlefield, and addresses a strength-based approach for the greater military communities in which they serve.

This paper presents some outcomes of the participation of Polish Military Contingents (PMC) in multinational missions and military operations within the UN, OSCE, EU and NATO mandate. The suicide risk among soldiers serving both in country and abroad is discussed. Selected legal issues and organization of the combat stress disorders prevention system in the Polish armed forces were presented. In particular, prevention activity before deployment, during deployment and after returning home was highlighted. Achievements and challenges in PTSD prevention and treatment in the PMC were discussed.

Battlefield stress is the consequence of man being exposed to the hostile environment of combat. Combat stress is specifically caused by man's fear of the dangers of combat, and is fueled and tempered by other variables such as morale, cohesion, fatigue, confidence, training and intensity of the combat. Treatment is often as simple as giving soldiers time to rest for a few hours or days, to get a shower and some sleep, and to talk about the feelings they have in the presence of a counselor. Only in rare cases do soldiers undergo more serious psychological treatment. One of the best strategies for dealing with stress is learning how to relax. However, relaxing is difficult to achieve in the battlefield. In this paper we suggest the use of mobile multimedia technology–PDA/cellular phones–for providing advanced coping techniques suitable to the battlefield context. Specifically, we developed a protocol based on mobile narratives, to be experienced on mobile multimedia technology: 3G cellular phones, IPODs or PDAs. Mobile narratives are audio-visual experiences, implemented on mobile devices, in which the narrative component is a critical aspect to induce a feeling of presence and engagement. Through the link between the feeling of presence and emotional state, mobile narratives may be used to improve mood state in their users. The rationale of the approach, a preliminary test of the proposed method, and a protocol for its use on the battlefield are presented and discussed.

The rate of co-morbidity is very high in posttraumatic stress disorder (PTSD) especially major depressive disorder and substance abuse. It is not clear if the suicidality in PTSD patients is predominantly caused by core PTSD symptoms or by co-morbid disorders. There is a lack of randomized controlled trials for treatment of suicidality in PTSD. Selective serotonin reuptake inhibitors (SSRIs) are widely used in PTSD treatment, but there is some evidence that they can increase risk of suicidality (self-harm behavior, suicidal thoughts, and suicide attempts) in younger age groups. Benzodiazepines have not been proven effective in the treatment of PTSD core symptoms. Benzodiazepines can even worsen clinical symptoms after acute traumatic experience, and they can induce consequent PTSD and depression, which may lead to increased suicidal risk.

In the territory of former Yugoslavia, wars were waged within the period of 1991-1995 on the territory of Croatia and Bosnia and Herzegovina, and in 1999 in the territory of Kosovo and Metohia during NATO aggression, which resulted in mental consequences, or wounds of war, in some of the participants. The aim of our study was to describe the wounds of war, suicide of war-veterans, and professional staff, participating in these wars. Our second aim of this study was to suggest some preventive measures that could help in the further application of the Suicide Prevention Program in the modern Army of Serbia. On the basis of the data obtained by psychological autopsy of suicide, selected were 30 professional staff who committed suicide within the period of 1999-2007; 10 of them were war-veterans and 20 were the control group. War-veterans have positive psychiatric heredity, they more intensively practice bodybuilding, more often were punished due to problems at work, while within the scope of the presuicidal syndrome, they manifest isolation more often in comparison with the control group formed of the professional staff who committed suicide in the same period. It is concluded that the further application of the Suicide Prevention Program is focused on four risk factors of suicide in returning troops: the past enviromental factors (taking part in wars), egzogenic (punishments at work), endogenic (genetic) and behavioral (early recognition of the presuicidal syndrome).

This article describes the process of the therapy in a group of Iraqi veterans, which took place in September, 2006. The psychotherapeutic meeting was organized by the Department of Psychiatry and Combat Stress in Warsaw. The group of veterans was composed of 16 male patients homogenous in age and ranking. During the meeting, the participants faced the opportunity to confront and to work through their traumatic experience.

The analysis of the interactions between participants showed an instant process of integration, creation of strong rules, and formation of three group leaders. Also, a change of attitude toward therapists (from disbelief to trust) occurred. The group rules were based on values such as loyalty and brotherhood transferred straight from the combat arena. Basic elements of group hierarchy were power of traumatic experience as well as range of damage.

The internal transformation of the participants took place during therapy. This resulted from death risk experience and working through the experienced trauma. Positive feedback and continuous contact with the clinic suggest that the veterans' problems call for psychotherapeutic treatment.

Although military personnel are trained for combat and peacekeeping operations, accumulating evidence indicates that deployment-related exposure to stress events is associated with mental health problems and suicidal behaviour. Suicide accounted for substantial mortality among army personal and veterans. This data could be partially explained with observation that war-zone exposures may have considerable negative emotional or behaviour consequences. On the other hand, it is also well known that some personal characteristics as impulsivity and aggression could be connected with higher suicide risk. The extent to which violent and aggressive behaviour in the aftermath of deployment can be attributed to combat experience remains an area of debate and ongoing investigation. The aim of our study was to evaluate negative life events of suicide victims in a month before suicide. On the other hand, aggression and impulsivity of suicide victims was evaluated. In the three-year period, 90 suicide victims (28 women and 62 men) in the central region of Slovenia were examined using the method of psychological autopsy performed by specially designed questionnaire and from medical documentation. We compared a subgroup of suicide victims with previous aggressive behaviour and a subgroup of suicide victims without any previous reported aggressive behaviour. We observed that suicide victims with previous aggressive behaviour have higher a number of negative life events in the month before suicide and have higher impulsivity then others. We also observed that suicide victims with previous aggressive behaviour directed toward others have more often previous suicide attempts than suicide victims without previous aggressive behaviour. It could be concluded that negative life events of suicide victims with previous experience of aggressive behaviour may additionally contribute to increased suicide risk. In military environments, attention should be paid to such vulnerable individuals, especially during pre-deployment periods.

For more than a decade, virtual reality (VR) has had a significant impact on behavioral healthcare, permeating the field with its multiple effective uses. One area in which VR shines is providing a continuum of care for the military to treat wounded warfighters. The Interactive Media Institute and its affiliate the Virtual Reality Medical Center are funded to provide VR as an adjunct to traditional training and therapeutic applications.

Pre-deployment, VR-enhanced Stress Inoculation Training (SIT) can be used to provide troops (e.g. combat medics, flight medics, tactical forces) with skill sets to accomplish their tasks. The immersive nature of VR allows soldiers to experience a near real-life combat situation and the precise control VR enables users to practice their tasks repetitively in identical or varied situations, whichever the individual trainee requires. Stressors can be increased systematically so that the skills learned can be performed under increasingly anxiety-provoking situations.

This creates soldiers who are better able to perform under the most demanding conditions. In addition, these virtual combat situations evoke physiological responses, creating the opportunity for troops to practice managing their stress reactions to high pressure or dangerous situations. It is hoped that this repetition and practice will produce soldiers who are more competent and resilient. Post-deployment, VR exposure can augment traditional cognitive-behavioral therapy protocols for treating Posttraumatic Stress Disorder (PTSD). While working with both active duty and veteran populations, it appears that VR exposure may be more effective in providing the individual with an environment in which he/she can stop the avoidance - often a hallmark of PTSD. In a VR environment, the individual is transported back into a wartime setting and can slowly and systematically begin to consolidate the fragmented memories in order to allow emotional processing to occur and desensitization to be achieved.

Finally, VR is being successfully used as an adjunct to traditional treatments for those with both chronic and acute pain, and for help in rehabilitating those who have sustained physical, cognitive or neurological injuries.