by Bob Carolla, J.D., NAMI national news director
In addressing mental illnesses, the U.S. military faces many of the same challenges as civilian society, in addition to situations unique to combat missions. It also has certain advantages in its arsenal. Particularly in suicide prevention, the military can offer leadership and provide examples for the rest of the nation.
Mental health crises among military personnel do not necessarily lead to discharge. Some soldiers on peacekeeping duty in Kosovo take SSRIs for depression. One recent Air Force study of 14 aviators who attempted suicide reported that 11 (79 percent) returned to flying status. And, depending on the circumstances, a person with bipolar disorder may be able to maintain his or her military career.
"We try to treat and return a person to duty as our goal," said Lt. Col. Elspeth Cameron Ritchie, a psychiatrist in clinical and program policy in the Office of the Assistant Secretary of Defense for Health Affairs. For military personnel, lack of health insurance is not a barrier to receiving treatment, as it often is among the general population. Furthermore, the structure of the military services and their communities make it easier to connect and reduce the social isolation that may contribute to psychiatric crises. Official policy encourages those in the military to "watch out for your buddy" and to seek treatment.
The military’s suicide rate approximates that of the nation’s civilian population, with variations by service. In 1996, the civilian rate was 10.8 per 100,000. The overall military rate ranges between 12 and 14 per 100,000. In 2002, however, the Air Force rate was 8.6 per 100,000—the service’s third lowest rate in two decades. Nonetheless, suicide is the second leading cause of death in the military, after accidents.
In "Suicidal Admissions in the United States Military," in the March 2003 issue of Military Medicine, Ritchie and two other contributors reviewed the records of 100 patients admitted for inpatient psychiatry at Walter Reed Army Medical Center in Washington, DC. Fifty-four of the patients had attempted suicide, and forty-six had significant suicidal ideation. Almost all were enlisted personnel. Their symptoms of depression included insomnia, anhedonia, poor energy, poor concentration, decreased appetite, and anxiety.
Discharge diagnoses in the study were adjustment disorder (37 percent), personality disorder (24 percent), major depressive episode (12 percent), bipolar disorder (5 percent), and other diagnoses (27 percent). Precipitating stresses prior to hospitalization were occupational (78 percent), marital or romantic (35 percent), financial (39 percent), deployment-related (35 percent), and/or other factors (33 percent).
Of 64 patients hospitalized for the first time, 56 percent returned to full duty, compared with 47 percent overall. Of those with previous psychiatric hospitalizations, approximately a third returned to duty.
Return to duty depends on a range and balance of several factors, including the patient’s goals, the medical recommendation, the patient’s military occupation, the location, and the likelihood of deployment. The needs of the service to some degree are analogous to the "reasonable accommodation" standard in civilian employment. A critical difference, however, is the military’s more clearly defined procedural structure for making such decisions. Medical discharges must be reviewed by a medical examination board and are subject to appeal. In contrast, in a civilian setting, the burden of seeking accommodation rests on the employee, usually in a more uncertain workplace environment and sometimes in the face of greater ignorance about or insensitivity to mental health concerns.
For a person with bipolar disorder or schizophrenia, the military environment may be incompatible with management of the illness. Lithium and certain other mood-stabilizing medications require regular blood tests for monitoring purposes; heat stress and dehydration are concerns; and all-night watch duty requirements or high-noise environments may cause serious disruption of sleep patterns. Medical discharges for those with bipolar disorder or schizophrenia are honorable.
Significant lessons can be found in the military’s approach to suicide prevention. The U.S. Department of Health and Human Services, the U.S. Surgeon General, and President Bush’s New Freedom Commission on Mental Health all have identified the Air Force’s program as a best practice model for the nation.
"Suicide is our most preventable cause of death," says Air Force Surgeon General Lt. Gen. Paul K. Carlton Jr. "Leadership and mentorship are our two most important tools in preventing tragic losses."
From 1990 to 1995, the incidence of suicide in the Air Force was rising at a statistically significant rate, although at levels comparable to or lower than those in the other services. The Air Force chief of staff—one of the Pentagon’s joint chiefs—ordered an aggressive response, declaring the suicide of even a single airman unacceptable. Multiple messages from top commanders went to Air Force personnel worldwide to make suicide prevention a priority.
The Air Force prevention strategy makes suicide a community, rather than a medical, problem. The result has been an 80 percent reduction in suicide.
The Army, Navy, and Marines noticed the results, and discussions among the services led to coordinated efforts. In November 2002, even as military tension with Iraq was growing, the Department of Defense for the first time dedicated a week to suicide prevention awareness across all services and launched a yearlong focus on improvements.
In addition to committed leadership, the Air Force model includes multiple levels of education, an integrated delivery system, and elements to fight the stigma that discourages people from seeking help.
According to Lt. Col. Rick Campise, the Air Force’s program manager for suicide prevention, 97 percent of those who self-refer experience no negative impact on their military careers. "Our goal is to help people cope before problems occur," Campise said.
When problems snowball and a commander needs to order a person to get help, the rate of those experiencing "no negative effect" on their career drops to 45 percent. By then, the person usually has built up a record of poor performance, emotional outbursts, or other inappropriate conduct that is difficult to overcome.
In the civilian world, a person must self-disclose to receive employment protection under the Americans with Disabilities Act—but the workplace culture may not be as openly encouraging and supportive.
The Air Force also has sought to reduce stigma by getting mental health care personnel out of their offices and clinics and making them visible throughout the community. "There needs to be a face attached," said Campise, adding that people need to realize that when they seek help, they will be seeing a person who is approachable.
The approach means "taking care of our own," according to Campise. And it’s an approach that is consistent with military tradition.
Information about the Air Force Suicide Prevention Program and links to a detailed pamphlet of initiatives and a tool kit for community education are available at http://phs.os.dhhs.gov/ ophs/BestPractice/usaf.htm. To read The Surgeon General’s Call to Action to Prevent Suicide, visit http://www.surgeongeneral.gov/library/calltoaction/calltocation.htm.