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Original Investigation |

Risk of Suicide Among US Military Service Members Following Operation Enduring Freedom or Operation Iraqi Freedom Deployment and Separation From the US Military

Mark A. Reger, PhD1; Derek J. Smolenski, MPH, PhD1; Nancy A. Skopp, PhD1; Melinda J. Metzger-Abamukang, BS1; Han K. Kang, DrPH2; Tim A. Bullman, MA3; Sondra Perdue, DrPH4; Gregory A. Gahm, PhD1
[+] Author Affiliations
1National Center for Telehealth and Technology, Joint Base Lewis-McChord, Tacoma, Washington
2Institute for Clinical Research, Department of Veterans Affairs, Washington DC VA Medical Center, Washington, DC
3Post-Deployment Health Strategic Healthcare Group, Office of Public Health, Department of Veterans Affairs, Washington, DC
4Healthcare Leadership, University of Washington Tacoma, Tacoma
JAMA Psychiatry. 2015;72(6):561-569. doi:10.1001/jamapsychiatry.2014.3195.
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Importance  A pressing question in military suicide prevention research is whether deployment in support of Operation Enduring Freedom or Operation Iraqi Freedom relates to suicide risk. Prior smaller studies report differing results and often have not included suicides that occurred after separation from military service.

Objective  To examine the association between deployment and suicide among all 3.9 million US military personnel who served during Operation Enduring Freedom or Operation Iraqi Freedom, including suicides that occurred after separation.

Design, Setting, and Participants  This retrospective cohort design used administrative data to identify dates of deployment for all service members (October 7, 2001, to December 31, 2007) and suicide data (October 7, 2001, to December 31, 2009) to estimate rates of suicide-specific mortality. Hazard ratios were estimated from time-dependent Cox proportional hazards regression models to compare deployed service members with those who did not deploy.

Main Outcomes and Measures  Suicide mortality from the Department of Defense Medical Mortality Registry and the National Death Index.

Results  Deployment was not associated with the rate of suicide (hazard ratio, 0.96; 99% CI, 0.87-1.05). There was an increased rate of suicide associated with separation from military service (hazard ratio, 1.63; 99% CI, 1.50-1.77), regardless of whether service members had deployed or not. Rates of suicide were also elevated for service members who separated with less than 4 years of military service or who did not separate with an honorable discharge.

Conclusions and Relevance  Findings do not support an association between deployment and suicide mortality in this cohort. Early military separation (<4 years) and discharge that is not honorable were suicide risk factors.

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Figure.
Hazard of Suicide and 99% CI as a Function of Calendar Time for All Members of the Cohort Before Separation From the Military

In the total cohort, the hazard function showed that the rate of suicide increased in a largely monotonic fashion.

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Comment on Risk of Suicide among US Military
Posted on April 7, 2015
David W. Orme-Johnson, PhD
Consultant
Conflict of Interest: I am a science consultant for the Maharishi Foundation, the teaching organization for the Transcendental Meditation technique. I did not receive any payment for writing this comment.

It is interesting that suicide is not related to being deployed to combat areas but to leaving the military, especially if soldiers had less than 4 years of service, and especially if they did not have an honorable discharge (1).  This suggests that these suicides are related to pre-military service, unprocessed trauma originating from such sources as lack of education, lack of social support, unemployment, substance abuse, and pre-existing mental health problems. For example, the data from this study show that uneducated (no high school education), young (17-18), unmarried, and Junior enlisted personnel had two to three times higher suicide rates than more educated, older (<35), married and Senior enlisted men (1).  It appears that the folks prone to suicide are ones that sought to escape from on-going trauma in civilian life by enlisting into the highly structured and safe military environment. But when they did not do well in the military either (early discharge, without honor), their hopes for a better life in the military faded. Let down, stressed, and feeling like failures, they could see no way out but to end it. As the authors expressed it: “Loss of a shared military identity, difficulty developing a new social support system, or unexpected difficulties finding meaningful work may contribute to a sense that the individuals do not belong or are a burden on others” (1).  I think the deeper issue is not the military or military deployment per se, but is what we can do as a society for our growing non-technological underclass whose job and life options are being squeezed down by automation. We need more focus on training men and women leaving the military with skills that will prepare them for a successful and rewarding civilian life in our rapidly evolving technological society. Some such programs are in place, like Boots to Suits, which has identified financial hardship as one of the main reasons for veteran suicide (2). However, even more basic than job training are stress reducing skills and skills that increase brain integration and frontal cortex executive abilities. Such skills are provided by the Transcendental Meditation technique (TM). The physiological changes seen during TM are in the opposite direction of those produced by stress, that is, reduced respiratory rate, plasma lactate, and skin conductance (3), and decreased stress hormones cortisol, epinephrine, and norepinephrine (4,5). Moreover, TM has been shown to be highly effective for reducing PTS, including depression, in war veterans (6,7) and war refugees (8). TM also increases brain integration (9), creativity, and intelligence, which predicts success in a wide range of fields, such as athletics and business (10). It should be offered to all military personnel, as well as in all our institutions, from schools to retirement homes.

References.

1. Reger MA, Smolenski DJ, Skopp NA, et al. Risk of Suicide Among US Military Service Members Following Operation Enduring Freedom or Operation Iraqi Freedom Deployment and Separation From the US Military. JAMA Psychiatry 2015.

2. Peneton D. Boots to Suits: Connecting Veterans to Career Opportunities. 2015; http://boots-to-suits.com/.

3. Dillbeck MC, Orme-Johnson DW. Physiological differences between Transcendental Meditation and rest. American Psychologist 1987;42:879–881.

4. Walton KG, Pugh N, Gelderloos P, Macrae P. Stress reduction and preventing hypertension: Preliminary support for a psychoneuroendocrine mechanism. Journal of Alternative and Complementary Medicine 1995;1(3):263-283.

5. Infante JR, Torres-Avisbal M, Pinel P, et al. Catecholamine levels in practitioners of the transcendental meditation technique. Physiology & Behavior 2001;72(1-2):141-146.

6. Brooks JS, Scarano T. Transcendental Meditation and the treatment of post-Vietnam adjustment. Journal of Counseling and Development 1985;64:212-215.

7. Rosenthal J, Grosswald S, Ross R, Rosenthal N. Effects of Transcendental Meditation (TM) in Veterans of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) with Posttraumatic Stress Disorder (PTSD): a Pilot Study. Military Medicine 2011;176(6):626.

8. Rees B, Travis F, Shapiro D, Chant R. Reduction in post traumatic stress symptoms in Congolese refugees practicing Transcendental Meditation. Journal of Traumatic Stress 2013;26:295-298.

9. Travis FT, Haaga D, Hagelin JS, et al. Effects of Transcendental Meditation practice on brain functioning and stress reactivity in college students. International Journal of Psychophysiology 2009;71(2):170-176.

10. Harung H, Travis FT, Blank W, Heaton D. Higher development, brain integration, and excellence in leadership. Management Decision 2009;47(6):872-894.

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