Suicidal Behaviors and the Use of Mental Health Services Among Active Duty Army Soldiers

In the active duty U.S. Army, 7% of soldiers seriously considered or attempted suicide since joining the military, and 1% did so in the past 12 months. These rates are comparable to rates for the U.S. age-group population of 18- to 29-year-olds, among whom 6% had suicidal thoughts, 2% made suicide plans, and 1% attempted suicide in the past year (20). However, comparisons of suicidality prevalence rates between general population samples and samples consisting of military personnel must be evaluated with caution, given that there are typically demographic differences between these groups. For example, Army personnel are predominantly male, younger than age 50, and employed. The prevalence of suicidal ideation and attempts has generally been found to be significantly higher among younger adults (aged 18 to 24) than among older age groups (21). In this study, 13% of soldiers reported considering or attempting suicide at some point in their lives, which approximates lifetime rates of suicidal ideation and attempt in the general U.S. population (14% and 5%, respectively) (22).

Although suicidality was often found to be strongly associated with the use of different types of mental health services in the past 12 months, approximately half of the soldiers who reported suicidality had not received any mental health care, even though such services are readily available at no financial cost. The latter finding is not unique to the military. A recent cross-national survey reported that 65% of individuals who had seriously thought about, made a plan, or attempted suicide in the past year had not received general medical or mental health treatment during that period (16). Low perceived need was the reason indicated most frequently for not obtaining treatment (16). Therefore, understanding the specific barriers to care for soldiers considering or attempting suicide is important to facilitate their mental health care. Notably, after the analyses adjusted for demographic characteristics and a history of suicidality, soldiers with suicidality in the past year were no more likely to report use of any service than those without suicidality, although they continued to be significantly more likely to be prescribed medication and to use the highest level of services. Those who have seriously considered or attempted suicide in the past year potentially use more specific higher-level interventions; however, initially some might seek services from their general practitioner. Therefore, the use of any service by some soldiers with suicidality and by soldiers without suicidality might appear similar because the soldiers with suicidality have yet to progress to more specific, higher levels of service use.

Numerous factors affect a service member’s ability or willingness to seek care, including perceived need; structural barriers, such as time constraints and availability (23); and perceptual barriers, such as mental illness stigma and beliefs that treatment will be ineffective (24–26). Notably, being young and male, characteristics that describe a majority of U.S. military members, is associated with decreased help-seeking behavior in the general population (27). Further, stoicism and autonomy—traits that are valued in military culture and encouraged throughout military training—may also diminish the likelihood that a service member will seek help.

These issues are being addressed in the U.S. Army through programs such as the Embedded Behavioral Health program, which provides greater access to mental health treatment and reduces stigma by embedding a team of behavioral health care providers within a battalion (28,29). However, additional evidence is needed to determine if this approach will reduce soldiers’ concerns about privacy or potential career effects (30). Further, the U.S. Air Force initiated the Managing Suicidal Behavior (MSB) project as an empirically based guide for outpatient practitioners to assess and manage suicidality among service members and improve and standardize quality of care (31). Although few controlled studies have investigated the effectiveness of training for service providers on patient outcomes, Oordt and colleagues (32) found that participation in MSB training resulted in increased confidence in assessing and managing suicide risk and changes in suicide care procedures and clinic policies at six-month follow-up. The Collaborative Assessment and Management of Suicidality (CAMS) approach, which emphasizes a collaborative therapeutic alliance between clinician and patient, has received empirical support with an active duty Air Force outpatient sample (33). After treatment, CAMS participants resolved their suicidality more quickly and attended fewer medical appointments unrelated to mental health than airmen who did not participate in CAMS. This approach is expected to be effectively implemented by other military branches (33).

The findings of this study must be interpreted in terms of several methodological considerations. Because this is a cross-sectional study, further research using longitudinal designs is needed to better determine the course of mental health service use and its relationship to suicidality. Specifically, the survey did not capture whether mental health services were used before or after considering or attempting suicide. The survey employed self-report techniques, which may raise validity concerns. However, procedures to promote honesty on self-report studies, such as ensuring respondents’ anonymity, having command leadership leave the room during the survey, and explaining the survey purpose, were applied (34). Nonetheless, recall bias could result in overreporting or underreporting of mental health service use and suicidality.

In addition, certain groups that were not available at the time of the survey, including currently deployed soldiers, are underrepresented in the survey, although previously deployed soldiers are well represented (17). Additional information regarding the nature of the suicidal symptoms and the specific details of mental health services used, such as duration of service, resolution of the presenting concern, and type of medication prescribed, is important to better understand the complex relationship of suicidal behaviors and mental health services utilization. Finally, although this study addressed the relationship between suicidality and the use of mental health services, the relationship of those services to mental disorders should be evaluated in future research.

Soldiers in the U.S. Army who seriously considered or attempted suicide were more likely to use mental health services and to receive the highest level of mental health care. In order to address the issue of suicide in the military, in recent years the U.S. Army has initiated or enhanced a number of programs aimed at preventing suicide. For example, the Ask, Care, Escort program focuses on training soldier peers or “buddies” to identify key risk factors among fellow soldiers and to intervene appropriately. Targeted briefings are now provided to command leaders, chaplains, and soldiers, and mandatory suicide prevention training has recently been implemented. In addition, soldiers who are preparing for or returning from deployment are supplied with resiliency training (30). Further research is needed to better understand the relationship between suicidal ideation and access to care, diagnosis, and receipt of appropriate care.

The authors thank Deborah Probe, M.A., for valuable assistance during the undertaking of the research summarized here. The opinions expressed are those of the authors and do not necessarily reflect the views of the U.S. Department of Defense, the Uniformed Services University of the Health Sciences, or the Center for the Study of Traumatic Stress.

Dr. Kessler has been a consultant to, served on advisory boards for, or received research support from Analysis Group, Appliance Computing II, AstraZeneca, Bristol-Myers Squibb, Cerner-Galt Associates, Eli Lilly & Company, EPI-Q, GlaxoSmithKline Inc., HealthCore Inc., Health Dialog, Hoffman-LaRoche, Inc., Integrated Benefits Institute, John Snow Inc., Johnson & Johnson Pharmaceuticals, Kaiser Permanente, Matria Inc., Mensante, Merck & Co, Inc., Mindsite, Ortho-McNeil Janssen Scientific Affairs, Pfizer Inc., Plus One Health Management, Primary Care Network, Research Triangle Institute, Sanofi-Aventis Groupe, Shire U.S., Inc., SRA International, Inc., Takeda Global Research & Development, Transcept Pharmaceuticals Inc., Walgreens, and Wyeth-Ayerst. He owns a 25% share in DataStat, Inc. Dr. Stein is coinvestigator for a research grant from Janssen and is a consultant for Care Management Technologies. The other authors report no competing interests.