A Soldiers Suicide and Effects

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Psychiatry 74(2) Summer 2011 107

2011 Guilford Publications, Inc.

Address correspondence to Matthew K. Nock, Ph.D., Harvard University, William James Hall, 1220, 33 KirklandStreet, Cambridge, MA 02138. E-mail: [email protected].

CommentaryNock

Commentary on When a Soldier Commits Suicide in Iraq:Impact on Unit and Caregivers

A Soldiers Suicide:Understanding its Effect on Fellow Soldiers

Matthew K. Nock, PhD

More people die by suicide each yeararound the world than by all wars, geno-cide, and interpersonal violence combined(World Health Organization, 2009). Alarm-ingly, recent figures suggest that U.S. ArmySoldiers, who are trained to kill others in thedefense of their country are now more likelyto die by their own hand than by that of anenemy combatant (U.S. Army, 2010). TheU.S. Army and National Institutes of Healthhave acted swiftly in response, launching amultitude of research initiatives aimed atunderstanding the causes of suicide amongSoldiers and identifying the most promisingdirections for intervention efforts. For exam-ple, the U.S. Army and National Institute ofMental Health recently partnered to launchthe Army STARRS project, a multi-site, $50million study aimed at identifying modifiablerisk and protective factors for suicide amongSoldiers (see www.ArmySTARRS.org). Thehope is that such efforts will reveal malleable

causal risk factors that can be targeted by in-terventions that ultimately will decrease therate of suicide among Soldiers.

A topic that has received far less re-search attention, both in the military andmore broadly, is the impact that suicide hason those close to the decedent. The excellentarticle by Dr. Carr appearing in this volume

sheds light on this important topic and pro-vides rich detail about how the effects of asuicide unfold over time. In this article, Dr.Carr reports on the tragic suicide of a Sol-dier while deployed to Iraq, and he describesin fine detail the impact that the Soldierssuicide had on those around him, includ-ing members of his unit, other Soldiers onhis base, and the health care professionalswho provided both mental health care priorto his suicide attempt and medical care im-mediately following his attempt. AlthoughShneidman (1973) famously suggested thateach suicide affects six people, more recentempirical work suggests that the actual num-ber directly affected by a suicide death variesdepending on the definition used but may beas high as 60 per suicide (Berman, 2011). Dr.Carrs paper provides a vivid report not onlyof how many fellow Soldiers are affected byeach suicide, but of the various ways such adeath can impact those around the fallen Sol-

dier. There are many valuable aspects of Dr.Carrs paper, but I would like to highlight thethree that I think are especially noteworthy.

First, the use of a case description pro-vides extremely rich information about thiscomplex clinical issue. Most prior studieson suicide and its effects take a hypothetico-deductive approach and use controlled de-


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108 Commentary

signs with quantitative assessment and dataanalysis in order to test investigator-derivedhypotheses. Such an approach is necessary toadvance the scientific understanding of thisissue, but provides somewhat limited op-portunities to observe the phenomenon ofinterest up close as it unfolds over time. Inutilizing a case study, Dr. Carrs article alsoprovides valuable information about severalof the unique aspects of suicide among Sol-diers. One of the most significant differencesbetween suicide in civilian versus militarycontexts is that in the military, and especial-ly among those in theater, the environment

already is one of outstandingly high stress,violence, and uncertainty and one in whichthe mission must continue with little time formourning or postvention. This is illustratedpowerfully in Dr. Carrs article in the de-scription of the physician who attempted torevive the Soldier and after his death had tocontinue his duties with the Soldiers bloodstains on his boots. In the civilian context, itis rare that someone would be attempting torevive a friend or colleague after an attempted

suicide (except perhaps in remote geograph-ic regions where the patient may be wellknown to the medical professional attempt-ing to revive him or her), and unimaginableto think that the medical professional wouldhave to continue about their work after theevent wearing their blood-stained garments.Yet, this is something that our Soldiers areasked to endure while they continue on withtheir assigned combat missions. This level ofdetail brings into clear focus the extremely

challenging situations our Soldiers endure ona regular basis that may contribute to highlevels of psychological distress.

Second, the use of a case study also pro-vides a clear clinical illustration of several re-cent scientific findings obtained from studiesof large groups. For instance, recent researchhas shown that: (a) more than 75% of peoplewho die by suicide see a health provider inthe year before their death, and 45% do sowithin the month before their suicide (Luo-ma, Martin, & Pearson, 2002)this was truewith the Soldier described in this case study;

(b) as many as 66% of people who die by sui-cide explicitly tell others about their suicidalthoughts prior to their death (Cavanagh etal., 2003)this Soldier told others about hissuicidal thoughts; (c) nearly 80% of patientswho kill themselves explicitly deny suicidalthoughts/intent in their last communicationbefore killing themselves (Busch, Fawcett, &Jacobs, 2003)this Soldier assured his clini-cian during their last meeting that he wouldnot act on his suicidal thoughts and deniedhaving them anymore; and (d) the risk ofsuicidal behavior is greatly increased in thepresence of multiple psychiatric disorders,

with depression being the strongest predictorof suicidal thoughts and problems with agita-tion and behavioral control the strongest pre-dictors of acting on suicidal thoughts (Nocket al., 2010a)this Soldier was diagnosedwith major depression and also had problemswith anger management. This article paints areal-life picture of how these factors play outin an individual case. On one hand, it is reas-suring to see the consistency between findingsfrom quantitative and qualitative studies. On

the other hand, both types of studies continueto highlight the enormous limitations in ourunderstanding of and ability to predict andprevent, suicide.

Third, this article highlights the needfor improved, evidence-based methods notjust for predicting and preventing suicide,but also for dealing with the immediate af-termath in a way that meets the needs ofthose affected, while maintaining/maximiz-ing the functioning of the force. Current

methods of suicide prediction rely largely onasking people if they are thinking about kill-ing themselves and if they say yes, keepingthem in a locked hospital setting until theyconvince those around them that they no lon-ger intend to do so. There are of course manylimitations to relying so heavily on a personsself-report, but this is at present virtually allwe have. In the current case, there were riskfactors (e.g., presence of major depression,anger problems) and more immediate warn-ing signs (e.g., talking about wanting to dieby suicide); however, the Soldier was able to


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Nock 109

convince those around him that he was notreally going to act on his suicidal thoughts.There is a tremendous need for the develop-ment of objective indicators of suicide risk,such as genetic/biological markers or cogni-tive/behavioral markers. There also is a seri-ous need to better understand which of themany prevention programs currently in useare actually effective, and which postventionprograms can decrease the risk of ongoingdistress and psychopathology among thoseaffected by suicide.

Recent research offers important pointsof departure in each of these areas. Indeed,

there is evidence that objective measures ofa persons genetic (Mann et al., 2006) andbehavioral (Nock et al., 2010b) data can im-prove the prediction of subsequent suicidal

behavior. There is some evidence for preven-tion programs employing physician educa-tion, training of gate-keepers, and meansrestriction (Mann et al., 2005). There alsois a growing body of research on the scienceof grief in general (Bonanno, 2010) and onthe effects of patient suicide on clinicians inparticular (Hendin et al., 2000). As researchproceeds down these and other avenues, itwill be important to continue to draw onqualitative case studies, such as the excellentone presented by Dr. Carr, and to continue towork to our greatest possible ability to pro-tect from self-harm the many Soldiers who so

bravely protect all of us from harm by oth-ers.

REFERENCES

Berman, A. L. (2011). Estimating the popu-lation of survivors of suicide: Seeking an evi-dence base. Suicide & Life-Threatening Behav-ior, 41(4), 110-116.

Bonanno, G. A. (2010). The other side of sad-ness: What the new science of bereavementtells us about life after loss. New York: BasicBooks.

Busch, K. A., Fawcett, J., & Jacobs, D. G.(2003). Clinical correlates of inpatient suicide.Journal of Clinical Psychiatry, 64(1), 14-19.

Cavanagh, J. T., Carson, A. J., Sharpe, M., etal. (2003). Psychological autopsy studies of sui-cide: A systematic review. Psychological Medi-

cine,33(3), 395-405.Hendin, H., Lipschitz, A., Maltsberger, J. T.,et al. (2000). Therapists reactions to patientssuicides. American Journal of Psychiatry,157(12), 2022-2027.

Luoma, J. B., Martin, C. E., & Pearson, J. L.(2002). Contact with mental health and pri-mary care providers before suicide: A review ofthe evidence. American Journal of Psychiatry,159(6), 909-916.

Mann, J. J., Apter, A., Bertolote, J., et al.(2005). Suicide prevention strategies: A system-atic review. Journal of the American MedicalAssociation, 294(16), 2064-2074.

Mann, J. J., Currier, D., Stanley, B., et al. (2006).Can biological tests assist prediction of suicidein mood disorders? International Journal ofNeuropsychopharmacology , 9,465-474.

Nock, M. K., Hwang, I., Sampson, N., et al.(2010a). Mental disorders, comorbidity, andsuicidal behaviors: Results from the NationalComorbidity Survey Replication. MolecularPsychiatry, 15, 868-876.

Nock, M. K., Park, J. M., Finn, C. T., et al.

(2010b). Measuring the suicidal mind: Implicitcognition predicts suicidal behavior. Psycho-logical Science,21(4), 511-517.

Shneidman, E. S. (1973). On the nature of sui-cide. San Francisco: Jossey-Bass.

U.S. Army. (2010). Army health promotion,risk reduction, suicide prevention report.

World Health Organization. (2009). Data andstatistics: Causes of death. Accessed Oct. 4,2009. http://www.who.int/healthinfo/statistics/

bodgbddeathdalyestimates.xls.


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