Psych 400 Final

Running head: SUICIDE RISK FOR ADOLESCENT MILITARY PERSONNEL

Suicide Risk and Alternative Treatment for Adolescent Military Personnel

Jonathan Lee Albert

University of Maryland Baltimore County

SUICIDE RISK FOR ADOLESCENT MILITARY PERSONNEL

Abstract

In this paper, research studies were reviewed to determine if suicide rates were

extensive among adolescents in the military, what interventions are applied, and what

solutions have been proposed or exist that could lower the prevalence of suicide in

adolescent military personnel. The existence of suicide in adolescents who join the

military is impacted by ethical injury, which has been defined by Bryan et al. (2014) as

actions that violate one’s principled code. Providing resources for spiritual guidance could

be a viable solution to increase positive mental health and decrease suicide risk for

adolescent military personnel.

Introduction

This paper reviews data regarding suicide among adolescent military personnel,

which includes their risk level, current treatments, and treatment interventions.

LeardMann et al. (2013) ran a prospective longitudinal study with a sample size of

491,659 military personnel who were recorded from 2001-2008 to assess the prevalence

of suicide in military personnel. The adolescent group of personnel consisted of

participants under the age of 25, and this group showed the highest risk of suicide, at

34.9%, among the entire group who committed suicide. According to Bryan et al. (2014)

the reasons for suicide point towards moral injury, which has been defined as actions that

violate one’s moral code. In this study, moral injury to the self, also known as

Transgressions-Self, was associated with significantly more severe suicidal ideation (B

= .424, SE = .171, p = .014, β = .203). In this study, the sample size was 151 Army and

Air Force personnel from ages 20 to 54, and a p < .05 was considered statistically

significant. Moreover, Breggin (2010) discussed that the newer antidepressants being

administered to military personnel have led to suicide, violence, and manic-like

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symptoms. The symptoms brought about by these antidepressants are similar to

posttraumatic stress disorder and are likely to worsen the condition for soldiers with

PTSD. As an alternative means of treatment, Luxton et al. (2012) presented a Caring

Letter Project, which was the first psychological intervention to reduce suicide in a

randomized clinical trial; the original Caring Letters Project was run by Motto (1976).

As stressed by Luxton et al. (2012), there has been growing empirical evidence that the

creation and maintenance of a caring personal connection, coupled with follow-up letters

or emails between caregivers and high-risk patients, can help prevent suicide.

This is further supported by the interpersonal-psychological theory of suicide,

proposed by Joiner & Van Orden (2008). The theory states that personnel with self-harm

tendencies also have perceptions of being a burden and feel a lack of belonging. These

personnel are more likely to attempt or complete suicide than are others. This theory is in

congruence with the idea that moral injury influences military personnel’s decision to

commit suicide.

These studies demonstrate that suicide has been a leading cause of death for

adolescents in the military. Therefore, it is imperative to create alternative treatments and

interventions for adolescent military personnel. To successfully combat suicide in

adolescent military personnel, new treatments that focus on moral injury must be

implemented.

Overview of Suicide Risk

LeardMann et al. (2013) addressed suicide risk among military personnel because

it has become an increasing problem since 2005, when its prevalence began a sharp

increase, and from 2012-2013, suicide was the leading cause of death among military

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personnel. For this study, LeardMann et al. (2013) drew randomly selected samples of

military personnel from 2001-2008 with an overall sample size of 491,659. This study,

known as the Millennium Cohort Study, is the largest longitudinal US military study to

date concerning suicide risk in military personnel. It was designed to evaluate the impact

serving in the military has on mental health. The suicide rate was constructed based on

groups of 100,000 personnel yearly from the overall sample. The adolescent group of

personnel, or those less than 25 years of age, showed the highest percentage of suicide

risk at 34.9%, and as age increased, the risk percentage for suicide went down.

Another result from the LeardMann et al. (2013) study was that certain

characteristics increased risk of suicide, which included having male gender, having

depression, having a manic-depressive disorder, and showing signs of heavy or binge

drinking. Surprisingly, no deployment-related factors such as combat experience,

cumulative days deployed, or number of deployments were associated with increased

suicide risk in the study analysis. Please refer to Appendix A for a visual representation

of all the LeardMann et al. (2013) findings discussed in this paper. This study provides

useful insight that age, among other characteristics, is significant concerning suicide in

the military.

Major Triggers to Suicidal Ideation

In a study by Bryan et al. (2014), the reasons for suicide among military personnel

are explored. In particular, virtuous injury to self and others was prominent, fully defined

as, “… ‘An act of transgression which shatters moral and ethical expectations that are

rooted in spiritual, cultural-based, organizational, and group-based rules about fairness

and the value of life.’ Early empirical work suggests that experiences characterized by

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betrayal (e.g., leadership failure, betrayal by peers or by civilians), acts of

disproportionate violence (e.g., revenge), excessive violence or cruelty toward civilians

(e.g., needless destruction of property, assault), and violence among peers (e.g., military

sexual trauma) are often associated with the signs and symptoms of moral injury, which

include guilt, shame, social problems, spiritual/existential issues, self-deprecation, and

emotional distress” (Bryan et al. 2014). All of these traumatic experiences have

contributed to moral injury. That injury has led to increased manic-depressive symptoms,

drinking problems, and other characteristics that the previous study found can increase

suicide risk.

In the Bryan et al. (2014) study, 151 Army and Air Force personnel from ages 20

to 54 were sampled. They were divided into three groups, including control, suicidal

ideation, and suicidal attempt. The suicidal ideation group thought about committing

suicide but never attempted it. The suicidal attempt group showed suicidal thoughts and

tried to commit suicide. A multivariable analysis of variables was used for this study. As

a result, moral injury to the self, also known as Transgressions-Self, was associated with

significantly more severe suicidal ideation (B = .424, SE = .171, p = .014, β = .203),

where a p-value< 0.05 was considered statistically significant. Moral injury to others,

known as Transgressions-Others, did not show significant results in the study but was

still considered to add towards ethical injury.

Posttraumatic stress disorder (PTSD) was explored as an overlapping construct

with similar triggers alongside moral injury in its contribution to suicide among military

personnel. PTSD was tracked by analyzing self-injurious thoughts and behaviors (SITB).

To account for SITB among the sample, the Beck Scale for Suicidal Ideation (BSSI) was

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used. Another multivariable analysis of variance was determined, and the results

indicated a significant between-groups difference, F (6, 290) = 2.956, p = .008, partial

η2 = .058, where a p < 0.05 was considered statistically significant. Further, the results

remained unchanged when adjustments were made for gender, age, posttraumatic stress

symptoms, depression, and hopelessness (Bryan et al. 2014). The data expressed in table

form are accessible in Appendix B.

Clearly, moral injury can be attributed as a trigger to suicide risk and is a major

issue for adolescent military personnel.

Current Treatment for Suicide Risk

As suicide has increased since 2005 in the military, so has prescription of

antidepressants. In a study conducted by Breggin (2010), he discusses that the newer

antidepressants being administered to military personnel have led to suicide, violence,

and manic-like symptoms. The author, Peter Breggin MD, has testified before the U.S.

House of Representatives Veterans Affairs Committee in 2010 and has presented at

various military conferences on combat stress to increase awareness of the damage

caused by antidepressants in relation to rates of suicide. In the Breggin (2010) study, he

found a probable causal relationship between increasing rates of antidepressant

prescription and increasing rates of suicide in the military.

As Breggin stated, the FDA in response to these accusations ran numerous double

blind placebo-controlled clinical trials to reevaluate many drugs that were being

administered to military personnel (Breggin. 2010). In 2009, an analysis of adult data was

run, including 372 double blind placebo-controlled clinical trials with 99,231

participants. The placebo group was found to show less risk of suicide and suicidal

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behavior than the antidepressant group. Interestingly, adults under 25 showed even more

susceptibility to the negative effects of the antidepressants (Breggin, 2010).

Furthermore, in spite of the official American Psychiatric Association's (2000)

Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision) supporting

the notion that antidepressants can cause symptoms and behaviors of mania and suicide,

they are still being used as treatment methods. The evidence is shown in the section on

manic episodes: "’Symptoms like those seen in a Manic Episode may also be precipitated

by antidepressant treatment such as medication’" (p. 361), including ‘criminal’ behavior,

‘antisocial’ behavior, ‘irritability, particularly when the person's wishes are thwarted,’

‘assaultive behavior,’ ‘physically assaultive’ behavior, ‘physically threatening’ behavior,

‘suicidal’ behavior, and shifts from anger to depression (pp. 359-261)’” (Breggin, 2010).

Clearly, antidepressants present a problem as much as a solution for adolescent military

personnel. Therefore, new methods of treatment must be explored to increase positive

mental health, thus decreasing moral injury and suicide rates.

Debriefing and Moral Injury

A current treatment that has shown effective results is debriefing. As Macdonald

et al. (2004) exemplified in their study, statistical significance was found in the analysis

of a study whose sample size composed of six Israeli infantry units. The data showed that

post-debriefing scores had a mean of 23.9, and were lower on the State Anxiety Inventory

compared to pre-debriefing scores with a mean of 25.6. To identify how debriefing

relates to moral injury, a closer look at the paradox of moral ethics in the military must be

considered.

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Militaries around the world and throughout time have faced the difficult challenge

of preparing warriors for combat and simultaneously maintaining a warrior’s moral

foundation. To win a war, militaries generally create a culture that promotes aggressive

and violent behavior. The cost of this necessary evil of warfare has been the backlash of

moral injury among military personnel. One good example of this repercussion comes

from World War I, when a few soldiers from the Canadian military were shot by their

own allies after the Canadian soldiers were deemed too weak for showing signs of trauma

(Macdonald et al. 2004).

In 2000, a study on debriefing was run with peacekeeping soldiers in Bosnia.

After their tour of duty in Bosnia, debriefing was administered to one group, and the

other soldiers were kept as a control group. The debriefed group showed only 7.4% of

intense distress, while the control group showed 25% of intense distress. Overall,

baseline scores of intense distress were low among all soldiers before debriefing was

conducted. Therefore, significant results were difficult to obtain despite the difference

between the control and debriefed group scores. Repression of trauma through alcohol

abuse was considered the primary reason for low baseline scores (Macdonald et al. 2004).

From these studies, it can be concluded that moral injury is a result of military culture

and post-war trauma. It is certainly a complex issue that requires further research and

numerous treatment methods.

Alternative Treatments

A successful alternative treatment has been the Caring Letter Project, run by

Luxton et al. (2012). In the study, 110 military personnel at suicide risk were sampled.

They were messaged brief letters and emails of encouragement for two years. The

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purpose of the study was to further examine whether the establishment and maintenance

of a warm-hearted personal connection, coupled with follow-up letters or emails between

caregivers and high-risk patients, could help prevent suicide. To assess the effect of

caring letters on participant suicidal risk, three measures were used: the 48-item Reason

for Living Inventory, the Patient Health Questionnaire including a 4-point scale, and the

5-point Suicidal Ideation Scale. No control group was used because the sample size was

too small to gain statistical significance in suicidal behavior outcomes.

However, patient re-admittance to the clinic for the study sample and the general

clinic population was compared on a descriptive basis. From the study sample, 15

participants returned to the clinic for additional treatment, which was 16.34% of the

comprehensive sample. From the all-inclusive clinic population, 20 patients or 7.39%

returned. A randomized controlled sample must be run to determine statistical

significance from the Caring Letters Project; however, this has been a solid effort to

develop an alternative treatment method for adolescent military personnel at risk for

suicide.

Conclusion

Major conclusions from this paper’s literature review include the notion that

suicide is a particular issue for adolescents in the military and that contemporary models

of prevention and treatment are not adequate. A review of current research advocates for

the addition of spirituality into treatment, which could restore a sense of meaning that

many adolescent military personnel have lost. Many struggle with the ability to forgive

themselves of guilt and shame for actions in combat or how to make sense of morally

disturbing events. The breakdown of a moral foundation cannot be cured with

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antidepressants alone. A renewed sense of morality has to be instilled through treatment

which incorporates spirituality.

Suicide has been the leading cause of death in the military for adolescents at

certain periods, including 2012-2013, and is still a chief cause of death today. Therefore,

it is imperative to find successful treatments and interventions for adolescent military

personnel when the current paradigm of medication and disability pay is not adequate.

Future studies may be conducted on the validity and reliability of programs for

adolescents in the military that include spirituality, to determine whether they are

effective or not, or on other solutions that could help prevent suicide in adolescent

military personnel and combat veterans.

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References

Bryan, A. O. (2014). Moral injury, suicidal ideation, and suicide attempts in a military

Sample. Traumatology. Retrieved from http://web.a.ebscohost.com.proxy-

bc.researchport.umd.edu/ehost/detail/detail?vid=7&sid=7e8e867e-9a77-43a1-

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Breggin, P. R. (2010). Antidepressant-Induced Suicide, Violence, and Mania: Risks for

Military Personnel. Ethical Human Psychology & Psychiatry. Retrieved from

http://web.b.ebscohost.com.proxy-bc.researchport.umd.edu/ehost/detail/

detail?sid=2e5c6056-92c7-4dae-

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hvc3Qtb

Gl2ZSZzY29wZT1zaXRl#db=pbh&AN=54453017

Joiner, T. E., & Van Orden, K. A. (2008). The interpersonal-psychological theory of

suicidal behavior indicates specific and crucial psychotherapeutic

targets. International Journal of Cognitive Psychology, 1, 80–89.

LeardMann, C. A. (2013). Risk Factors Associated With Suicide in Current and Former

US Military Personnel. JAMA. Retrieved frhttp://jama.jamanetwork.com.proxy-

bc.researchport.umd.edu/article.aspx?articleid=1724276

Luxton, D. D. (2012). Caring Letters Project: A military suicide-prevention pilot

program.

Crisis: The Journal of Crisis Intervention and Suicide Prevention. Retrieved from

http://web.b.ebscohost.com.proxy-bc.researchport.umd.edu/ehost/detail/

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Macdonald, C. M. (2004). Evaluation of Stress Debriefing Interventions with Military

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Military Medicine, 168.

Motto, J. A. (1976). Suicide prevention for high-risk persons who refuse

treatment. Suicide and Life-Threatening Behavior, 6, 223–230

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Appendix A

Figure 1: Characteristics of Millennium Cohort Participants by Suicide Death

(LeardMann et al, 2013).

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Appendix B

Figure 1: Mean Moral Injury Event Scale scores with 95% confidence intervals for

participants with no history of self-injurious thoughts and behaviors, history of suicidal

ideation, and history of suicide attempt (Bryan et al. 2014).

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