Two years ago, a New York Times article sent to Navy psychiatrists (“For Some troops, Powerful Drug Cocktails Have Deadly Results,” February 12, 2011) lead to an email exchange on our role in providing access to medications used by the 32 percent of soldiers who committed suicide by overdose. I, naively, replied to all: “I am curious about the other 68 percent? I suspect those soldiers are dying by self-inflicted gunshot.”
The vociferous responses made me realize how much easier it is to discuss suicide by overdose than suicide by gun. Out of curiosity, I Googled “soldier suicide by gun.” It turns out I was right – about two-thirds of soldier suicides are the result of self-inflicted gunshot wounds. I also discovered I had a lot to learn about the myths of suicide.
Despite all of the efforts by the Military Services to reverse the trend, the soldier suicide rate continues to climb. For the past three years, according to the 2009 - 2012 Department of Defense Suicide Event Reports (DoDSER), more soldiers have died by suicide than in combat.
In 2012, statistics released by the Department of the Army reported that 349 military service members committed suicide, while 295 died in combat.
Existing suicide prevention strategies are not working. Many are based on an existing set of myths about suicide and the individuals who attempt it that are simply incorrect.
Myth #1: People who attempt suicide want to die.
False: Ninety percent – 9 out of 10 individuals – who attempt suicide and survive, will not go on to die by suicide. If they really wanted to die, wouldn't they try until they succeeded?
Myth #2: People who attempt suicide have a major mental illness.
False: Only 26 percent of suicide completers have ever seen a mental health provider. DoDSER data indicates the majority of military suicide completers did not have a prior mental health diagnosis.
Myth #3: Suicide is most often planned and premeditated.
False: Most suicides are a quick impulsive reaction to an acute stressor. Seventy percent of suicide attempters make the attempt within one hour of the decision and 24 percent make a suicide attempt within five minutes of the decision.
Myth #4: The most effective means of reducing suicides is by addressing "The Why" or the reason individuals attempt suicide.
False: The most effective means of reducing suicides is by addressing "The How," or the means or method of the suicide attempt. Those who use a gun rarely survive the first attempt. Eighty-five percent of suicide attempts with a gun are fatal, while only 2 percent of suicide attempts by overdose are fatal. Those who attempt suicide with less lethal means most often survive and never attempt again.
Myth #5: We can identify those at highest risk for suicide, and only those identified as high risk are at high risk.
False: Only 26 percent of suicide completers showed any signs that may have identified them as high risk. Most suicide victims do not become “high risk” until the hour before the attempt, usually involving an acute relationship stress, alcohol and a gun (more than 90 percent use a personal gun).
Myth #6: The increased suicide rate is a result of war and deployments.
False: The suicide rate is equal and increasing for those service members who have never deployed.
Myth #7: The most effective way to reduce suicide is by improving access to mental health counseling.
False: According to research from the Harvard School of Public Health, most suicide victims show no sign of mental illness and do not become suicidal until one hour before the attempt.
Access to mental health services is not the issue; quick access to lethal means is. The most effective way to reduce suicides is by reducing quick access to lethal means so that emotions have time to cool down. There are a number of past success stories that support this idea.
- "The British coal-gas story": In 1950s Britain the number one method of suicide was sticking one's head in the oven and turning on the coal gas heater. Coal gas has a high carbon monoxide content and causes death in minutes. Once Britain converting its home heating to natural gas though, the suicide rate was cut by 30 percent.
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The Israeli Soldier story: In Israel, the number one method of soldier suicide was by guns on weekends and holidays. In 2006, after the Israeli military implemented a policy that soldiers could not take their gun home on weekends and holidays, the suicide rate immediately dropped 40 percent.
- The Ellington Bridge story: In the 1980s, Washington, D.C.'s Ellington Bridge accounted for half of the city's jumping suicides. Simply putting up a barrier on the bridge rails — even with another similar bridge running parallel to it — reduced the local suicide rate 50 percent. This points to suicides as mainly impulsive and requiring three ingredients: Ease, speed and certainty of death.
We can help soldiers and others considering suicide by reducing access to lethal means, so that they have time to seek help. A public health education campaign is the only way to do this.
Seattle has already implemented one particularly effective public health campaign, after which we can model suicide prevention efforts. In the early 70s, after realizing that on-the-scene life-saving techniques can keep a heart-attack victim alive long enough to receive medical care, Seattle started its Medic One campaign, the first city-wide network of paramedics. The campaign included a major public education campaign about CPR. Later, defibrillators were made widely available.
To save hearts, we improved access to lifesaving means. To save soldiers minds, we must learn to reduce access to lethal means. Both require educating the public, not just potential victims.
Much of this education can be integrated into existing military public health education at no cost. The military services already provide tremendous annual public health education to service members, including pre and post-deployment health screenings and briefings with family members and suicide prevention training courses.
Simple changes to the health screening forms military doctors use in these sessions can begin to accomplish this and would cost nothing. The Harvard School of Public Health already provides free material and education on lethal means access online.
This is a public health issue, not a second amendment issue. Soldiers have a right to drink alcohol, use tobacco, drive and ride a motorcycle. We assume they all have access to these things, so we educate them all on the risks and safe use. We educate all military personnel on safe sex and condom use. We educate all military personnel on flossing.
Likewise, we can educate military personnel on safe access to the guns they own without violating their right to own them.
