Experts Debate Link Between Deployment And Suicide Risk
There is a very interesting debate over combat deployment and suicide risk in the December 18 issue of the Journal of the American Medical Association.
The conversation unfolds in the letters section, and it addresses the results of a JAMA study published in August that suggested military deployment is not associated with suicide risk.
The finding took many people by surprise as it contradicts the stories we’ve heard about service members who were deeply affected by deployment and subsequently took their own lives. When I recently mentioned this study to a veteran of the Afghanistan war, he didn’t waste a second before laughing with disbelief.
Yet, we also know that anecdotes aren’t everything–in fact, they’re only the beginning in science. In terms of understanding military suicide, important data points are often overlooked. The Defense Department’s most recent annual suicide surveillance report (PDF), for example, shows that half of those who died by suicide hadn’t deployed to Iraq or Afghanistan, and only 15 percent directly experienced combat.
When the JAMA study was published in August, it raised the idea that other risk factors, like binge drinking and depression, play a more decisive role in suicide risk. That may well be, but several experts in this field have written to JAMA pointing out limitations in the study’s design and urging researchers to consider the complexity of the relationship between deployment experience and combat.
Drs. Remington Nevin and Elspeth Cameron Ritchie, who have appeared in this blog before here and here, argue that the study suffered from a sampling bias. The authors deny this charge, but another trio of experts writes the study’s analysis model is vulnerable to bias.
“This study draws attention to depression, posttraumatic stress disorder, and alcohol problems as risk factors for suicide, but we believe the method of analysis was flawed in regard to deployment,” said Mary Jo Larson, Grant A. Ritter, and Rachel Sayko Adams, all researchers for the Heller School for Social Policy and Management at Brandeis University.
While Craig J. Bryan and Tracy A. Clemans, both of the National Center for Veterans Studies in Salt Lake City, agreed with the study’s primary conclusions, they raised concerns about the study’s limitations, primarily that it did not include traumatic brain injury as a variable. TBIs, which are often sustained in combat, are a “significant risk factor for suicidal ideation among deployed military personnel,” they wrote.
The study’s authors, Dr. Charles W. Hoge, Cynthia A. LeardMann, and Dr. Edward J. Boyko, of the Walter Reed Army Institute of Research, the Naval Health Research Center in San Diego, and the Veterans Affairs Puget Sound Health Care System in Seattle, respectively, responded to criticism of the study, but they also acknowledged the complexity of suicide in the military population:
It is important not to misinterpret our findings as suggesting that the conflicts in Iraq and Afghanistan have had no cumulative effect. Since 2005, suicide incidence in the Army increased just as sharply among soldiers who did not deploy as those who did. This corresponded to a steep increase in mental disorders in the military population overall, likely a product of intense wartime demands affecting soldiers throughout all phases of the deployment cycle.
I think these letters show just exactly how challenging it is to untangle the relationship between suicide and combat experience, and that we haven’t yet designed the best study to evaluate that dynamic.
Bryan and Clemans make this compelling argument when they write that scientists need to better understand the forces that moderate deployment experience and risk factors for suicide. Then they reframe the debate powerfully by writing: “The question that should therefore be asked is not, ‘Is deployment related to suicide?’ but rather, ‘For whom and under what circumstances is deployment related to suicide risk?’”