ORLANDO, FLA. — Primary care physicians and psychiatrists outside the military health care system have a pivotal role to play in helping to lower suicide rates, which have been on the rise across all components of the U.S. Army, according to according to Col. Elspeth Cameron Ritchie, MC USA.
There were about 166 suicides in the Army in 2009, a rate of approximately 21 suicides per 100,000 people, or more than twice the rate in 2001.
“We have had difficulties with access to care, we have stigma … and our services are only partially integrated,” said Dr. Ritchie, medical director of the Army Medical Department's Office of Strategic Communications.
A lack of providers who accept the military health plan, TRICARE, is a barrier to those seeking care, Dr. Ritchie said. “The best way you as a provider can help is to sign up for TRICARE.” Physicians who register for the program (www.tricare.mil
Although most active and veteran military personnel receive health care services through institutions such as Walter Reed Army Medical Center and the Veterans Affairs system, there are exceptions. For example, some soldiers are students, have private insurance, or are members of the Reserves. This is where private sector physicians come in, she said.
Risk factors for suicide among a military population can differ from those in the general population. The typical solider at risk of suicide does not have a long history of mental health issues. “What we don't see is major mental illness,” such as schizophrenia or bipolar disorder, that is disabling. Only about 5% of military suicides are associated with a diagnosis of personality disorders, which is “lower than I would have expected,” said Dr. Ritchie, who also is a professor of psychiatry at Uniformed Services University of the Health Sciences, Bethesda, Md.
“We are seeing more and more” suicides spurred by relationship breakups and legal problems, she said. Under such circumstances, “unfortunately, screening does not work very well. They could screen just fine but get the 'Dear John' or 'Dear Jane' letter, buy a 12-pack, and go out and shoot themselves.”
Effective interventions in a military population will require a comprehensive look at all the elements around suicide, including posttraumatic stress disorder (PTSD), mild traumatic brain injury (TBI), and depression. “This is not going to be an issue for just 1 or 2 years; these are going to be issues for 20 years or 40 years,” Dr. Ritchie said. “So we all need to work on this together.”
The type of warfare many soldiers see when deployed in Afghanistan or Iraq increases their risk for mild TBI and associated symptoms. “The signature weapon of this war is the blast. And that causes a lot of symptoms.” Reexperiencing the trauma, numbing/avoidance, and physiologic arousal (“flight or fight” response) are the three main PTSD symptom clusters.
Army research suggests that soldiers need at least 2 years of noncombat time before their symptoms of anxiety and depression begin to wane. Reintegration can be a time of elevated risk for self-harm. “They have this high adrenaline from being in theater, and they don't know what to do with it. They take out a motorcycle and drive it at 120 mph.
“2009 was extraordinary year for suicide—highest they have been,” Dr. Ritchie said. “It seems lower so far this year. We are holding our breath.”