This article was co-authored by Stephanie Bender, DA, MA, LMHC.

Misconceptions, Risk Factors, and How You Can Help

The military suicide rate has gradually increased over time. Among active-duty members, the suicide rate per 100,000 significantly rose from 2015 (20.3) to 2020 (28.7). Most of the suicides were completed by enlisted service members less than 30 years old. The most common method of suicide was a firearm, followed by hanging/asphyxiation. (1)

Misconceptions about Military Suicide (1, 3)

Due to stigma of mental health problems, cultural issues, and ways in which the media covers suicide, there are many beliefs among the general population and the military about suicide that are not true. Some are:

• Seeking mental health treatment will negatively impact one’s ability to obtain a security clearance and pursue a chosen career.
  • Fact: Seeking mental health treatment, in and of itself, does not negatively impact one’s ability to obtain/retain a security clearance. In fact, waiting to seek mental health treatment may cause increased work-related problems that could negatively affect one’s career.
• After receiving hospital care for mental health issues, individuals are no longer at risk for suicide.
  • Fact: Suicide risk is significantly higher immediately following hospitalization when individuals are in the process of adjusting to their previous lives and return to settings in which stressors previously occurred.
• Most military firearm deaths are from combat.
  • Fact: Most military firearm deaths are from suicide.
• Suicide risk is not related to how firearms are stored.
  • Fact: Unsafe firearm storage increases suicide risk. Those who lock or unload guns when not in use are much less likely to die from suicide when compared to those who keep them unlocked and/or loaded.
• Most people who have suicidal thoughts die by suicide.
  • Fact: Most people who think about suicide do not act on these thoughts.
• Suicide is never impulsive.
  • Fact: Some individuals ponder suicide for significant periods of time, while others do not. It can take less than 10 minutes between thinking and acting on suicidal thoughts and concomitant use of substances can increase impulsivity.
• Most military suicides are completed by individuals who experience deployment and/or combat.
  • Fact: Most military suicides are completed by individuals who have never been deployed and/or experienced combat.

Suicide Risk Factors (1, 2, 3)

Suicide is rarely caused by a single issue. It is a complex phenomenon, precipitated by a combination of emotional, psychological, physical, and cultural/environmental circumstances. Many military suicide risk factors are similar to those in the general public; but some are unique to military life. Major military suicide risk factors include:

Life circumstances

• Relationship problems
• Financial problems
• Legal issues
• Lack of advancement or having a sense of a loss of honor due to a disciplinary action
• Lack of social support
• Challenges related to post-deployment reintegration
• Multiple redeployments
• Challenges related to retirement and re-engaging in civilian life

Physical/Psychological issues

• History of physical/sexual abuse, violence, or trauma
• Prior suicide attempt and/or family history of suicide
• Prior or current alcohol and substance misuse
• Severe or prolonged combat stress
• Combat-related psychological injury
• Traumatic Brain Injury

Environmental/Cultural issues

• Limited access to mental health care
• Religious beliefs that support suicide as a solution; negative attitudes toward getting help
• Perception of being weak or placing career at risk if mental health support is sought
• Stigma from family, friends, and colleagues

How the Military is Addressing Suicide (5)

Due to concerning levels of suicide in the military population, in March 2022, Secretary of Defense Lloyd J. Austin announced the creation of a Suicide Prevention and Response Independent Review Committee to explore and recommend interventions to address suicide and the mental health of military service and family members. Findings and recommendations will add to the already existing information and initiatives the Department of Defense has previously established across all or specific to military branches.

New Suicide Hotline

The 988 Suicide and Crisis Lifeline launched in July 2022. Congress designated the new 988 dialing code to improve access to crisis services in a way that meets our country’s growing suicide and mental health-related crisis care needs.

988 connects those experiencing mental health, substance use, or suicidal crises with trained crisis counselors through the National Suicide Prevention Lifeline. People can also dial 988 if they are worried about a loved one who may need these types of crises supports. Chat is also available.

Pressing “1” after dialing 988 will connect you directly to the Veterans Crisis Lifeline which serves our nation’s Veterans, service members, National Guard and Reserve members, and those who support them. For texts, continue to text the Veterans Crisis Lifeline short code: 838255.

Learn more about 988 in Magellan’s blog post: https://mfed.info/988.

How Family and Friends Can Help (6)

Family and friends can also help prevent suicide by (6):

• Being aware of risk factors (see above-listed risk factors) and warning signs such as:
  • Statements regarding no reason to live or being a burden to family
  • Buying or storing means to suicide such as weapons or medications
  • Making plans to say goodbye such as updating wills and giving away possessions
• Being supportive and non-judgmental
• Staying involved: just asking “how was your day?” can help one feel supported and connected
• Giving positive affirmations that the loved one is not a burden and is loved
• Knowing how to contact emergency help
  • Call 911, 988, or the Military/Veteran Crisis line at 1-800-273-8255 (press 1)
  • If there is any chance that someone might get injured:

– Remain calm

– Remove yourself or your children from any danger

– If possible, remove items that the person can use in a suicide attempt

For a downloadable version of this article, please visit MFed Inform.

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References

1. Department of Defense Under Secretary of Defense for Personnel and Readiness. Annual Suicide Report. Calendar Year 2020. https://www.dspo.mil/Portals/113/Documents/CY20%20Suicide%20Report/CY%202020%20Annual%20Suicide%20Report.pdf?ver=0OwlvDd-PJuA-igow5fBFA%3d%3d
2. Military OneSource. When a Service Member May Be at Risk for Suicide. Sept. 2, 2021. https://www.militaryonesource.mil/health-wellness/mental-health/suicide/when-a-service-member-may-be-at-risk-for-suicide/
3. Association for Behavioral and Cognitive Therapies. (No date) ABCT Fact Sheet. Military Suicide. https://www.abct.org/fact-sheets/military-suicide/
4. Suitt TH. Watson Institute. International & Public Affairs. Brown University. High Suicide Rates among United States Service Members and Veterans of the Post 9/11 Wars. June 21, 2021. https://watson.brown.edu/costsofwar/files/cow/imce/papers/2021/Suitt_Suicides_Costs%20of%20War_June%2021%202021.pdf
5. U.S. Department of Defense. May 17, 2022. DOD Names Lead for Suicide Prevention and Response Independent Review Committee. https://www.defense.gov/News/News-Stories/Article/Article/3034968/dod-names-lead-for-suicide-prevention-and-response-independent-review-committee/
6. Mental Illness Research Education and Clinical Center. Suicide Prevention: A Guide for Military and Veteran Families (no date). (https://www.mirecc.va.gov/visn19/docs/A_Guide_for_Military_Veteran_Families.pdf

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Stephanie Bender, DA, MA, LMHC is a Regional Supervisor for Magellan Federal working in the Military and Family Life Counseling Program. Stephanie currently manages school-based MFLCs in Virginia Beach, VA. Stephanie received her undergraduate degree in Family Studies from Messiah University, her Master’s Degree in Counseling from the Seattle School of Theology and Psychology, and her Doctorate in Ecopsychology and Environmental Humanities from Viridis Graduate Institute. She has been independently licensed since 2008 in the state of Washington. Stephanie’s grandfathers were Veterans of the Army, and her father is a retired Lieutenant Colonel in the Air Force. Stephanie’s hobbies include hiking in the mountains, taking walks with her goats, and hosting visitors to her hometown of Olympia, WA.

By Dr. Beall-Wilkins and Dr. Jamie Hanna

Magellan Health hosted a free webinar for September Suicide Prevention Awareness Month. If your question wasn’t answered during the webinar, or if you would just like to learn more about suicide prevention, read on for information shared by our webinar presenters, Dr. Rakel Beall-Wilkins, MD, MPH, and Dr. Jamie Hanna, MD. For more information and resources addressing suicide prevention, and to watch the recording of this webinar, visit MagellanHealthcare.com/Suicide-Prevention.

Question: Please say more about the interplay between chronic pain and suicide risk.

Dr. Beall-Wilkins: It is estimated that the prevalence of suicidal ideation is roughly three times greater in people living with chronic pain compared to those who do not have chronic pain, and chronic pain is linked to higher rates of not only suicidal ideation but also suicide attempts and completed suicides.[1] When coupled with impaired functionality and disability, chronic pain can result in socioeconomic hardships and limitations in access to care that further exacerbate both physical and mental health symptoms. Chronic pain and depression often go hand-in-hand, and clinical studies have shown that upwards of 85% of people with chronic pain have experienced severe depression.[2] It is essential that patients with chronic pain be routinely screened for psychiatric symptoms and acute safety concerns, and that they be referred to treatment if issues arise.

Question: Is a person really considered suicidal if they have considered it a lot but have never acted on their thoughts? What measures can we put in place for individuals with a baseline of passive suicidal ideation who are in outpatient therapy?

Dr. Hanna: Understanding the risk factors that can lead to suicidal behavior provides an opportunity to identify and support people at risk for suicide. Risk factors include a previous suicide attempt, diagnosis of mental illness/substance use, isolation, social/legal problems, trauma in childhood, a family history of suicide, recent stressors and access to lethal means. Learn more about suicide risk and protective factors from the American Foundation for Suicide Prevention and the Centers for Disease Control and Prevention. Suicidal ideation – or thoughts about suicide – is also an important risk factor and can be a warning sign of imminent suicidal behavior. There is greater risk when suicidal thoughts occur more often, over greater time periods or are more challenging to control; there are fewer barriers to acting on the thoughts; and the reason for the suicidal thoughts is to stop the pain. Identifying suicidal ideation and implementing treatment strategies are critical in preventing suicide.

It is always the goal to treat suicidality in the least restrictive setting and subsequently, treatment of suicidal ideation often occurs in the outpatient setting. There are a variety of measures that can be put in place to assess and treat suicidal thoughts in the outpatient setting. Some of these include screening, crisis intervention, and evidence-based and research-informed interventions.

One example of a screening tool is the Columbia-Suicide Severity Rating Scale (C-SSRS). This scale focuses on evidence-based metrics to assess the severity of suicidal ideation and behavior. Items on the scale also serve to differentiate between suicidal and non-suicidal self-injurious behavior.

Crisis intervention assistance is typically provided by connecting a person in crisis to trained staff for support and referral to additional services. The goal is to impact key risk factors for suicide, including depression and hopelessness, increase future mental healthcare access, and put space and time in between suicidal thoughts and action. Examples of crisis intervention services include the National Suicide Prevention Lifeline (1-800-273-8255) and Crisis Text Line (text HOME to 741741).

There are only a small number of evidence-based treatment interventions directly targeting suicide risk. These include cognitive behavioral therapy for suicide prevention (CBT-SP), dialectical behavior therapy (DBT) and Collaborative Assessment and Management of Suicidality (CAMS). Additional research-informed interventions include collaborative safety planning and reducing access to lethal means. These interventions are emphasized in both the CDC suicide prevention strategy and the Zero Suicide approach to suicide prevention.

Question: What do you say to someone who says they want to die and that life is torture, and asks why they were born? What types of things can you tell the person going through this, and how do you do it without sounding judgmental?

Dr. Beall-Wilkins: Feelings of despair, hopelessness, worthlessness and helplessness are commonly experienced by people who are in the midst of a mental health crisis. During episodes of emotional distress, it can be very difficult for some people to think positively or constructively, and this can manifest itself in the form of self-deprecating statements and thoughts of self-harm. When someone is feeling this way, it can be helpful to reassure them that things can get better, and that comprehensive treatment can improve how they feel. It’s also very important to assess their safety, inquire about any thoughts they may be having of hurting themselves or someone else, and encourage them to seek immediate professional help if they’re feeling unsafe.

Question: I had a family member take her life on 9/7. She went about her day as normal, and then chose to take her life that evening after placing her kids down for the night. As a family member, we are still trying to figure out why. Is this a normal feeling? Similarly, for people attempting to support those with suicidal thoughts, or who have tried to support someone who died by suicide, what suggestions do you have to help them find the balance between supporting the suicidal individual and feeling overly responsible for the suicidal individual’s choices, behaviors, etc.?

Dr. Hanna: When a loved one dies by suicide, intense emotions – such as disbelief, anger, guilt, isolation and despair – can become overwhelming, and there is no right or wrong way to feel. Many people will feel confused as they try to understand why their loved one chose suicide. And it is likely there will always be unanswered questions. The events which lead to suicide are often complex and most commonly there are many factors that contribute to a person ending their life.

The feeling of guilt can lead suicide survivors to blame themselves for the death of their loved one. It is critical that survivors do not blame themselves, and that they seek support and engage in self-care. Support and self-care can include reaching out to community members, such as friends, family, co-workers and mental health providers. Both in-person and online support groups are available specifically for suicide survivors. The American Foundation for Suicide Prevention provides resources to find a support group. It can also be beneficial to seek professional help with a licensed therapist or psychiatrist, especially for symptoms of depression and thoughts of suicide.

Question: The hardest part about helping someone who is suicidal is the concern that the police will be called, and the person will end up in handcuffs. How can we change this?

Dr. Beall-Wilkins: It is often the case that family and friends of those who are experiencing acute mental health crises face the prospect of summoning law enforcement to assist in maintaining safety and facilitating transportation to care. This can be a very daunting prospect and a growing movement of advocates, policymakers and mental health providers are now pushing for reforms that would reduce the likelihood of adverse outcomes in these circumstances.[3] One such reform involves greater collaboration between police departments and mental health clinicians, including training, education and joint response to crisis calls. Preliminary data indicate this approach can be a very effective means of reducing adverse outcomes, increasing public safety and strengthening trust within communities.[4]

Question: Is being suicidal hereditary? Are the mental/emotional issues that caused a previous suicide in a family hereditary?

Dr. Hanna: There is clear evidence that suicide can run in families, and family history of suicide has been identified as a significant risk factor for suicide. Studies show that individuals who have a parent or sibling die by suicide are two and a half times more likely to die by suicide than those without a family history of suicide. Research has identified a number of genes that appear to be associated with suicide risk. Psychiatric illness has also been shown to run in families and is a risk factor for suicide. Depression plays a role in over half of all suicide attempts. Children of parents with depression are three times as likely to develop major depression, anxiety disorders and substance use – all of which increase the risk of suicide.

While family history of suicide and psychiatric illness are important risk factors of suicide, other risk factors include previous suicide attempts, depression, substance use, stressful life events, physical illness and access to lethal means, among others. Suicide occurs as a result of many interacting genetic and environmental factors. Family members share genes, and they often share experiences – they eat together, live together and face economic stressors and loss together. These shared experiences may combine with genetics to increase an individual’s vulnerability to suicide. This does not mean that everyone with a family history and increased risk of suicide will have suicidal behavior, but that they could be more vulnerable and should take steps to reduce their risk. These may include early evaluation and treatment of mental illness and building protective factors to buffer against suicidal behavior.

Question: Could you speak to the legalities of those who need help but are past the age of responsibility, and family members and friends are told there is nothing they can do if the person refuses the help or that we can’t keep them somewhere against their will?

Dr. Beall-Wilkins: In most jurisdictions, the ability to commit an individual to treatment against their will is typically conferred by the courts based upon three guiding principles: harm to self, harm to others and evidence of significant mental deterioration that renders an individual unable to practice self-care in their own best interest. If an adult person is explicitly stating an intention to hurt themselves or others, or exhibiting grave mental disability, they can be involuntarily committed for observation, evaluation and acute stabilization.

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Rakel Beall-Wilkins, MD, MPH, served as a medical director for Magellan Healthcare. Prior to joining Magellan in 2018, Dr. Beall-Wilkins assisted in the launch of an addiction psychiatry clinic embedded within Harris Health System’s Healthcare for the Homeless Program, to combat local impacts of the nationwide opioid and synthetic cannabinoid (“K2”) epidemics. Dr. Beall-Wilkins also served as a member of the Baylor College of Medicine faculty with clinical duties at both the Ben Taub General Hospital Psychiatric Emergency Center and the Thomas Street Health Center. There she helped to expand behavioral health services by launching a neurocognitive clinic collaborative to better screen, diagnose and treat individuals with HIV/AIDS-associated neurocognitive disorder and psychiatric comorbidities. She is a graduate of the University of Texas at Austin and the Johns Hopkins School of Public Health, where she obtained a Master of Public Health degree. She obtained her medical degree from Baylor College of Medicine. 

Jamie Hanna, MD, serves as the medical director for the Magellan of Louisiana Coordinated System of Care (CSoC) program. She is board certified in Psychiatry and Child and Adolescent Psychiatry. Prior to joining Magellan in 2020, Dr. Hanna served as an assistant professor and assistant training director with Louisiana State University School of Medicine, working with the acute behavioral health unit, and leading the psychiatric consultation liaison service and emergency psychiatric services at Children’s Hospital of New Orleans. Dr. Hanna completed medical school at the University of Alabama School of Medicine and a subsequent internship in Pediatrics, residency in General Psychiatry, fellowship in Child and Adolescent psychiatry, and fellowship in Infant Mental Health with Louisiana State University in New Orleans.

For more information and resources addressing suicide prevention, and to watch the recording of this webinar, visit MagellanHealthcare.com/Suicide-Prevention.

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[1] Pergolizzi JV (2018) The risk of suicide in chronic pain patients. Nurs Palliat Care 3: doi: 10.15761/NPC.1000189.

[2] Sheng, J., Liu, S., Wang, Y., Cui, R., & Zhang, X. (2017). The Link between Depression and Chronic Pain: Neural Mechanisms in the Brain. Neural plasticity, 2017, 9724371. https://doi.org/10.1155/2017/9724371

[3] https://www.npr.org/2020/09/18/913229469/mental-health-and-police-violence-how-crisis-intervention-teams-are-failing

[4] https://www.apa.org/monitor/2021/07/emergency-responses

Written by Thomas Lane, NCPS, CRPS

Every 40 seconds someone dies by suicide somewhere in the world.[1] The human tragedy of death by suicide is getting worse, with global suicide rates increasing 60% in the past 45 years.[1] Most people reading this article will know someone who has been impacted by suicide. One group of folks especially at risk for a suicide attempt are those who have tried to complete suicide previously. Data suggests that 20% of attempt survivors will make another attempt.[2]

I am one with personal experience. I am part of that 20%. As a double attempt survivor, I have haunting memories of those periods in my life when I was more fearful of living than I was afraid of dying. For me, those were the darkest, loneliest, and longest days of my life. After my second attempt in the winter of 1998, I wound up on a ventilator. I was in a coma for 12 days and when I woke up, I felt like someone was choking me. And I was angry. At the time, when I was literally regaining consciousness and coming back to the land of the living, my mom was downstairs with hospital administrators signing an agreement to discontinue life support for me.

As the saying goes, timing is everything.

After a lengthy and very shaky period, I began to get better. I was receiving good mental healthcare, redefining my circles of support, and I had a purpose. I came to believe I still had work to do. Now. On this planet. I had twice crossed the line of deciding I could not be here. Despite my best efforts, I was still here, facing my life. I decided I would seek meaning from as many of my experiences as I could. For the past 20-plus years, I have worked to build and advance peer support, particularly within the context of publicly funded healthcare systems, but also at the grassroots level and through public/private partnerships. I am more convinced than ever of the value, importance and unique perspectives folks with lived experience bring to the table, specifically those who choose to pursue careers as peer specialists. It has been and continues to be a transformative movement, even more so when we understand that many folks who make a choice to work in the peer support field, in the same delivery systems that may not have served them well, do so out of a passion for the work and to give back, to pay it forward.

I share this very personal experience as context for my next point.

In a 2016 survey of Magellan members receiving peer support services, 98% reported their certified peer specialist helps them to, both, improve their quality of life, and feel hopeful about their recovery.[3] Knowing what we do now about the effectiveness of peer support, and understanding the value of lived experience, I believe we can agree about the importance of connecting attempt survivors with peer supporters who have had similar experiences. For most, if not all, attempt survivors, there is a crucial time period after an attempt; I needed intensive support in the days following my second attempt. Sadly, intensive support is not always available, let alone offered by a peer who is also an attempt survivor. I can’t help but wonder, what would universal referral to, or at least an orientation about, peer support opportunities by and for attempt survivors, look like? Considering the COVID-19 pandemic, we have seen a rapid, albeit sometimes rocky, migration to technology-enabled service delivery. Interestingly, peer support has been “technology-enabled” for years in the form of peer-operated warmlines. If you’re not familiar with warmlines, check out the National Empowerment Center at https://power2u.org/peer-run-warmlines-resources/ for great information.

When we consider suicide, we know it is all about prevention, that is, preventing people from attempting to take their own lives. I don’t believe there is a higher calling. Many of my peers with the shared experience of being an attempt survivor have expressed to me this is the most important work they do. We see the positive impact of attempt survivors speaking out about their experiences. We see the importance of eliminating shame associated with the topic of suicide. We know suicide is preventable. We understand that prevention requires dialogue, and dialogue isn’t always comfortable. Nonetheless, the topic of suicide must be brought out of the shadows and recognized as the public health crisis it is, one that we can do something about through evidence-based prevention and education practices. We know it does not increase a person’s likelihood of attempting suicide to talk with them about what they’re feeling. Fortunately, there are many, many organizations pledged to this work. From grassroots organizations founded by survivors of suicide loss to nationally recognized organizations, the conversation is changing. We must continue to be intentional in our approach.

National Suicide Prevention Awareness Month helps shine a light on this often misunderstood and taboo topic. Let’s keep the conversation going for the other eleven months of the year. As peers, let’s renew our commitment to offering support, speaking out and holding the hope for someone until they are able to hold it for themselves. As fellow human beings, let’s take inspiration from Emily Dickinson, and tap the eternal hope perched in all of us.

“Hope is the thing with feathers, that perches in the soul

And sings the tune without the words

And never stops…at all.”

For information about Magellan events during Suicide Prevention Awareness Month, suicide prevention downloadable materials and more free resources, visit our suicide prevention website.

[1] https://www.who.int/mental_health/prevention/suicide/suicideprevent/en/

[2] https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-017-1317-z

[3] Magellan Peer Support Services Outcomes in Pennsylvania, 2016