DSM5 in Distress

The DSM's impact on mental health practice and research

The Epidemic of Suicide in the Military

Ten suggested interventions

With understandable urgency, Secretary of Defense Leon Panetta has made suicide one of his top priorities, instructing commanders at all levels to feel acutely accountable for it. The numbers are startling. On average, one active duty soldier is committing suicide each day, twice the number of combat deaths and twice the civilian rate. Suicides have jumped dramatically since 2005 and increased by 18 percent in just the last year. The DOD and VA are groping for explanations and plans of action—clearly, just commanding the commanders to prevent suicide can't possibly do very much. And sadly, psychiatry has no ready or certain answers, no sure way to predict or prevent suicide. Research in this area has huge methodological problems and is unlikely to bear any low-hanging fruit. So we may have to rely on obvious, common sense suggestions:

1) Stop over-deploying and over-extending our soldiers–withdraw troops from all combat zones as soon, and as fully, as possible. Our continued presence seems to make bad situations worse and entails enormous human and financial costs. It is long past time to cut our losses in these lost causes.

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2) Stop the rampant over-medication of our troops with psychotropic and pain drugs. An astonishing 8 percent of military personnel (110,000 soldiers) are taking a psychotropic medication, often two or more different kinds in dangerous polypharmacy combinations. Abuse of prescription drugs is now a bigger problem than abuse of illegal drugs. Simple quality control of physician prescribing habits and pharmacy distribution systems could greatly improve this important contributor to suicide and accidental overdose.

3) Train commanders to combat the cluster effect. Suicide is contagious—each occurrence makes suicide seem a more reasonable choice for imitators. Almost 40 percent of military personnel know someone who has committed suicide. Command should emphasize that suicidal feelings are common and that getting help for them is brave and soldierly; but that actually killing yourself is selfish, unnecessary, uncool, and places a grave and lasting burden on buddies, family, and country.

4) Guarantee jobs for veterans for the first two years after military service—either in the government or the private sector. Financial distress and unemployment are major contributors to suicide. Our discharged troops often have poor future prospects and face stigmas in the job market. Many may need transitional assistance to avoid the frustration and joblessness.

5) Provide extensive and readily available mental health services for identifying and treating depression and PTSD—two major risk factors for suicide. Treat these more with cognitive/behavior therapy, less with drugs.

6) Provide extensive and readily available substance abuse programs to help alleviate this other major risk factor for suicide. 

7) Target special help for soldiers who have gotten into trouble and face administrative or criminal charges—another risk factor for suicide.

8) Provide much more support for families and readily available family therapy to reduce domestic conflict and try to salvage marriages on the rocks.

9) Appropriate gun control laws for all would help reduce the risks of suicide and violence for vets.

10) Avoid future wars of choice. We have fought three large-scale, unwinnable wars in 50 years—coming out weaker, poorer, less respected, less feared, no safer, and with generations of warriors who were spiritually and physically wounded. Will we never learn from the past?

The suicide problem is just the very tip of a much larger iceberg. That one active duty soldier per day is desperate enough to commit suicide speaks volumes of the less obvious, but significant, distress experienced by many other soldiers and veterans. We have a responsibility to stop overextending ourselves in poorly chosen "wars of choice" and to pick up the pieces of the harms already done.

Allen Frances, M.D., was chair of the DSM-IV Task Force and is currently professor emeritus at Duke.

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