CanJPsychiatry 2015;60(4):200–202
Letters to the Editor Military Deployments, Posttraumatic Stress Disorder, and Suicide Risk in Canadian Armed Forces Personnel and Veterans Dear Editor: In your September 2014 issue, Dr Brunet and Dr Monson1 cite Canadian Armed Forces (CAF) data showing no association of suicide during military service with ever having deployed. We would like to clarify our LQWHUSUHWDWLRQRIWKLV¿QGLQJ Contrary to the authors’ assertion, we do not interpret this as evidence against the suicidogenic effects of military trauma. Indeed, the professional–technical reviews done DIWHUHDFKPLOLWDU\VXLFLGHKDYHLGHQWL¿HGGHSOR\PHQW related posttraumatic stress disorder (PTSD) as one factor among many in at least some recent suicides. Brunet and Monson attribute the lack of association of ever having deployed with suicide to the depletion of vulnerable individuals in the serving population through medical release of those who no longer meet the CAF’s VWULQJHQWPHGLFDO¿WQHVVVWDQGDUGV7KLVLVFHUWDLQO\DQ important factor, and there is, indeed, evidence of greater suicide risk after release from CAF service in modern veterans.2 No difference has been seen in suicidal ideation rates between serving personnel and civilians.3 But there are other potential explanations for the lack of association between ever having deployed and suicide while in service. First, ever having deployed is a crude PDUNHUIRUH[SRVXUHWRGHSOR\PHQWUHODWHGWUDXPDEHFDXVH the extent of exposure varies dramatically depending on deployment circumstances that vary from person to person.4 We have used this marker largely because the VPDOOQXPEHURI\HDUO\VXLFLGHVSUHFOXGHVDPRUHUH¿QHG approach. Second, as one factor among many driving suicide, deployment may not have a strong enough contribution to be detectable at the level of the population. ,QGHHGQRVLJQL¿FDQWSRSXODWLRQDWWULEXWDEOHIUDFWLRQ for deployment in relation to suicidal ideation has been detected.57KLV¿QGLQJFRPHVIURPWKHVDPH&$)VXUYH\ data that Brunet and Monson used to demonstrate the strong link between PTSD and suicidality. Finally, we should not dismiss out of hand the possibility that the totality of the policies, programs, and services available to CAF personnel mitigate the risk of suicide in those with a history of deployment. This may account for the lack of a striking increase in the CAF suicide rate during the past decade. This stands in stark contrast to the precipitous increases in the US military during the same period.6 We caution against assuming that US military VXLFLGH¿QGLQJVFLWHGE\%UXQHWDQG0RQVRQ7,8 must apply to the CAF.
200 : La Revue canadienne de psychiatrie, vol 60, no 4, avril 2015
7KH¿QGLQJWKDWHYHUKDYLQJGHSOR\HGLVQRWDVLJQL¿FDQW suicide risk factor in serving personnel has not diminished our commitment to understanding and managing the adverse health effects of military service. Instead, it has informed our approach to suicide prevention as not primarily a deployment health problem, but instead as a public health problem, requiring the targeting of the full range of determinants of mental health and suicidal behaviour in our prevention efforts.9 Disproportionate emphasis on the role of deployment, PTSD, or any other single factor is not an effective approach to suicide prevention.
Acknowledgement This work was funded through baseline salary support from the Department of National Defence and Veterans Affairs Canada.
References 1. Brunet A, Monson E. Suicide risk among active and retired Canadian soldiers: the role of posttraumatic stress disorder. Can J Psychiatry. 2014;59(9):457–459. 2. Statistics Canada. Canadian Forces Cancer and Mortality Study 2011. Ottawa (ON): Statistics Canada; 2011 [cited 2012 Jul 2]. Available from: KWWS ZZZVWDWFDQJFFDSXE±[ ±[HQJSGI. 3. Belik SL, Stein MB, Asmundson GJ, et al. Are Canadian soldiers more likely to have suicidal ideation and suicide attempts than Canadian civilians? Am J Epidemiol. 2010;172(11):1250–1258. 4. Zamorski MA, Rusu C, Garber BG. Prevalence and correlates of mental health problems in Canadian Forces personnel who GHSOR\HGLQVXSSRUWRIWKHPLVVLRQLQ$IJKDQLVWDQ ¿QGLQJV from postdeployment screenings, 2009–2012. Can J Psychiatry. 2014;59(6):319–326. 6DUHHQ-%HOLN6/$¿¿72HWDO&DQDGLDQPLOLWDU\SHUVRQQHO¶V population attributable fractions of mental disorders and mental health service use associated with combat and peacekeeping operations. Am J Public Health. 2008;98(12):2191–2198. 6. Armed Forces Health Surveillance Center. Deaths by suicide while on active duty, active and reserve components, US Armed Forces, 1998–2011. MSMR. 2012;19(6):7–10. 7. Nock MK, Stein MB, Heeringa SG, et al. Prevalence and correlates of suicidal behavior among soldiers: results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry. 2014;71(5):514–522. 8. Schoenbaum M, Kessler RC, Gilman SE, et al. Predictors of suicide and accident death in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS): results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry. 2014;71(5):493–503. 9. Zamorski MA. Suicide prevention in military organizations. Int Rev Psychiatry. 2011;23(2):173–180.
Mark A Zamorski, MD, MHSA (OL]DEHWK5ROODQG+DUULV3K' Rakesh Jetly, MD, FRCPC Andrew Downes, MD Jeff Whitehead, MD, MSc, FRCPC Ottawa, Ontario Jim Thompson, MD David Pedlar, PhD Charlottetown, Prince Edward Island
www.LaRCP.ca
Letters to the Editor Military Deployments, Posttraumatic Stress Disorder, and Suicide Risk in Canadian Armed Forces Personnel and Veterans Dear Editor: In your September 2014 issue, Dr Brunet and Dr Monson1 cite Canadian Armed Forces (CAF) data showing no association of suicide during military service with ever having deployed. We would like to clarify our LQWHUSUHWDWLRQRIWKLV¿QGLQJ Contrary to the authors’ assertion, we do not interpret this as evidence against the suicidogenic effects of military trauma. Indeed, the professional–technical reviews done DIWHUHDFKPLOLWDU\VXLFLGHKDYHLGHQWL¿HGGHSOR\PHQW related posttraumatic stress disorder (PTSD) as one factor among many in at least some recent suicides. Brunet and Monson attribute the lack of association of ever having deployed with suicide to the depletion of vulnerable individuals in the serving population through medical release of those who no longer meet the CAF’s VWULQJHQWPHGLFDO¿WQHVVVWDQGDUGV7KLVLVFHUWDLQO\DQ important factor, and there is, indeed, evidence of greater suicide risk after release from CAF service in modern veterans.2 No difference has been seen in suicidal ideation rates between serving personnel and civilians.3 But there are other potential explanations for the lack of association between ever having deployed and suicide while in service. First, ever having deployed is a crude PDUNHUIRUH[SRVXUHWRGHSOR\PHQWUHODWHGWUDXPDEHFDXVH the extent of exposure varies dramatically depending on deployment circumstances that vary from person to person.4 We have used this marker largely because the VPDOOQXPEHURI\HDUO\VXLFLGHVSUHFOXGHVDPRUHUH¿QHG approach. Second, as one factor among many driving suicide, deployment may not have a strong enough contribution to be detectable at the level of the population. ,QGHHGQRVLJQL¿FDQWSRSXODWLRQDWWULEXWDEOHIUDFWLRQ for deployment in relation to suicidal ideation has been detected.57KLV¿QGLQJFRPHVIURPWKHVDPH&$)VXUYH\ data that Brunet and Monson used to demonstrate the strong link between PTSD and suicidality. Finally, we should not dismiss out of hand the possibility that the totality of the policies, programs, and services available to CAF personnel mitigate the risk of suicide in those with a history of deployment. This may account for the lack of a striking increase in the CAF suicide rate during the past decade. This stands in stark contrast to the precipitous increases in the US military during the same period.6 We caution against assuming that US military VXLFLGH¿QGLQJVFLWHGE\%UXQHWDQG0RQVRQ7,8 must apply to the CAF.
200 : La Revue canadienne de psychiatrie, vol 60, no 4, avril 2015
7KH¿QGLQJWKDWHYHUKDYLQJGHSOR\HGLVQRWDVLJQL¿FDQW suicide risk factor in serving personnel has not diminished our commitment to understanding and managing the adverse health effects of military service. Instead, it has informed our approach to suicide prevention as not primarily a deployment health problem, but instead as a public health problem, requiring the targeting of the full range of determinants of mental health and suicidal behaviour in our prevention efforts.9 Disproportionate emphasis on the role of deployment, PTSD, or any other single factor is not an effective approach to suicide prevention.
Acknowledgement This work was funded through baseline salary support from the Department of National Defence and Veterans Affairs Canada.
References 1. Brunet A, Monson E. Suicide risk among active and retired Canadian soldiers: the role of posttraumatic stress disorder. Can J Psychiatry. 2014;59(9):457–459. 2. Statistics Canada. Canadian Forces Cancer and Mortality Study 2011. Ottawa (ON): Statistics Canada; 2011 [cited 2012 Jul 2]. Available from: KWWS ZZZVWDWFDQJFFDSXE±[ ±[HQJSGI. 3. Belik SL, Stein MB, Asmundson GJ, et al. Are Canadian soldiers more likely to have suicidal ideation and suicide attempts than Canadian civilians? Am J Epidemiol. 2010;172(11):1250–1258. 4. Zamorski MA, Rusu C, Garber BG. Prevalence and correlates of mental health problems in Canadian Forces personnel who GHSOR\HGLQVXSSRUWRIWKHPLVVLRQLQ$IJKDQLVWDQ ¿QGLQJV from postdeployment screenings, 2009–2012. Can J Psychiatry. 2014;59(6):319–326. 6DUHHQ-%HOLN6/$¿¿72HWDO&DQDGLDQPLOLWDU\SHUVRQQHO¶V population attributable fractions of mental disorders and mental health service use associated with combat and peacekeeping operations. Am J Public Health. 2008;98(12):2191–2198. 6. Armed Forces Health Surveillance Center. Deaths by suicide while on active duty, active and reserve components, US Armed Forces, 1998–2011. MSMR. 2012;19(6):7–10. 7. Nock MK, Stein MB, Heeringa SG, et al. Prevalence and correlates of suicidal behavior among soldiers: results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry. 2014;71(5):514–522. 8. Schoenbaum M, Kessler RC, Gilman SE, et al. Predictors of suicide and accident death in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS): results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry. 2014;71(5):493–503. 9. Zamorski MA. Suicide prevention in military organizations. Int Rev Psychiatry. 2011;23(2):173–180.
Mark A Zamorski, MD, MHSA (OL]DEHWK5ROODQG+DUULV3K' Rakesh Jetly, MD, FRCPC Andrew Downes, MD Jeff Whitehead, MD, MSc, FRCPC Ottawa, Ontario Jim Thompson, MD David Pedlar, PhD Charlottetown, Prince Edward Island
www.LaRCP.ca
