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 interpretation of this finding. 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 after each military suicide have identified deploymentrelated 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 stringent medical fitness standards. This is certainly an 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 marker for exposure to deployment-related trauma because 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 small number of yearly suicides precludes a more refined 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. Indeed, no significant population attributable fraction for deployment in relation to suicidal ideation has been detected.5 This finding comes from the same CAF survey 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 suicide findings cited by Brunet and Monson7,8 must apply to the CAF.
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The finding that ever having deployed is not a significant 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.
This work was funded through baseline salary support from the Department of National Defence and Veterans Affairs Canada.
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: http://www.statcan.gc.ca/pub/82–580-x/ 82–580-x2005001-eng.pdf. 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 deployed in support of the mission in Afghanistan: findings from postdeployment screenings, 2009–2012. Can J Psychiatry. 2014;59(6):319–326. 5. Sareen J, Belik SL, Afifi TO, et al. Canadian military personnel’s 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 Elizabeth Rolland-Harris, PhD Rakesh Jetly, MD, FRCPC Andrew Downes, MD Jeff Whitehead, MD, MSc, FRCPC Ottawa, Ontario Jim Thompson, MD David Pedlar, PhD Charlottetown, Prince Edward Island
Letters to the Editor
Posttraumatic Stress Disorder: The Misappropriation of Military Suicide Causation and Medication Treatment of Posttraumatic Stress Disorder Dear Editor:
over benefits and uncertainty over pension eligibility, intoxication, very severe depression with suicidal intention, panic or anxiety attacks, and so on. PTSD, per se, will not feature here except in the company of the above factors or where insomnia and nightmares have been so severe and poorly treated.
I read with interest your September 2014 issue of The CJP. Brunet and Monson1 and Sareen2 deserve some compliment for shading light on suicides in the military and the treatment of posttraumatic stress disorder (PTSD).
Insomnia and nightmares are sentinel symptoms of PTSD. Failure to tackle these early and decisively will doom the patient to the extent that all the other PTSD symptoms will become worse.6
PTSD is but one of the causes of suicides here but it carries far more political and media gravitas. The need to pay attention to psychological autopsies of individual suicides is a more rational approach and the golden road to solving the problem of suicides in the military.
Prazosin is the most effective medication management of nightmares today. It is not promoted as it should because it is long out of patent, dirt cheap, and not backed by big pharma.
I write as someone who was on the front line treating veterans and soldiers during a period of 3 years in a remote Canadian Armed Forces (CAF) base, a time frame encompassing the war in Afghanistan and the Haiti earthquake disaster, but also treated veterans of the Rwandan genocide, the Oka riots in Quebec, and the Bosnian crisis. At this CAF base, for this time period, no Canadian soldier or veteran died by suicide. In the Medical Professional Technical Suicide Review Report of the National Defence published in September 2013,3 following a spate of soldier suicides, the authors identified the following reasons, with percentages, among completed suicides as the major causes: relationship failure and conflict (44.4%), financial problems (15.8%), chronic physical health problems (13.2%), legal disciplinary issues (10.5%), and mental health history that collectively accounted for 47.4%, of which, 21% suffered from depression, 18.5% suffered from PTSD, and 21.1% suffered from substance use disorder. In an original investigation of risk factors for suicides among American service men, LeardMann et al4, p 496 identified male sex, depression, manic depressive disorder, heavy or binge drinking, and alcoholrelated problems as factors. They failed to identify any deployment-related factors as risk factors, including PTSD. Effective management of suicidal and homicidal behaviours must be achieved in 2 sequential stages of assessment aiming to place the patient in 1 of 2 suicide risk groups: immediate suicide or a suicide flashpoint group where the psychache as enunciated by Edwin Shneidman5 is so overwhelming that suicide is the only act that can remove the pain; or chronic suicide risk group, which is the universal suicide risk of 1% plus the risk attached to individual psychiatric diagnosis. Most of the rash of suicides that occurred in the last couple of years, and particularly earlier this year, were the results of failures in the immediate or flashpoint group. From my personal experience, suicide flashpoint group was mostly comprised of relationship failures, conflict with chain of command, acute financial distress, angst against Veterans Affairs or disability and pension agencies www.TheCJP.ca
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. Sareen J. Posttraumatic stress disorder in adults: impact, comorbidity, risk factors, and treatment. Can J Psychiatry. 2014;59(9):460–467. 3. Collins R, Matheson H, Sedge P, et al. Medical professional technical suicide review report. Surgeon General Health Research Report. SGR 2013–007; 2013 Sep. 4. LeardMann CA, Powell TM, Smith TC, et al. Suicide factors associated with suicide in current and former US military personnel. JAMA. 2013;310(5):496–506. 5. Leenaars A. Review. Edwin S Shneidman on suicide. Suicidology Online. 2010;1:5–18. 6. Raskind MA, Peskind ER, Kanter ED, et al. Reduction of nightmares and other PTSD symptoms in combat veterans by prazosin: a placebo-controlled study. Am J Psychiatry. 2003;160(2):371–373.
Daniel Chinedu Okoro, MD, DPM, LMCC, FRCPC, DABPN, FAPA Calgary, Alberta
REPLY Dear Editor: In a recent letter1 discussing the papers of Dr Brunet and Dr Monson2 and of Dr Sareen3 published in the September 2014 issue of The CJP, Dr Okoro points out that suicide among the military (and among civilians, as a matter of fact) is a multi-faceted problem with no single cause. We can only agree that suicide involves multiple risk factors acting together. However, we disagree with him that posttraumatic stress disorder (PTSD) is not an important one. Several studies have documented that PTSD is a strong risk factor for suicidal behaviour.4,5 Further, many of the life events or reasons for attempting suicide uncovered by the Medical Professional Technical Suicide Review Report of the National Defence6 and invoked by Dr Okoro, such as relationship failure, or financial problems, may also underlie a nondiagnosed mental health problem, including PTSD, emphasizing the need for detection and treatment of mental health problems as part of a sound public health approach to the problem of suicide among the military. The Canadian Journal of Psychiatry, Vol 60, No 4, April 2015 W 201
Letters to the Editor
Dr Okoro attributes the rash of suicides that occurred in the last couple of years, and particularly early in 2014, in the active and retired military, as the results of failures in what he calls the immediate or flashpoint group.7 We agree that impulsivity is a major determinant of suicidality.8 However, many latent class analyses have found several classes of suicide completers.9 Dr Okoro states that in his personal experience the causes of suicide in the suicide flashpoint group do not include PTSD as one of the major causes. Although personal experience is certainly a source of information to be respected, in no way can it replace data derived from empirical research and epidemiologic surveys to inform decision makers and policy planners. In closing, we agree with Dr Okoro about the importance of treating insomnia in PTSD10 and the need for clinicians to use prazosin,11 which is not promoted by industry.
1. Okoro DC. Posttraumatic stress disorder: the misappropriation of military suicide causation and medication treatment of PTSD. Can J Psychiatry. 2015;60(4):201. 2. 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.
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3. Sareen J. Posttraumatic stress disorder in adults: impact, comorbidity, risk factors, and treatment. Can J Psychiatry. 2014;59(9):460–467. 4. Nepon J, Belik SL, Bolton J, et al. The relationship between anxiety disorders and suicide attempts: findings from the National Epidemiologic Survey on Alcohol and Related Conditions. Depress Anxiety. 2010;27:791–798. 5. Selaman ZM, Chartrand HK, Bolton JM, et al. Which symptoms of post-traumatic stress disorder are associated with suicide attempts? J Anxiety Disord. 2014;28(2):246–251. 6. Collins R, Matheson H, Sedge P, et al. Medical professional technical suicide review report. Surgeon General Health Research Report. SGR 2013–007; 2013 Sep. 7. LeardMann CA, Powell TM, Smith TC, et al. Suicide factors associated with suicide in current and former US military personnel. JAMA. 2013;310(5):496–506. 8. McGirr A, Turecki G. The relationship of impulsive aggressiveness to suicidality and other depression-linked behaviors. Curr Psychiatry Rep. 2007;9:460–466. 9. Séguin M, Beauchamp G, Robert M, et al. Developmental models of suicide trajectories. Br J Psychiatry. 2014;205:120–126. 10. Leenaars A. Review. Edwin S Shneidman on suicide. Suicidology Online. 2010;1:5–18. 11. Raskind MA, Peskind ER, Kanter ED, et al. Reduction of nightmares and other PTSD symptoms in combat veterans by prazosin: a placebo-controlled study. Am J Psychiatry. 2003;160(2):371–373.
Alain Brunet Montreal, Quebec Jitender Sareen Winnipeg, Manitoba