Trends in suicide rates among military conscripts Schroderus M, Lonnqvist JK, Aro HM. Trends in suicide rates among military conscripts. Acta Psychiatr Scand 1992: 86: 233-235.
I
The purpose of this study was to analyse the trends in suicide rates among conscripts in Finland and to compare them with suicide rates in men of the same age in the general population. The suicide rates among conscripts slightly increased from the mid-1960s until the mid-l970s, but this rise was less marked than among young men in the population as a whole. In the 1970s and 1980s, the suicide mortality among conscripts was half of that among civilian men of the same age in the population. The implications for suicide prevention are discussed.
The increasing suicide rate among young people has aroused concern in many industrialized countries (1, 2). In most countries, military service is carried out at the age of about 20, which is when suicide is known to be a significant cause of death. Military service is preceded by a physical examination, and many suicide risk factors detected at the examination, such as mental disorders, alcohol and drug abuse, antisocial behaviour and serious somatic illnesses, lead to exemption from or deferment of military service. The same factors combined with difficulties in coping with military service may later lead to conscripts interrupting their military service. Presumably, therefore the risk of suicide among those selected for military service is smaller than among young men in general. The conditions during military service may also have an impact. It has been assumed, for example, that by paying little attention to individual needs, military service may increase suicide rates among conscripts. It can similarly be assumed that liberalization of service conditions would reduce suicide rates. The earlier statistics, dating back to the nineteenth century, showed that suicide was more common among soldiers than among civilians (3,4). Suicide rates also seem to decrease during wartime and to increase after a war. The studies carried out have not usually examined military conscripts separately, and the influence of age on suicide rates has not been taken into account. In the Federal Republic of Germany in 19591965, suicide rates in 20- to 24-year-old men in the army were markedly lower than those in men of the same age in civilian life. Suicide rates in the German
M. Schroderus’, J. K. Lonnqvist’, H. M. Aro’
’
Central Military Hospital, National Public Health Institute, Department of Mental Health, Helsinki, Finland
Key words: suicide; military psychiatry; epidemiology Dr. Martti Schroderus, Central Military Hospital, Mannerheimintie 164, SF-00300 Helsinki, Finland Accepted for publication April 12, 1992
army at that time were considerably lower than earlier in 1921-1933 and 1934-1935 (5). In Norway, suicide rates among conscripts in 1952-1956 were slightly lower than among 20- to 29-year-old men in civilian life. In 1945-1965, suicide was on the whole less common among conscripts than in the corresponding civilian population (6). Between 1977 and 1984, suicide rates among conscripts in Norway were still markedly lower than in 20- to 24-year-old men in general. Similar observations were made in Finland and Sweden. However, in Norway the ratio of suicides among conscripts to those in 20- to 24-yearold men in general (0.52) was markedly higher than in Finland (0.29) and Sweden (0.17) (7). In the United States, the suicide rate among military personnel was twice as high as among civilians before the First World War, and 50% higher before the Second World War (8). The suicide rate among recruits fell by almost one third from 1925-1940 until 1947-1958. During 1981-1982, suicide rates in 20- to 24-year-old recruits in the United States were almost 50% lower than those in the corresponding civilian population (9). During 1982- 1984, suicide rates in 17- to 24-year-old white men in the United States army were markedly lower than among 15- to 24-year-old white men in civilian life (10, 11). In Finland, suicide rates in young men have increased considerably since the 1960s and are now higher than in any other country in western Europe (12). Trends in suicide rates in the Finnish army have been similar to those in the United States, Norway and Germany (13-16). The purpose of this study was to make a reliable investigation of the trends in suicide rates among 233
Schroderus et al.
conscripts in Finland and to compare them with suicide rates in men of the same age in the general population. In the latter group, suicide rates increased rapidly from the mid- 1960s until the mid1970s, associated with the general change in the structure of Finnish society. Our hypotheses were that the trend in the suicide rate among military conscripts would differ from that in the rest of the young men, and that, due to the assumed effect of selection, a similar increase in the suicide rate would not be seen among conscripts.
Suicide rate p e r 100.000 70
~
~
Material and methods
Finland has an obligatory 8- to 11-month military service for males, usually performed at the age of 20. The data about suicides committed by these Finnish conscripts between 1945 and 1988 are based on information collected by the General Headquarters. All deaths among military conscripts are carefully investigated by the medical section and a special investigation office. In the study reported here, we checked the cause of death from the files of the Central Statistical Office of Finland and from the medical examination cards and their appendixes from each military district. The suicide rate was calculated from the mean annual numbers of conscripts. These, in turn, are calculated from the annual means of monthly numbers of conscripts. The annual numbers of conscripts varied from 23,185 (1946) to 43,245 (1968). The number increased from the first study year up to 1968. Since then the numbers have fallen at the same rate as the birth cohorts. Suicide data for young men in the population as a whole are based on official cause-of-death data from the Central Statistical Office. Mortality rates have been calculated as the annual number of suicides per 100,000 people. In Fig. 1, suicide rates are given in 3-year running averages to reduce the random variations associated with small numbers. As the material covers the whole country, the changes are examined without testing their statistical significance.
n
19-year old nirri
++
?0-year old men
*
Conscripts
Fig. 1 . Suicide rate (per 100,000) among conscripts and among civilian men aged 19 and 20 in the population (curves represent centred 3-year running averages)
with that in 19- and 20-year-old civilian men, using 3-year running averages in 1972-1987, a period for which accurate age data relating to suicides were available. The suicide rate among conscripts remained fairly stable between 1972 and 1985 and markedly lower than among men of the same age in civilian life. When the numbers of suicides in 19- to 20-yearold conscripts for the period 197 1 to 1988 were compared with those of civilian men aged 19-20, conscripts accounted for 5-19% (mean 13%) of all suicides in this group. Based on the estimate of the proportion of conscripts in the age group, however, the expected figure would have been about 35 %, i.e. the suicide rate among conscripts between 197 1 and 1988 was only about half of that among civilian men of the same age.
Results
Between 1945 and 1988, the number of suicides ( n = 208) among military conscripts varied between 1 and 10 cases a year (mean 4.7). The annual suicide rate varied from 3 to 40 per 100,000. Suicide rates among conscripts fell dramatically after the Second World War, between 1946 and 1950, and a slight fall continued until the mid-1960s. After 1965, the suicide rates among conscripts slightly increased till the mid-1970s. This increase was, however, less marked than among 15- to 19-year-old and 20- to 24-year-old men in the population as a whole. Fig. 1 compares the suicide rate among conscripts
234
Discussion
Most studies investigating suicide in the army have not examined mortality in military conscripts separately. Comparison of studies is further complicated by the fact that recruiting and service conditions vary in different countries. In Finland, military service is obligatory for the whole male age group (20year-olds), the rate of exemption is low and the period of service (8 to 11 months) is short compared with that in other countries. Service conditions in Finland correspond to those in the other Nordic countries.
Suicide rates in conscripts Reliable assessment of suicide rates requires data about the risk population, that is the numbers of conscripts and their annual variation, the different lengths of service and the age structure of military conscripts. In addition, the cause of death must be determined reliably and in a way that is comparable in time series. In the material described here, we formed the risk population on the basis of monthly means, calculated the ages to the nearest year, and checked the cause of death separately in all unclear cases. In this way we believe we have been able to describe the variations in the suicide rate among conscripts in a reliable way. Interpretation of the results is also affected by variations in the small annual absolute numbers. We have used 3-year running averages to reduce the resulting risk of misinterpretation. Definition of cause of death and suicide data for the population as a whole are considered reliable in Finland (17, IS). Suicides among conscripts arouse great publicity and may easily give the idea that suicide rates in this group are particularly high. They were, in fact, high in the 1930s. However, within 5 years after the Second World War, there was a sharp fall in suicide rates. During this time period the change in the suicide rates among conscripts is probably due to the post-war liberalization of service conditions. The steep increase in suicide rates in young men in Finland after 1965 is consistent with the general trends in suicide rates in Europe (1, 2). In Finland, the increase was particularly strong. The most important finding in our study was that the increase in suicide rates among conscripts was not as great as in young men in civilian life. In fact, the risk of suicide in conscripts was about half of that in the rest of the male population of same age. This finding agrees with the results obtained in the United States, the Federal Republic of Germany and Norway. The most important single factor accounting for this finding is probably the fact that, since the end of the 1960s, more attention has been paid to the screening of military conscripts, particularly as regards mental disorders. In the 1970s and the 1980s, interruption of military service became more common. As a result, the number of young men at greatest risk of suicide has diminished in the military service. Another, probably less important, factor may be the improvement of service conditions and, in the 1980s, mental health work carried out among conscripts. However, suicide remains one of the major causes of death among conscripts. Suicide prevention in the army can be improved by identifying risk groups at pre-induction physical examination, by improving service conditions in general (contents of service and arrangement of leave) and certain activities (guard and firing exercise) in particular, by improving con-
scripts’ health care and social welfare and by considering interruption of service in risk situations. In practice, the goal of suicide prevention among conscripts should be to minimize the risk factors associated with the army and to maximize the support available in the army to deal with problems in civilian life. It should be remembered that 4 of 5 suicides in young men occur either before or after military service. As the number of young men who have been exempted from military service is increasing, preventive measures should be directed at this group in particular, since the risk of suicide in this group is much higher than among those who complete their military service normally. References 1. BARRACLOUCH B. International variation in suicide rate of 15-24-year olds. SOCPsychiatry Psychiatr Epidemiol 1988: 23: 75-84. 2. DIEKSTRA RFW. Suicide and attempted suicide: an international perspective. Acta Psychiatr Scand 1989: 80 (suppl 354): 1-24. 3. MASARYK T. Suicide and the meaning of civilization (WEIST WB, BATSONGB, trans). Chicago: University of Chicago Press, 1970 (originally published 188 1). E. Suicide: a study in sociology (SPAULDING 4. DURKHEIM JA, SIMPSON G, trans). New York: Free Press, 1951 (originally published 1897). 5. BRICKENSTEIN R. Beitrage zur Wehrpsychiatrie. Bonn: Bundesminist. der Verteidigung, 1967: 122-151. J. Suicides and attempted suicides in the Nor6. ENGELSTAD wegian armed forces during peace time. Milit Med 1968: 133: 437-449. 7. HYTTEN K, WEISAETH L. Suicide among soldiers and young men in the Nordic countries, 1977-1984. Acta Psychiatr S c a d 1989: 79: 224-228. 8. YESSLER P. Suicide in the military. In: Resnik H, ed. Suicidal behaviors. London: Churchill 1968: 241-254. 9. ROTHBERG J, JONESF. Suicide in the U.S. Army: epidemiological and periodic aspects. Suicide Life Threat Behav 1987: 17: 119-132. 10. ROTHBERG J, URSANOR, HOLLOWAY H. Suicide in the United States military. Psychiatr Ann 1987: 17: 545-548. 11. ROTHBERG J, ROCKN, SHAWJ, JONESF. Suicide in United States army personnel, 1983-1984. Milit Med 1988: 153: 61-64. 12. World health statistics annual, 1990. Geneva: World Health Organization, 1991. 13. KIVALOM, GRONROOS E. Puolustusvoimissa tapahtuneista itsemurhista. Sotilaslaaketieteellinen Aikakauslehti 1959: 34: 89-100. 14. PONTEVA M, KAUKINEN K, LOIKKANEN I, LUMIOJ. Itsemurhat Suomen puolustuslaitoksessa. Sotilaslaaketieteellinen Aikakauslehti 1971: (no 2): 41-55. 15. PONTEVA M. Aspects on the suicides of conscripts in the Finnish defense forces. Psychiatr Fenn 1981: 12: 97-103. 16. PONTEVA M. De finska bevaringarnas sjukdomspanorama 1881-1985. Ann Med Milit Fenn 1988: 63: 92-95. J. Suicide in Helsinki: An epidemiological and 17. LONNQVIST socialpsychiatric study of suicides in Helsinki in 1960-61 and 1970-71. Espoo: Monographs of Psychiatria Fennica 1977: 8. 18. KARKOLAK. Kuolemantapauksen luokitteleminen itsemurhaksi. Suomen Laakarilehti 1990: 45: 1421-1425.
235
I
The purpose of this study was to analyse the trends in suicide rates among conscripts in Finland and to compare them with suicide rates in men of the same age in the general population. The suicide rates among conscripts slightly increased from the mid-1960s until the mid-l970s, but this rise was less marked than among young men in the population as a whole. In the 1970s and 1980s, the suicide mortality among conscripts was half of that among civilian men of the same age in the population. The implications for suicide prevention are discussed.
The increasing suicide rate among young people has aroused concern in many industrialized countries (1, 2). In most countries, military service is carried out at the age of about 20, which is when suicide is known to be a significant cause of death. Military service is preceded by a physical examination, and many suicide risk factors detected at the examination, such as mental disorders, alcohol and drug abuse, antisocial behaviour and serious somatic illnesses, lead to exemption from or deferment of military service. The same factors combined with difficulties in coping with military service may later lead to conscripts interrupting their military service. Presumably, therefore the risk of suicide among those selected for military service is smaller than among young men in general. The conditions during military service may also have an impact. It has been assumed, for example, that by paying little attention to individual needs, military service may increase suicide rates among conscripts. It can similarly be assumed that liberalization of service conditions would reduce suicide rates. The earlier statistics, dating back to the nineteenth century, showed that suicide was more common among soldiers than among civilians (3,4). Suicide rates also seem to decrease during wartime and to increase after a war. The studies carried out have not usually examined military conscripts separately, and the influence of age on suicide rates has not been taken into account. In the Federal Republic of Germany in 19591965, suicide rates in 20- to 24-year-old men in the army were markedly lower than those in men of the same age in civilian life. Suicide rates in the German
M. Schroderus’, J. K. Lonnqvist’, H. M. Aro’
’
Central Military Hospital, National Public Health Institute, Department of Mental Health, Helsinki, Finland
Key words: suicide; military psychiatry; epidemiology Dr. Martti Schroderus, Central Military Hospital, Mannerheimintie 164, SF-00300 Helsinki, Finland Accepted for publication April 12, 1992
army at that time were considerably lower than earlier in 1921-1933 and 1934-1935 (5). In Norway, suicide rates among conscripts in 1952-1956 were slightly lower than among 20- to 29-year-old men in civilian life. In 1945-1965, suicide was on the whole less common among conscripts than in the corresponding civilian population (6). Between 1977 and 1984, suicide rates among conscripts in Norway were still markedly lower than in 20- to 24-year-old men in general. Similar observations were made in Finland and Sweden. However, in Norway the ratio of suicides among conscripts to those in 20- to 24-yearold men in general (0.52) was markedly higher than in Finland (0.29) and Sweden (0.17) (7). In the United States, the suicide rate among military personnel was twice as high as among civilians before the First World War, and 50% higher before the Second World War (8). The suicide rate among recruits fell by almost one third from 1925-1940 until 1947-1958. During 1981-1982, suicide rates in 20- to 24-year-old recruits in the United States were almost 50% lower than those in the corresponding civilian population (9). During 1982- 1984, suicide rates in 17- to 24-year-old white men in the United States army were markedly lower than among 15- to 24-year-old white men in civilian life (10, 11). In Finland, suicide rates in young men have increased considerably since the 1960s and are now higher than in any other country in western Europe (12). Trends in suicide rates in the Finnish army have been similar to those in the United States, Norway and Germany (13-16). The purpose of this study was to make a reliable investigation of the trends in suicide rates among 233
Schroderus et al.
conscripts in Finland and to compare them with suicide rates in men of the same age in the general population. In the latter group, suicide rates increased rapidly from the mid- 1960s until the mid1970s, associated with the general change in the structure of Finnish society. Our hypotheses were that the trend in the suicide rate among military conscripts would differ from that in the rest of the young men, and that, due to the assumed effect of selection, a similar increase in the suicide rate would not be seen among conscripts.
Suicide rate p e r 100.000 70
~
~
Material and methods
Finland has an obligatory 8- to 11-month military service for males, usually performed at the age of 20. The data about suicides committed by these Finnish conscripts between 1945 and 1988 are based on information collected by the General Headquarters. All deaths among military conscripts are carefully investigated by the medical section and a special investigation office. In the study reported here, we checked the cause of death from the files of the Central Statistical Office of Finland and from the medical examination cards and their appendixes from each military district. The suicide rate was calculated from the mean annual numbers of conscripts. These, in turn, are calculated from the annual means of monthly numbers of conscripts. The annual numbers of conscripts varied from 23,185 (1946) to 43,245 (1968). The number increased from the first study year up to 1968. Since then the numbers have fallen at the same rate as the birth cohorts. Suicide data for young men in the population as a whole are based on official cause-of-death data from the Central Statistical Office. Mortality rates have been calculated as the annual number of suicides per 100,000 people. In Fig. 1, suicide rates are given in 3-year running averages to reduce the random variations associated with small numbers. As the material covers the whole country, the changes are examined without testing their statistical significance.
n
19-year old nirri
++
?0-year old men
*
Conscripts
Fig. 1 . Suicide rate (per 100,000) among conscripts and among civilian men aged 19 and 20 in the population (curves represent centred 3-year running averages)
with that in 19- and 20-year-old civilian men, using 3-year running averages in 1972-1987, a period for which accurate age data relating to suicides were available. The suicide rate among conscripts remained fairly stable between 1972 and 1985 and markedly lower than among men of the same age in civilian life. When the numbers of suicides in 19- to 20-yearold conscripts for the period 197 1 to 1988 were compared with those of civilian men aged 19-20, conscripts accounted for 5-19% (mean 13%) of all suicides in this group. Based on the estimate of the proportion of conscripts in the age group, however, the expected figure would have been about 35 %, i.e. the suicide rate among conscripts between 197 1 and 1988 was only about half of that among civilian men of the same age.
Results
Between 1945 and 1988, the number of suicides ( n = 208) among military conscripts varied between 1 and 10 cases a year (mean 4.7). The annual suicide rate varied from 3 to 40 per 100,000. Suicide rates among conscripts fell dramatically after the Second World War, between 1946 and 1950, and a slight fall continued until the mid-1960s. After 1965, the suicide rates among conscripts slightly increased till the mid-1970s. This increase was, however, less marked than among 15- to 19-year-old and 20- to 24-year-old men in the population as a whole. Fig. 1 compares the suicide rate among conscripts
234
Discussion
Most studies investigating suicide in the army have not examined mortality in military conscripts separately. Comparison of studies is further complicated by the fact that recruiting and service conditions vary in different countries. In Finland, military service is obligatory for the whole male age group (20year-olds), the rate of exemption is low and the period of service (8 to 11 months) is short compared with that in other countries. Service conditions in Finland correspond to those in the other Nordic countries.
Suicide rates in conscripts Reliable assessment of suicide rates requires data about the risk population, that is the numbers of conscripts and their annual variation, the different lengths of service and the age structure of military conscripts. In addition, the cause of death must be determined reliably and in a way that is comparable in time series. In the material described here, we formed the risk population on the basis of monthly means, calculated the ages to the nearest year, and checked the cause of death separately in all unclear cases. In this way we believe we have been able to describe the variations in the suicide rate among conscripts in a reliable way. Interpretation of the results is also affected by variations in the small annual absolute numbers. We have used 3-year running averages to reduce the resulting risk of misinterpretation. Definition of cause of death and suicide data for the population as a whole are considered reliable in Finland (17, IS). Suicides among conscripts arouse great publicity and may easily give the idea that suicide rates in this group are particularly high. They were, in fact, high in the 1930s. However, within 5 years after the Second World War, there was a sharp fall in suicide rates. During this time period the change in the suicide rates among conscripts is probably due to the post-war liberalization of service conditions. The steep increase in suicide rates in young men in Finland after 1965 is consistent with the general trends in suicide rates in Europe (1, 2). In Finland, the increase was particularly strong. The most important finding in our study was that the increase in suicide rates among conscripts was not as great as in young men in civilian life. In fact, the risk of suicide in conscripts was about half of that in the rest of the male population of same age. This finding agrees with the results obtained in the United States, the Federal Republic of Germany and Norway. The most important single factor accounting for this finding is probably the fact that, since the end of the 1960s, more attention has been paid to the screening of military conscripts, particularly as regards mental disorders. In the 1970s and the 1980s, interruption of military service became more common. As a result, the number of young men at greatest risk of suicide has diminished in the military service. Another, probably less important, factor may be the improvement of service conditions and, in the 1980s, mental health work carried out among conscripts. However, suicide remains one of the major causes of death among conscripts. Suicide prevention in the army can be improved by identifying risk groups at pre-induction physical examination, by improving service conditions in general (contents of service and arrangement of leave) and certain activities (guard and firing exercise) in particular, by improving con-
scripts’ health care and social welfare and by considering interruption of service in risk situations. In practice, the goal of suicide prevention among conscripts should be to minimize the risk factors associated with the army and to maximize the support available in the army to deal with problems in civilian life. It should be remembered that 4 of 5 suicides in young men occur either before or after military service. As the number of young men who have been exempted from military service is increasing, preventive measures should be directed at this group in particular, since the risk of suicide in this group is much higher than among those who complete their military service normally. References 1. BARRACLOUCH B. International variation in suicide rate of 15-24-year olds. SOCPsychiatry Psychiatr Epidemiol 1988: 23: 75-84. 2. DIEKSTRA RFW. Suicide and attempted suicide: an international perspective. Acta Psychiatr Scand 1989: 80 (suppl 354): 1-24. 3. MASARYK T. Suicide and the meaning of civilization (WEIST WB, BATSONGB, trans). Chicago: University of Chicago Press, 1970 (originally published 188 1). E. Suicide: a study in sociology (SPAULDING 4. DURKHEIM JA, SIMPSON G, trans). New York: Free Press, 1951 (originally published 1897). 5. BRICKENSTEIN R. Beitrage zur Wehrpsychiatrie. Bonn: Bundesminist. der Verteidigung, 1967: 122-151. J. Suicides and attempted suicides in the Nor6. ENGELSTAD wegian armed forces during peace time. Milit Med 1968: 133: 437-449. 7. HYTTEN K, WEISAETH L. Suicide among soldiers and young men in the Nordic countries, 1977-1984. Acta Psychiatr S c a d 1989: 79: 224-228. 8. YESSLER P. Suicide in the military. In: Resnik H, ed. Suicidal behaviors. London: Churchill 1968: 241-254. 9. ROTHBERG J, JONESF. Suicide in the U.S. Army: epidemiological and periodic aspects. Suicide Life Threat Behav 1987: 17: 119-132. 10. ROTHBERG J, URSANOR, HOLLOWAY H. Suicide in the United States military. Psychiatr Ann 1987: 17: 545-548. 11. ROTHBERG J, ROCKN, SHAWJ, JONESF. Suicide in United States army personnel, 1983-1984. Milit Med 1988: 153: 61-64. 12. World health statistics annual, 1990. Geneva: World Health Organization, 1991. 13. KIVALOM, GRONROOS E. Puolustusvoimissa tapahtuneista itsemurhista. Sotilaslaaketieteellinen Aikakauslehti 1959: 34: 89-100. 14. PONTEVA M, KAUKINEN K, LOIKKANEN I, LUMIOJ. Itsemurhat Suomen puolustuslaitoksessa. Sotilaslaaketieteellinen Aikakauslehti 1971: (no 2): 41-55. 15. PONTEVA M. Aspects on the suicides of conscripts in the Finnish defense forces. Psychiatr Fenn 1981: 12: 97-103. 16. PONTEVA M. De finska bevaringarnas sjukdomspanorama 1881-1985. Ann Med Milit Fenn 1988: 63: 92-95. J. Suicide in Helsinki: An epidemiological and 17. LONNQVIST socialpsychiatric study of suicides in Helsinki in 1960-61 and 1970-71. Espoo: Monographs of Psychiatria Fennica 1977: 8. 18. KARKOLAK. Kuolemantapauksen luokitteleminen itsemurhaksi. Suomen Laakarilehti 1990: 45: 1421-1425.
235
