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Suicide Prevention in the

Military:
the US Air Force Study
Eric D. Caine, M.D.
ICRC-S
Department of Psychiatry
University of Rochester Medical Center
Rochester, NY
Urgent Need to Reduce Suicide Rates
The Public Health Rationale!
• People intent on suicide often do not seek
help.
• Seemingly “normal” people kill themselves.
• Fatal attempts often are first attempts.
• So-called “risk factors” are common; suicide is
rare, such that risk factors are NOT predictive.
• To prevent people from “becoming suicidal,”
we reach beyond clinic and hospital walls into
communities.
Air Force Suicide Prevention Program:
Quarterly Suicide Rates

Knox et al., AJPH 2010


US Armed Forces Suicide Rate

USNI News 2018


US Armed Forces Suicides, by Service
Who is the focus for MH care?
Where is the focus for prevention?

General Population

“Distressed”

“Severely Distressed”
The “high-risk” conundrum…
...finding THE NEEDLE in the stack of needles!
• The US suicide rate is 14 per 100,000 per year in the
general population; = 0.14 per 1000, or 0.014 per 100.
That means probabilistically you can say with ~99.9%
likelihood that any person from the general population
will not kill him/herself in the coming year.

• If the suicide rate is ~700 per 100,000 among clinically


depressed people, it is ~7 per 1000, or ~0.7 per 100
depressed individuals. That means probabilistically you
can say with ~99.3% likelihood that any depressed
person will not kill him/herself imminently.
USAF Suicide Prevention Program
1996 ➛ ∼2007
• Public health-community orientation: “The Air Force Family”
• Broad involvement of key leaders: Medics-Mental Health,
Public Health, Personnel, Command, Law Enforcement, Legal,
Family Advocacy, Child & Youth, Chaplains, CIS; Walter-Reed
Army Inst. of Research; CDC
• Consistent leadership involvement
• 11 initiatives clustering in four areas
– Increase awareness and knowledge
– Increase early help seeking
– Change social norms
– Change selected policies
• Common Risk Model
The USAF Active Duty Community

• 350,000 active duty service members (ADAF)


• Educated, employed, housed, health care, one
language (removes some key risk factors)
• Clearly identified community leaders and
defined, cohesive community structure
• Prescreened; low illicit drug use (1%); discharge
for mental illness
• Formal and informal gatekeeper networks at
multiple levels of the community

Caine, September 2002


Leading ADAF Causes of Death
1990 -1995
Suicide
Homicide 24%
4%

Other
4%

Disease
20%
Unintentional
Injuries
(Accidents)
48%

Litts, April 2000


Mental Health Services among
Personnel with Legal Problems
Suicides 1990 – 1995 (n = 92)

Received Mental
Health Care
No Mental Health 18%
Care
82%

Litts, April 2000


AF Suicides vs AF Population
Risk Factors *

Relationship Problems

UCMJ Problems Legal


AF Population
Problems
AF Suicides

Substance Abuse

Depression

Job Stress

0 10 20 30 40 50 60 70
Percent

*Litts, April 2000: Data from various sources,


covering various timeframes between 1990 and 1995.
USAF Suicide Prevention Initiatives (1996)
Initiatives Action
I. Leadership involvement • Encourage commanders to
actively support suicide
prevention
II. Addressing suicide • Incorporate suicide
through professional prevention into
military education (PME) Professional Military
Education (PME)
curricula
III. Guidelines for • Improve referrals of active
commanders: use of mental duty members for mental
health services health evaluations

Caine, September 2002


USAF Suicide Prevention Initiatives (1996)
Initiative Action
IV. Community preventive • Increase preventive
services functions performed by
mental health personnel
V. Community education • Four different intervention
and training levels forming a preventive
network of individuals
VI. Investigative interview • Changes in policies to
policy (hand-off policy) ensure individuals under
investigation for legal
problems assessed for
suicide potential
Caine, September 2002
USAF Suicide Prevention Initiatives (1996)
Initiative Action
VII. Critical Incident Stress • Establishment of a
Management (CISM) multidisciplinary CISM
Team to respond to
completed suicides
VIII. Integrated Delivery • Establishment of a seamless
System (IDS) for human system of services across
services prevention multidisciplinary human-
service prevention activities
IX. Limited patient privilege • Established psychotherapist-
patient privilege for
individuals at risk for suicide

Caine, September 2002


USAF Suicide Prevention Initiatives (1996)

Initiative Action
X. Behavioral health survey • Tool for assessing
behavioral health aspects
of a unit available to any
commander
XI. Epidemiological • Central surveillance data
database and surveillance base for fatal and nonfatal
system self-injuries (Suicide Event
Surveillance System or
SESS)

Caine, September 2002


Suicide Rate Trends by Service
(per 100,000)
Air Force Army Navy Marines

20

15

10

5
1990

1991

1992

1993

1994

1995

1996

1997

1998

1999
Litts, April 2000
USAF Pre- vs. Post-prevention Outcomes

• Rates of accidental death and homicide decreased


significantly (p= .001), in addition to suicide
• Rates of cases for judicial hearings for violent offenses
dropped (p=.01)
• Rates of moderate and severe family violence
decreased (p=.0001)
• Rates of mild family violence increased (p=.0001)
• Rates of hospitalization for mental health diagnoses
decreased (p=.001); rates of use of ambulatory
services for mental health diagnoses increased
(p=.001)

Knox et al., BMJ 2003


Knox et al., BMJ 2003
Air Force Suicide Prevention Program:
Quarterly Suicide Rates

Knox et al., AJPH 2010


Levels of Implementation of USAF
Suicide Prevention Program in 2004

Knox et al., AJPH 2010


USAF Overview
• Suicide—2nd leading cause of death—urgency
• Community leaders unified and engaged—necessary
political will—top-down component
• Collaborative, global community action—a public health
response including work force and home settings, as well
as health professionals
• “Layered” approach to prevention, including altered
structure, & function of community agencies—‘bottom-
up component’
• Target: Stronger individuals and families—transforming
community culture
• Decreased suicide rate, violent crime, and accidental
death rates—common risks; violence reduction as a
target
• *No change in access to lethal methods*
Caine, September 2002
USAF SUICIDE PREVENTION: Limitations
• Retrospective analyses
• Service-wide, uncontrolled intervention
• Multiple, unlinked data sets
• Limited definition of key intermediate variables,
despite “implied” measures based on targeted
interventions—missing critical measures
• Inherent likelihood of future rise in suicides (the effect
of postponing outcomes in chronic diseases)
• Uncertain application to other organizations and
communities

Caine, September 2002


“Indicated” Approach to
Prevention
Mortality
threshold

Identify and treat


Population

high-risk

Low High
Suicide Risk Modified from Crosby
“Selective” Approach to
Prevention
Mortality
threshold
Identify & treat
groups at risk
Population

of becoming
suicidal

Low High
Suicide Risk Modified from Crosby
Universal Approach to
Prevention
Mortality
threshold
Population

Move
population
risk

Low High
Suicide Risk Modified from Crosby
Prevention of death from self-injury –
suicide, drug deaths, alcohol related
diseases – must form a mosaic…
...built within the contexts of local geography
(community settings) and the social ecology of
populations – and of individuals, as well as
families. Effective prevention will involve
multiple complementary components. This
mosaic cannot be built or effectively sustained
outside the domains of people’s lives!
Outcomes!
• Without scientifically collected and
scrutinized data, policy implementation
will be limited to “intuition,” which is
subject to multiple observer and
interpreter biases.
• Without well-designed trials and rigorous
evaluation studies, it will be impossible to
assess whether intuitively appealing “face
valid” interventions save lives and warrant
broad dissemination across communities.
Eric D. Caine, M.D.
eric_caine@urmc.rochester.edu