Rethinking Suicide Prevention:
A Proactive Approach to Military Wellness
By: Keionna Baker
In the ever-shifting landscape of our lives, an urgent reality commands our attention — suicide is now the second leading cause of death for individuals 20–34 years old, according to the Centers for Disease Control’s 2021 report. Adults aged 35–64 account for 46.8% of all suicides in the United States, and suicide is the 8th leading cause of death for this age group. These statistics fuel our quest for understanding as we explore the intricate realms of suicide, parasuicide, and the haunting specter of suicidal ideations defined by the American Psychological Association. Looking beyond the statistics, we need to rethink how we typically react and move from reacting to crises right away to being more proactive and preventive, particularly within the military community.
Suicidal ideations, though often connected to major depressive episodes, rarely escalate to attempts, a revelation that compels us to rewrite our approach. The stark reality of 7.1 million attempted suicides and over 48,000 lives lost in 2021 alone beckons us to action.
Together, we embark on a path that reimagines suicide prevention, forging a culture of compassion, understanding, and forward-thinking strategies. The path of rethinking and understanding suicide leads us toward a future where these strategies converge to reshape the landscape of military wellness — one where military communities can take proactive actions to decrease the number of deaths by suicide.
Rise in Military Suicide
The Defense Suicide Prevention Office revealed in its quarterly report that the overall number of active-duty suicides was 94 from January through March of 2023, up 25% compared to 75 troops who took their own lives in the first three months of 2022. 1 “Data has shown a rise in military suicide in the past decade, including a significant spike in 2020 during the coronavirus pandemic.”1 Some of the prevention strategies suggested included restricting troops’ access to firearms, a form of means restriction, which we will discuss in more detail later, and increasing the age for purchasing weapons and ammunition to 25.
Several psychosocial factors are associated with suicide risk, with the most common individual stressors for the military including relationship problems, administrative/legal issues, and workplace difficulties. Multiple studies have been documented by Dr. Craig J. Bryan (2022), the author of “Rethinking Suicide,” demonstrating no significant correlation between deployments and suicide rates.
What is Being Done in Response?
To respond to this significant threat within our military community, leaders have “enacted the long-awaited Brandon Act to allow troops to seek mental health services confidentially and any time they need it.”2 The Brandon Act was named after a service member who died by suicide in 2018. In addition to this, the United Service Organizations (USO) strives to deliver services to foster connection, which includes “around-the-clock” hospitality for traveling service members and their families. The USO has facilities in most airports, on base installations, and in combat zones “to prove a comfortable gathering space to build community and make connections.”2
Additionally, there are nonprofit agencies such as Mission 22 that focus on offering programs and events to support veterans, families, and military communities in resiliency efforts. The National Veteran Suicide Prevention Organization List provides many additional organizations that support suicide prevention. While these organizations and resources are wonderful, there is still more work to be done, including shifting our perception.
Impact of Mental Illness and Acute and Chronic Substance Use on Suicide
There are several areas we can begin to analyze to shift our historical thinking of suicide and explore more effective measures for suicide prevention. One of these is clarifying the role of mental illness.
Public perception is often that individuals are retrospectively diagnosed with mental illness in an autopsy after a death by suicide. However, studies show that “only 46% of U.S. citizens who died by suicide between 1999 and 2016 had a known mental health diagnosis at the time of death”. 3
When considering mental health pathology, in a meta-analysis where 365 studies over the previous 50 years were examined, it was concluded that “mental illness was only weakly correlated with suicide and suicide attempts.”3 However, many individuals were not diagnosed. This doesn’t mean that mental illness did not exist—particularly acute adjustment disorders and cluster B traits.
Another area of interest is the role of acute and chronic substance use. An article from the National Institute of Health from Pompili et al. (2010) reveals that alcohol use has consistently been implicated in the precipitation of suicidal behavior and may lead to suicidality through disinhibition, impulsiveness, and impaired judgment. Although psychological autopsies have limited statistical power, we can confirm through these autopsies that alcohol was in the blood of 28–29% of American suicide victims, elevating the need to focus on the impact of alcohol and substances when considering preventative strategies.
The National Institute of Health article has cited various clinical studies that implicated alcoholism as the strongest single predictor of subsequent completed suicide in a sample of attempted suicides. In other studies, through NIH, not only have alcohol and drug use disorders been associated with suicide, but chronic alcohol consumption has been identified as having a fivefold higher risk than social drinkers. Acute alcohol intoxication and chronic alcohol use or dependence have continued to be implicated in increased risk factors for suicide, per the National Institute of Health article by Rizk et al. (2021).
The article notes that since 2001, the past-year prevalence of high-risk drinking has increased by 29.9%, and alcohol use disorder (AUD) by 49.4%, and these rising rates of alcohol misuse are accompanied by a 35% increase in alcohol-related suicide deaths. 4 Alcohol and opioids are noted to be the most common substances identified in suicide decedents at 22% and 20%, respectively. There continue to be significant opportunities for further research to differentiate chronic and acute effects of alcohol and opioid usage on suicidality and interventions to best support this population.
Collectively, these findings have led to the need to look at a new way of assessing and addressing suicide. Modern research offers a new conceptual model for suicide prevention that identifies a missing link of acute factors impacting the cycle of suicide attempts.
Understanding Risk Factors
Naturally, many unique factors and events are working together to create the potential for suicide. Additionally, high-stress levels in each of these areas—cognitive, behavioral, emotional, and physical—impact what can be considered a crisis.
Baseline risk factors are a part of the individual’s natural predisposition for suicide. These factors include skills deficits in distress tolerance, emotion regulation, and interpersonal communication, each increasing the likelihood of maladaptive coping in response to stressful situations and triggering events. Things such as an inability to solve problems, poor self-perception, prior attempts at suicide, mental health disorders, etc., would also fall in the category of baseline factors.
Acute risk factors are more pressing and cause for alarm. For these, we also look at the domains of cognitive, behavioral, emotional, and physical factors. Acute factors in the cognitive domain are automatic thoughts and assumptions related to a stressful event. Behavioral factors are efforts the individual may make to reduce or avoid distress, such as substance use or isolation. Acute emotional factors include feelings of depression, guilt, and anger. Physically acute factors can surface as agitation, pain, or insomnia. Acute factors fluctuate in very short-term events and are also identified as triggers.
Activating events are the situations that move individuals from baseline to acute risk factors. These events may include relational problems, financial stress, perceived loss, physical sensations, and negative memories. 1 “According to the fluid vulnerability theory, predispositions (baseline factors) will only lead to an acute suicidal crisis if the individual’s predispositions are activated (acute factors) or “turned on” by a contextual stimulus, sometimes referred to as “triggers,” or an activating event.1
Having a better understanding of how the predisposition of an individual works with activating events to produce an acute suicidal response, we can now look at some preventative measures.
Restrict Access to Lethal Means
Assess whether an individual at risk for suicide has access to a firearm or other lethal means for suicide. Work with the individual and his or her support system to limit access to these means until the individual is no longer feeling suicidal.
Mindfulness can be a beneficial coping skill. In mindfulness, individuals use diaphragmatic breathing and progressive muscle relaxation to manage their physiological arousal by targeting the parasympathetic nervous system, effectively reducing negative emotional states. Mindfulness skills training targets the cognitive domain and is intended to offset the vulnerability by strengthening the patient’s awareness of his/her internal state and the context within which these states are experienced. 5
Cognitive Behavioral Therapy (CBT)
When considering treatment options for individuals with acute risk factors such as substance abuse and suicidality, Cognitive Behavioral Therapy can be a useful intervention. Ilgen and Kleinburg developed a modified version of CBT that focuses specifically on suicidal behaviors in those with substance use disorders. The benefit of discussion related to the patient’s connection between substance abuse and the tendency toward violent behaviors was noted as a positive.7
Schedule a Screening
Activating events such as relationship problems, financial stress, perceived loss, physical sensations, and negative memories have been shown to increase acute risk factors such as substance use, social withdrawal, agitation, anger, guilt, etc. 5
The Joint Commission (JTC) issued a report with patient safety goals to be in effect in 2019, which recommended screening for all patients seeking treatment for behavioral health complaints. Some screenings provided by the JTC include the:
- Patient Safety Screener
- Tool for Assessment of Suicide Risk Adolescent Screener
- Ask Suicide-Screening Questions (ASQ) Toolkit
The report also notes that the Columbia-Suicide Severity Rating (C-SSRS) Scale can be used for both screening and more in-depth assessment.
Plan a Social Event
Activity planning is a behaviorally oriented technique designed to target the imbalance of suicidal individuals because they have more aversive than pleasurable life events. 5 This technique aims to increase the client’s engagement in pleasurable and meaningful activities that have been abandoned due to mood disturbance.
Create a Coping Card
Coping cards are a method of support and reinforcement of skills learned in treatment. They can be created using a 3×5 index card made to be transportable and a physical reminder of adaptive cognitive and behavioral strategies that the person can always keep with them. These cards are designed to serve as a visual memory aid to remind patients to utilize their skills. 5
Additional interventions that may be beneficial for those grappling with acute risk factors include increasing follow-up consultations of individuals at risk for alcohol abuse, promotion of safe drinking, and online tools for monitoring alcohol intake may counteract the increase of harmful alcohol use. 8
Changing the game in suicide prevention within the military is not just about stats and strategies. It’s about understanding, caring, and developing new ideas that can make a difference. So, as we kick aside the old ways and dive into the nitty-gritty of suicide and its complexities, we’re unveiling a roadmap that’s all about hope and change. Let’s ditch the old playbook, think outside the box, and join forces to take military wellness to a whole new level.
- 1 Clark, Liz, “Department of Defense (DoD) Quarterly Suicide Report (QSR) 1st Quarter, CY 2023”. Accessed August 10, 2023, https://www.dspo.mil/Portals/113/Documents/QSR/2023/TAB%20A_20230623_QSR%20Rpt_Q1%20CY23_vf.pdf?ver=r8d0Jqji8pORC05TwZ2sKQ%3d%3d
- 2 USO. “Military Suicide Rates Are at an All-Time High”. Last modified June 27, 2022, https://www.uso.org/stories/2664-military-suicide-rates-are-at-an-all-time-high-heres-how-were-trying-to-help.
- 3 Bryan, C. J. (2022). Rethinking suicide: Why prevention fails, and how we can do better. Oxford University Press.
- 4 Rizk et al. (2021) Rizk, M. M., Herzog, S., Dugad, S., & Stanley, B. (2021). Suicide Risk and Addiction: The Impact of Alcohol and Opioid Use Disorders. Current Addiction Reports, 8(2), 194-207. https://doi.org/10.1007/s40429-021-00361-z
- 5 Bryan, C. J., & Rudd, M. D. (2018). Brief cognitive-behavioral therapy for suicide prevention. The Guilford Press.
- 6 Thom, R., Hogan, C., & Hazen, E. (2020). Suicide Risk Screening in the Hospital Setting: A Review of Brief Validated Tools. Psychosomatics, 61(1), 1-7. https://doi.org/10.1016/j.psym.2019.08.009
- 7 Ilgen, M., PhD., & Kleinberg, F., M.S.W. (2011). The Link Between Substance Abuse, Violence, and Suicide: Implications and Interventions. Psychiatric Times, 28(1), 25-27. https://go.openathens.net/redirector/liberty.edu?url=https://www.proquest.com/trade-journals/link-between-substance-abuse-violence-suicide/docview/856676551/se-2
- 8 Wasserman, D., Iosue, M., Wuestefeld, A., & Carli, V. (2020). Adaptation of evidence-based suicide prevention strategies during and after the COVID-19 pandemic. World Psychiatry, 19(3), 294-306. https://doi.org/10.1002/wps.20801
- Bryan, C. J. (2022). Rethinking suicide: Why prevention fails, and how we can do better. Oxford University Press.
- Bryan, C. J., & Rudd, M. D. (2018). Brief cognitive-behavioral therapy for suicide prevention. The Guilford Press.
- Clark, Liz, “Department of Defense (DoD) Quarterly Suicide Report (QSR) 1st Quarter, CY 2023”. Accessed August 10, 2023, https://www.dspo.mil/Portals/113/Documents/QSR/2023/TAB%20A_20230623_QSR%20Rpt_Q1%20CY23_vf.pdf?ver=r8d0Jqji8pORC05TwZ2sKQ%3d%3d
- Ilgen, M., PhD., & Kleinberg, F., M.S.W. (2011). The Link Between Substance Abuse, Violence, and Suicide: Implications and Interventions. Psychiatric Times, 28(1), 25-27. https://go.openathens.net/redirector/liberty.edu?url=https://www.proquest.com/trade-journals/link-between-substance-abuse-violence-suicide/docview/856676551/se-2
- Rizk, M. M., Herzog, S., Dugad, S., & Stanley, B. (2021). Suicide Risk and Addiction: The Impact of Alcohol and Opioid Use Disorders. Current Addiction Reports, 8(2), 194-207. https://doi.org/10.1007/s40429-021-00361-z
- Stars and Stripes. “Military suicides rose in 1st quarter of 2023 compared to same time last year, Pentagon report says”. Last modified July 3, 2023, https://www.stripes.com/theaters/us/2023-07-03/military-suicides-pentagon-report-10631188.html
- Stars and Stripes. “New Pentagon policy looks to expand mental health care access for troops”. Last modified May 5, 2023, https://www.stripes.com/theaters/us/2023-05-05/military-mental-health-suicide-pentagon-10024837.html
- Thom, R., Hogan, C., & Hazen, E. (2020). Suicide Risk Screening in the Hospital Setting: A Review of Brief Validated Tools. Psychosomatics, 61(1), 1-7. https://doi.org/10.1016/j.psym.2019.08.009
- Uniformed Services University. “Suicide in the Military”. Accessed August 10, 2023, https://deploymentpsych.org/disorders/suicide-main
- USO. “Military Suicide Rates Are at an All-Time High”. Last modified June 27, 2022, https://www.uso.org/stories/2664-military-suicide-rates-are-at-an-all-time-high-heres-how-were-trying-to-help.
- Wasserman, D., Iosue, M., Wuestefeld, A., & Carli, V. (2020). Adaptation of evidence-based suicide prevention strategies during and after the COVID-19 pandemic. World Psychiatry, 19(3), 294-306. https://doi.org/10.1002/wps.20801
- World Health Organization. “Suicide”. Last modified June 17, 2021, https://www.who.int/news-room/fact-sheets/detail/suicide
Keionna Baker has been a Regional Supervisor for the Military Family Life Counseling Program since 2022 and began as an MFLC in 2017. She earned her bachelor’s degree in social work from Austin Peay State University and went on to gain a master’s degree in mental health counseling in 2011. She is currently working on her doctoral degree in Community Mental Health Counseling from Liberty University.