ArticlePDF Available

Raising the clinical standard of care for suicidal soldiers: An army process improvement initiative


Abstract and Figures

From 2004 to 2008, the suicide rate among US Army Soldiers increased 80%, reaching a record high in 2008 and surpassing the civilian rate for the first time in recorded history. In recent years, the rate of Army suicides rose again; the year 2012 reflects the highest rate of military suicides on record. There is a need to assess current behavioral health practices to identify both effective and ineffective practices, and to adapt services to meet the needs of the Army behavioral health patient population. This paper discusses a process improvement initiative developed in an effort to improve clinical processes for suicide risk mitigation in an Army behavioral health clinic located in the catchment area of the US Army Southern Regional Medical Command.
Content may be subject to copyright.
A preview of the PDF is not available
... It is the second leading cause of death among 15-24 years-old [3]. While the US saw only a minor change in suicide rates among civilian population during recent years, suicide rate in the US army have increased dramatically [4][5][6][7]. ...
... This evaluation consisted of a cognitive test comprised of four subtests measuring intellectual ability. In this study, we divided the soldiers into three intellectual classifications: low (10-30), average (40-70), and high (80-90), according to an independent scale comprised of four subtests measuring the intellectual ability assumed to be equivalent to IQ scores [5,8,[21][22][23]. ...
... Previous studies investigating civilians [17,31,32] and soldiers in other armies [5,16] claimed that psychiatric diagnosis comprises a greater risk for suicide [17]. In our study, we found that soldiers bearing a psychiatric diagnosis of Cluster B or C Personality Disorder at induction are significantly more likely to die by suicide. ...
Objective: Young age, availability of weapons, and stressful life events, increase the risk of suicide. The aim of the present study was to assess additional risk factors for suicide in the Israeli army. Methods: We conducted a case-control study, to assess risk factors for suicide. The cases comprised soldiers who died by suicide during their military service (n=462; 0.039% of all soldiers in the cohort). The control group consisted of soldiers who did not commit suicide but were in active service during the investigated period (n=1,170,895; 99.96%). Predictor variables, including socio-demographic and psychiatric diagnoses, were considered. Results: Using a Generalized Linear Model with a Binary Logistic dependent variable to predict suicide, while controlling the effect of intervening variables, we found the following variables enhanced the risk for committing suicide: male (RR=6.703; P<0.001), country of origin: Ethiopia (RR=4.555; P=0.014), low socioeconomic status (RR=1.448; P=0.016) and low adjustment difficulties (RR=2.324; P<0.001). In addition, we found that in males only, Cluster B Personality Disorder (RR=2.548; P=0.027), low (RR=1.657; P=0.002), to average motivation to serve in a combat unit (RR=1.322; P=0.046) increased the risk for suicide. Conclusions: IDF Soldiers bearing a psychiatric diagnosis or severe adjustment difficulties remained tightly monitored through their military service, and were found to be at a lower risk for suicide. However, those enlisted with mild (low) difficulties, were found to be at greater risk for suicide, as well as soldiers whose country of origin is Ethiopia. Suicide prevention program should focus on monitoring soldiers with these risk factors, together with soldiers' guidance regarding help seeking and de-stigmatizing suicide.
... The military context comprises a unique factor in many respects regarding suicide and suicidal behavior (Archuleta et al., 2014;Nock et al., 2014;Shelef et al., 2015Shelef et al., , 2017. The military population is comprised mainly of young people aged 18-24, the demographic group that incurs the highest risk for suicide and suicide attempts (Archuleta et al., 2014;Nock et al., 2014;Schoenbaum et al., 2014). ...
... The military context comprises a unique factor in many respects regarding suicide and suicidal behavior (Archuleta et al., 2014;Nock et al., 2014;Shelef et al., 2015Shelef et al., , 2017. The military population is comprised mainly of young people aged 18-24, the demographic group that incurs the highest risk for suicide and suicide attempts (Archuleta et al., 2014;Nock et al., 2014;Schoenbaum et al., 2014). The stressful conditions characteristic of military service comprise an additional risk factor for suicide (Bodner et al., 2006;Nock et al., 2013a,b;Nock et al., 2014;Yacobi et al., 2013), as does the availability of firearms (Hoge and Castro, 2012;Lubin et al., 2010;Reisch et al., 2013;Zamorski, 2011), and a perceived stigma against seeking help from mental health professionals (Knox et al., 2010;Nock et al., 2013a,b;Zamorski, 2011). ...
Background: A non-fatal suicide attempt is a strong predictor of suicide. This study aimed to examine personal characteristics and psychiatric diagnoses among Druze soldiers who attempted suicide during their military service. Method: The research group (n = 180) included all Druze soldiers who had attempted suicide between the years 2008-2012 (This number encompassed 18.4% of all suicide attempts in the IDF during those years). Three control groups were examined: Jewish soldiers who had attempted suicide (n = 155), and two additional groups comprising Druze and Jewish combat soldiers who had not attempted suicide (n = 5,255 and n = 205,819, respectively). Results: While Druze soldiers were diagnosed with psychiatric conditions less frequently than their Jewish counterparts, the more prolonged time to diagnosis among Druze may account for increased severity at time of diagnosis, thus increasing the risk of suicide attempt. A multivariate analysis revealed that the odds of a suicide attempt among Druze soldiers were much higher than among Jewish soldiers (OR 20.53; p < .001). In addition, it was found that average and high socioeconomic levels, strong Hebrew language skills, and high intelligence levels were protective factors against attempted suicide (p < .001, R2 = 0.217). Limitations: The three control groups were samples, while the research group (Druze attempters) consisted of all instances of attempted suicide during the study period. Comparing only samples would have offered less statistical power; therefore, using all the records in the research group improved accuracy.
... Although military service members are routinely asked if they endorse current suicidal ideation, a frequent outcome from such an endorsement is a psychiatric hospitalization, where suicide-specific treatment is limited. Further, some military Behavioral Health Clinics lack a system for tracking ongoing suicidal ideation, which may preclude service members from receiving potentially life-saving treatment (Archuleta et al., 2014). ...
... Considering that service members may not stay in one location long enough to complete a lengthy treatment protocol, CAMS aims to efficiently resolve suicidality in relatively short order within 12 sessions (Jobes, Wong, Conrad, Drozd, & Neal-Walden, 2005) or as short as six to eight sessions (Jobes et al., in press). CAMS has been the centerpiece of systemslevel "process improvement" interventions to raise the clinical standard of care for suicidal risk across mental health services in military treatment facilities (Archuleta et al., 2014). ...
Full-text available
Despite the enormous humanitarian and economic toll of suicide, mental health systems of care are largely underprepared to work effectively with suicidal individuals and suicide is a leading "Sentinel Event" in U.S. health care settings (The Joint Commission, 2016). In response to these concerns, a recent policy initiative called "Zero Suicide" has advocated a systems-level response to the suicidal risk within health care and this policy initiative is yielding positive results (Hogan & Goldstein Grumet, 2016). Along these lines, a "stepped care" approach developed by Jobes (2016) has been adapted and used within the Zero Suicide curriculum as a model for systems-level care that is suicide-specific, evidence-based, least-restrictive, and cost-effective. The Collaborative Assessment and Management of Suicidality (CAMS) is an example of one suicide-specific evidence-based clinical intervention that can be adapted and used across the full range of stepped care service settings (Jobes, 2016). This article describes various applications and uses of CAMS at all service levels and highlights CAMS-related innovations. It is argued that psychological services are uniquely poised to make a major difference in clinical suicide prevention through a systems-level approach using evidence-based care such as CAMS. (PsycINFO Database Record
... Further evidence of its effectiveness is based on an expanding body of literature which has shown significant effects in reducing suicide ideation using CAMS among a variety of populations in several different settings. Such studies have been conducted with college students in an outpatient setting (Jobes, Jacoby, Cimbolic & Hustead, 1997), in randomised control studies in a mental health clinic, with patients in an inpatient setting ( Ellis, Rufino, Allen, Fowler & Jobes, 2015; Ellis, Green, Allen, Jobes & Nadorff, 2012; Ellis, Allen, Woodson, Frueh & Jobes, 2009) and among suicidal service members and veterans (Archuleta et al., 2014;Jobes, Lento & Brazaitis, 2012;Bryan, Jennings, Jobes & Bradley, 2012;Nademin et al., 2008). ...
Full-text available
Individuals experiencing homelessness are often exposed to various risk factors that increase their vulnerability towards suicide. With high rates of documented suicidal attempts, ideation and behaviours among this population, and recent initiatives pushed by our own national strategies, there is an ever-growing need for evidence-based assessment and management of suicide among individuals experiencing homelessness. However, there is a substantially limited evidence-base of such practices in an Irish context. It was for these reasons that Dublin Simon Community’s Sure Steps Counselling Service established a pilot project from November 2016 to February 2018 with clients and staff to evaluate one such evidence-based approach, the Collaborative Assessment and Management of Suicidality (CAMS). This report assesses the CAMS Approach in terms of ease of training, implementation into practice and its effectiveness for reducing suicidal thoughts and behaviour among the homeless population. It is the hope that such a report will inform practices and guidelines both within Dublin Simon Community as well as among homeless services nationally and internationally.
... Aside from the burden of routine military experience, these adjustment challenges may exacerbate the stress experience (Bodner et al., 2006(Bodner et al., , 2007. The military context is unique in many aspects regarding suicide (Archuleta et al., 2014;Nock et al., 2014). The under-reporting of psychiatric history among young military personnel and the stigma that deters them from seeking help (Friedman, 2014;Greene-Shortridge et al., 2007) make military service a particularly vulnerable period for suicide-related crises (Knox, et al., 2010;Nock, et al., 2013a;Zamorski, 2011). ...
... The increase in suicide rates in U.S. military personnel since 2003 has been dramatic [1,2] even compared to the steady increase in suicide rates of the general U.S. population [3]. Much effort has been expended to identify risk factors for preventing suicide in the U.S. military [4], and many prevention strategies have been employed. ...
Background: There is an ongoing debate on the effectiveness of suicidal behavior prevention measures in the military. The association of three widely used tools with severe suicide attempts was assessed in this setting. Methods: Thirty-nine Israeli soldiers (59% males), mean age 19 yrs., who attempted suicide during military service were divided into two groups: severe (n = 14; 35.9%) and moderate suicide attempts, and were assessed using the Scale for Suicide Ideation (SSI), Suicide Intent Scale (SIS) and the Columbia Suicide Severity Rating Scale (C-SSRS). Results: Seven items from the SSI (p = 0.008), two items from SIS and one item from C-SSRS were associated with severe suicide attempts. Kendall's tau-b correlation with bootstrap demonstrated stability of these correlations. Conclusion: Greater severity of suicidal ideation was associated with more severe suicide attempts. The combination of male gender, available firearms and current severe suicide ideation is high-risk danger sign in a military setting, even when reported intent to die is low.
... Suicide is the second leading cause of death worldwide among adolescents and young adults aged 15-24 (Sullivan et al., 2015). In contrast to the stable trend in the rate of suicide among civilians in the US, the suicide rate in the US army has dramatically increased (Archuleta et al., 2014;Nock et al., 2014). This evidence suggests that soldiers might be a particularly relevant population for suicide research, and Israeli soldiers might be particularly relevant for such research because of compulsory military service for all citizens who reach the age of 18. ...
Introduction: Despite the accumulated knowledge about suicide, suicidal acts remain difficult to predict, and many suicides are acted out impulsively. Methods: We performed a psychological autopsy study based on inquiries about the deaths of all male soldiers aged 18-21 years who served in the Israeli army and died by suicide between 2009 and 2013 (n = 69). The study population was first divided into two groups: those who had depressive disorder (n = 31); and those who did not (n = 38). Socio-demographic characteristics of the subjects and the characteristics of the suicidal act were compared. Afterwards, the study population was re-divided by the presence or absence of impulsive personality traits (n = 22, and n = 47, respectively), and investigated for distinct suicidal behavior features. Results: No significant socio-demographic differences were found between the depressed and non-depressed suicide victims. The depressed group had showed more signs of planning the act (47% vs. 23%), and had expressed suicidal ideation in the days preceding the suicide (51.6% vs. 21%). One third of the subjects were found to have an impulsive personality trait, with significantly more histories of disciplinary issues, violence and cluster B personality disorders. Alcohol use during the act was significantly more prevalent among impulsive than non-impulsive subjects (45.4% vs. 14.9%). Conclusion: Identification of distinct clinical groups of suicide victims among young males might help clinicians evaluate high risk cases, and may provide valuable opportunities to alleviate and prevent these events in the future.
... Suicide is a major cause of death in young adults worldwide [15,30], and the leading cause of death in the military in peacetime [5,31,39]. Increased attention to military suicide prevention was stimulated by the rising suicide rate in The US Army, despite considerable investment in mental health services [24,33], contrasting with minor change in the civilian suicide rate [32]. While causal factors remain uncertain [20,33,38], depression and alcohol-related problems appear to be more important than military factors, such as deployment [20,25,32,38]. ...
Full-text available
Objective: To evaluate the effectiveness of the IDF Suicide Prevention Program, implemented since 2006. Design: Quasi-experimental (before and after) cohort study. Participants: Two cohorts of IDF mandatory service soldiers: the first inducted prior to (1992-2005, n=766,107) and the second subsequent to (2006-2012, n=405,252) the launching of the intervention program. Exposure: The IDF Suicide Prevention Program is a population-based program, incorporating: reducing weapon availability, de-stigmatizing help-seeking behavior, integrating mental health officers into service units, and training commanders and soldiers to recognize suicide risk factors and warning signs. Main outcome measure: Suicide rate and time to suicide in cohorts before and after exposure to the Suicide Prevention Program. Results: Trend analysis showed lower suicide rates in the cohort after intervention. The hazard ratio for the intervention effect on time to suicide was 0.44 (95% CI=0.34-0.56, P<.001) among males. Lower risk was associated with: male gender; born in Israel; higher socio-economic status; higher intelligence score; and serving in a combat unit (HR=0.43: 95% CI=0.33-0.55). Conclusions: There was a 57% decrease in the suicide rate following the administration of the IDF Suicide Prevention Program. The effect of the intervention appears to be related to use of a weapon, and being able to benefit from improved help-seeking and de-stigmatization. Future efforts should seek to extend the program's prevention reach to other demographic groups of soldiers. The success of the IDF program may inform suicide prevention in other military organizations and in the civilian sector.
Objective: Suicide is a major public health concern among military servicemembers and previous research has demonstrated an association between bullying and suicide. This study evaluated the association between workplace bullying and suicidal ideation via perceived burdensomeness and thwarted belongingness which were hypothesized to mediate this association. Method: Four hundred and seventy-one suicidal Army Soldiers and U.S. Marines completed self-report measures of suicidal ideation, thwarted belongingness, perceived burdensomeness, and bullying. A series of regressions were used to test the hypothesized mediation model using the baseline data from a larger clinical trial. Results: Perceived burdensomeness was a significant mediator of the association between bullying and the level of suicidal ideation, but thwarted belongingness was not a significant mediator. Conclusions: Perceived burdensomeness may represent a malleable target for intervention to prevent suicide among military service members, and should be evaluated further as an intervening variable with regard to suicidality in the setting of bullying victimization.
This chapter will present the two suicide facilitating processes (dissociation and habituation) and their relationship to suicidal behaviour. Nearly all empirical research deals with the causes and factors of suicide, with the understanding that not everyone who is considered at risk will actually turn to suicidal behaviour. Suicide facilitating factors are different from the reason for suicide in that they do not constitute a direct cause for suicide, even though they do raise the risk of the suicidal act. In the literature there are two suicide facilitating processes: dissociation and habituation. The dissociation concept may turn into an ineffective mechanism of severance and escape from coping. This severance mechanism manifests, among others, in a lack of physical pain sensation and in indifference towards the body and the self. In stressful situations it may be a factor which facilitates executing the suicidal behaviour. The habituation concept refers to the substantial ability to carry out the suicidal idea through a mental process of practice, coping with pain and self-harm. When this ability is acquired, the risk of suicidal behaviour increases. These two on their own cannot directly bring to suicide, but their presence increases the probability of suicidal behaviour, and thus their investigation constitutes an important addition to the understanding of the suicidal process.
Although most military personnel returning from recent deployments will readjust successfully to life in the United States, a significant minority will exhibit PTSD or some other psychiatric disorder. Practitioners should routinely inquire about war-zone trauma and associated symptoms when conducting psychiatric assessments. Treatment should be initiated as soon as possible, not only to ameliorate PTSD symptoms but also to forestall the later development of comorbid psychiatric and/or medical disorders and to prevent interpersonal or vocational functional impairment. If evidence-based practices are utilized, complete remission can be achieved in 30%-50% of cases of PTSD, and partial improvement can be expected with most patients. We can all look forward to future break-throughs that will improve our capacity to help people with PTSD.
Family separations are an intrinsic part of military life. The temporary loss of a family member through deployment brings unique stresses to a family in three different stages: predeployment, survival, and reunion. Most families adapt to these stresses well. In families without adequate coping skills, however, these stresses can lead to problems which the family presents to the health care system. Health care providers must be aware of these stresses, the high-risk families, their clinical manifestations, and techniques for preventing and treating them. This article provides some help for health care providers dealing with these issues.