Annotation by Kemuel Philbrick, MD, FAPM
Kang HK, Bullman TA, Smolenski DJ, Skopp NA, Gahm GA, Reger MA
Ann Epidemiol 2014, Nov 28 [Epub ahead of print]
ANNOTATION (Kemuel Philbrick)
The Finding: Although suicide rates among military personnel in the Army and Marine Corps are higher than for comparable civilian peers, deployment to the war zones of either Iraq or Afghanistan did not contribute to the excess suicides. Rather, after controlling for multiple variables that have emerged in other studies, deployed veterans had a lower risk of suicide when compared with their nondeployed counterparts. (Parenthetically, suicide rates among Navy and Air Force personnel are lower than for comparable civilian peers.) Not surprisingly, the risk was higher among younger, male, white, enlisted (as opposed to officer ranks), unmarried veterans. Further, the risk factors positively associated with completed suicide were similar among male and female veterans. There was also no significant difference in risk between those who were deployed once and those who were deployed multiple times. In both the deployed and nondeployed populations, the suicide rate was highest during the first 3 years after discharge from active service.
Strengths and Weaknesses: This study examined postservice mortality of all former active military personnel associated with the Iraq and Afghanistan wars who were discharged from service through 2007, enabling a study sample of nearly 1.3 million troops with follow-up that ranged from 2-9 years. Possible weaknesses include the fact that military personnel with identified behavioral or psychological morbidity may have been prevented from deploying in the first place. Moreover, the study is unable to assess whether there may be psychological sequelae of deployment relevant to suicide risk that will only become apparent with longer-term follow-up.
Relevance: The media has given considerable attention to the rise of suicide rates in military personnel, and although many former service members receive care at Veterans Affairs (VA) medical facilities, consultation psychiatrists regularly encounter former military personnel who prompt evaluation for risk of suicidality. This study reminds us that service members who were never deployed do not enjoy a prophylactic benefit with regard to suicide risk.
Purpose: We conducted a retrospective cohort mortality study to determine the postservice suicide risk of recent wartime veterans comparing them with the US general population as well as comparing deployed veterans to nondeployed veterans.
Methods: Veterans were identified from the Defense Manpower Data Center records, and deployment to Iraq or Afghanistan war zone was determined from the Contingency Tracking System. Vital status of 317,581 deployed and 964,493 nondeployed veterans was followed from the time of discharge to December 31, 2009. Underlying causes of death were obtained from the National Death Index Plus.
Results: Based on 9353 deaths (deployed, 1650; nondeployed, 7703), of which 1868 were suicide deaths (351; 1517), both veteran cohorts had 24% to 25% lower mortality risk from all causes combined but had 41% to 61% higher risk of suicide relative to the US general population. However, the suicide risk was not associated with a history of deployment to the war zone. After controlling for age, sex, race, marital status, branch of service, and rank, deployed veterans showed a lower risk of suicide compared with nondeployed veterans (hazard ratio, 0.84; 95% confidence interval, 0.75-0.95). Multiple deployments were not associated with the excess suicide risk among deployed veterans (hazard ratio, 1.00; 95% confidence interval, 0.79-1.28).
Conclusions: Veterans exhibit significantly higher suicide risk compared with the US general population. However, deployment to the Iraq or Afghanistan war, by itself, was not associated with the excess suicide risk.