Suicide Risk

Suicide Risk Resources for Providers

The Centers for Disease Control and Prevention (CDC), in a June 2019 issue of National Vital Statistics Reports, reported that more than 47,000 Americans died by suicide in 2017. Data from an earlier CDC report  indicated that approximately 54 percent of Americans who died by suicide in 2015 had no known history of a mental health disorder. This is consistent with what the Department of Defense (DoD) Suicide Event Report (DoDSER) Annual Reports have indicated about military suicide decedents for many years – approximately half had no known mental health diagnoses (e.g., 54.7 percent in 2018, 50.8 percent in 2017, and 52.8 percent in 2016). Note, however, that this does not mean that those who died by suicide were not affected by some form of mental health concern; it only means that mental health diagnoses were not recorded in their medical records.

The CDC and DoDSER data are also similar with regard to the relative frequencies with which certain psychosocial stressors in those who die by suicide occur. For example, the CDC found relationship problems in 42.4 percent of those who died by suicide in 2015 and job or financial problems in 16.2 percent of suicide decedents. According to the 2018 DoDSER Annual Report, 39.2 percent of service members who died by suicide had relationship problems in the ninety days before the event and 18.7 percent had recent workplace problems.

Similarities aside, we know that military service members’ lives are generally very different from the lives of civilians. Service members are subject to frequent relocations, overseas deployments, and stressful experiences related to combat and significant time away from their families. The DoD and its partners continue to examine how various military-specific stressors could contribute to suicide-related behaviors and mortality in the force.

In 2018, regardless of whether or not an individual voluntarily disclosed – or was assessed for – suicidal thoughts, feelings, or behaviors, 52.9 percent of service members who died by suicide used some form of military health care or social services in the ninety days prior to death. Among those who accessed military health care, the types of services used ranged from medical to mental health to family assistance, as shown below. Note that some service members used more than one type of health care or social service, so the total will not equal 100 percent.

  • 48.2 percent received treatment in a medical treatment facility, not including mental health services
  • 29.5 percent received outpatient mental health services
  • 9.4 percent received substance abuse services
  • 9.0 percent received inpatient mental health services
  • 5.8 percent received family assistance programs

Although suicide is a serious public health problem, it is preventable. All providers in the Military Health System should be attuned to suicidal ideation and behaviors in their patients and refer them to mental health specialists whenever suicide may be an issue.

Common Warnings

Common warning signs of suicidal behavior (i.e., signals of intention to engage in suicidal behaviors):

Warning Signs

  • Talking about wanting to die
  • Threatening to hurt or kill oneself
  • Planning or preparing for a suicide attempt (e.g., buying a gun)
  • Making financial and other arrangements for dependents
  • Social withdrawal
  • Substance abuse

High Risk Groups

Groups at higher than average risk for suicide include those with histories of the following (Office of the Surgeon General & National Action Alliance for Suicide Prevention, 2012):

  • Previous suicide attempt(s)
  • Non-suicidal self-injury
  • Psychiatric diagnoses
  • Traumatic brain injuries
  • Military service (i.e., service members and veterans)

In addition to the above groups, providers should consider the level of suicide risk for service members who are or have:

Recently discharged
from a hospital
Exposure to suicide
Soldiers who have been discharged from an inpatient psychiatric unit in the past 12 months have a suicide rate that is 14-fold higher than the rate for other soldiers (263.9 per 100,000 compared to 18.5 per 100,000; Kessler et al., 2015). An even higher rate of suicide (568 per 100,000) was observed in veterans with depression who were within three months of a psychiatric hospitalization discharge (Valenstein et al., 2009). Recent studies have estimated that between 57 percent (Hom et al., 2017) and 65 percent (Bryan et al., 2017) of service members have been exposed to suicide in their lifetimes. For those exposed to suicide deaths, 43 percent (Hom et al., 2017) to 64 percent (Bryan et al., 2017) of the deaths occurred during the service members’ military service. It is estimated that up to 135 individuals are exposed to suicide with each suicide death (Cerel et al., 2018), meaning that as many as 64,530 individuals could have been affected by the 478 military suicide deaths in 2016 (CY2016 DoDSER). Impacts of exposure to suicide include increased risk for suicidal ideation, suicide behavior, and death by suicide as well as depression and anxiety (Cerel et al., 2018).
Other than honorable discharge from the military Traumatic experiences during childhood
Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF) veterans with other-than-honorable discharges from service are at double the risk for suicide attempts than veterans with honorable discharges (Reger et al., 2015). While the care for veterans falls under the purview of the Department of Veterans Affairs, this statistic highlights the need for early intervention as prevention in the Department of Defense. Exposure to adverse childhood experiences (ACEs) is associated with two to five times the risk of a suicide attempt (Dube et al., 2001). Individuals with a history of military service in the all-volunteer era (i.e., enlistment post-1973) have significantly higher rates of ACEs than civilians. ACEs more prevalent in the military population include parental separation or divorce, household drug and/or alcohol abuse, exposure to domestic violence, emotional abuse, household physical abuse and sexual abuse (Blosnich et al., 2014).
Lesbian, gay, bisexual,
and/or transgender (LGBT)
There are an estimated 85,500 service members who identify as LGBT (Gates, 2010; Gates & Herman, 2014). Approximately 40 percent of LGB individuals and 50 percent of transgender individuals report a lifetime history of suicidal ideation and an estimated 17 percent of LGB and 30 percent of transgender individuals have a lifetime history of a suicide attempt. Suicide deaths among LGBT individuals are difficult to estimate due to the general lack of sexual and gender orientation data in death records (Matarazzo et al., 2014).

Some common risk factors for suicide-related thoughts and behaviors:

Chronic Risk Factors Acute Risk Factors
  • Mental disorders
  • Medical conditions
  • History of a past suicide attempt
  • Financial difficulties
  • Relationship difficulties
  • Legal problems
  • Adverse childhood experiences
  • Loss of employment
  • Loss of a relationship
  • Loss of housing
  • Onset of psychiatric symptoms
  • Loss of status or rank
  • Interpersonal assault
  • Suicide death of a relative or peer

Protective Factors

Protective Factors
  • Employment
  • Responsibilities to others
  • Strong interpersonal bonds
  • Resilience
  • Sense of belonging and identity
  • Access to health care
  • Optimistic outlook

Suicide rates as documented in the Calendar Year 2018 DoDSER Annual Report

Changes in the Suicide Rate over Time, Active Component Counts and Rates by Component, All Services
When the active components of the Army, Navy, Air Force, and Marine Corps are combined, an overarching rate of suicide can be calculated. The annual suicide mortality rate for the active component increased from 2011 to 2018. Across the services, there were 325 suicides in the active component (a rate of 24.8 suicides per 100,000 active-component service members), 81 in the reserves (22.9 suicides per 100,000 reservists), and 135 in the National Guard (30.6 suicides per 100,000 members of the Guard).
Active Component Rates,
By Service
Reserve and National Guard Rates
The annual suicide mortality rates for the active components of the Air Force (18.5 suicides per 100,000 airmen), the Army (29.5 suicides per 100,000 soldiers), the Marine Corps (31.4 suicides per 100,000 Marines), and the Navy (20.7 suicides per 100,000 sailors) showed evidence of increases from 2011 to 2018. The annual suicide mortality rate for the reserves (all services combined) showed evidence of an increase from 2011 to 2018. In contrast, there was evidence of stability in the suicide mortality rate for the National Guard (Air and Army combined) from 2011 to 2018.
Military Component Rates vs. U.S. Population Rates
Examination of a slice of the U.S. population that matches the military population in terms of age and sex revealed that the rates of suicide for the U.S. population and the active component and reserves are statistically comparable. In contrast, the National Guard’s 2018 suicide rate was statistically significantly higher than the age- and sex-adjusted U.S. adult population rate.