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Wednesday, March 5. 2014
A new study: High suicide rates for soldiers in, out of war
A while ago, Junk Science put in a well-deserved plug for Dr. Paul McHugh and Dr. Sally Satel in his piece, in which he notes that the majority of military suicides have never been near combat.
I could discuss the topic of suicide and suicidality for days. Suicide is not one thing. It is endlessly complex, and definitely not always accompanied by clinical depression or other mental illness. Shame, guilt, loss, or anger are often prominent components, along with personality disorders, Bipolar, psychosis, and other things.
PTSD? Readers know that I tend to think that it is not a "disorder" but a normal variant. The people who put the DSM together can't tell the difference.
Here's the article by Elise Cooper to which he was reacting: Suicide in the Armed Forces: Not a Disgrace
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mostly young people, placed in high stress situations without any recognition of their effort by anyone, in a macho culture where showing any sign of human emotion is considered a sign of weakness and gets you seriously bullied by your peers.
Small wonder there's a higher suicide rate than among say gardeners...
Please.... I was in the PRP program for quite a few years in the service, and it was required to 'talk' to the shrinks roughly every 6mhs to 'check on your mental health'. It was a travesty - instead of sensing the condition, it was probing questions, like, you ever feel like shooting yourself? Your coworkers? Do you know what a noose is? Do you ever feel totally alone?
Hell, most of the time, you watched the Sun rise and set, watch the seasons change, the grass grow, and the rabbits fornicate. You could tell the different ones, due to their coloration, and gave them funny names. You did stuff to keep sane, not think of ending the mortal coil.
I look at the numbers with skepticism - sure, combat is tough, but you fight to protect your comrades, and revel in their companionship, and (at least in my case) look for avenues to expend your pent-up 'stuff' (sports, non-MIL outdoor activities, meditation, ect).
Sometimes, I think these studies are like the 'When did you stop beating your wife?' questions....
Dr. Bliss - I'm interested in your opinion on the DSMs. I realize the difficult situation we are in as physicians in terms of reimbursements. From a global perspective, it's my feeling - indeed, it's fact - that the biggest problem is that we have gradually shifted from a free market in medicine where prices are determined by what a willing seller (the doctor) and a willing buyer (the patient) find mutually agreeable to a government controlled/influenced market where prices rose due to government subsidies (in their various forms) to "unsustainable" - or at least intolerable - levels. Lately, we have seen the consequences of those policies of WW2 and the LBJ era with the left continuing to promise more and better services for either less cost (hahahahaha) or or by making the "rich" pay for it all.
Now, back to my origin DSM question - it's my opinion that the last few iterations of the DSM were largely constructed not with clinical medicine in mind, but with the goal of labeling more people as having some disorder so that their "treatment" would have to be paid by insurance.
PS - my first paragraph was meant as an explanation for what has motivated the DSM creators to act as they have (although that is not an excuse for their behavior).
What about the famous suicides of antiquity, Socrates for example, how are they to be classified?
Here is the Cooper link that works:
We are still reeling from the recent suicide of a classmate of an offspring. West Point, Ranger, brilliant, handsome, married, happy. Three combat tours. Shotgun. Gruesome. No note.
Has anybody given thought to the possibility that those soldiers may realize who they're working (i.e. putting their life on the line) for?
As someone who sought treatment for active suicidal ideation while in the military, I can tell you that one contributing factor is the Cardinal Rule of Imbecilic Management. This rule states that any problem can be solved by someone who is motivated enough.
This means that it is no longer necessary to make sure that people have the means to accomplish their responsibilities. If they care enough, they'll overcome whatever problems they encounter, and if they don't, then obviously they lack dedication.
Thus a failure in the chain of command to make sure that a person has the necessary experience, training or material support is no longer something to be blamed on the chain of command. If the subordinate cares enough, he'll overcome these problems.
Also, it is perfectly okay to insist that a subordinate always obey every regulation, come down like a ton of bricks every time he sticks his nose outside of established procedures, and then put him in a position where success requires him to go around the regulations and procedures that we have been drumming into him for the past four to sixteen years.
It goes without saying that no failure by any subordinate can be blamed on his chain of command, ever.
And if this drives a few people to consider killing themselves, we can always gin up a program to beg them not to do it.
In large measure, the suicide rate seems to be about normal, maybe even a little less, than that seen in civilian life. Some of it is probably attached to mental status that has nothing to do with service in the military. What makes it dramatic is that the total population of combat veterans is shrinking on a daily basis. For instance, I was surprised by an interesting little factoid about Vietnam combat veterans - of the 2,709,918 Americans who served in Vietnam, less than 680,000 are estimated to be alive today. Of the 2,709,918 who served, 410,000 were involved directly in active ground combat. Of those, only 140,000 are still alive today. It would seem to me that as the number of veterans decreases, the percentage of suicides would increase.
If I may be allowed to slide off topic a little, there is a bright side: You would think that Vietnam veterans would be bitter given the indifferent and often hostile treatment given us when we returned as compared to today's combat veteran, it's really not the case.
1 - Vietnam Veterans are less likely to be in prison - only one-half of one percent of Vietnam Veterans have been jailed for crimes.
2 - 85% of Vietnam Veterans made successful transitions to civilian life.
3 - 97% of Vietnam-era veterans were honorably discharged.
4 - 91% of actual Vietnam War veterans and 90% of those who saw heavy combat are proud to have served their country.
5 - 74% say they would serve again, even knowing the outcome.
Which kind of explains why the suicide rate among Vietnam veterans is considerably lower than other veterans. We went through trial by combat and trial by surviving a hostile and often dismissive civilian population.
Last, but not least, I have to mention this: the number of Americans falsely claiming to have served in-country is 13,853,027 or to put it another way, FOUR OUT OF FIVE WHO CLAIM TO BE Vietnam vets are not.
I guess it must be chic to be a Vietnam vet.
I'll accept as truth that most vets do transition back successfully (although I'd like to dig more into that stat, how is successfully defined? If you show up for work every day but beat your wife after a combat tour, is that successful? just as an example).
However, that 15% can't be minimized. I have volunteered at a homeless shelter. Veterans accounted for 25% of the men who stayed at that shelter. They had their own wing, own programs, because of their shared experiences. Even if 85% are successful, the 15% that aren't need more support than they are currently getting.
(Full disclosure, I am the child of a Vietman vet. Yes, he served in country, and yes, he successfully transitioned back into society upon the end of his tour and served 23 years in the military.)
Most people who commit suicide have mental illness often undiagnosed. The suicide issue in the military seems to be more about a political agenda then anything else. The suicide rate in the military is not out of line with the suicide rate of any group of Americans in a similar age group. Ironically the biggest incentive to commit suicide is not bullying or stress but recognition. That is someone who because of their mental state might consider suicide is far more likely to do it if they think they will become the object of attention because of it. If you want to prevent suicide then ignore suicide or even more effective shame it derisively. But that would go against our nature so we will coddle it, glorify it and thus encourage it.
Unremediated stress can contribute to emotional problems, I think we can agree.
Unfortunately for our current and recent servicemembers, the old releases we had (e.g. in Vietnam) are not available -- Smoking cigarettes (which really do seem to assist in reducing stress), drinking alcohol (or more precisely getting drunk once in a while), and getting laid (you might find yourself getting busted for fornication or violating rules against aiding and abetting trafficking in persons) -- are all in the "bad" column now.
Additionally, military healthcare seems to have become a major employer of psych/soc majors who need someplace to use their postgraduate degrees. Gotta give them a way to pay off their college loans, you know.
So, GI, just bottle it up, suck it up, and get labeled nuts when you return to CONUS and answer wrong on your PDHRA (Post-Deployment Health Reassessment).