As suicide rates among soldiers climbed to new highs four years ago, researchers prepared surveys for the largest study to date of mental health risk within the military.
The study's new findings, published as three papers in JAMA Psychiatry, show that soldiers who join the military come in with much higher rates of mental illness than the general public and that most suicides can be traced to these pre-enlistment conditions.
Researchers organized 327 meetings at Army installations across the country in 2011. A total of 5,428 soldiers — some in large auditoriums, some in small field offices — filled out questionnaires that they knew would be matched to their administrative records.
Almost 85 percent reported a mental health problem that began before they entered the military — with particularly high rates of impulsive behavior, trouble controlling anger and substance abuse.
Lead author Ronald Kessler, a professor of health care policy at Harvard Medical School, said many men and women reported developing new conditions while in the service. The soldiers' anxiety, depression and PTSD were layered onto their existing problems.
The soldiers’ anxiety, depression and PTSD were layered onto their existing problems.
"The combination of the two is a potent mix because those disorders are the dominant predictors of suicidality," Kessler said.
Kessler’s research is triggering a vigorous debate within the Army: Should it focus on tighter screening of recruits or on more services for active and retired members?
Tighter screening may be difficult, Kessler said, when, in any given year, one in four Americans meets the criteria for a mental disorder. Former Army Surgeon General Dr. Eric Schoomaker said more aggressive screening alone may be counterproductive.
"Anything that requires self-identification, if it has an adverse impact on the individual, is going to simply lead to a failure to reveal the information and avoid the consequences of it," he said. "I think that it's going to drive it underground."
Schoomaker said the Army is looking for ways, perhaps using genetic markers, to identify soldiers who don’t ask for, but need, mental health treatment. This research points to a need for specific services, Schoomaker said, not a blanket increase in mental health care.
"Finding those individuals and those patterns of behavior — like drug and alcohol issues or preexisting mental health problems — and those elements of service — such as deployment, short times between deployments — that will lead to targeting services to specific, very high-risk individuals," Schoomaker said. "I think that’s the direction that these data take us in."
But Schoomaker and Kessler cannot explain all of the findings. Why did suicide rates increase during the wars in Iraq and Afghanistan for those who were never deployed? Among soldiers who did see combat, why is the risk of suicide higher for men than women? And why doesn’t marriage help prevent suicide for soldiers as it does for civilians?
Kessler said he and his and colleagues are continuing their research to answer those questions and look at the challenges ahead.
"The war in Iraq has ended, the war in Afghanistan is winding down," he said, "but we’re going to be living with the residuals of these wars for years and years to come."
Residuals rooted in a soldier's young life. Almost half (47 percent) of those surveyed who attempted suicide after they put on a uniform had tried once before they enlisted.