403

Suicide Prevention in the US Army: Lessons Learned and Future Directions

Chapter 25

SUICIDE PREVENTION IN THE US 

ARMY: LESSONS LEARNED AND 

FUTURE DIRECTIONS

ELSPETH CAMERON RITCHIE, MD, MPH*; WALTER MORALES, MSA†; MICHAEL RUSSELL, PhD‡; 

BRUCE CROW, PsyD§; WAYNE BOYD, MDiv¥; KELLY FORYS, PhD¶; and STEVEN BREWSTER, MD, MPH**

INTRODUCTION

HISTORY OF SUICIDE PREVENTION IN THE US ARMY

ARMY SUICIDE PREVENTION PROGRAM

Initiatives and Efforts to Minimize Suicidal Behavior

Recent Initiatives

OPERATION IRAQI FREEDOM THEATER SUICIDE ASSESSMENT

Discussion

Summary of Theater Suicide Assessment

PSYCHIATRIC EPIDEMIOLOGICAL CONSULTATIONS IN THE US ARMY

Description and Background

Initiation of an Epidemiological Consultation and Operational Support

Epidemiological Consultation Activities on the Ground and Data Sources

Methods in the Epidemiological Consultation

Results and Lessons Learned

SUMMARY

*Colonel, US Army (Retired); formerly, Psychiatry Consultant to The Surgeon General, US Army, and Director, Behavioral Health Proponency, Office 

of The Surgeon General, Falls Church, Virginia; currently, Chief Clinical Officer, District of Columbia Department of Mental Health, 64 New York 

Avenue NE, 4th Floor, Washington, DC 20002

†

Sergeant Major, US Army (Retired); Program Manager, Army Suicide Prevention Program, Army G-1, Headquarters, Department of the Army, 300 

Army Pentagon, ATTN: Army G-1 (DAPE-HR), Washington, DC 20310-0300

‡ Lieutenant Colonel, Medical Service Corps, US Army;Army Medical Department Neuropsychology Consultant, Warrior Resiliency Program, Lincoln 

Center, Suite 300, 7800 Interstate 10 West, San Antonio, Texas 78230

§

Colonel, Medical Service Corps, US Army; Clinical Psychology Consultant to the Surgeon General, US Army, and Director, Warrior Resiliency Program, 

Southern Regional Medical Command, Brooke Army Medical Center, San Antonio, Texas 78234

¥

Colonel, Chaplain Corps, US Army; Staff Officer, Comprehensive Soldier Fitness, Headquarters, Department of the Army, Zachary Taylor Building 

(NC3), 2530 Crystal Drive, Room 512B, Arlington, Virginia 22202; formerly, Program Manager, Directorate of Health Promotion and Wellness, US 

Army Center for Health Promotion and Preventive Medicine, Aberdeen Proving Ground, Maryland 

¶

Psychologist, Department of Outpatient Behavioral Health, Landstuhl Regional Medical Center, CMR 402, Box 1045, APO AE 09180; formerly, Psychologist, US Army Center for Health Promotion and Preventive Medicine, Aberdeen Proving Ground, Maryland

**Colonel, Medical Corps, US Army; Commander, US Army Medical Activity–Bavaria, Vilseck, Germany, Unit 28038, APO AE 09112 formerly, Directorate 

of Epidemiology and Disease Surveillance, US Army Center for Health Promotion and Preventive Medicine, Aberdeen Proving Ground, Maryland
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Combat and Operational Behavioral Health

INTRODUCTION

The goal of all the military services is to provide the 

serving men and women the best available support to 

assist them in overcoming the stressors that military 

service entails. The services utilize training and 

education, counseling, intervention, and postvention 

measures to help them find alternative and appropriate ways of dealing with stress and minimize the risk 

of suicide. 

The spectrum of suicide behaviors (which ranges 

from gestures to serious attempts to completed suicides) and stress from the high operational tempo 

continue to have an effect on readiness and mission 

accomplishment. The Army Suicide Prevention Program’s mission is to preserve readiness for soldiers, 

families, and Department of the Army civilians by 

continuing to develop policies and procedures that 

are designed to minimize suicidal behavior. Unfortunately, the Army-wide suicide rate has been trending 

upward every year since 2004. The total Army suicide 

rate in 2009 was 21.7 per 100,000, an increase from the 

rate of 9.8 per 100,000 observed at the beginning of 

hostilities in 2001.1

This chapter first describes the history of suicide 

prevention in the Army, then delineates current initiatives and some recent results of the Epidemiological 

Consultation Teams, and provides a theater update. 

This chapter is focused mainly on the Army because 

the authors are all affiliated with that service. However, 

all the military services have robust suicide prevention 

programs and the suicide prevention managers meet 

regularly. For example, there is a regular Suicide Prevention and Risk Reduction Committee meeting, formerly 

hosted by Health Affairs and more recently by the Defense Center of Excellence. Likewise, there is an annual 

Suicide Prevention Conference, which in recent years 

has included the Department of Veterans Affairs.

HISTORY OF SUICIDE PREVENTION IN THE US ARMY

Psychological characteristics and ideas that can lead 

a soldier to engage in a heroic disregard of personal 

safety on the battlefield can also lead to self-destructive 

behaviors when not at war. In 1897, Emile Durkheim 

advanced the first theories of suicide in the military. 

He defined suicide as those cases of death that resulted 

either indirectly or directly from something that the 

victim had done, knowing that death would result 

from this action.2

 Of note were those individuals who 

were not sufficiently bound to social groups, alienated, 

and who were said to engage in egoistic suicide. At the 

opposite end of the psychological spectrum, Durkheim 

proposed the idea of altruistic suicide, said to be a result 

of excessive integration, in which individuals become 

so immersed into social groups that they lose sight of 

individuality and are willing to sacrifice themselves 

to the group’s interests, even at the cost of their own 

lives. Not surprisingly, the most common cases of 

altruistic suicide were said to occur among members 

of the military.3

The idea that at least some suicides were preventable evolved slowly throughout the 20th century. In 

the 1930s, Karl Menninger, a psychiatrist, wrote the 

influential book Man Against Himself,

4

 which extended 

Freud’s concept of the death instinct. In the 1950s, two 

psychologists, Norman L Farberow and Edwin S Schneidman, introduced several key concepts in suicide 

research and prevention. These concepts led to the 

opening of the Los Angeles Suicide Prevention Center, 

which provided a model for immediate consultation, 

guidance, and assistance to the suicidal person.5

This activity spurred the Los Angeles County 

coroner to first engage mental health professionals 

in determining cause of death via a “psychological 

autopsy,”6

 which is a methodology for determining 

not just how a person died, but why. It is a diligent 

process that requires gathering information from all 

available records as well as extensive interviews with 

those who knew the deceased.7 The US Army relied 

on psychological autopsies during the 1990s, but that 

process has now been replaced by the Army Suicide 

Event Report,8 which will be covered in more detail 

in this chapter. Currently, psychological autopsies are 

principally used to help determine the manner of death 

in equivocal cases, that is, when there is a question as 

to whether it was an accident, suicide, or homicide. 

The American Association of Suicidology (AAS), 

founded in 1968, was the first national organization 

aimed at understanding suicide and its prevention.9

Coincident with this national presence, publications 

dealing with the problem in the military began to appear, although no formal suicide prevention program 

was yet established.10

Army research psychologists and psychiatrists at 

the Walter Reed Army Institute of Research (WRAIR) 

in Washington, DC, became interested in the causes 

of suicide among Army personnel and began several 

influential reviews of suicide deaths.11 In 1988, Colonel Nicholas Rock published an influential 10-year 

review of suicide and suicide attempts in the Army.12

A number of articles by Dr Joseph Rothberg and others followed.13–20
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Suicide Prevention in the US Army: Lessons Learned and Future Directions

The 1980s were a time of increased interest and 

dramatic progress in military suicide prevention efforts. On November 1, 1985, the Department of the 

Army (DA) published DA Pamphlet (PAM) 600–70, 

Guide to the Prevention of Suicide and Self-Destructive 

Behavior,

21 which discussed many of the myths of 

suicide and suggested a strategy to prevent selfdestructive behavior. This was followed on September 30, 1988, by DA PAM 600–24, Suicide Prevention 

and Psychological Autopsy,

22 which detailed many of 

the principles of suicide prevention first suggested 

by Farberow and Schneidman, and later the AAS. 

This pamphlet set forth policy and procedures for 

establishing the Army Suicide Prevention Program 

(ASPP) and conducting psychological autopsies. It 

provided guidance for all suicide-prevention activities of the Army and it also provided the rationale, 

circumstances of use, and guidance for reporting 

psychological autopsies. 

In 1999, the Army contracted with the AAS to 

produce Suicide Prevention: A Resource Manual for 

the United States Army,

9

 which used principles of 

community mental health to establish prevention 

programming “intended to save lives and reduce the 

impact of self-harm behaviors using a three-tiered 

approach to achieve the best-coordinated prevention possible.”9(p3) In general, the first level—primary 

prevention—consisted of those command programs 

100

90

80

70

60

50

40

30

20

10

87

59

49 46

34

25

34 35

24

24 34 35 19 22 31 30 41 44

CY01 CY02 CY03 CY04 CY05 CY06 CY07 CY08 CY09

0 0 0 6 12 15 19 18 43

Confirmed

Pending

0

Figure 25-1. Active duty suicides in the US Army January 1, 2001, through June 15, 2009. Data includes active duty, Army 

Reserve, and Army National Guard. “Pending” data not available for 2001 through 2003.

CY: calendar year

Data source: US Army G-1, Human Resources Policy Directorate.

designed to anticipate critical junctures in a person’s 

career and make these less stressful. The next level—

secondary prevention—included those command 

programs of special support and crisis counseling 

needed when persons encounter times of crisis and 

may be helped by a caring professional. The final 

level—tertiary prevention—was designed to provide 

immediate care for a potentially life-threatening 

crisis, and required care by a mental health professional. These common suicide prevention strategies 

are still in use today. 

In December 1999, the chief of staff, US Army, 

directed a review of the ASPP. In 2000, the Army G-1 

(formerly the Army Deputy Chief of Staff for Personnel), in collaboration with the Office of The Surgeon 

General (OTSG) and the Office of Chief of Chaplains, 

completed a review and determined that the program 

was basically sound, but needed to emphasize leadership involvement and offer more advanced training. In 

2001, the Army implemented the Suicide Prevention 

Campaign Plan, which emphasizes preventive and 

intervention measures, directs commanders to take 

ownership of the program, and synchronizes and 

integrates resources at installation level. More recent 

efforts by the Army Suicide Prevention Task Force 

have built upon these actions. Despite these efforts, 

the rate of suicide in the Army has continued to rise 

(Figure 25-1).
406

Combat and Operational Behavioral Health

ARMY SUICIDE PREVENTION PROGRAM

Initiatives and Efforts to Minimize Suicidal 

Behavior 

Army G-1 

The Army G-1 is the Army’s proponent for the ASPP 

and collects demographic data on completed suicides. 

These data assist the Army G-1, commanders, program 

managers at the installation level, and “gatekeepers” 

Army-wide in the identification of trends and the 

development of new initiatives, tailored and targeted 

training, and policies to minimize suicidal behavior. 

The ASPP, as detailed in DA PAM 600-24,22 also established a Suicide Prevention Task Force at each installation. In 2006, the Army G-1 formed an “Integrated 

Product Team” to integrate and synchronize efforts 

at the Headquarters, Department of the Army level. 

The team met regularly to identify ongoing initiatives, 

gaps in resources, and trends. Of main concern was the 

implementation of tailored and targeted training for 

soldiers and leaders. 

Army programs have focused on training the 

gatekeepers—leaders, chaplains, behavioral health 

officers, and others. In the October 26, 2005, issue of 

the Journal of the American Medical Association, Mann 

and colleagues noted: 

Where the roles of gatekeepers are formalized and 

pathways to treatment are readily available, such as 

in the military, educating gatekeepers helps reduce 

suicidal behavior. Demonstration projects for other 

gatekeepers with intermediate outcome measures, 

such as referral rates and psychiatric treatment rates, 

should be conducted.23

To educate gatekeepers, the Army G-1 has contracted with outside organizations like Living Works 

Education and the QPR (Question, Persuade, Refer) 

Institute from Spokane, Washington, to provide suicide 

awareness training.

For several years, the mainstay of Army suicide 

intervention was the “Applied Suicide Intervention 

Skills Training” (ASIST) program,24 a commercial product of LivingWorks, Calgary, Alberta, Canada. In 2002, 

the Army funded service-wide ASIST workshops25

with accompanying computer interactive-training 

software. In 2005, the Army G-1 funded QPR workshops26 Army-wide to provide additional resources 

in suicide-prevention awareness training, prevention, 

intervention skills, and risk identification to installations throughout the Army. Organizations have the 

option to use the training resource that best meets their 

needs; many continue to use Living Works Education, 

which has certified over 700 “gatekeepers” in suicide 

prevention and intervention,25 as their primary training resource. In addition, QPR Institute has certified 

hundreds of trainers in suicide prevention.26

The G-1 also conducts many other training activities, to include:

	 •	 Ensuring suicide-prevention training is provided to all deployed soldiers as part of the 

deployment cycle support process.

	 •	 Revitalizing the Installation Suicide Prevention Committee/Task Force to adopt Army 

key strategies for suicide prevention and 

actively coordinate with efforts of major subordinate units.

	 •	 Developing and distributing suicide awareness cards that focus on buddy care, warning 

signs/risk factors, and resources (the card is 

a graphic training aid [GTA #12-001-01] that 

can be ordered through the installation and 

community Training Audiovisual Support 

Center). 

The Medical Command and The Surgeon General 

The OTSG and the US Army Medical Command 

(MEDCOM) support the ASPP by providing medical 

care, research and data analysis, and assessment of 

medical support systems. In 2007, OTSG established a 

dedicated Suicide Prevention Office within MEDCOM 

to ensure greater visibility of programs, obtain data, 

identify trends, and provide timely information to 

leaders. This office sought to standardize methods and 

procedures for future epidemiological consultation 

(EPICON) teams, improve behavioral health surveillance methods for postmortem review, and continue 

Department of Defense Suicide Event Reports (DoDSER) for suicide attempts and/or completions, which 

are reported to the installation suicide prevention 

program manager. However, currently its functions 

were subsumed under a new suicide surveillance cell 

managed by the former US Army Center for Health 

Promotion and Preventive Medicine (CHPPM), recently renamed Public Health Command (Provisional) 

or PHC(P). In the subsequent discussion, CHPPM will 

be used for past efforts and PHC(P) for current and 

future efforts. 

CHPPM also supported the ASPP by focusing on 

continuous research and the development of awareness and training resources. For example, during calendar year 2006, CHPPM’s main effort was to distribute 

2,000 suicide awareness training kits to chaplains. Topics in this training program include suicide awareness, 

warning signs of suicidal thinking and behavior, and 
407

Suicide Prevention in the US Army: Lessons Learned and Future Directions

intervention skills development. 

These suicide prevention activities are part of an 

ongoing effort, which includes suicide awareness 

briefings tailored for populations, tip cards, and 

warning signs and risk factors cards for distribution 

during training. CHPPM developed the acronym 

ACE — “Ask,” “Care,” and “Escort” — to serve as the 

intervention centerpiece idea to assist buddies who 

may be suicidal (Figure 25-2). “Ask” centers around 

the idea of asking the buddy about state of mind and 

whether the buddy is suicidal (ie, “Are you thinking 

about suicide?”). “Care” focuses on employing active 

listening skills and understanding the situations to 

provide the right mix of resources or help. “Escort” 

involves not leaving the buddy alone, but rather either 

escorting or finding someone to take this soldier to a 

professional for help.

Awareness is a key piece of the ASPP. CHPPM took 

the lead in promoting awareness by the development 

of posters for dissemination throughout the Regular 

Army, the Army National Guard (ARNG), and the US 

Army Reserves (USAR). In 2007, CHPPM finalized and 

initiated distribution of suicide awareness briefing 

content, via chaplains’ channels, to enhance soldiers’ 

skills in identifying personnel at risk, to assist interventions with the individual, and to provide guidance 

for referring or escorting the soldier to professional 

help. Chaplains and other facilitators can obtain all 

supporting materials (ie, tip cards, brochures, posters, 

briefings) through CHPPM’s suicide prevention Army 

Knowledge Online (AKO) Web site (https://www.

us.army.mil/suite/page/334798) and their Health Information Operations Web site (http://chppm-www.

apgea.army.mil/hio_public/orders.aspx).

MEDCOM’s Suicide Risk Management and Surveillance Office (SRMSO) managed the primary tool for 

surveillance of Army suicide, the DoDSER, which is a 

reporting and tracking mechanism for completed suicides and nonlethal events that result in hospitalization 

and/or evacuation. The original Army Suicide Event 

Report (ASER) was developed, with initial validation 

conducted by the US Army Medical Research Unit, 

Europe, as a means to track in near, real-time, suicides 

and suicidal behaviors of Army personnel within the 

US Army, Europe.27

Following the recommendation of the Mental 

Health Advisory Team (MHAT) I,28 MEDCOM issued 

a policy directing that the ASER be used throughout 

the Iraqi Theater of Operations. The SRMSO, located 

at Fort Lewis, Washington, had operational oversight 

of the ASER, and conducted routine data analyses and 

published reports of these findings. In 2008, all the 

services began using this report form, which became 

the DoDSER. The SRMSO also has responsibility for 

updating changes to the DoDSER. 

The SRMSO has directed that the DoDSER should 

be completed for all fatalities, hospitalizations, and 

evacuations where the injury or injurious intent is 

self-directed. It is not meant to replace the psychological autopsy, which is limited to fatalities in which the 

manner of death is equivocal, (eg, it is unclear whether 

it is an accident, suicide, or homicide). The DoDSER 

is available at: https://dodser.t2.health.mil/dodser/. 

(Chapter 24 in this volume discusses suicide surveillance programs.) CHPPM (now PHC [P])assumed 

operational control of the Army suicide surveillance 

program in 2009.

Chief of Chaplains

The Army Chaplaincy continues its “Strong Bonds” 

program (enriching and developing lasting relationships for both married and single personnel through 

the use of relationship-building seminars and workshops) Army-wide through the efforts of its 1,500 active 

duty chaplains and 1,200 reserve component chaplains. 

Suicide prevention awareness and intervention training continues to be its main effort in support of the 

ASPP. The Chaplaincy provides extensive counseling 

Ask your buddy

Care for your buddy

Escort your buddy

• Have the courage to ask

the question, but stay calm

• Ask the question directly,

e.g. Are you thinking of

killing yourself?

• Remove any means that

could be used for self-injury

• Calmly control the situation;

do not use force

• Actively listen to produce relief

• Never leave your buddy alone

• Escort to the chain of

command, a Chaplain,

a behavioral health

professional, or

a primary care provider

Figure 25-2. “ACE” card developed by US Army Center for 

Health Promotion and Preventive Medicine.
408

Combat and Operational Behavioral Health

to soldiers and family members, some of whom may 

need to see a mental health professional. The Office of 

the Chief of Chaplains has worked very closely with 

CHPPM to develop a standardized suicide prevention 

awareness briefing for all chaplains and leaders. This 

training support package was completed in 2007, 

and is now available to all Army chaplains. Furthermore, the ACE (Peer) Suicide Intervention Program 

for soldiers and junior leaders is now being taught at 

the Chaplain Annual Sustainment Training course. 

Approximately 200 chaplains received this training 

in 2008. 

Installation Management Command

Garrison commanders provide support to tenant 

units at the installation level. As such, they are charged 

with coordinating suicide prevention activities at the 

installation level. The Installation Management Command (IMCOM) has established the garrison director 

of human resources as responsible for ASPP execution 

at the installation levels. One of the initiatives is to 

eliminate confusion about the roles and responsibilities in support of the ASPP. Senior leaders throughout 

IMCOM support the program by engaging the leadership at the region and installation levels. An additional 

support to the Army’s ASPP is the establishment of 

community health promotion councils (CHPCs) on 

every Army installation. The Army, via Army Regulation (AR) 600-63, Army Health Promotion,

29 has directed 

each Army installation to create a CHPC. The CHPC 

will ensure a proactive, coordinated, and synchronized 

local program. It will be the responsibility of each 

CHPC to ensure that suicide prevention activities 

are carried out in accordance with guidance from the 

Army’s ASPP plan.

Army National Guard 

The ARNG coordinates extensively with the active 

Army for training and policy development, workshops, conferences, and marketing. The ARNG Suicide 

Prevention Program reflects the active Army’s program, with several differences due to the nature of the 

ARNG. The main differences and challenges involve 

data collection and availability of resources. 

Like the active Army, the ARNG program takes a 

holistic approach that addresses suicide prevention, 

intervention, and postvention. Leaders and program 

managers initiate proactive measures to prevent suicide within their states by enhancing life skills in areas 

such as alcohol and drug abuse prevention, stress and 

anger management, communication, and conflict resolution training. In addition, personnel receive training 

in suicide risk identification and learn procedures for 

crisis intervention and referral. And finally, considering the devastating impact a suicide has on those who 

knew the deceased, the ARNG suicide prevention 

program includes postvention, which is also known 

as “prevention for the next generation.”

In April 2007, the ARNG directed that all states appoint a suicide prevention program manager (SPPM) 

at each Joint Forces Headquarters. Having a program 

manager at the state level will allow a greater degree 

of suicide surveillance for states, as well as more 

accurate national oversight. The SPPM administers 

a statewide ARNG Suicide Prevention Program for 

both military and civilian leaders, managers, supervisors, soldiers, and family members. Administering 

a program of this magnitude requires coordination 

with commanders, surgeons, chaplains, personnel 

officers, mental health staff, health promotion staff, 

and public affairs personnel throughout the state, 

as well as local agencies and helping services, local 

law enforcement, civilian coroners, and hospitals. 

The SPPMs receive suicide intervention training and 

conduct suicide prevention, intervention, and postvention training and awareness activities throughout 

their respective states. 

The ARNG goal is to provide intervention skills 

training to at least one soldier per company-sized 

unit. All soldiers will receive annual suicide awareness 

training. To maximize valuable resources, the ARNG 

SPPM has compiled a directory of all ASIST-trained 

National Guardsmen to share with active Army and 

USAR. The services often collaborate to provide training to the different components. The state SPPM tracks 

and reports all attempted and completed suicides to its 

state’s Joint Forces Headquarters and to the National 

Guard Bureau SPPM. The state SPPM identifies trends 

and provides decision support when possible factors 

lead to an increase of suicides. 

The challenges inherent in collecting accurate 

data about the suspected suicide of a soldier serving 

in a traditional status (“M Day,” or one weekend a 

month) lie in the fact that the details of the suicide are 

contingent upon reports by family members, medical 

authorities, and local law enforcement investigations. 

Most ARNG soldiers who died by suicide had been 

in a traditional drilling status, rather than on active 

duty in a Title 10 status. Although AR 600-63, Army 

Health Promotion, requires a review to be conducted 

by a mental health officer for any active or reserve 

component soldier on active duty whose death meets 

specific criteria for suicide or suspected suicide,29(chap5, 

para5-8) there is no such requirement for ARNG soldiers 

not on active duty.

In addition to tracking and reporting, the ARNG 
409

Suicide Prevention in the US Army: Lessons Learned and Future Directions

differs from the active Army in terms of resources 

available. Whereas active duty soldiers deploy from 

and return to a post where all resources for support 

are usually available without charge, easily identifiable, and in a designated geographic area, the ARNG 

deploys from and returns to communities across the 

state. Resources available to each ARNG member are 

dependent on what the local community provides, and 

therefore vary from member to member. Because the 

state SPPMs are from the local community, they will 

be familiar with these local resources. They will ensure 

soldiers and families are aware of these resources and 

are able to identify problems and refer personnel in 

crisis to an appropriate source of help. This information is included in annual suicide prevention briefings 

and published in Army suicide prevention policies 

and guidelines.

An increasing number of benefits have become 

available to all ARNG soldiers. The TRICARE Transitional Assistance Membership Program is available 

for 6 months to ARNG soldiers returning from deployment, with the option to buy in to the TRICARE program for a length of time determined by the amount of 

time the soldier was deployed. In addition, all soldiers, 

regardless of whether they were ever deployed, can 

take advantage of Military OneSource (available at 

www.MilitaryOneSource.com), which will contract 

with a local mental healthcare professional to provide 

six counseling sessions at no cost to the soldier. 

The ARNG SPPM has created two suicide-prevention Web sites for soldiers and families. One is public 

and can be found at http://www.virtualarmory.

com/WellBeing/suicide. The other site is restricted to 

members of the ARNG who have a Guard Knowledge 

Online (GKO) account and password and is located at 

https://gkoportal.ngb.army.mil/C15/C5/SuicidePreventionProgram.

Army Reserves

The USAR faces all of the challenges described by 

the ARNG. Furthermore, their regions are large, and 

soldiers are often “cross-leveled” from one area of the 

country into another. Thus gathering accurate data is 

an enormous challenge. Recent initiatives in the USAR 

have included: (a) implementing suicide-awareness 

training into family programs, (b) appointing ASPP 

managers at major subordinate commands, (c) forming 

community health promotion councils, (d) developing policy guidance for referral of soldiers to mental 

health, and (e) directing chaplains to develop reporting 

requirements for suicide prevention training. 

Recent Initiatives

The Army Campaign Plan for Health Promotion, 

Risk Reduction, and Suicide Prevention 

The vice chief of staff for the Army established the 

Army Suicide Prevention Task Force (ASPTF) in March 

2009 in response to the Army’s increasing suicide rate. 

The ASPTF’s effort has resulted in approximately 250 

tasks throughout the Army that are currently being 

executed. The resultant effort of the ASPTF has been 

published as the “Army Campaign Plan for Health 

Promotion, Risk Reduction, and Suicide Prevention,” 

which is directly monitored by the vice chief of staff for 

the Army; the tasks identified will substantially change 

the way the Army provides care to its extended family. 

This campaign plan reaffirms the Army’s commitment 

to care for its greatest strategic assets—soldiers, families, and civilians. 

Behavioral and Social Health Outcomes Program

The Army has established an epidemiological surveillance program that will utilize the public health 

process approach to developing a behavioral health 

and social outcomes capability. The mission of the 

PHC(P) Behavioral and Social Health Outcomes Program is to protect combat readiness and soldier health 

by addressing psychological and social threats through 

surveillance and in-depth analysis of behavioral health 

and disease outcomes; tracking rates and changes in 

trends in deployed and nondeployed populations; 

and projecting BH epidemiology. In addition, working 

with the Army G-1, a specialized suicide analysis cell 

was funded to conduct suicide-specific analysis and 

surveillance in support of the ASPP.

In 2008, the Army contracted with the National 

Institute of Mental Health to assist the Army in a 

comprehensive research effort that will lead to better prevention strategies and fewer suicides. This 

memorandum of agreement spans over 5 years and 

represents an Army investment of $50 million. The 

Behavioral and Social Health Outcomes Program and 

National Institute of Mental Health are collaborating 

to provide and analyze these data. 

OPERATION IRAQI FREEDOM THEATER SUICIDE ASSESSMENT

The previous MHATs have reviewed the status of 

the Operation Iraqi Freedom (OIF) theater’s suicide 

prevention and surveillance program, including an 

analysis of completed suicides (see Exhibit 25-1 for 
410

Combat and Operational Behavioral Health

a discussion of the first MHAT). The MHAT V conducted a similar review of Multi-National Force-Iraq’s 

prevention and surveillance program and a detailed 

analysis of completed suicides.

A team was requested by the Multi-National 

Corps-Iraq (MNC-I) commander to do a theater 

assessment in the fall of 2007. The team worked in 

parallel with MHAT V and with information from 

the Criminal Investigations Division (CID) and a 

review by SRMSO. A detailed “Summary of Theater 

Suicides” for 2007 was presented by the forensic investigator, MNC-I CID, on October 2, 2007.30 A similar 

review, limited to Army personnel, was performed by 

the SRMSO at Fort Lewis, Washington, 2 weeks later, 

with a focus on soldiers in Iraq and Iraq suicides. 

The results of all studies are similar, and thus will be 

examined together. 

As has been consistently true for reviews going 

back as far as 20 years,12 military suicide is most often 

precipitated by the loss of a relationship—either a 

spouse or other intimate partner. The SRMSO study 

reflected that 68% of Iraq suicides had had an intimate 

relationship failure, compared to 56% of the suicides 

in the non-Iraq population. This highlights the importance of the “Dear John” letter or e-mail, or other 

messages communicating the end of a relationship, as 

an implicated factor in the deployed setting.

A second major cause implicated in suicide is loss of 

career, usually through the Uniform Code of Military 

Justice (UCMJ) or other criminal charges. Approximately 35% of Army suicide cases in the Iraqi theater 

of operations had recent UCMJ charges—higher than 

the suicides in the continental United States. The CID 

review for all services found a 24% incidence of UCMJ 

charges.30 These two factors alone—loss of relationship 

and loss of career—appear to account for the majority 

of the suicides seen in the Iraqi theater of operations.

The Iraq CID review suggests that 60% of the 2007 

suicides showed behavioral changes or signs of depression prior to their suicides. The SRSMO review of DoDSER data also suggests that a substantial percentage 

of Army personnel who commit suicide sought help: 

50% of all suicides presented to a medical treatment 

facility (MTF) for care within 30 days of the event. 

This supports research literature, which suggests that 

although people considering suicide may not be able 

to accurately identify their problems as emotional in 

nature, or marshal the right resources to help them, 

they manifest an awareness that something is wrong 

and may seek out primary care.31–35 This highlights the 

importance of suicide prevention and awareness in the 

primary care and pastoral settings. 

EXHIBIT 25-1

OPERATION IRAQI FREEDOM AND SUICIDE PREVENTION

In 2003, the Office of The Surgeon General (OTSG) deployed a Mental Health Advisory Team (MHAT) to Kuwait 

and Iraq to assess soldiers’ mental health issues. Every year since then, an MHAT team has visited the theater of 

operations and produced a comprehensive report. MHAT II and V included Afghanistan. The full reports are available on the www.armymedicine.mil Web site. Recommendations that are especially relevant to suicide prevention 

include: 

1. Establishing a behavioral health consultant position in theater that will synchronize and coordinate behavioral health resources needed across the area of operations.

2. Establishing a modified theater suicide prevention program based on both current installation-based strategies and lessons learned from epidemiological consultations and MHAT visits to the theater of operations. 

These strategies include:

 a. Designating proponents to manage the suicide prevention program. (The proponent for the Operation 

Iraqi Freedom theater of operations was appointed in June 2006.)

 b. Establishing a command climate that encourages help-seeking behavior.

 c. Maintaining vigilance by leaders and soldier-peers (buddy care).

 d.Conducting continuous training throughout the deployment cycle.

 e. Implementing the surveillance of completed suicides/suicide attempts using the Army Suicide Event 

Report . 

Nonetheless, military suicide continues to be a significant problem in Iraq. Theater rates of suicide have trended 

upward since 2004, and remain elevated compared to both the total Army rate and rates observed in the civilian 

population. 
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Suicide Prevention in the US Army: Lessons Learned and Future Directions

Discussion

The US Public Health Service considers suicide 

risk and prevention in terms of relative risk factors

and protective factors for suicide.36,37 These factors have 

been adopted by the Centers for Disease Control and 

Prevention (CDC) and are used to frame the discussion of suicide in Iraq.

Risk Factors

Risk Factors most relevant to Army suicide in Iraq 

include:

1. Loss (relational, social, work, or financial). This 

has consistently been the key variable associated with suicide. It appears that long tour 

duration, in itself, does not increase rate of 

suicide, but rather serves as a secondary factor in provoking marital disruption and in 

kindling the loss of relationships.

2. Isolation, a feeling of being cut off from other 

people. The Soldier Survey assesses this directly by asking whether soldiers are “feeling 

distant or cut off from people.” Results note 

that 51.8% of all soldiers surveyed have experienced these feelings of isolation. Morale, 

Welfare and Recreation efforts to deliver mail 

and enhance Internet and phones, have probably helped, but this variable should continue 

to be monitored over time, and efforts to keep 

soldiers feeling engaged in what is going on 

“back home” should be encouraged.

3. Barriers to accessing behavioral health treatment. 

As the troop footprint in Iraq surged, the 

supply of behavioral healthcare providers in 

theater expanded less robustly in 2006 and 

2007.

4. Easy access to lethal methods. It has been proposed that the ready availability of weapons 

is a contributory factor for the elevated 

suicide rate in theater. Although firearms 

do increase the lethality of suicide attempts, 

epidemiological studies do not clearly support a finding that either gun ownership, 

in general, or living in a country that bans 

firearms result in a lower population suicide rate. Furthermore, the troops that have 

been deployed in Iraq since 2003 have had 

weapons readily available. Any rise in this 

rate cannot solely be attributed to weapons 

availability.

5. Unwillingness to seek help because of the stigma 

attached to mental healthcare. Stigma continues to be a major issue in the willingness of 

service members to seek care. Soldier and 

leader interviews indicate first-line supervisors are the primary barriers to seeking care. 

This is fueled by a perception that seeking 

behavioral healthcare is “shamming” or attempting to avoid duty. A need for further 

efforts to educate these first-line supervisors 

is indicated (Exhibit 25-2).

EXHIBIT 25-2

STIGMA ASSOCIATED WITH SEEKING 

BEHAVIORAL HEALTHCARE 

Four types of stigma are generally seen: (1) career, 

(2) leadership, (3) peer-to-peer, and (4) personal. 

Stigma was reported differently across rank groups; 

lower enlisted were more concerned about peer and 

self-perceptions, senior enlisted were most concerned about their careers and perceived leadership 

abilities.

Career

•	 On permanent record, affects future promotion and employment

	 •	 End career, lose retirement

	 •	 Lose security clearance

	 •	 “Boarded out” rather than rehabilitated

Leadership

	 •	 Some “old school,” senior NCOs, and early

promoted NCOs create/maintain stigma

	 •	 More stigma for senior enlisted, others think

they can’t lead, fear of affecting retirement

	 •	 Many squad/platoon leaders don’t support

	 •	 Treated differently; doubt “warrior” abilities;

ridicule those with a profile

Peer-to-Peer

	 •	 Peer stigma is the worst

	 •	 More stigma if never deployed

	 •	 Treated differently, ridiculed

	 •	 Gossiped about/perceived as faking

Personal

	 •	 Weak, isolated, embarrassed

	 •	 Profile makes them feel worthless

	 •	 Pride/denial

	 •	 Don’t want to be viewed as a “bad” soldier
412

Combat and Operational Behavioral Health

Protective Factors

Protective factors for suicide buffer individuals from 

suicidal thoughts and behavior. To date, protective 

factors have not been studied as extensively or rigorously as risk factors. Identifying and understanding 

protective factors is, however, equally as important as 

researching risk factors. Protective factors that act to 

reduce suicide probability in Iraq include:

1. Lack of intoxicants. Alcohol is a known risk 

factor for both civilian and military suicides. 

The relative lack of availability of intoxicants 

in the theater of operations should therefore 

act to lower the rate of suicide. It has long 

been known that intoxicants make the act of 

suicide more likely through disinhibition effects. (The National Violent Death Reporting 

System examined toxicology tests of those 

who committed suicide in 13 states, and 

33.3% tested positive for alcohol; 16.4% for 

opiates; 9.4% for cocaine; 7.7% for marijuana; 

and 3.9% for amphetamines.38)

2. Effective clinical care for mental, physical, and 

substance abuse disorders. Certain units within 

the theater of operations deployed with a 

comprehensive plan for deployment cycle 

support, and a number of best practices for 

effective soldier support, which appear to 

have produced a significant decrease in aberrant behaviors, including suicide, after the 

program was implemented.39 These results 

suggest wider adoption of the deployment 

cycle support model for the brigade combat 

team.

3. Easy access to a variety of clinical interventions 

and support for help seeking. Recent redistribution of troops in the battle space calls for 

equally agile shifts in behavioral health support, which is a strong argument for locating 

the theater mental health consultant at the 

MNC-I level. This also calls for increased efforts to destigmatize the act of seeking mental 

healthcare services.

4. Family and community support. Efforts to 

strengthen family and unit bonds should 

be encouraged, and the definition needs to 

be broadened to include significant others 

regardless of marital status.

5. Skills in problem solving and conflict resolution. 

Relationship enrichment and training, at both 

the soldier and the family readiness group 

level, designed to improve communication 

will assist in reintegration and strengthening 

relationships. All available evidence supports 

stabilizing relationships as the single most 

effective suicide prevention intervention.

6. Cultural and religious beliefs that discourage 

suicide and support instincts for self-preservation.

There have long been observed differences 

in suicide rates across gender, as well as 

racial and cultural lines.40 This illustrates 

the powerful basis of cultural beliefs for acceptable and socially appropriate behavior. 

For example, certain cultural beliefs support 

the idea of suicide in response to dishonor. 

Similar idea threads permeate the military 

culture (ie, death before dishonor, respect for 

the Samurai as portrayed in the media, popularity of movies in which suicide or death is 

seen as a logical approach to failure.) This 

opens up the possibility of “suicide-proofing” 

the military culture with carefully crafted 

messages against soldier suicide (ie, “Don’t 

let the enemy win,” “Don’t let your buddies 

down,” “Make it home alive”).

Summary of Theater Suicide Assessment

The Multi-National Force-Iraq has an active suicide 

prevention committee, chaired by the chief of clinical 

operations for the command surgeon. This has recently 

been augmented by the MNC-I Suicide Prevention 

Board, which is chaired by the corps chief of staff. The 

current suicide training program is being completely 

reconfigured into a much more robust program, which, 

once established, will require further review to gauge 

effectiveness. 

The DoDSER is being widely used in the theater by 

behavioral healthcare providers, but only for suicides 

or suicidal gestures by Army personnel. Although 

numerous service-specific mental health tracking 

systems exist, a single, joint tracking system capable 

of monitoring suicides, mental health evacuations, and 

use of mental health/combat stress control services in 

a combat environment does not exist. 

PSYCHIATRIC EPIDEMIOLOGICAL CONSULTATIONS IN THE US ARMY

Description and Background 

Sending a behavioral health EPICON team to investigate an apparent suicide cluster is an emerging 

strategy in the US Army (Table 25-1). An epidemiological consultation is analogous to any other medical consultation in that the existence of a problem is verified 

through history and examination/investigation of the 
413

Suicide Prevention in the US Army: Lessons Learned and Future Directions

Table 25-1

Common behavioral health epidemiological consultation themes

Theme

Ft 

Leonard 

Wood 

2001 

(suicide)

Ft Bragg 

2002 

(homicide)

Ft Riley 

2005 

(suicide)

Ft Hood 

2006 

(suicide)

Ft 

Campbell 

2008 

(suicide)

Ft Carson 

2009 

(homicide)

Individual Risk Factors

Deployment: length, multiple, unpredictability    

Combat intensity 

Family separation, relationship stress, lack of 

support

    

Increased violence against persons including 

spouse/family

    

Increased use of alcohol and drugs, and related 

offenses

   

Previous gestures/attempts/BH contact      

Manipulating, malingering    

Legal and financial issues     

History of misconduct 

Systems Issues

Stigma: personal, leadership, career     

Poor service delivery for dependents   

Transition, reintegration (one size fits all)     

Problems with BH services, FAP, ASAP      

Lack of standardized screening, tracking, intervention, data collection

     

Leadership/management climate      

ASAP: Army Substance Abuse Program

BH: behavioral health

FAP: Family Advocacy Program

Data source: US Army Center for Health Promotion and Preventive Medicine.

problem, a differential list of potential causes may be 

established, and data analysis is used to generate recommendations for remedy and prevention. EPICONs 

are public health investigations of clusters, outbreaks, 

or epidemics of symptoms or illnesses. They are modeled after the CDC’s “EPIAID,” which is a service that 

CDC provides to state and local health departments. 

The concepts behind an EPICON are drawn from the 

public health literature and are adapted to behavioral 

health. The EPICON mission was originally established at the WRAIR in 1969 and transferred to CHPPM 

in 1994. In the Army, EPICONs were originally limited 

exclusively to infectious diseases and environmental 

exposures. However, this mechanism was expanded to 

include clusters of behavioral health problems after an 

outbreak of suicidal behaviors at Fort Leonard Wood, 

Missouri, in 2000. 

Every suicide case in the US Army receives a thorough investigation, with participation from multiple 

organizational entities on an installation, to collect data 

to determine if current factors or conditions exist that 

may be mitigated to prevent future suicides (Figure 

25-3 and Figure 25-4). It is occasionally necessary to 

replicate this process using the population-based approaches of an EPICON to look at communities and 

organizations in a similar manner. The authors and 

others have participated in the five EPICONS that 

have been performed since 2000: (1) Fort Leonard 
414

Combat and Operational Behavioral Health Percentage of Population

Number/Severity of Risk Factors

Very Low

Risk

Lower

Risk

Average Risk Higher

Risk

Very High

Risk

 Facts

Individual

• Criminality/Misconduct

• Alcohol/Drugs

• BH Issues (untreated/undertreated)

Unit

• Turnover

• Leadership (Stigma)

• Training/Skills

Environment

• Turbulence

• Family Stress/Deployment

• Community

• Stigma

Individual, Unit, and

Environment Factors

Population Interventions

Percentage of Population

Number/Severity of Risk Factors

Very Low

Risk

Lower

Risk

Average Risk Higher

Risk

Very High

Risk

Army Campaign Plan:

• Health Promotion, Risk Reduction, and

Suicide Prevention

• Increase Resiliency

• Decrease Alcohol/Drug Abuse

• Decrease Untreated/Undertreated BH

• Decrease Stigma to Seeking Care

• Decrease Relationship/Family Problems

• Decrease Legal/Finance Issues

Installation:

• Reintegration (Plus)

 Mobile Behavioral Health Teams

 Mental Toughness Training

Resiliency Training

 Military Family Life Consultants

Decompression Reintegration

Warrior Adventure

• Consistent Stigma Reduction themes

Figure 25-3. Causal factors. Multiple individual, unit, and community factors appear to have converged to shift the population risk to the right. This would put more soldiers in the “very high risk” category, making clustering more likely.

BH: behavioral health

Figure 25-4. Suicide factors to consider. Although it is important to identify and help individual soldiers, the biggest impact 

will come from programs that shift the overall population risk back to the left. Effective medical treatment can prevent individuals from increasing in risk or decrease their risk, but it cannot shift overall population risk very much.

BH: behavioral health

Wood, Missouri, in 2000, following the deaths of two 

recruits by suicide; (2) Fort Bragg, North Carolina, in 

2003 following two murders and two murder-suicides; 

(3) Fort Riley, Kansas in 2005, following six suicides 

in 14 months; (4) Fort Hood, Texas, which had 22 suicides between 2003 and 2005, and (5) Fort Campbell, 

Kentucky, with 14 soldier suicides between 2006 and 

2007. There was an EPICON at Fort Carson, Colorado, 

in 2008, which focused on homicides, but included 

other violent crimes and suicides. At the time of this 

writing, there is another EPICON to examine suicides 

and accidental deaths in the warrior transition units. 

An EPICON may become necessary when the 

requirements for epidemiological expertise or even 

simple personnel exceed the resources of a theater or 

regional medical command. EPICON teams hold the 

benefit of bringing in new resources capable of focusing solely on the issue at hand, free of the distractions 

and demands inherent to supporting a community or 

organization. Additionally, the higher level of tasking 
415

Suicide Prevention in the US Army: Lessons Learned and Future Directions

authority associated with EPICONs may open doors 

to data sources and collaboration that are difficult to 

achieve when such investigations are conducted with 

a local approach. It is important to note that EPICONs 

are not staff assistance visits or inspections, nor are they 

research endeavors. EPICONs provide a mechanism 

to investigate a disease cluster on an urgent/emergent 

basis. They can be conducted as a public health initiative without a research protocol. The perception that 

there is a problem (eg, increased numbers of suicide 

behaviors, homicides, etc) can lead to request for an 

EPICON.

Initiation of an Epidemiological Consultation and 

Operational Support

The request for an EPICON usually originates from 

local leadership (eg, hospital, brigade, or installation 

commander). Implementing an EPICON requires extensive coordination and approval, particularly from 

the local leadership of the installation that is involved, 

as well as OTSG, MEDCOM, and other stakeholders. 

Both AR 40-5, Preventive Medicine,

41 and DA PAM 40-

11, Preventive Medicine,

42 task the commander, PHC(P), 

with the responsibility to provide EPICON support 

worldwide. PHC(P) responds to such taskings from 

MEDCOM and OTSG through the Proponency Office for Behavioral Health and the Proponency Office 

for Preventive Medicine. PHC(P) is readily able to 

assemble a team of experts (often pulling resources 

from throughout the Army) to deploy on short notice. 

All tasking should come through OTSG/MEDCOM 

for purposes of validation, command visibility, and 

resourcing approval. The process of validation is one 

that should take place between the theater or regional 

medical command and MEDCOM/OTSG. 

It may be necessary to draw on resources from 

the Armed Forces Health Surveillance Center and 

PHC(P) to analyze data in this process. Command 

interest, political pressure, and media attention may 

all influence the validation of an EPICON. The PHC(P) 

operational support section is capable of facilitating 

country clearances, travel orders, funding citations, 

travel reservations, hotel accommodations, and even 

work environment requirements such as computer 

connections, meeting room reservations, and rental 

cars. In preparing for an EPICON, it is a great help 

to prearrange for a meeting room that can accommodate the entire EPICON team during evenings and on 

weekends. This working space should have computer 

connections and the ability to accommodate screen 

projection of computer documents. 

A team leader will be selected, usually a senior 

officer. EPICONs have had teams of varying sizes 

from 4 to 14 people, composed of individuals from 

OTSG, PHC(P), the regional medical centers, installation, and subject matter experts from throughout the 

Army. The challenge is balancing the need to include 

all of the stakeholders, but not overwhelm the local 

environment. Appropriate agency representatives 

may include behavioral health, chaplains, installation 

management activity, and the G-1. The local behavioral 

health leadership should be included as much as possible, as they will need to contribute to the analysis 

and implementation of recommendations. 

The following representatives should be considered 

as members of any behavioral health EPICON team:

	 •	 team leader: senior preventive medicine officer or behavioral health specialist;

	 •	 local senior behavioral health clinician (social

work, psychology, psychiatry);

	 •	 epidemiologist with appropriate database

development support;

	 •	 chaplain;

	 •	 Army Substance Abuse Program representative;

	 •	 safety officer representative with knowledge

of Army risk reduction data;

	 •	 health risk communication specialist;

	 •	 G-1 representative; and

	 •	 unique representation depending on the

target population (such as senior noncommissioned officers, unit behavioral health specialist, division surgeon, local civilian resources, 

and unit/installation public affairs officer).

Once a team has been established, it is essential to 

formulate a schedule from which all of the team members can work. This timeline will establish the necessary planning meetings, the dates of deployment, and 

deadlines for work to be done in preparation for the 

EPICON, as well as documentation requirements. 

All members must understand the importance of 

meeting the timelines established by the EPICON 

leader. Scheduling the time for the team to visit is 

always a challenge. Most assessments have taken 1 to 

2 weeks, and may require repeated visits. An inbrief 

and outbrief must be arranged with the local installation command, and often the hospital command. 

Other important agencies with whom to communicate 

include behavioral health, chaplains, CID, and Army 

Community Services, including Family Advocacy, 

Risk Reduction Program, and the Army Substance 

Abuse Program. Clinical records, including medical, 

behavioral health, family advocacy, and substance 

abuse, should be reviewed on the index cases. Much 

of this work can be done in advance of the actual 
416

Combat and Operational Behavioral Health

EPICON visit by the installation and local MTF in 

the interest of efficiency and to maximize use of time 

on the ground once the team arrives. It would be 

helpful for all established EPICON team members to 

review previous copies of installation-level EPICONs 

conducted in the past. Such EPICONs are available 

through the PHC(P) Directorate of Epidemiology and 

Disease Surveillance. 

The content of the inbrief to be presented to the 

installation and MTF commands should be completed 

in advance of the EPICON deployment. The inbrief 

should clearly reflect the team’s understanding of the 

command’s intent for the EPICON. This will often 

include an initial hypotheses held by those who are 

at the installation. (Note that initial hypotheses are 

often wrong, but it is critical to recognize both the 

concerns and the questions asked by leadership as a 

starting point.) The inbrief should include a description of the team composition, a schedule (to include 

the outbrief date), a plan of action, and realistic requirements for support. It is important to establish a 

senior unit or installation leader to serve as a point 

of contact in advance of the EPICON’s deployment. 

Discussions prior to the visit with the point of contact 

and relevant staff will help to reduce any misunderstandings or communication shortfalls in advance of 

the prebrief to senior leadership, which is most often 

a general officer.

Epidemiological Consultation Activities on the 

Ground and Data Sources 

As previous team members have performed this 

mission, they have learned many lessons, both in the 

science and practical application of this consultative 

service. Whenever possible, the EPICON team should 

arrive at its destination on the same day. It is important 

to have a team meeting immediately after arrival to 

review the overall plan, schedule, and ground rules. 

No overt activity or interviews should be conducted 

before the command has received its prebrief and has 

given the team permission to proceed. Engaging the 

command staff early and frequently throughout the 

EPICON process can be very beneficial.

Outbreaks of completed suicides are hard to study 

because they are very rare and present challenges for 

epidemiological analysis. As of 2008, the rate in the 

US Army was 20/100,000/year. This compares to the 

demographically matched population of 20/100,000/

year. Even more rare in the Army are homicides paired 

with suicides. However, similar psychological dynamics may lead to both suicides and suicide-homicides. 

These dynamics are usually in the context of broken 

intimate relationships, with accompanying fears of humiliation, rejection, and loss. In general the motives for 

suicide and methods of suicide are reflective of the historical Army findings. The top apparent motivations 

for suicide in soldiers were found to be relationship 

failures, followed by legal and occupational difficulties 

and financial problems. Severe mental illness leading 

to suicide is rare in the military population but may occur. Among soldiers, impulsivity and substance abuse 

are more often than not contributing factors. Chronic 

pain, medical disability, and individual perceptions of 

general health all merit further analysis as risk factors 

for suicide in the military. Deaths by firearm, hanging, 

and jumping are the most common methods. All of the 

findings above mirror historical trends and substantiate the importance of looking across the spectrum of 

medical and social data on an installation during an 

EPICON. 

The following data sources have proven helpful in 

evaluating individual suicides in the military:

	 •	 medical and behavioral health records,

	 •	 ASERs,

	 •	 CID files,

	 •	 AR 15-6 (commander’s inquiry reports),

	 •	 RCA reports,

	 •	 Post-Deployment Health Assessment/PostDeployment Health Re-Assessment records,

	 •	 deployment data (date arriving and departing, location, days in theater),

	 •	 enlistment medical waiver data,

	 •	 Army Substance Abuse Program records,

	 •	 Family Advocacy Program data,

	 •	 line-of-duty reports, and

	 •	 Armed Forces Institute of Pathology data.

The most useful individual suicide data sources 

have proven to be DoDSERS, RCA reports, and CID 

reports. It is important to get the installation commander’s support to gain access to all of these data 

sources. Although the above data are useful for looking at the index cases on an installation (see following 

section on epidemiological methods), it is also useful 

to evaluate population data from the community. 

Population-based data from an installation or theater 

can reveal important information on trends related to 

leadership, morale, operations tempo, mental health 

support, alcohol-related events, domestic violence, 

and so forth. All of these are important indicators of 

the behavioral health of a community and may offer 

insight in the generation of hypotheses or reveal associations in the course of epidemiological analysis 

that lead to recommendations. 

The following are useful sources of population data 

on Army installations:
417

Suicide Prevention in the US Army: Lessons Learned and Future Directions

	 •	 installation population size and demographics (denominator data),

	 •	 installation deployment cycle and impact on

population calculations,

	 •	 behavioral health utilization and workload,

	 •	 behavioral health staffing,

	 •	 Army risk reduction data,

	 •	 Military OneSource reports,

	 •	 Army Substance Abuse Program data, and

	 •	 installation-level Family Assistance Program

data.

Additionally, it may be helpful to conduct interviews and focus groups to explore concerns of the 

soldiers (junior enlisted and junior noncommissioned 

officers), military leadership, MTF staff, communitybased agencies and installation support staff, and 

military family members or familiy readiness groups. 

Such sessions, when conducted by experienced health 

risk communications specialists, can reveal important 

information on prevailing perceptions, stigma associations, knowledge status, and morale within subpopulations on an installation. When collected early, this 

information can help guide the course of the EPICON. 

It also can be useful in targeting intervention strategies 

at the community level. 

Likewise, surveys can be of great assistance when 

applied to an appropriate number of individuals. In 

most of the EPICONs that have been completed, staff 

from WRAIR or PHC(P) performed anonymous soldier 

surveys. The surveys ask about a wide range of issues, 

including access to care and command climate. The 

most recent survey administered by PHC(P) looked 

for associations with self-reported suicidal ideation. 

Surveys contribute to the inclusion of quantifiable 

data into the report. The hardest challenge in working 

with the command is finding time for their soldiers 

to take the surveys, especially in a high operations 

tempo environment. PHC(P) has the ability to generate electronic form surveys, which can greatly reduce 

data-entry workload and errors in analysis. 

During the EPICON visit, it is essential to establish 

a close working relationship with both the MTF and 

the installation PAOs. All information released publicly 

must go through these individuals. Similarly, after the 

EPICON document summary is drafted, it must go 

through the local PAOs for review prior to the submission to command or OTSG/MEDCOM. 

While working an EPICON, it is necessary to generate daily situation reports, which must be forwarded 

to PHC(P) Operations and up to OTSG. EPICONs are 

high visibility missions with tremendous sensitivity 

to the command. The team should document each 

day’s activities (interviews, meetings, surveys, presentations) to reference in writing the EPICON final 

document. 

Methods in the Epidemiological Consultation 

Suicide outbreaks are unique from other types 

of disease outbreaks because the perception of the 

outbreak itself may lead to further cases, especially 

in an adolescent population. This characteristic must 

be taken into consideration in EPICON activities. Behavioral health assessments may use concepts from 

infectious diseases epidemiology, such as “exposure” 

to index cases, “contagion,” and “isolation.” Epidemiologic methodology in an EPICON should be guided by 

the services of an experienced epidemiologist on the 

team. Although the outline presented below is not the 

focus of this chapter, it is important to briefly discuss 

epidemiologic methods for understanding behavioral 

health EPICONS. 

During an EPICON, basic epidemiological strategies should be followed, to include: 

	 •	 defining the questions or current hypotheses

(one of these may determine if there is an 

actual outbreak), 

	 •	 conducting hypothesis-generating interviews

to broaden knowledge of the subject and what 

should be evaluated more thoroughly, 

	 •	 establishing a case definition for this public

health study, 

	 •	 conducting an investigation using epidemiological methods, 

	 •	 completing initial analysis,

	 •	 providing initial findings and recommendations to leadership, and 

	 •	 completing final analysis and write-up.

In general, epidemiologic methods of study include: 

(a) case series (clinical, forensic, etc); (b) case-control 

studies (eg, suicide cases vs controls); (c) cross-sectional 

studies (eg, compare cases with rest of battalion); (d) 

soldier surveys (usually done by WRAIR or PHC(P)); 

and (e) focus-group interviews.

The basic questions are: 

	 •	 Is there a real outbreak of suicidal behavior?

	 •	 Is the rate significantly higher than expected

(eg, when compared to like installations or the 

overall Army)? 

	 •	 What factors contributed to the outbreak

and how can they be compared against one 

another?

	 •	 What recommendations can be made to address the problem? 
418

Combat and Operational Behavioral Health

When defining inclusion criteria for cases, the team 

must determine an outbreak time frame, the individuals included, and their location. An index case definition must also describe who is not included as a case. 

An example from the Fort Campbell, Kentucky, index 

case definition is described below:

Index cases were defined as all confirmed and pending suicides occurring between January 1, 2006 and 

October 31, 2007 based on Army G-1 and Armed 

Forces Institute of Pathology (AFIP) data. There were 

a total of 14 index cases in this time period. Cases 

were restricted to active duty soldiers who were assigned to Fort Campbell, Kentucky, at time of death. 

Family member, civilian, and retiree suicides were 

not included in this analysis because of limitations to 

medical and legal data available on non–active-duty 

deaths. 

One useful tool inherent to any EPICON is an “epicurve.” Traditionally, a team shows the time course of 

an epidemic by drawing a graph of the number of cases 

by their date of onset. This graph, called an epidemic 

curve, or “epi-curve,” gives a simple visual display of 

the outbreak’s magnitude and time trend. 

Suicides and suicide rates on an installation are 

always sensitive issues. It is critical to keep the command informed of the status of the assessment. The 

command must be briefed on the results before any 

information is released outside of the command. It is 

important to clarify the level of detail (ie, full report 

or briefing slides) desired by the command.

Writing the report is a laborious and time-consuming process, especially if the team members have 

been gone for several weeks for the mission. Upon 

their return, other duties often interfere with report 

writing. Different sections of the report may be assigned to different people. It is helpful to develop 

and adhere to a time line, which is set by the senior 

officer. Another practical suggestion is that plane 

rides home should be dedicated to report writing; 

team members should ensure that computer batteries 

are charged. PHC(P) uses a standardized EPICON 

report format that may easily be transformed into a 

publishable document.

Media attention may or may not be present. There 

was intensive media attention on the Fort Bragg EPICON. The redacted report was eventually put on the 

Army medicine Web site (www.armymedicine.army.

mil). In other cases, media interest is less prominent. 

However, all team members should be reminded not 

to discuss their work with the media without appropriate clearances. 

Results and Lessons Learned

Each EPICON has led to recommendations based on 

internal assessments of the particular installation that 

was evaluated. Although each installation’s situation 

is unique, the overall recommendations will be summarized here, as the reports have had some parallel 

themes. However, it must be noted that these assessments have been performed on installations where 

there were apparent suicide clusters, and thus may not 

be indicative of Army installations as a whole. 

The common findings are: 

	 •	 there is a perceived shortage of behavioral

health assets, despite efforts of local commanders to hire more resources, 

	 •	 there is a stigma involved in seeking help,

	 •	 forward-deployed assets are more effective,

	 •	 marital therapy should be more available,

	 •	 more integration of resources is desirable,

	 •	 command is very interested in solving these

problems, and 

	 •	 the effort is essential to maintaining the

strength of the fighting force. 

Both the local and the overall command have been 

very interested in these results. In all cases commanders and the medical departments have taken the recommendations seriously. Some examples follow:

	 •	 The Fort Leonard Wood, Missouri, report led

to the expansion of the “Medical Moment 

of Truth” at the reception battalion, and to a 

reexamination of the “unit watch” protocol.

	 •	 The Fort Bragg, North Carolina, EPICON

spurred development of the Deployment 

Cycle Support program.

	 •	 The Fort Riley, Kansas, EPICON led to an

increase in marital therapy resources.

	 •	 The Fort Hood, Texas, EPICON reinvigorated

the installation-wide risk reduction committees.

	 •	 The Fort Campbell, Kentucky,EPICON recommended an improvement in the quality of the 

“risk reduction” data.

SUMMARY

Suicide prevention is a continuing challenge. The 

rate continues to increase, despite development and 

use of educational and training materials. The behavioral health epidemiological consultation process is 
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a useful method of assessing clusters of suicides and 

suicidal behaviors. The results help to guide both installation and Army-wide efforts to focus on gaps in 

outreach, education, and treatment.

There are caveats, however. It is notoriously difficult 

to measure the effectiveness of any suicide prevention 

program. Because the focus is often on completed suicides, it is not known how many have been prevented 

via proactive measures by the command and staff. 

Additionally, the suicide rates are not necessarily a 

good marker of the mental health of the force. There 

are other instruments available to assess effectiveness of suicide prevention programs and the quality 

of services delivered. These include, for example, the 

DoDSER, unit surveys, and gatekeeper training.

Suicide affects the psychological and physical health 

of soldiers, units, family members, and friends. The 

approach to prevention, intervention, and postvention 

must be an integrated, multifactorial endeavor involving all levels of the command and family resources. The 

information presented here illustrates the current initiatives, many of which were developed from lessons 

learned in the past. Building products and strategies 

based on those lessons should enhance the ability to 

save lives in the future. 

The rate of suicides has doubled in the Army in the 

last 6 years. Every suicide is a tremendous tragedy, for 

the soldier, for the family, and for the Army. Risk factors for suicide include a break-up in a relationship and 

trouble at work. Medical issues, especially chronic pain 

or disability, may precipitate a suicide attempt. Alcohol 

abuse can disinhibit someone in many ways and result 

in self-injury. In recent years, there has been a rise of 

suicides in senior noncommissioned officers, senior 

officers, female soldiers, and soldiers in the warrior 

transition units. Medical soldiers are not immune.

There are numerous educational resources for 

soldiers and families detailing suicide awareness and 

intervention for someone in trouble. To take care of 

fellow soldiers (“Ask, Care, and Escort”), ask about 

their issues, take care of them, and do not leave them 

alone. Get them to a chaplain, a medic, combat stress 

control, or their command. “Shoulder to shoulder: No 

Soldier stands alone.”

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