“Medically Ready Force…Ready Medical Force” DCoE Summit The Incidence of Suicide in the US Armed Forces: Select Findings from the Department of Defense Suicide Event Report (DoDSER) Larry D. Pruitt, Ph.D., Derek J. Smolenski, Ph.D., MPH, & Nigel E. Bush, Ph.D. National Center for Telehealth and Technology “Medically Ready Force…Ready Medical Force”

“Medically Ready Force…Ready Medical Force” Disclosure The views expressed in this presentation are those of the presenter and do not reflect the official policy of the Department of Defense or the U.S. Government. I have no relevant financial relationships to disclose. I do not intend to discuss devices, products or procedures which are off-label, unlabeled, experimental, and/or not FDA approved. “Medically Ready Force…Ready Medical Force”

“Medically Ready Force…Ready Medical Force” Learning Objectives At the conclusion of this presentation the participants will be able to: Discuss the rates and risk factors associated with Service members that die by suicide. Interpret how the occurrence of suicide differs between the U.S. general population and the Services. Assess risk and plan interventions based on current risk factors affecting the Service member population. “Medically Ready Force…Ready Medical Force”

“Medically Ready Force…Ready Medical Force” Biography Larry D. Pruitt, Ph.D. Program Lead for the DoD Suicide Event Reporting (DoDSER) system Licensed Clinical Psychologist in the Research Division at T2 Ph.D. in Clinical Psychology from the University of Nevada, Reno, including a clinical internship at the Sierra Nevada VA Medical Center “Medically Ready Force…Ready Medical Force”

“Medically Ready Force…Ready Medical Force” T2 & DCoE The National Center for Telehealth & Technology Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury DHA Healthcare Operations Our Mission: To lead the innovation of health technology solutions for psychological health and traumatic brain injury, and deliver tested, valued health solutions that improve the lives of our nation’s warriors, veterans and their families. Our vision is world-class health care and optimized health in the DoD through effective leveraging of behavioral science and technology. “Medically Ready Force…Ready Medical Force”

“Medically Ready Force…Ready Medical Force” T2 Web Presence afterdeployment.dcoe.mil militarykidsconnect.dcoe.mil dodser.t2.health.mil startmovingforward.dcoe.mil militaryparenting.dcoe.mil familiesnearandfar.org “Medically Ready Force…Ready Medical Force” Source: http://www.t2health.dcoe.mil

“Medically Ready Force…Ready Medical Force” T2 mobile Applications Twenty T2 mobile applications as they appear on a mobile device “Medically Ready Force…Ready Medical Force” Source: http://www.t2health.dcoe.mil

A Day in the Life of T2 Applications 1,200 website visits 2,500 mobile apps downloaded 10,000 times mobile apps used Daily use of T2’s mobile health products “Medically Ready Force…Ready Medical Force” Source: http://www.t2health.dcoe.mil

“Medically Ready Force…Ready Medical Force” Research Endeavors Telehealth Can tele-mental health be delivered directly to the home? Can telehealth save money? Mobile Health Can an ‘app’ really collect accurate psychological screening information? Can internet-based self-care solutions for PTSD actually reduce symptoms? Emerging Technologies Is virtual reality exposure therapy better than the standard treatment for PTSD? Suicide Can a smartphone app improve clinical treatments for suicide behaviors? Is mild TBI associated with military suicides? “Medically Ready Force…Ready Medical Force”

“Medically Ready Force…Ready Medical Force” Logo for DoD Suicide Event Report “Medically Ready Force…Ready Medical Force” Source: http://www.t2health.dcoe.mil/programs/DoDSER

Healthy Warrior Effect U.S. Armed Forces’ suicide rates have traditionally been lower than the general population (Eaton et al., 2006) Service Member Population: - Is employed - Meets basic educational and intellectual standards - Participates in routine physical conditioning - Has access to health care services - Passes basic enlistment criteria The General Population: - Includes the unemployed and those without housing and other resources - Includes those with severe psychiatric disorders - Includes teens and elderly individuals - Includes other cohorts with known risk profiles for suicide “Medically Ready Force…Ready Medical Force”

“Medically Ready Force…Ready Medical Force” Changing Landscape Army suicide rates decreased significantly during WW I and II (Rothberg et al., 1987) No evidence of an increase in suicide during Korean War or Vietnam War eras Suicide rates among U.S. Service members have increased significantly between Vietnam era and Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) (Reger, et al., in press) This increase during OEF/OIF has puzzled researchers Contrasts with Healthy Warrior Effect by violating expectations of occurrence “Medically Ready Force…Ready Medical Force”

Unadjusted Suicide Rates 2008-2014 Suicides per 100,000 Service members Unadjusted Suicide Rates 2008-2014 “Medically Ready Force…Ready Medical Force” Source: http://www.t2health.dcoe.mil/programs/DoDSER

Unadjusted Suicide Rates 2008-2014 Suicides per 100,000 Service members Unadjusted Suicide Rates 2008-2014, by Service “Medically Ready Force…Ready Medical Force” “Medically Ready Force…Ready Medical Force” 14 Source: http://www.t2health.dcoe.mil/programs/DoDSER

“Medically Ready Force…Ready Medical Force” A Need for Better Data DoD Suicide Event Report (DoDSER) System: - A web-based application to collect standardized DoD suicide surveillance data. DoDSER Annual Report: - A congressionally reviewed report that characterizes and contextualizes Service member suicide data to inform decision makers. “Medically Ready Force…Ready Medical Force” Source: https://dodser.t2.health.mil

DoDSER Data Collection Process “Medically Ready Force…Ready Medical Force”

Select Findings CY 2014 DoDSER Annual Report “Medically Ready Force…Ready Medical Force”

“Medically Ready Force…Ready Medical Force” CY 2014 Suicide Rates 438 deaths due to suicide 269 Active Component suicides 169 Reserve Component suicides 80 deaths in the Reserves 89 deaths in the National Guard Combined Active Component Compared to Combined Reserves Rates per 100,000 “Medically Ready Force…Ready Medical Force” Source: http://www.t2health.dcoe.mil/sites/default/files/CY-2014-DoDSER-Annual-Report.pdf

Active Component Demographic Risk Factors Rate Per 100,000 SMs Age Ethnicity Race Sex “Medically Ready Force…Ready Medical Force” Source: http://www.t2health.dcoe.mil/sites/default/files/CY-2014-DoDSER-Annual-Report.pdf

Active Component Demographic Risk Factors Rate Per 100,000 SMs Marital Status Education Rank “Medically Ready Force…Ready Medical Force” Source: http://www.t2health.dcoe.mil/sites/default/files/CY-2014-DoDSER-Annual-Report.pdf

“Medically Ready Force…Ready Medical Force” Method of Suicide 68.3% of SM suicides were due to injuries caused by firearms 92.2% of these firearms were personal possessions 7.3% of these firearms were military issued Firearm(s) present in the immediate environment of 63.1% of decedents DoDSER 2014 Suicide Methods, by Service “Medically Ready Force…Ready Medical Force” Source: http://www.t2health.dcoe.mil/sites/default/files/CY-2014-DoDSER-Annual-Report.pdf

Methods for Attempted Suicide Most frequent methods for attempting suicide were Drug overdose (56.2%) Sharp or blunt objects (13.9%) Asphyxiation (11.5%) DoDSER 2014 Suicide Attempt Method, by Service “Medically Ready Force…Ready Medical Force” Source: http://www.t2health.dcoe.mil/sites/default/files/CY-2014-DoDSER-Annual-Report.pdf

Health Care Utilization Prior to Suicide 60.9% of decedents had engaged medical, behavioral health, or support services within the 90 days prior to their death. Known Treatment History, 90 Days Prior to Suicide CY 2012 CY 2013 CY 2014 Reported categories are not mutually exclusive “Medically Ready Force…Ready Medical Force” Source: http://www.t2health.dcoe.mil/sites/default/files/CY-2014-DoDSER-Annual-Report.pdf

Behavioral Health History 49.8% of suicides had a history of at least one behavioral health disorder 14.2% had a history of major depressive disorder 9.9% were known to have a diagnosis of PTSD 49.1% had no known history of a behavioral health disorder Known History of Behavioral Health Disorder CY 2012 CY 2013 CY 2014 Reported categories are not mutually exclusive “Medically Ready Force…Ready Medical Force” Source: http://www.t2health.dcoe.mil/sites/default/files/CY-2014-DoDSER-Annual-Report.pdf

Communicated Potential for Self-Harm 29.2% of decedents made a known communication of potential for self-harm prior to the event Verbal – 68.3% Text – 31.7% Written – 7.3% Other – 7.3% Recipients of Communication Prior to Suicide CY 2012 CY 2013 CY 2014 Reported categories are not mutually exclusive “Medically Ready Force…Ready Medical Force” Source: http://www.t2health.dcoe.mil/sites/default/files/CY-2014-DoDSER-Annual-Report.pdf

Psychosocial Stressors Relationships 36.7% of decedents had a failed intimate partner relationship within 90 days prior to suicide Comparable proportion for suicide attempts (38.7%) Family or Relationship Stressors 90 Days Prior to Suicide CY 2012 CY 2013 CY 2014 Reported categories are not mutually exclusive “Medically Ready Force…Ready Medical Force” Source: http://www.t2health.dcoe.mil/sites/default/files/CY-2014-DoDSER-Annual-Report.pdf

Psychosocial Stressors Legal & Administrative Problems At least one known legal/admin. problem in 32.7% of cases Civil legal problems the most frequent legal issues among decedents Article 15/NJP the most frequent legal issues among suicide attempts Legal/Administrative Stressors 90 days Prior to Suicide CY 2012 CY 2013 CY 2014 Reported categories are not mutually exclusive “Medically Ready Force…Ready Medical Force” Source: http://www.t2health.dcoe.mil/sites/default/files/CY-2014-DoDSER-Annual-Report.pdf

Operational Deployment 54.4% of decedents had a history of at least one deployment to OEF and/or OIF/OND 1 Deployment 20.9% 2 Deployments 17.1% 3+ Deployments 16.4% Known Combat History Prior to Suicide Suicides on Deployment “Medically Ready Force…Ready Medical Force” Source: http://www.t2health.dcoe.mil/sites/default/files/CY-2014-DoDSER-Annual-Report.pdf

Unadjusted Suicide Rates 2008-2014 Revisited Suicides per 100,000 Service members “Medically Ready Force…Ready Medical Force” Source: http://www.t2health.dcoe.mil/sites/default/files/CY-2014-DoDSER-Annual-Report.pdf

Comparison to the U.S. Population DoD Populations are predominantly young and male General population of the U.S. is much more evenly distributed To compare these groups directly, that difference must be accounted for U.S. Population DoD Age and sex distributions of the U.S. Population and the DoD Population “Medically Ready Force…Ready Medical Force” Source: www.cdc.gov/injury/wisqars

Adjusted Suicide Rate, DoD 2012-2014 “Medically Ready Force…Ready Medical Force” Source: http://www.t2health.dcoe.mil/sites/default/files/CY-2014-DoDSER-Annual-Report.pdf

Adjusted Rates, by Service 2012-2014 “Medically Ready Force…Ready Medical Force” Source: http://www.t2health.dcoe.mil/sites/default/files/CY-2014-DoDSER-Annual-Report.pdf

“Medically Ready Force…Ready Medical Force” Summary Most common demographic profile: Young, white, males, high-school educated, enlisted Suicide rates in CY 2014 were not statistically different from the age- and sex-adjusted suicide rates of the U.S. population The rate of suicide for the Active Component, all Services, was 19.9 per 100,000 Service members Air Force: 18.5 per 100,000 Service members Army: 23.8 per 100,000 Service members Marine Corps: 17.9 per 100,000 Service members Navy: 16.3 per 100,000 Service members “Medically Ready Force…Ready Medical Force”

“Medically Ready Force…Ready Medical Force” Summary Continued Non-military firearms continue to be the most common method for suicide (62.9%) Drug overdose continues to be the most common method of suicide attempt (57%) Half of decedents had a diagnosed behavioral health condition Many attended a health care appointment shortly before their death Most common stressors included failed relationships and civil legal proceedings “Medically Ready Force…Ready Medical Force”

“Medically Ready Force…Ready Medical Force” CY 2015 DoDSER Currently under review for public release Cover of the CY 2015 DoDSER Annual Report “Medically Ready Force…Ready Medical Force”

“Medically Ready Force…Ready Medical Force” References Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. (2005). Web-based Injury Statistics Query and Reporting System (WISQARS). Retrieved from www.cdc.gov/injury/wisqars. Eaton, K. M., Messer, S. C., Garvey Wilson, A. L., & Hoge, C. W. (2006). Strengthening the Validity of Population‐Based Suicide Rate Comparisons: An Illustration Using US Military and Civilian Data. Suicide and Life-Threatening Behavior, 36(2), 182-191. Pruitt, L.D., Smolenski, D., Reger, M., Bush, N., Skopp, N., & Campise, R.L. (2016). Department of defense suicide event report – calendar year 2014 (Publication No. 6-9C3997A). Retrieved from: http://www.t2health.dcoe.mil/programs/dodser Reger, M.A., Reger, G.M., Krieg, C., Pruitt, L.D., Smolenski, D.J., Skopp, N.A., & Bush, N. (In Press). What’s changed? A comparison of army suicide surveillance data to cases from 1975-1982. Suicide and Life-Threatening Behavior. Rothberg, J. M.., Jones, F. D. (1987). Suicide in the U.S. Army: Epidemiological and Periodic Aspects. Suicide and Life Threatening Behavior, 17(2), 199-132. “Medically Ready Force…Ready Medical Force”

“Medically Ready Force…Ready Medical Force” Contact Information Larry Pruitt, Ph.D. National Center for Telehealth & Technology Joint Base Lewis McChord, WA Larry.d.pruitt21.civ@mail.mil http://www.t2health.dcoe.mil/programs/dodser “Medically Ready Force…Ready Medical Force”