April 15, 2015: Military statisticians, analysts and epidemiologists (experts on medical statistics) have long sought to convince people outside the military that the rise in suicide rates within the military had little to do with the stress of combat and mostly to do with the stresses of military life for all those in uniform during wartime. Recent studies of four million military personnel who served in Iraq and Afghanistan confirmed that there was no relationship between exposure to combat and changes in the suicide rate. What was found was a connection with the percentage of people getting out of the military and their problems with readjusting to civilian life. This process takes people from a disciplined lifestyle where everyone feels they are performing an important job, whether or not they are in combat, to a very different environment. Civilian life, in contrast, is more chaotic and seems less meaningful. The impact of that change appears to contribute more to suicides than the stress of being in a combat zone.

For example, among the four million people studied some 32,000 died while in service, about 15 percent because of suicide. Only 22 percent of those who committed suicide had served in Iraq or Afghanistan. A disproportionate number of suicides occurred in the year before leaving the military and investigations of these deaths indicated that most were the result of the psychological stresses associated with leaving the service. Some, not all, of those in combat demonstrated links between combat stress and suicide.

In other words, the increased suicides were not concentrated among the combat veterans (who make up less than 15 percent of those in the military) but more evenly distributed among all service personnel. For example, 77 percent of suicides were among troops who had never gone overseas. The military, especially the army, has long documented all deaths and a 2013 Department of Defense study of all suicides from 2001-2008 (when the heavy fighting in Iraq ended) indicated there was no link between combat stress and suicide.  A similar study of 2009-2012 suicides showed the same pattern. Researchers didn’t expect the trends for causes (which remained consistent through 2001-2008) to change. The researchers also point out that the reasons for suicides in the military are quite similar to those for civilian suicides, especially when victims are of the same age, education, and other factors as their military counterparts.

These revelations were not well received by the mass media in the United States, which makes much of the rising suicide rate in military (but pays less attention to rising suicide rates among civilians of the same age and education). The military suicide rate was 9 per 100,000 in 2001 and 17.5 in 2012. This was declared to be a health emergency, and to a certain degree it was. What was missed in all the discussion was the higher suicide rate in the army was far below the rate for civilians of military age (17-60), which was 25 per 100,000.

The fact of the matter is that the military seeks to recruit only people who have an above average ability to deal with stress, especially for the minority headed for combat jobs. It’s not just combat stress the military worries about but stresses suffered by all the troops doing civilian type jobs but often under stressful (combat zone) conditions. It has long been known that most military suicides were men and women who were never in combat or even overseas. But since the military suicide rate is so much lower than those of comparable civilians, it hardly matters. There are so few actual suicides in the military each year that a few soldiers having family problems can cause the rate to seemingly spike. That’s largely what has been happening.

The military has been doing a lot to keep their suicide rate down. That rate peaked at 23 in 2009, and then declined. Some of the increase was from the impact of so many troops suffering from PTSD (post-traumatic stress disorder), but the new study shows that this was a small factor in suicides. The danger of suicide led to many PTSD sufferers, or those who might have it, to be given anti-stress medications. Use of these medicines increased 76 percent between 2001 and 2009. By then, some 17 percent of all troops took these drugs, including six percent of those in combat zones. In 2001, the troops used these drugs to about the same degree as the civilian population (ten percent).

The losses to stress have been growing in the last decade. For example, for every soldier killed in a combat zone, one is sent back home for treatment of acute stress. Most of these are not combat troops. For every one of those cases there are several less serious ones that are treated in the combat zone. Many of these stressed troops are no longer able to perform all their duties. This is sometimes the case with troops taking anti-stress drugs. Some of these medications slow you down, which can be fatal if you find yourself in combat or an emergency situation. Many troops on these medications are no longer sent overseas. They can perform well back in the United States but this complicates the job of finding enough troops to go perform combat jobs.

Problems with stress and mental health in general were seen as an inevitable result of so many NCOs and officers doing their third or fourth combat tours (in Iraq or Afghanistan). Thus, a PTSD epidemic has been created by the unprecedented exposure of so many troops to so much combat in so short a time. Once a soldier has PTSD they are often no longer fit for combat, and many troops headed for Afghanistan after 2008 fell into this category. PTSD makes it difficult for people to function or get along with others. With treatment (medication and therapy) you can recover from PTSD. But this can take months or years.

Nearly a century of energetic effort to diagnose and treat PTSD (including much recent attention to civilian victims stressed via accidents or criminal assault) made it clear that most troops eventually got PTSD if they were in combat long enough. During World War II it was found that, on average, 200 days of combat would bring on a case of PTSD for your average American soldier. After World War II methods were found to delay the onset of PTSD (more breaks from combat, better living conditions in the combat zone, prompt treatment when PTSD was detected). That's why combat troops in Iraq and Afghanistan often slept in air conditioned quarters, had Internet access, a lot of amenities, and a two week vacation (anywhere) in the middle of their combat tour. This extended their useful time in combat, before PTSD set in. No one is yet sure what the new combat days average is, and new screening methods are an attempt to find out. But more troops appear to be hitting, or approaching, the limits.

What the army does know is that a large percentage of its combat troops serving in Iraq and Afghanistan have had over 200 days of combat. Some have three or four times that. A major reason for army generals talking (starting in 2007) about the army "needing a break" (from combat) was the growing loss of many combat experienced troops and leaders (especially NCOs) to PTSD. The army won't give out exact figures, partly because they don't have much in the way of exact figures. But over the next decade, the army will get a clearer picture of how well they have coped with PTSD among troops who have, individually, seen far more combat than their predecessors in Vietnam, Korea, or World War II.

The army is dealing with PTSD and combat stress head on, believing that a lot of troops have experienced an unhealthy amount of combat stress. Experience so far has shown that PTSD can be delayed, perhaps for a long time. When a soldier does come down with it, PTSD can often be treated and its effects reversed. This has large ramifications for non-military medicine, for many civilians suffer from PTSD. That's why military recruits are screened for their ability to handle stress and resist PTSD. In the civilian community, there are far more people who can acquire PTSD after exposure to much less stress.