Demographic and Occupational Risk Factors Associated With Suicide-Related Aeromedical Evacuation Among Deployed U.S. Military Service Members

Casey L Straud; Brian A Moore; Willie J Hale; Lt Col Monty Baker; Lt Col Cubby L Gardner; Col Antoinette M Shinn; Jeffrey A Cigrang; Brett T Litz; Jim Mintz; Jose M Lara-Ruiz; COL Stacey Young-McCaughan; Lt Col Alan L Peterson; for the STRONG STAR Consortium

doi:10.1093/milmed/usaa201

. 2020 Dec 30;185(11-12):e1968–e1976. doi: 10.1093/milmed/usaa201

Demographic and Occupational Risk Factors Associated With Suicide-Related Aeromedical Evacuation Among Deployed U.S. Military Service Members

Casey L Straud ^1,², Brian A Moore ³, Willie J Hale ^4,⁵, Monty Baker ⁶, Cubby L Gardner ⁷, Antoinette M Shinn ⁸, Jeffrey A Cigrang ⁹, Brett T Litz ^10,^11,¹², Jim Mintz ¹³, Jose M Lara-Ruiz ¹⁴, Stacey Young-McCaughan ¹⁵, Alan L Peterson ^16,^17,¹⁸; for the STRONG STAR Consortium

¹ Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, 7550 Interstate Highway 10 West, Suite 1325, San Antonio, TX 78229

² Department of Psychology, University of Texas at San Antonio, One UTSA Circle, San Antonio, TX 78249

³ Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, 7550 Interstate Highway 10 West, Suite 1325, San Antonio, TX 78229

⁴ Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, 7550 Interstate Highway 10 West, Suite 1325, San Antonio, TX 78229

⁵ Department of Psychology, University of Texas at San Antonio, One UTSA Circle, San Antonio, TX 78249

⁶ Wilford Hall Ambulatory Surgical Center, JBSA-Lackland, 2200 Bergquist Drive, San Antonio, TX 78236

⁷ Wilford Hall Ambulatory Surgical Center, JBSA-Lackland, 2200 Bergquist Drive, San Antonio, TX 78236

⁸ Wilford Hall Ambulatory Surgical Center, JBSA-Lackland, 2200 Bergquist Drive, San Antonio, TX 78236

⁹ School of Professional Psychology, Wright State University, 3640 Colonel Glenn Hwy, Dayton, OH 45435

¹⁰ Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, 150 South Huntington Avenue, Jamaica Plain, Boston, MA 02130

¹¹ Department of Psychiatry, Boston University School of Medicine, 720 Harrison Avenue, Boston, MA 02118

¹² Department of Psychological and Brain Sciences, Boston University, 64 Cummington Mall, Boston, MA 02215

¹³ Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, 7550 Interstate Highway 10 West, Suite 1325, San Antonio, TX 78229

¹⁴ Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, 7550 Interstate Highway 10 West, Suite 1325, San Antonio, TX 78229

¹⁵ Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, 7550 Interstate Highway 10 West, Suite 1325, San Antonio, TX 78229

¹⁶ Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, 7550 Interstate Highway 10 West, Suite 1325, San Antonio, TX 78229

¹⁷ Department of Psychology, University of Texas at San Antonio, One UTSA Circle, San Antonio, TX 78249

¹⁸ Office of Research and Development, South Texas Veterans Health Care System, 7400 Merton Minter Boulevard, San Antonio, TX 78229

This manuscript was previously presented as a poster at the 34th annual meeting of the International Society of Traumatic Stress Studies, Washington, DC, November 2018.

The views expressed herein are solely those of the authors and do not reflect an endorsement by or the official policy or position of the U.S. Air Force, the Department of Defense, the Department of Veterans Affairs, or the U.S. Government.

PMCID: PMC7980481 PMID: 32776113

ABSTRACT

Introduction

Suicide is a significant problem in the U.S. military, with rates surpassing the U.S. general population as of 2008. Although there have been significant advances regarding suicide risk factors among U.S. military service members and veterans, there is little research about risk factors associated with suicide that could be potentially identified in theater. One salient study group consists of service members who receive a psychiatric aeromedical evacuation out of theater. The primary aims of this study were as follows: (1) determine the incidence of suicide-related aeromedical evacuation in deployed service members, (2) identify demographic and military characteristics associated with suicide-related aeromedical evacuation, and (3) evaluate the relationship between suicide-related aeromedical evacuation from a deployed setting and military separation.

Materials and Methods

This was an archival analysis of U.S. Transportation Command Regulating and Command and Control Evacuation System and Defense Manpower Data Center electronic records of U.S. military service members (N = 7023) who were deployed to Iraq or Afghanistan and received a psychiatric aeromedical evacuation out of theater between 2001 and 2013. χ² tests of independence and standardized residuals were used to identify cells with observed frequencies and proportions, respectively, that significantly differed from what would be expected by chance. In addition, odds ratios were calculated to provide context about the nature of any significant relationships.

Results

For every 1000 psychiatric aeromedical evacuations that occurred between 2001 and 2013, 34.4 were suicide related. Gender, ethnicity, branch of service, occupation classification, and deployment theater were associated with suicide-related aeromedical evacuation (odds ratios ranged from 1.37 to 3.02). Overall, 53% of all service members who received an aeromedical evacuation for any psychiatric condition had been separated from the military for a variety of reasons (both voluntary and involuntary) upon record review in 2015. Suicide-related aeromedical evacuation was associated with a 37% increased risk of military separation compared to evacuation for another psychiatric condition (P < 0.02).

Conclusions

Findings provide novel information on risk factors associated with suicide-related aeromedical evacuation as well as military separation following a suicide-related aeromedical evacuation. In many cases, the psychiatric aeromedical evacuation of a service member for suicidal ideations and their subsequent separation from active duty is in the best interest of the individual and the military. However, the evacuation and eventual military separation can be costly for the military and the service member. Consequently, the military should focus on indicated prevention interventions for individuals who show sufficient early signs of crisis and functional problems so that specialized interventions can be used in theater to prevent evacuation. Indicated prevention interventions should start with leaders’ awareness and mitigation of risk and, when feasible, evidence-based interventions for suicide risk provided by behavioral health (eg, brief cognitive behavioral therapy for suicide). Future research should evaluate the feasibility, safety, and efficacy of delivering suicide-related interventions in theater.

INTRODUCTION

Every 26 seconds, someone in the United States (U.S.) attempts suicide.¹ Suicide is the 10th leading cause of death in the U.S. and approximately 50,000 individuals die by suicide each year.² The average rate of suicide in the U.S. is 14.5 per 100,000, and this number has continued to increase in recent years.³ Although the military has historically experienced lower suicide rates compared to the U.S. general population, research has found that suicide risk has become considerably greater among U.S. active duty military service members, with suicide rates surpassing the U.S. general population as of 2008.^4–7 In fact, at the height of the troop drawdown from Afghanistan, suicide was identified as the second-leading cause of death in the U.S. military.⁸ According to the Department of Defense Suicide Event Report, the recent prevalence of suicide across military branches has ranged from 19 to 36 per 100,000 service members, which is substantially higher than the U.S. general population.⁹ Given the rising incidence of suicide in the military, it is imperative to identify risk factors for suicidality so that individuals can receive preventative care before crisis, despair, and hopelessness arise.

Research has identified a number of factors associated with suicide risk among active duty military service members. Studies investigating demographic risk factors have largely found that service members who die by suicide are more likely to be younger in age (17–24), Caucasian, junior enlisted, and male.⁶^,^10–14 Individuals with lower education and who have never married are also at elevated risk of suicidality.¹⁵ However, further evaluation of such demographic risk factors has identified nuanced associations. For example, although men are at greater risk for death by suicide, women are more likely to attempt suicide and endorse suicidal ideation.¹⁶^,¹⁷ Gender differences in suicide also shrink substantially during a deployment. A recent study found that suicide risk disproportionately increases among females in comparison to males during deployment.⁶

Epidemiological studies have not shown a consistent association between deployment-related factors (eg, combat exposure, length of deployment, and number of deployments) and suicide deaths despite elevated risk of suicidality during deployment.¹⁸^,¹⁹ This may be, in part, because of suicide screening procedures during the predeployment medical screening process. However, it is also likely the case that the relationship between suicide and deployment is more complex and nuanced. For instance, evidence suggests that the type of combat exposure (eg, witnessing atrocities, killing in combat, and moral injury) is related to increased suicide risk.^20–22 Similarly, deployment to a combat zone has been identified as a factor associated with elevated risk of suicide.²³ Social, occupational, and personal factors during deployment (eg, poor unit cohesion and life events) have also been linked to suicide risk. In one study,²⁴ service members with greater combat exposure demonstrated lower levels of suicidal ideation when they reported higher levels of unit cohesion, highlighting the importance of considering social factors as a buffer from combat stress. In addition, the occurrence of major life events (e.g, divorce and recent loss of rank) during a deployment has been shown to increase vulnerability and suicide risk.¹³ Personal characteristics such as current mental health diagnosis, adverse childhood experiences, and history of mental health problems have also been identified as risk factors related to successful suicide among Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) service members.^25–27 Not surprisingly, access to firearms is another factor associated with increased suicide risk in the military.²⁸

Although there have been significant advances regarding suicide risk factors among U.S. military service members, a majority of these findings are based on postdeployment research.²⁹^,³⁰ Limited studies have directly evaluated risk factors for suicide during deployment while in theater.^31–34 One salient group that may help to address this topic area consists of service members who receive a psychiatric aeromedical evacuation out of theater. Previous research has reported that approximately 10% of service members aeromedically evacuated out of Iraq or Afghanistan were medically transported for psychiatric reasons.³⁵^,³⁶ Service members who received a psychiatric aeromedical evacuation were more likely to be female, enlisted, younger, and persons of color.^37–40 Furthermore, the decision to aeromedically evacuate a service member for psychiatric reasons is also related to significant long-term consequences. Approximately 53% of individuals who received a psychiatric aeromedical evacuation subsequently separated from the military for voluntary and involuntary reasons.³⁷ This study also found that individuals who were separated because they were “Unqualified for Active Duty” were more than 4 times as likely to have received a psychiatric aeromedical evacuation.

Overall, further evaluation on the incidence of suicide-related aeromedical evacuation may better inform the conceptualization of suicide in the military. Further identification of suicide-related psychiatric aeromedical evacuation trends may provide novel information on risk factors related to suicide to better inform prevention and intervention strategies. Finally, it is important to evaluate the relationship between suicide-related psychiatric aeromedical evacuation and military separation to determine the personal, career, and financial factors that may be associated with this event. Such outcomes will provide critical information to better inform mental health policy in the U.S. military.

This research was a follow-on study based on previous research that evaluated factors associated with psychiatric aeromedical evacuation.³⁷ The primary aims were as follows: (1) determine the incidence of suicide-related psychiatric aeromedical evacuation in U.S. service members deployed to Iraq or Afghanistan from 2001 to 2013, (2) examine the risk factors associated with suicide-related psychiatric aeromedical evacuation in order to better inform mental health policy designed to reduce risk for suicide in theater, and (3) evaluate the relationship between suicide-related aeromedical evacuation from a deployed setting and military separation.

METHODS

Study Design

This was a cross-sectional, observational study that included U.S. military service members (N = 7023) who were deployed to Iraq or Afghanistan and received a psychiatric aeromedical evacuation out of theater between 2001 and 2013. Archival analyses were conducted using U.S. Transportation Command Regulating and Command and Control Evacuation System and Defense Manpower Data Center electronic records to evaluate demographic, clinical, and military attrition information (see Peterson et al.³⁷ for a complete description of study design and procedures). All data were retrieved in 2015. The study was approved by the Institutional Review Boards at The University of Texas Health Science Center at San Antonio, 59th Medical Wing at Joint Base San Antonio-Lackland, and Wright-Patterson Air Force Base, Ohio.

Measures

Personal and Military Demographics

Personal demographics for military service members included categorical, self-report information on gender, age, race, ethnicity, marital status, and education level (Table I). Race and ethnicity were categorized as Caucasian, African American, Hispanic, Asian, and “Other Race.” Military characteristic demographics included service branch, military pay grade, occupation classification (combat arms, combat support, and combat service support), number of deployments, and combat theater (OEF and OIF). Demographic characteristic comparative analyses between this sample and the entire 2013 active duty military force were conducted to determine how this sample is proportionally related to the military population (see baseline manuscript).³⁷

TABLE I.

Demographic and Military Characteristics (N = 7023)^*

	Total		Suicide Related		Other Psychiatric		χ²	P	OR
Characteristic	N	%	n	%	n	%	χ²	P	OR
Female	1128	16.1	67	38.9^b	1061	15.61	25.12	<0.001	2.06
Age							3.10	0.21
≤30	5606	79.8	204	84.3	5402	79.7
3–40	1179	16.8	32	13.2	1147	16.9
≥40	236	3.4	6	2.5	230	3.4
Race/Ethnicity							14.71	0.01
Caucasian	4636	66.6	133	55.9^a	4503	67.0			—
African American	1101	15.8	54	22.7^b	1047	15.6			1.75
Hispanic	668	9.6	28	11.8	640	9.5			1.48
Other	929	8.0	23	9.7	531	7.9			1.61
Marital Status							2.29	0.32
Married	3850	54.8	127	52.5	3723	54.9
Never Married	2797	39.8	97	40.1	2700	39.8
Divorced/Other	376	5.4	18	7.4	358	5.3
Education							3.58	0.47
≤High School	5932	84.5	205	84.7	5727	84.5
HS–Some College	520	7.4	23	9.5	497	7.3
≥Bachelor’s Degree	492	7.1	13	5.3	479	7.1
Branch^*							19.26	<0.001
Army	5418	77.1	187	77.3	5231	77.1			0.55
Marine Corps	671	9.6	10	4.1^a	661	9.7			0.23
Air Force	542	7.7	33	13.6^b	509	7.5			—
Navy	392	5.6	12	5.0	380	5.6			0.49
Enlisted	6660	95.4	230	96.2	6430	95.4	0.40	0.53
Occupation Category							10.37	0.006
Combat Service Support	3684	52.5	140	57.9	3544	52.3			1.72
Combat Arms	1779	25.3	40	16.5^a	1739	25.6			—
Combat Support	1560	22.2	62	25.6	1498	22.1			1.80
Number of Deployments							5.63	0.13
1	3505	49.9	132	54.5	3373	49.7
2	2048	29.2	55	22.7	1993	29.4
3+	1470	21.0	55	22.7	1415	20.9
OEF Theater	2201	39.3	124	65.3^b	2077	38.4	55.59	<0.001	3.02
ISC Separation	3741	53.3	147	60.7	3594	53.0	5.63	0.02	1.37
Involuntary Separation	2439	73.7	103	78.0	2336	73.5	1.35	0.245

Open in a new tab

OR were not calculated for nonsignificant effects. Cell counts and proportions are based on available data across variables. OR, odds ratio; OEF, Operation Enduring Freedom; ISC, Interservice Separation Code; —, reference category for OR statistics.

^{^*}

Branch ORs in the table are displayed as the inverse (1/OR) of estimates in text and indicate groups are less likely to receive a psychiatric aeromedical evacuation compared to reference group (Air Force).

Superscripts indicate cell standardized residuals estimates for suicide-related aeromedical evacuation and were less than −1.96^a or greater than 1.96^b.

Psychiatric Aeromedical Evacuation

Psychiatric aeromedical evacuation data included quarterly (every 3 months) reports on psychiatric aeromedical evacuation by year (2001–2013). Quarterly reports were partitioned as follows: Quarter 1, Q1: January to March, Q2: April to June, Q3: July to September, and Q4: October to December. Data points also had a primary psychiatric diagnosis that initiated the aeromedical evacuation based on the International Classification of Diseases, 9th revision. To enhance data interpretability, we partitioned suicidality into 2 coding categories of “suicide ideation” and “suicide attempt.” We also dismantled suicide attempt by method. Finally, we aggregated the 2 suicide categories into a “suicide-related” category.

Military Separation Characteristics

Data based on military separation were evaluated using the Interservice Separation Code (ISC). The ISC data collected provided an extensive list of reasons for military separation in this sample. The most common reasons for separation in this sample were temporary disability retirement (21.9%), expiration of term of service (19.6%), and Other ISC code (11.4%). Given that one of our aims was to evaluate the association between military separation and suicide-related psychiatric aeromedical evacuation, ISC codes were collapsed into 2 broad categories of “separated from the military for any reason” and “not separated from the military.” To further evaluate the nature of military separation, we partitioned ISC codes into 2 additional categories of “voluntary” separation or “involuntary” separation. Voluntary separation codes included retirement (20–30 years of service) and expiration of term of service. Involuntary separation codes included character (eg, court martial, commission of serious offense, behavior disorder, drug use), disability (eg, temporary disability retirement, disability with severance pay, unqualified for active duty), and health factors (eg, failure to meet weight standards). See Peterson et al³⁷ for a more comprehensive list of separation codes.

Statistical Analyses

Count and percentile statistics, or mean and standard deviation as appropriate, were calculated to evaluate demographic, psychiatric aeromedical evacuation, and military separation characteristics for the total sample and for the suicide-related aeromedical evacuation category. Study aims were predominantly addressed using chi-square (χ²) tests of independence. First, we assessed the frequency of suicide-related aeromedical evacuation in comparison to the total number of psychiatric aeromedical evacuations stratified by quarterly report. Suicidality data were dismantled to examine the rate of suicidal ideation and suicide attempt or method. Next, we compared demographic and military characteristic differences between service members with a “suicide-related” aeromedical evacuation versus “other psychiatric reason” for aeromedical evacuation. Finally, we evaluated the relationship between suicide-related aeromedical evacuation and increased risk of military separation. Among separated service members, we also evaluated the nature of military separation (“voluntary” versus “involuntary”). Odds ratios (OR) were calculated to determine the nature of significant relationships. Furthermore, standardized residuals (z) less than −1.96 and greater than 1.96 were used to identify cells with observed proportions significantly different from what would be expected by chance. We provided detailed statistical results in Table I. P, OR, and z values are provided in text to describe significant associations between variable. All analyses were conducted using SPSS version 25 (Statistical Package for the Social Sciences, Chicago, IL).

RESULTS

Overall, 242 of the 7023 (34.4 per 1000) psychiatric aeromedical evacuations that occurred between 2001 and 2013 were attributable to a suicide-related diagnosis (Figs. 1 and 2). The average annual rate of suicide-related evacuations was 4.1 per 100, with rates that ranged from 0.8 (2007) to 14.9 per 100 (2002). The highest incidence of suicide-related aeromedical evacuations occurred from 2012 to 2013 (n = 107). Approximately 44% of all suicide-related aeromedical evacuations occurred in this period. This increase in suicide-related aeromedical evacuations simultaneously coincided with a declining trend in the overall number of psychiatric aeromedical evacuations (Fig. 1). In addition, 57% (n = 137) of psychiatric aeromedical evacuations during this timeframe had a primary evacuation code of suicide attempt, whereas the remaining 43% (n = 105) had a primary code of suicidal ideation. In terms of suicide attempt method, most service members (58%) received a nonspecified or other-specified diagnostic code. The most common suicide attempt method beyond a nonspecified code was poisoning as a result of a controlled substance (35%). Interestingly, only 6 suicide attempts (<5%) were coded as because of a firearm or handgun during the study period.

Incidence of aeromedical evacuations from theater by year.

Incidence of suicide-related aeromedical evacuations from theater by year.

Demographic and Military Characteristics Risk Factors

Personal demographic results indicated that gender (P < 0.001) and race/ethnicity (P = 0.01) were associated with suicide-related aeromedical evacuation (see Table I for detailed information on all χ² tests). More specifically, women were significantly overrepresented (z = 5.0) in the suicide-related aeromedical evacuation sample and were 106% more likely (OR = 2.06) to be in the suicide-related sample compared to men. Regarding race and ethnicity, African American service members were overrepresented (z = 3.0) in the suicide-related aeromedical evacuation sample, whereas Caucasian service members were underrepresented (z = −3.6). Furthermore, service members who identified as a person of color were 60% more likely to be in the suicide-related sample compared to Caucasian service members (OR = 1.60). More specifically, compared to Caucasian service members, there was an increased likelihood of being in the suicide-related sample of 75% for African American service members (OR = 1.75), 48% for Hispanics (OR = 1.48), 17% for Asians (OR = 1.17), and 61% for service members who were classified as “Other” race/ethnicity (OR = 1.61).

Results for military characteristics yielded that service branch (P < 0.001), occupation classification (P < 0.006), and deployment theater (P < 0.001) were associated with suicide-related aeromedical evacuation. Regarding service branch, Air Force service members were overrepresented (z = 3.5) in the suicide-related sample, whereas Marines were underrepresented (z = −2.9). Specifically, Air Force service members were 81% (OR = 1.81) more likely to be in the suicide-related sample compared to Army, 105% (OR = 2.05) compared to Navy, and 329% (OR = 4.29) compared to Marines.

Results for military occupation classification indicated that combat arms were underrepresented in the suicide-related category (z = −3.5) and that combat service support (OR = 1.71) and combat support (OR = 1.80) were more likely to be in the suicide-related sample compared to combat arms. Results by theater suggested that OEF service members were overrepresented (z = 6.8) in the suicide-related sample and were 202% more likely to be in the suicide-related sample compared to OIF service members (OR = 3.02).

Military Separation

In total, 53% of all service members who received an aeromedical evacuation for any psychiatric reason from 2001 to 2013 had been separated from the military upon record review in 2015. Results indicated that 61% of those who received a suicide-related aeromedical evacuation had been separated from the military, a rate of 39 per 1000 service members. Suicide-related evacuation was associated with a 37% increased likelihood (OR = 1.37) of separation from the military for any reason compared to evacuation for another psychiatric condition (P < 0.02). We explicated the nature of this relationship by partitioning separated service members into “voluntary” or “involuntary” separation groups. Overall, 74% of all service members who had been separated following a psychiatric aeromedical evacuation had been involuntarily separated. The rate of involuntary separation was only marginally greater (78%) among service members who received a suicide-related aeromedical evacuation (P = 0.15).

DISCUSSION

The primary aims of this study were to examine the incidence of suicide-related aeromedical evacuation, identify demographic and military characteristics associated with suicide-related aeromedical evacuation, and evaluate the association between suicide-related aeromedical evacuation from a deployed setting and subsequent military separation among U.S. military personnel. Between October 2001 and October 2013, 3.4% of psychiatric aeromedical evacuations out of a deployed location in Iraq or Afghanistan were suicide related, a rate of 34.4 per 1000. Interestingly, the overall rate of suicide-related aeromedical evacuation was relatively low until 2011 and then began to rapidly increase with rates peaking between 2012 and 2013. This trend may in part be explained by historical events. From 2002 to 2008 there was a significant increase in the overall size of the military force deployed in support of OIF and OEF. Following 2008, the number of service members deployed to Iraq began to decrease. However, these decreases were offset by an increased number of service members deployed to Afghanistan. Furthermore, OIF concluded at the end of 2011, and although OEF continued until 2014, the OEF troop surge also began to decrease at the beginning of 2012. A potential explanation for the increases in suicide-related aeromedical evacuation between 2012 and 2013 may reflect the most severe combat psychiatric casualties of combat operations. That is, as there were decreases in combat operations and in the overall deployed force during this time, patients with suicidality may have been evacuated to possibly strengthen the remaining deployed forces in light of overall decreases in the broader force.

The second aim of this study was to identify demographic and military risk factors associated with a suicide-related psychiatric aeromedical evacuation. In comparison to service members who were aeromedically evacuated for another psychiatric reason, suicide-related evacuees were more likely to be female and a person of color. In addition, suicide-related evacuees were more likely to be in the Air Force and to serve in a noncombat arms role in support of OEF. These findings differed from a majority of prior research on demographic risk factors associated with suicide.^10–14^,¹⁸ Of particular interest was our findings that service members serving in combat arms roles were less likely to be aeromedically evacuated for a suicide-related diagnosis compared to service members serving in noncombat arms roles. A possible explanation for this finding is that combat arms personnel receive intensive training that simulates a combat environment before deployment, which may mitigate a debilitating psychological response. On the other hand, individuals serving in combat support or combat service support are less likely to receive intensive combat stress training, but rather specialized training for their duty station. It may also be the case that service members are required to serve in roles outside of their occupational specialty and training while in a deployed setting (ie, patient administration at a combat theater hospital), which increases exposure to unanticipated trauma exposures for combat service support personnel. A final possibility may be that individuals who serve in combat support and combat service support roles have more immediate access to medical providers, increasing the likelihood of a suicide-related aeromedical evacuation.

Gender and branch results may also be as a result of occupation classification findings. Women and Airmen are more likely to serve in combat support and combat service support roles in comparison to a combat arms role compared to male service members and other branches, respectively. Therefore, these groups may be more susceptible to stress vulnerability factors that are relevant to these occupation classifications. Alternatively, as stated above, a potential protective factor for women and Airmen serving in noncombat roles may be increased availability to medical providers if they need mental health services. Although this is the case, it does not fully capture the current findings as all participants in our sample received a psychiatric aeromedical evacuation. An additional factor for consideration is health-seeking behavior. Women are typically more likely to seek care in comparison to men. Therefore, it makes sense that women are more likely to report mental health symptoms, such as suicidality, which may result in a psychiatric aeromedical evacuation. It may also be the case that this trend translates to the Air Force in comparison to other branches. Future research should further evaluate the interaction between these variables to better illuminate the observed trends.

The findings from this study provide novel information on subsequent military separation specifically associated with suicide-related aeromedical evacuation. To our knowledge, there is no published research on this topic. Prior research has found that psychiatric aeromedical evacuation is related to an increased risk (almost 4 times greater likelihood) of military separation compared to the general military population.³⁷ In the current study, service members who received a suicide-related aeromedical evacuation were found to be at an even greater risk, with a 37% increased likelihood of military separation for any reason compared to those who received a psychiatric aeromedical evacuation for another psychiatric diagnosis. Results indicated a majority of service members (78%) were involuntarily separated, but the reason for a psychiatric aeromedical evacuation (suicide related versus other) was not associated with an increased risk of involuntary separation. It is important to note that military separation was not directly caused by the psychiatric aeromedical evacuation. Rather, a suicide-related aeromedical evacuation was associated with an increased likelihood of separation compared to a psychiatric aeromedical evacuation for another psychiatric reason. This association could be correlated with the severity of symptoms and other comorbid conditions in service members who received suicide-related aeromedical evacuations, to the extent that they no longer were fit for service.

One finding that warrants discussion is the incidence of suicide-related aeromedical evacuation. The incidence of suicide-related aeromedical evacuation was much lower than what might be expected based on prior research related to suicide ideation and attempts.^3–5^,¹²^,¹³ The difference might be attributable to differences in data sources. Prior epidemiological studies used survey methods to collect clinical data, whereas we used administrative, electronically coded data. It is likely the case that a proportion of service members who had a primary diagnostic code other than suicide (ie, depressive disorder, posttraumatic stress disorder, etc.) may have experienced comorbid suicide-related symptoms that were not specifically coded in the database.

Another noteworthy finding was that a majority of diagnostic codes in our study did not specify suicide attempt method (58%). A possible explanation for this is that military health providers used codes that would mitigate potential career impact on service members. It may also be the case that military health providers were not fully apprised of suicide attempt code specifications. In addition, there were only 6 documented cases of a firearm-related suicide attempt during the study period. The most likely explanation for this is that a completed suicide by firearm in theater would not result in a psychiatric aeromedical evacuation. This trend may also provide a partial justification for the finding that service members of color presented with higher risk of suicide-related psychiatric aeromedical evacuation compared to white service members. It could be that white service members utilized more lethal means to attempt and complete a suicide, thereby obscuring the observed race findings in this study. A future study incorporating Department of Defense Suicide Event Report data for these service members is needed to better understand these outcomes.

This study is not without limitations. One important limitation to note is that the current manuscript used data from 2001 to 2013 and does not include more recent years up until the time of publication. Future research should investigate risk factors associated with suicide-related psychiatric aeromedical evacuation using more recent years to determine if our findings generalize beyond 2013. Despite this limitation, findings from this study remain relevant to understanding and preventing suicide in deployed service members.

CONCLUSIONS

Suicide remains a significant problem in the U.S. military. Findings from this study suggest that suicide is also relevant in the context of psychiatric aeromedical evacuation. Compared to aeromedical evacuation for other psychiatric reasons, a suicide-related aeromedical evacuation is more likely to be related to military separation for any reason (voluntary or involuntary). In many cases, the psychiatric aeromedical evacuation of a service member for suicidal ideations and their subsequent discharge from active duty is in the best interest of the individual and the military. Service members who are evacuated out of theater for a suicide-related problem likely will not meet medical retention standards, resulting in later separation from the military by choice or systemic factors. However, the significant consequences associated with any psychiatric aeromedical evacuation also suggest that the military might benefit from an increased emphasis on indicated prevention for individuals who show sufficient early signs of crisis and functional problems so that specialized interventions can be used in theater to prevent suicide. Indicated prevention interventions should begin with leaders’ awareness and mitigation of risk. This may include increased efforts to train leaders to identify service members who are having trouble fitting in and are withdrawn or who are having difficulty performing their jobs and then to mitigate the risk before it reaches a crisis, such as suicide. When feasible, delivery of evidence-based treatments such as brief cognitive behavioral therapy for suicide⁴¹ may be beneficial to reduce symptoms and help service members remain in theater and complete their tour of duty. Preliminary findings on treatment of posttraumatic stress symptoms in a combat zone have demonstrated that evidence-based psychotherapy can be safely and effectively adapted for delivery to deployed military personnel.⁴⁰ Future research should evaluate the feasibility, safety, and efficacy of delivering suicide-related interventions in theater.

ACKNOWLEDGMENT

The authors would like to thank Julie Collins and Joel Williams for their assistance in the completion of this manuscript.

Contributor Information

Casey L Straud, Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, 7550 Interstate Highway 10 West, Suite 1325, San Antonio, TX 78229; Department of Psychology, University of Texas at San Antonio, One UTSA Circle, San Antonio, TX 78249.

Brian A Moore, Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, 7550 Interstate Highway 10 West, Suite 1325, San Antonio, TX 78229.

Willie J Hale, Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, 7550 Interstate Highway 10 West, Suite 1325, San Antonio, TX 78229; Department of Psychology, University of Texas at San Antonio, One UTSA Circle, San Antonio, TX 78249.

Lt Col Monty Baker, Wilford Hall Ambulatory Surgical Center, JBSA-Lackland, 2200 Bergquist Drive, San Antonio, TX 78236.

Lt Col Cubby L Gardner, Wilford Hall Ambulatory Surgical Center, JBSA-Lackland, 2200 Bergquist Drive, San Antonio, TX 78236.

Col Antoinette M Shinn, Wilford Hall Ambulatory Surgical Center, JBSA-Lackland, 2200 Bergquist Drive, San Antonio, TX 78236.

Jeffrey A Cigrang, School of Professional Psychology, Wright State University, 3640 Colonel Glenn Hwy, Dayton, OH 45435.

Brett T Litz, Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, 150 South Huntington Avenue, Jamaica Plain, Boston, MA 02130; Department of Psychiatry, Boston University School of Medicine, 720 Harrison Avenue, Boston, MA 02118; Department of Psychological and Brain Sciences, Boston University, 64 Cummington Mall, Boston, MA 02215.

Jim Mintz, Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, 7550 Interstate Highway 10 West, Suite 1325, San Antonio, TX 78229.

Jose M Lara-Ruiz, Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, 7550 Interstate Highway 10 West, Suite 1325, San Antonio, TX 78229.

COL Stacey Young-McCaughan, Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, 7550 Interstate Highway 10 West, Suite 1325, San Antonio, TX 78229.

Lt Col Alan L Peterson, Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, 7550 Interstate Highway 10 West, Suite 1325, San Antonio, TX 78229; Department of Psychology, University of Texas at San Antonio, One UTSA Circle, San Antonio, TX 78249; Office of Research and Development, South Texas Veterans Health Care System, 7400 Merton Minter Boulevard, San Antonio, TX 78229.

FUNDING

Funding for this work was made possible by the U.S. Department of Defense through the Air Force Medical Support Agency contract FA8650-13-2-6408 executed by the 711th Human Performance Wing.

REFERENCES

1. Drapeau C, McIntosh J; for the American Association of Suicidology . U.S.A. Suicide: 2018 Official Final Data. Washington, DC, American Association of Suicidology, 2020. Available at https://suicidology.org/wp-content/uploads/2020/02/2018datapgsv2_Final.pdf; accessed March 2, 2020.
2. Centers for Disease Control and Prevention; National Center for Injury Prevention and Control . Web-based Injury Statistics Query and Reporting System (WISQARS), 2019. Available at https://www.cdc.gov/injury/wisqars/index.html; accessed March 2, 2020.
3. United Health Foundation . America’s Health Rankings Analysis of CDC WONDER Online Database, Underlying Cause of Death, Multiple Cause of Death Files, 2020. Available at https://www.americashealthrankings.org/explore/annual/measure/Suicide/state/ALL; accessed March 2, 2020.
4. Eaton KM, Messer SC, Wilson ALG, Hoge CW: Strengthening the validity of population-based suicide rate comparisons: an illustration using U.S. military and civilian data. Suicide Life Threat Behav 2006; 36(2): 182–91. doi: 10.1521/suli.2006.36.2.182. [DOI] [PubMed] [Google Scholar]
5. Hoge CW, Castro CA: Preventing suicides in US service members and veterans. JAMA 2012; 308(7): 671–2. doi: 10.1001/jama.2012.9955. [DOI] [PubMed] [Google Scholar]
6. Schoenbaum M, Kessler RC, Gilman SE, et al. : Predictors of suicide and accident death in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS): results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiat 2014; 71(5): 493–503. doi: 10.1001/jamapsychiatry.2013.4417. [DOI] [PMC free article] [PubMed] [Google Scholar]
7. Smith NB, Sippel LM, Rozek DC, et al. : Courses of suicidal ideation among military veterans in residential treatment for posttraumatic stress disorder. J Depress Anxiety 2020; 37(3): 273–84. doi: 10.1002/da.22993. [DOI] [PMC free article] [PubMed] [Google Scholar]
8.Hoyert DL, XJQ: Deaths: preliminary data for 2011. Natl Vital Stat Rep 2012; 61(6): 1–50. Available at. https://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_06.pdf accessed March 2, 2020. [PubMed] [Google Scholar]
9. Department of Defense; Office of the Under Secretary of Defense . DoDSER: Department of Defense Suicide Event Report: Calendar Year 2017 Annual Report, 2018. Available at https://www.pdhealth.mil/sites/default/files/images/docs/TAB_B_DoDSER_CY_2017_Annual_Report_508_071619.pdf; accessed March 2, 2020.
10. Black SA, Gallaway MS, Bell MR, Ritchie EC: Prevalence and risk factors associated with suicides of Army soldiers 2001–2009. Mil Psychol 2011; 23(4): 433–51. doi: 10.1080/08995605.2011.590409. [DOI] [Google Scholar]
11. Gallaway MS, Bell MR, Lagana-Riordan C, Fink DS, Meyer CE, Millikan AM: The association between US Army enlistment waivers and subsequent behavioral and social health outcomes and attrition from service. Mil Med 2013; 178(3): 261–6. doi: 10.7205/MILMED-D-12-00316. [DOI] [PubMed] [Google Scholar]
12. Bush NE, Reger MA, Luxton DD, et al. : Suicides and suicide attempts in the U.S. military, 2008–2010. Suicide Life Threat Behav 2013; 43(3): 262–73. doi: 10.1111/sltb.12012. [DOI] [PubMed] [Google Scholar]
13. Hyman J, Ireland R, Frost L, Cottrell L: Suicide incidence and risk factors in an active duty US military population. Am J Public Health 2012; 102(Suppl 1): S138–46. doi: 10.2105/AJPH.2011.300484. [DOI] [PMC free article] [PubMed] [Google Scholar]
14. Logan J, Skopp NA, Karch D, Reger MA, Gahm GA: Characteristics of suicides among US army active duty personnel in 17 US states from 2005 to 2007. Am J Public Health 2012; 102(Suppl 1): S40–4. doi: 10.2105/AJPH.2011.300481. [DOI] [PMC free article] [PubMed] [Google Scholar]
15. Ursano RJ, Kessler RC, Naifeh JA, et al. : Risk of suicide attempt among soldiers in Army units with a history of suicide attempts. JAMA Psychiat 2017; 74(9): 924–31. doi: 10.1001/jamapsychiatry.2017.1925. [DOI] [PMC free article] [PubMed] [Google Scholar]
16. Anestis MD, Bryan CJ: Means and capacity for suicidal behavior: a comparison of the ratio of suicide attempts and deaths by suicide in the US military and general population. J Affect Disord 2013; 148(1): 42–7. doi: 10.1016/j.jad.2012.11.045. [DOI] [PubMed] [Google Scholar]
17. Maris RW, Berman AL, Silverman MM. Comprehensive Textbook of Suicidology. New York, NY, The Guilford Press, 2000. [Google Scholar]
18. Reger MA, Smolenski DJ, Skopp NA, et al. : Risk of suicide among US military service members following Operation Enduring Freedom or Operation Iraqi Freedom deployment and separation from the US military. JAMA Psychiat 2015; 72(6): 561–9. doi: 10.1001/jamapsychiatry.2014.3195. [DOI] [PubMed] [Google Scholar]
19. Leard-Mann CA, Powell TM, Smith TC, et al. : Risk factors associated with suicide in current and former US military personnel. JAMA 2013; 310(5): 496–506. doi: 10.1001/jama.2013.65164. [DOI] [PubMed] [Google Scholar]
20. Sareen J, Cox BJ, Afifi TO, et al. : Combat and peacekeeping operations in relation to prevalence of mental disorders and perceived need for mental health care: findings from a large representative sample of military personnel. Arch Gen Psychiatry 2007; 64(7): 843–52. doi: 10.1001/archpsyc.64.7.843. [DOI] [PubMed] [Google Scholar]
21. Maguen S, Madden E, Cohen BE, Bertenthal D, Neylan TC, Seal KH: Suicide risk in Iraq and Afghanistan veterans with mental health problems in VA care. J Psychiatr Res 2015; 68: 120–4. doi: 10.1016/j.jpsychires.2015.06.013. [DOI] [PubMed] [Google Scholar]
22. Bryan AO, Bryan CJ, Morrow CE, Etienne N, Ray-Sannerud B: Moral injury, suicidal ideation and attempts in a military sample. Dent Traumatol 2014; 20: 154–60. [Google Scholar]
23. Institute of Medicine : Gulf War and Health: Volume 6: Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related Stress. Washington, DC, The National Academies Press, 2008. doi: 10.17226/11922. [DOI] [Google Scholar]
24. Mitchell MM, Gallaway MS, Millikan AM, Bell M: Interaction of combat exposure and unit cohesion in predicting suicide-related ideation among post-deployment soldiers. Suicide Life Threat Behav 2012; 42(5): 486–94. doi: 10.1111/j.1943-278X.2012.00106.x. [DOI] [PubMed] [Google Scholar]
25. Cigrang JA, Balderrama-Durbin C, Snyder DK, et al. : Predictors of suicide ideation across deployment: a prospective study. J Clin Psychol 2015; 71(9): 828–42. doi: 10.1002/jclp.22192. [DOI] [PubMed] [Google Scholar]
26. Afifi TO, Taillieu T, Zamorski MA, Turner S, Cheung K, Sareen J: Association of child abuse exposure with suicidal ideation, suicide plans, and suicide attempts in military personnel and the general population in Canada. JAMA Psychiat 2016; 73(3): 229–38. doi: 10.1001/jamapsychiatry.2015.2732. [DOI] [PubMed] [Google Scholar]
27. Millner AJ, Ursano RJ, Hwang I, et al. : STARRS-LS collaborators. Prior mental disorders and lifetime suicidal behaviors among U.S. Army soldiers in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Suicide Life Threat Behav 2019; 49(1): 3–22. doi: 10.1111/sltb.12394. [DOI] [PMC free article] [PubMed] [Google Scholar]
28. Dempsey CL, Benedek DM, Zuromski KL, et al. : Association of firearm ownership, use, accessibility, and storage practices with suicide risk among US Army soldiers. JAMA Netw Open 2019; 2(6): e195383. doi: 10.1001/jamanetworkopen.2019.5383. [DOI] [PMC free article] [PubMed] [Google Scholar]
29. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL: Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004; 351(1): 13–22. doi: 10.1056/NEJMoa040603. [DOI] [PubMed] [Google Scholar]
30. Shen YC, Arkes J, Williams TV: Effects of Iraq/Afghanistan deployments on major depression and substance use disorder: analysis of active duty personnel in the US military. Am J Public Health 2012; 102(Suppl 1): S80–7. doi: 10.2105/AJPH.2011.300425. [DOI] [PMC free article] [PubMed] [Google Scholar]
31. Ursano RJ, Herberman Mash HB, Kessler RC, et al. : Factors associated with suicide ideation in US Army soldiers during deployment in Afghanistan. JAMA Netw Open 2020; 3(1): e1919935. doi: 10.1001/jamanetworkopen.2019.19935. [DOI] [PMC free article] [PubMed] [Google Scholar]
32. Lee H-J, Goudarzi K, Baldwin B, Rosenfield D, Telch MJ: The Combat Experience Log: a web-based system for the in theater assessment of war zone stress. J Anxiety Disord 2011; 25(6): 794–800. doi: 10.1016/j.janxdis.2011.03.018. [DOI] [PubMed] [Google Scholar]
33. Riddle MS, Sanders JW, Jones JJ, Webb SC: Self-reported combat stress indicators among troops deployed to Iraq and Afghanistan: an epidemiological study. Compr Psychiatry 2008; 49(4): 340–5. doi: 10.1016/j.comppsych.2007.07.007. [DOI] [PubMed] [Google Scholar]
34. Cohen SP, Brown C, Kurihara C, Plunkett A, Nguyen C, Strassels SA: Diagnoses and factors associated with medical evacuation and return to duty for service members participating in Operation Iraqi Freedom or Operation Enduring Freedom: a prospective cohort study. Lancet 2010; 375(9711): 301–9. doi: 10.1016/s0140-6736(09)61797-9. [DOI] [PubMed] [Google Scholar]
35. Harman DR, Hooper TI, Gackstetter GD: Aeromedical evacuations from Operation Iraqi Freedom: a descriptive study. Mil Med 2005; 170(6): 521–7. doi: 10.7205/milmed.170.6.521. [DOI] [PubMed] [Google Scholar]
36. Stetz MC, McDonald JJ, Lukey BJ, et al. : Psychiatric diagnoses as a cause of medical evacuation. Aviat Space Environ Med 2005; 76: C15–20. [PubMed] [Google Scholar]
37. Peterson AL, Hale WJ, Baker MT, et al. : Psychiatric aeromedical evacuations of deployed active duty U.S. military personnel during Operations Enduring Freedom, Iraqi Freedom, and New Dawn. Mil Med 2018; 183(11–12): e649–58. doi: 10.1093/milmed/usy188. [DOI] [PubMed] [Google Scholar]
38. Rundell JR: Demographics of and diagnoses in Operation Enduring Freedom and Operation Iraqi Freedom personnel who were psychiatrically evacuated from the theater of operations. Gen Hosp Psychiatry 2006; 28(4): 352–6. doi: 10.1016/j.genhosppsych.2006.04.006. [DOI] [PubMed] [Google Scholar]
39. Wilmoth MC, Linton A, Gromadzki R, Larson MJ, Williams TV, Woodson J: Factors associated with psychiatric evacuation among service members deployed to Operation Enduring Freedom and Operation Iraqi Freedom, January 2004 to September 2010. Mil Med 2015; 180(1): 53–60. doi: 10.7205/milmed-d-14-00213. [DOI] [PubMed] [Google Scholar]
40. Peterson AL, Foa EB, Resick PA, et al. : A nonrandomized trial of prolonged exposure and cognitive processing therapy for combat-related posttraumatic stress disorder in a deployed setting. Behav Ther 2020. doi: 10.1016/j.beth.2020.01.003. [DOI] [PubMed] [Google Scholar]
41. Rudd MD, Bryan CJ, Wertenberger EG, et al. : Brief cognitive-behavioral therapy effects on post-treatment suicide attempts in a military sample: results of a randomized clinical trial with 2-year follow-up. Am J Psychiatry 2015; 172(5): 441–9. doi: 10.1176/appi.ajp.2014.14070843. [DOI] [PubMed] [Google Scholar]

[ref1] 1. Drapeau C, McIntosh J; for the American Association of Suicidology . U.S.A. Suicide: 2018 Official Final Data. Washington, DC, American Association of Suicidology, 2020. Available at https://suicidology.org/wp-content/uploads/2020/02/2018datapgsv2_Final.pdf; accessed March 2, 2020.

[ref2] 2. Centers for Disease Control and Prevention; National Center for Injury Prevention and Control . Web-based Injury Statistics Query and Reporting System (WISQARS), 2019. Available at https://www.cdc.gov/injury/wisqars/index.html; accessed March 2, 2020.

[ref3] 3. United Health Foundation . America’s Health Rankings Analysis of CDC WONDER Online Database, Underlying Cause of Death, Multiple Cause of Death Files, 2020. Available at https://www.americashealthrankings.org/explore/annual/measure/Suicide/state/ALL; accessed March 2, 2020.

[ref4] 4. Eaton KM, Messer SC, Wilson ALG, Hoge CW: Strengthening the validity of population-based suicide rate comparisons: an illustration using U.S. military and civilian data. Suicide Life Threat Behav 2006; 36(2): 182–91. doi: 10.1521/suli.2006.36.2.182. [DOI] [PubMed] [Google Scholar]

[ref5] 5. Hoge CW, Castro CA: Preventing suicides in US service members and veterans. JAMA 2012; 308(7): 671–2. doi: 10.1001/jama.2012.9955. [DOI] [PubMed] [Google Scholar]

[ref6] 6. Schoenbaum M, Kessler RC, Gilman SE, et al. : Predictors of suicide and accident death in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS): results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiat 2014; 71(5): 493–503. doi: 10.1001/jamapsychiatry.2013.4417. [DOI] [PMC free article] [PubMed] [Google Scholar]

[ref7] 7. Smith NB, Sippel LM, Rozek DC, et al. : Courses of suicidal ideation among military veterans in residential treatment for posttraumatic stress disorder. J Depress Anxiety 2020; 37(3): 273–84. doi: 10.1002/da.22993. [DOI] [PMC free article] [PubMed] [Google Scholar]

[ref8] 8.Hoyert DL, XJQ: Deaths: preliminary data for 2011. Natl Vital Stat Rep 2012; 61(6): 1–50. Available at. https://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_06.pdf accessed March 2, 2020. [PubMed] [Google Scholar]

[ref9] 9. Department of Defense; Office of the Under Secretary of Defense . DoDSER: Department of Defense Suicide Event Report: Calendar Year 2017 Annual Report, 2018. Available at https://www.pdhealth.mil/sites/default/files/images/docs/TAB_B_DoDSER_CY_2017_Annual_Report_508_071619.pdf; accessed March 2, 2020.

[ref10] 10. Black SA, Gallaway MS, Bell MR, Ritchie EC: Prevalence and risk factors associated with suicides of Army soldiers 2001–2009. Mil Psychol 2011; 23(4): 433–51. doi: 10.1080/08995605.2011.590409. [DOI] [Google Scholar]

[ref11] 11. Gallaway MS, Bell MR, Lagana-Riordan C, Fink DS, Meyer CE, Millikan AM: The association between US Army enlistment waivers and subsequent behavioral and social health outcomes and attrition from service. Mil Med 2013; 178(3): 261–6. doi: 10.7205/MILMED-D-12-00316. [DOI] [PubMed] [Google Scholar]

[ref12] 12. Bush NE, Reger MA, Luxton DD, et al. : Suicides and suicide attempts in the U.S. military, 2008–2010. Suicide Life Threat Behav 2013; 43(3): 262–73. doi: 10.1111/sltb.12012. [DOI] [PubMed] [Google Scholar]

[ref13] 13. Hyman J, Ireland R, Frost L, Cottrell L: Suicide incidence and risk factors in an active duty US military population. Am J Public Health 2012; 102(Suppl 1): S138–46. doi: 10.2105/AJPH.2011.300484. [DOI] [PMC free article] [PubMed] [Google Scholar]

[ref14] 14. Logan J, Skopp NA, Karch D, Reger MA, Gahm GA: Characteristics of suicides among US army active duty personnel in 17 US states from 2005 to 2007. Am J Public Health 2012; 102(Suppl 1): S40–4. doi: 10.2105/AJPH.2011.300481. [DOI] [PMC free article] [PubMed] [Google Scholar]

[ref15] 15. Ursano RJ, Kessler RC, Naifeh JA, et al. : Risk of suicide attempt among soldiers in Army units with a history of suicide attempts. JAMA Psychiat 2017; 74(9): 924–31. doi: 10.1001/jamapsychiatry.2017.1925. [DOI] [PMC free article] [PubMed] [Google Scholar]

[ref16] 16. Anestis MD, Bryan CJ: Means and capacity for suicidal behavior: a comparison of the ratio of suicide attempts and deaths by suicide in the US military and general population. J Affect Disord 2013; 148(1): 42–7. doi: 10.1016/j.jad.2012.11.045. [DOI] [PubMed] [Google Scholar]

[ref17] 17. Maris RW, Berman AL, Silverman MM. Comprehensive Textbook of Suicidology. New York, NY, The Guilford Press, 2000. [Google Scholar]

[ref18] 18. Reger MA, Smolenski DJ, Skopp NA, et al. : Risk of suicide among US military service members following Operation Enduring Freedom or Operation Iraqi Freedom deployment and separation from the US military. JAMA Psychiat 2015; 72(6): 561–9. doi: 10.1001/jamapsychiatry.2014.3195. [DOI] [PubMed] [Google Scholar]

[ref19] 19. Leard-Mann CA, Powell TM, Smith TC, et al. : Risk factors associated with suicide in current and former US military personnel. JAMA 2013; 310(5): 496–506. doi: 10.1001/jama.2013.65164. [DOI] [PubMed] [Google Scholar]

[ref20] 20. Sareen J, Cox BJ, Afifi TO, et al. : Combat and peacekeeping operations in relation to prevalence of mental disorders and perceived need for mental health care: findings from a large representative sample of military personnel. Arch Gen Psychiatry 2007; 64(7): 843–52. doi: 10.1001/archpsyc.64.7.843. [DOI] [PubMed] [Google Scholar]

[ref21] 21. Maguen S, Madden E, Cohen BE, Bertenthal D, Neylan TC, Seal KH: Suicide risk in Iraq and Afghanistan veterans with mental health problems in VA care. J Psychiatr Res 2015; 68: 120–4. doi: 10.1016/j.jpsychires.2015.06.013. [DOI] [PubMed] [Google Scholar]

[ref22] 22. Bryan AO, Bryan CJ, Morrow CE, Etienne N, Ray-Sannerud B: Moral injury, suicidal ideation and attempts in a military sample. Dent Traumatol 2014; 20: 154–60. [Google Scholar]

[ref23] 23. Institute of Medicine : Gulf War and Health: Volume 6: Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related Stress. Washington, DC, The National Academies Press, 2008. doi: 10.17226/11922. [DOI] [Google Scholar]

[ref24] 24. Mitchell MM, Gallaway MS, Millikan AM, Bell M: Interaction of combat exposure and unit cohesion in predicting suicide-related ideation among post-deployment soldiers. Suicide Life Threat Behav 2012; 42(5): 486–94. doi: 10.1111/j.1943-278X.2012.00106.x. [DOI] [PubMed] [Google Scholar]

[ref25] 25. Cigrang JA, Balderrama-Durbin C, Snyder DK, et al. : Predictors of suicide ideation across deployment: a prospective study. J Clin Psychol 2015; 71(9): 828–42. doi: 10.1002/jclp.22192. [DOI] [PubMed] [Google Scholar]

[ref26] 26. Afifi TO, Taillieu T, Zamorski MA, Turner S, Cheung K, Sareen J: Association of child abuse exposure with suicidal ideation, suicide plans, and suicide attempts in military personnel and the general population in Canada. JAMA Psychiat 2016; 73(3): 229–38. doi: 10.1001/jamapsychiatry.2015.2732. [DOI] [PubMed] [Google Scholar]

[ref27] 27. Millner AJ, Ursano RJ, Hwang I, et al. : STARRS-LS collaborators. Prior mental disorders and lifetime suicidal behaviors among U.S. Army soldiers in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Suicide Life Threat Behav 2019; 49(1): 3–22. doi: 10.1111/sltb.12394. [DOI] [PMC free article] [PubMed] [Google Scholar]

[ref28] 28. Dempsey CL, Benedek DM, Zuromski KL, et al. : Association of firearm ownership, use, accessibility, and storage practices with suicide risk among US Army soldiers. JAMA Netw Open 2019; 2(6): e195383. doi: 10.1001/jamanetworkopen.2019.5383. [DOI] [PMC free article] [PubMed] [Google Scholar]

[ref29] 29. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL: Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004; 351(1): 13–22. doi: 10.1056/NEJMoa040603. [DOI] [PubMed] [Google Scholar]

[ref30] 30. Shen YC, Arkes J, Williams TV: Effects of Iraq/Afghanistan deployments on major depression and substance use disorder: analysis of active duty personnel in the US military. Am J Public Health 2012; 102(Suppl 1): S80–7. doi: 10.2105/AJPH.2011.300425. [DOI] [PMC free article] [PubMed] [Google Scholar]

[ref31] 31. Ursano RJ, Herberman Mash HB, Kessler RC, et al. : Factors associated with suicide ideation in US Army soldiers during deployment in Afghanistan. JAMA Netw Open 2020; 3(1): e1919935. doi: 10.1001/jamanetworkopen.2019.19935. [DOI] [PMC free article] [PubMed] [Google Scholar]

[ref32] 32. Lee H-J, Goudarzi K, Baldwin B, Rosenfield D, Telch MJ: The Combat Experience Log: a web-based system for the in theater assessment of war zone stress. J Anxiety Disord 2011; 25(6): 794–800. doi: 10.1016/j.janxdis.2011.03.018. [DOI] [PubMed] [Google Scholar]

[ref33] 33. Riddle MS, Sanders JW, Jones JJ, Webb SC: Self-reported combat stress indicators among troops deployed to Iraq and Afghanistan: an epidemiological study. Compr Psychiatry 2008; 49(4): 340–5. doi: 10.1016/j.comppsych.2007.07.007. [DOI] [PubMed] [Google Scholar]

[ref34] 34. Cohen SP, Brown C, Kurihara C, Plunkett A, Nguyen C, Strassels SA: Diagnoses and factors associated with medical evacuation and return to duty for service members participating in Operation Iraqi Freedom or Operation Enduring Freedom: a prospective cohort study. Lancet 2010; 375(9711): 301–9. doi: 10.1016/s0140-6736(09)61797-9. [DOI] [PubMed] [Google Scholar]

[ref35] 35. Harman DR, Hooper TI, Gackstetter GD: Aeromedical evacuations from Operation Iraqi Freedom: a descriptive study. Mil Med 2005; 170(6): 521–7. doi: 10.7205/milmed.170.6.521. [DOI] [PubMed] [Google Scholar]

[ref36] 36. Stetz MC, McDonald JJ, Lukey BJ, et al. : Psychiatric diagnoses as a cause of medical evacuation. Aviat Space Environ Med 2005; 76: C15–20. [PubMed] [Google Scholar]

[ref37] 37. Peterson AL, Hale WJ, Baker MT, et al. : Psychiatric aeromedical evacuations of deployed active duty U.S. military personnel during Operations Enduring Freedom, Iraqi Freedom, and New Dawn. Mil Med 2018; 183(11–12): e649–58. doi: 10.1093/milmed/usy188. [DOI] [PubMed] [Google Scholar]

[ref38] 38. Rundell JR: Demographics of and diagnoses in Operation Enduring Freedom and Operation Iraqi Freedom personnel who were psychiatrically evacuated from the theater of operations. Gen Hosp Psychiatry 2006; 28(4): 352–6. doi: 10.1016/j.genhosppsych.2006.04.006. [DOI] [PubMed] [Google Scholar]

[ref39] 39. Wilmoth MC, Linton A, Gromadzki R, Larson MJ, Williams TV, Woodson J: Factors associated with psychiatric evacuation among service members deployed to Operation Enduring Freedom and Operation Iraqi Freedom, January 2004 to September 2010. Mil Med 2015; 180(1): 53–60. doi: 10.7205/milmed-d-14-00213. [DOI] [PubMed] [Google Scholar]

[ref40] 40. Peterson AL, Foa EB, Resick PA, et al. : A nonrandomized trial of prolonged exposure and cognitive processing therapy for combat-related posttraumatic stress disorder in a deployed setting. Behav Ther 2020. doi: 10.1016/j.beth.2020.01.003. [DOI] [PubMed] [Google Scholar]

[ref41] 41. Rudd MD, Bryan CJ, Wertenberger EG, et al. : Brief cognitive-behavioral therapy effects on post-treatment suicide attempts in a military sample: results of a randomized clinical trial with 2-year follow-up. Am J Psychiatry 2015; 172(5): 441–9. doi: 10.1176/appi.ajp.2014.14070843. [DOI] [PubMed] [Google Scholar]

PERMALINK

Demographic and Occupational Risk Factors Associated With Suicide-Related Aeromedical Evacuation Among Deployed U.S. Military Service Members

Casey L Straud, PsyD

Brian A Moore, PhD

Willie J Hale, PhD

Lt Col Monty Baker, USAF, BSC

Lt Col Cubby L Gardner, USAF, NC

Col Antoinette M Shinn, USAF

Jeffrey A Cigrang, USAF (Ret.), BSC

Brett T Litz, PhD

Jim Mintz, PhD

Jose M Lara-Ruiz, PhD

COL Stacey Young-McCaughan, AN, USA (Ret.)

Lt Col Alan L Peterson, USAF (Ret.), BSC

ABSTRACT

Introduction

Materials and Methods

Results

Conclusions

INTRODUCTION

METHODS

Study Design

Measures

Personal and Military Demographics

TABLE I.

Psychiatric Aeromedical Evacuation

Military Separation Characteristics

Statistical Analyses

RESULTS

FIGURE 1.

FIGURE 2.

Demographic and Military Characteristics Risk Factors

Military Separation

DISCUSSION

CONCLUSIONS

ACKNOWLEDGMENT

Contributor Information

FUNDING

REFERENCES

ACTIONS

PERMALINK

RESOURCES

Similar articles

Cited by other articles

Links to NCBI Databases