Dr. Ruwan M Jayatunge M.D.

The tragic death of Michael McNeil of the Canadian Armed Forces has raised many questions. According to the news reports Warrant officer Michael McNeil who suffered from Posttraumatic Stress Disorder (PTSD) had committed suicide at the Canadian Forces Base Petawawa in Ontario. He was one of three Canadian soldiers to commit suicide this week.

McNeil had a distinguished military career. He joined the Canadian forces in October 1994 and served in Bosnia in 1998, Kosovo in 1999 and Afghanistan in 2009. His death is a tragedy that filled with irreplaceable void.

Annually a significant numbers of soldiers commit suicide. Sadly Warrant officer Michael McNeil became another victim of combat related PTSD.

Military suicides are complex in nature. Often life stresses and ongoing battle stress could negatively affect the combatant. Lack of social, administrative and professional support is seen as predisposing factors. Military suicide can occur as a sudden response following acute stress reaction or it can be well planned. Sometimes soldiers contemplate their suicides for a number of years.

World War 1 to Afghanistan

Combatants of the WW1 faced extremely harsh conditions in the muddy and rat infested trenches. The soldiers suffered physical and psychological consequences of the trench war. Estimated suicides during the World War One still remain unknown. According to the Military Historians a large number of combatants committed suicide between 1914 to 1918. Depressed and physically worn-out soldiers took their lives inside the trenches. The trench suicides became common during the WW1. Some suicides occurred after the demobilization. Captain Guy Nightingale was one of the WW1 soldiers who witnessed the horrors of the war in Gallipoli. He was haunted by combat related reminiscences and in 1935 he took his own life. At the time of his death Captain Guy Nightingale was 43 years old.

 During the World War 2 combat fatigue consumed thousands of soldiers.  Many suicides in the battle fields were covered up in the Western as well as in the Eastern fronts. By the end of the War hundreds of German and Japanese soldiers committed suicide. The combat trauma of the WW2 still echoes around the globe. The analysis of official death certificates on file at the California Department of Public Health reveals that 532 California veterans over age 80 committed suicide between 2005 and 2008 (Glantz, 2010).

Nearly 8,744,000 personnel were on active duty during the Vietnam War.  Average age of 58,148 killed in Vietnam was 23.11 years. (Vietnam War Statistics) Since 1975, nearly three times as many Vietnam veterans have committed suicide than were killed in the war. Over 150,000 have committed suicide since the war ended. (Dean 2000). Kang (2010) indicates that level of combat trauma as indirectly measured by having PTSD and being wounded in action was associated with the risk of suicide among Vietnam veterans.  

Persian Gulf War veterans PTSD rates are similar to Vietnam and Iraq combat vets (Rubush, 2010) Studies examining the mental health of Persian Gulf War veterans have found that rates of PTSD stemming from this war range anywhere from about 9% to approximately 24%. These rates are fairly consistent with the rates of PTSD found among Vietnam veterans and Iraq War veterans. (Rubush,2012). The suicide rate has been increased among American troops as numbers have reached nearly one per day in 2012, according to new Pentagon data. Based on the report over the first 155 days of 2012, 154 active-duty troops have committed suicide.

 Military Suicides: Problem without a Solution

According to Dr. Charles P. McDowell of the US Air Force military suicides had been viewed as an individual rather than collective problem; therefore, they have been seen as a problem without a solution because the death of the victim precluded any possibility of a more favorable outcome. There may even have been some general sense that someone who attempted or committed suicide could not be a great loss to the service. In short, suicides within the military have historically been viewed as an individual problem rooted in the pathology of the victim and therefore beyond the control of command authorities. (Homicide and Suicide in the Military-Charles MC Dowell)

 Suicides Triggered by Post Combat Depression 

 The component of depression was evident to Dr. Mendez Da Costa who introduced the term Irritable heart during the US Civil War and Lt Col (Dr.) Fredric Mott who coined the term Shell Shock during the World War one. Depression is common among the combatants. The feeling of guilt and despair plays a major role in post combat depression. Post combat depression is evident among some combatants who were exposed to traumatic battle events. Apart from common depressive signs, Post Combat Depression is usually characterized with unresolved mental conflicts, survival guilt, negative interpretation of combat events and pessimistic outlook on the post combat environment (Jayatunge 2010).

Depression is a mood disorder in which pathological moods and related vegetative and psychomotor disturbance dominate the clinical picture. The Post combat depression  is described as a group of symptoms such as anhedonia (feeling of sadness and loss of ability to experience pleasure) low energy, decreased libido, reduced life interests, somatic pain, alienation, numbing, self-blame and survival guilt that is experienced by combat solders after exposing to traumatic battle events. Depression causes a disturbance in a soldier’s feelings and emotions. They may experience such extreme emotional pain that they consider or attempt suicide.

Soldiers could suffer from depression as a result of survival guilt, collateral damage to the civilians and constantly living in a socially deprived environment. Many soldiers become desolated about their lives and tend to have nostalgic feelings. They gradually shift away from the rational reasoning and find death as an answer to their agonizing problems. Social isolation, moving away from their buddies and lack of unit help and cohesion aggravate the situation leading the soldier to commit suicide.

 Suicides and Combat Related PTSD

The studies have shown that PTSD could be a disabling condition that affects the war veterans. Norris et al. (2002) indicate that Posttraumatic Stress Disorder (PTSD) represents a common, if not the most prevalent, mental health problem in community studies in post-conflict areas. Numerous researches indicate that there is a correlation between combat trauma and suicidal behaviors (Knox, 2008). Studies suggest that suicide risk is higher in persons with PTSD (Ferrada,  Asberg, ., Ormstad, & Lundin 1998). Many researchers believe that    disturbing symptoms of PTSD increase the suicide risk and others of the view that comorbid psychiatric symptoms that are associated with PTSD drive the victims to commit suicide.  Studies estimated that patients suffering from PTSD have up to a seven-fold increased incidence of suicide, and four-fold increased risk of death from all external sources (Bullman &Kang, 1994).

 Preventing Military Suicides 

Military suicides denote the unproductive way of managing the soldiers during the war and in the post combat era. It is the duty of the military organization to prevent suicides and self-harm among the soldiers.  Suicides do not occur in a vacuum and sometimes soldiers plan their suicides for months and in some instances for years. Many victims show suicide warning signs prior to their fatal acts. The unit members and the unit leaders should be trained and educated about the suicide warning signs.  

Combat trauma can cause depression and anxiety related ailments and often the victims are overwhelmed by stress and could become psychologically vulnerable.  As a result of these complications a combatant could think of suicide as the final solution. Therefore combat stress reactions should be detected effectively and extensive screening and potential case identification would be important to prevent suicides in the military.

 War trauma is not specific to ranks and it could affect soldiers as well as the officers. The stigmatization of mental health issues is a debilitating problem in treatment of traumatized war veterans. Sometimes stigma and discrimination prevent combatants to seek psychological help. Therefore de stigmatization and health education are key components in preventing suicides in the military.

A special attention should be given to the combatants with the past history of hazardous combat exposure and if any signs of PTSD or Depression emerge they should be referred for medical treatments. The health staff should   actively screen for potential victims and offer support with respect and empathy.

  References 

Bullman, T. A., & Kang, H. K. (1994). Posttraumatic Stress Disorder and the Risk of Traumatic Deaths Among Vietnam Veterans. Journal of Nervous & Mental Disease, 182(1), 604-610.

 Dean, C. (2000). Nam Vet : Making Peace with Your Past Wordsmith Publishing.

Ferrada-Noli, M., Asberg, M., Ormstad, K., Lundin, T., & Sundbom, E. (1998). Suicidal behavior after severe trauma. Part 1: PTSD diagnoses, psychiatric comorbidity and assessment of suicidal behavior. Journal of Traumatic Stress, 11, 103-112.

 Glantz, A. (2010). ”‰Older veterans twice as likely to take their own lives as those returning from Iraq and Afghanistan. The Bay Citizen. 

Jayatunge, R.M. (2010). Post Combat Depression (PCD) retrieved from  http://www.lankaweb.com/news/items/2010/10/19/post-combat-depression-pcd/

Norris, FH, Friedman MJ, Watsan PJ, Byrne CM, Diaz E, Kaniasty K. 60,000 disaster victims speak: Part 1. An empirical review of the empirical literature, 1981–2001. Psychiatry. 2002;65:207 –2239.

MC Dowell , C. Homicide and Suicide in the Military

 Rothberg JM, Rock NL, Del Jones F. (1984). Suicide in United States Army personnel, 1981–1982. Mil Med ;149(10):537-541.