Healing Combat Trauma

Comparing Risk of Suicide in Veterans to Non-Veterans

Periodically I wish we were doing a section on this site called "What We Knew, When" because the unfortunate tendency in the world at large, for whatever reason, is to suggest that so little is known about PTSD and combat veterans that we can keep re-discovering it, at great expense and to the detriment of the veterans affected themselves (and their family members, who also have to cope with this).

One case in point that I ran across the other day is this. Back in 1986, before some of the servicemembers in the current war climate were even born, the New England Journal of Medicine reported in a study that veterans were "65% more likely to die from suicide and 49% more likely to die in a motor vehicle accident than non-vets of the same age."

The article's authors affirmed, "We conclude that the most likely explanation for these findings is that military service during the Vietnam War caused an increase in subsequent deaths from suicide and motor-vehicle accidents." (N Engl J Med 1986; 314:620–4.)

I bring this up because even the other day, a civilian wondered -- on hearing the statistics of how many suicides are being reported in the Army -- how the rate of suicide in those who've served compares to the civilian rate. The short answer? It's much higher. The current figures for servicemember suicides are one every 36 hours; for veterans, an also-shocking 18 every day -- and those figures have been valid for a while. (If you want to learn about civilian suicide rates, you'll have to do your own homework here, but the NIMH is a good place to start. The figures are a bit old but periodically update.) As a general point of reference, in 2007 it was known to be twice that of the civilian population.

Periodically new studies arise that make different claims -- a recent one says there's no difference at all, but perhaps their window of "in the past year" was too small -- but as a general rule of thumb, it's higher than civilians and the NEJM reference cited above is an interesting metric about how much higher. It also makes mention of motor vehicle accidents, which have a certain overlap with suicide in terms of method. 

Another recent study which seems to have gotten no traction in the news is that suicide is also higher for veterans who've suffered traumatic brain injuries ("TBI"). (The figure they mentioned is 1.55% the rate of non-veterans.) And of course TBI and PTSD frequently go together in recent veterans. This isn't to impugn the current veterans' sturdiness level in some manner, but rather to remind us all perhaps of the higher costs of serving. Let's all keep an eye on this issue, and exercise both compassion and interest as it develops over time.

Editor's note: Over the years, we've written quite extensively on suicide on this site, so there's lots of good information if you want to delve into it further -- from personal essays to suicide maps across the U.S. to even what seems to help forestall or prevent suicide. And of course this section also includes some worthwhile wisdom from the acknowledged "father of suicidology," Edwin Shneidman, M.D., whose words are well worth knowing and remembering.

A Nutritional Clue Offers Hope for Military Suicides

It's not often enough that we get to report some good news about suicide and the military -- for months now, the numbers have been climbing in the wrong direction, with few notable exceptions to the trend.

However, just recently, a development from a most unusual quarter shows some true promise for the future. And for those unfamiliar with the effect that nutrition has on brain and emotional health, the results may truly surprise.

Maybe you've never associated C-RATs, MREs, or even meals served in base dining halls, in the U.S. and in the war zone, with impressive nutritional credentials -- but that may be the wave of the future if the military takes steps to improve servicemembers' mental health through a closer attention to nutrition's effect on the brain and the emotions.

A study published in the August 23, 2011 issue of Journal of Clinical Psychiatry online links military suicides to a low level of docosahexaenoic acid (DHA), an Omega-3 essential fatty acid found in fish and flax seed, but which the body doesn't manufacture -- in other words, which needs to be supplemented through diet.

According to the press relase about the study from the Uniformed Services University of the Health Sciences:

"Scientists at the National Institute on Alcohol Abuse and Alcoholism (NIAAA) led by Capt. Joseph R. Hibbeln, M.D., teamed with researchers at the Uniformed Services University of the Health Sciences (USUHS) in Bethesda, Md., to analyze a sample of suicide deaths among U.S. military personnel on active duty between 2002 and 2008. The researchers compared levels of omega-3 fatty acids of 800 individuals who committed suicide with those of 800 randomly selected controls — service members who were matched with the suicide cases by age, sex, and rank. They found that all the service members had low omega-3 levels, and that suicide risk was greatest among individuals with the lowest levels of docosahexaenoic acid (DHA), the major omega-3 fatty acid concentrated in the brain. The new study is reported online in the Journal of Clinical Psychiatry." 

The study, entitled "Suicide Deaths of Active-Duty US Military and Omega-3 Fatty-Acid Status: A Case-Control Comparison," "found that service personnel with higher levels of DHA in their blood were less likely to take their own lives," according to Military.com, continuing "Servicemen whose medical records showed they had low levels of DHA in their blood were 62% more likely to have been suicide victims than those with the highest levels."

The background -- a fish story

An earlier study, from 2004, sets the stage for our understanding:

"Even though the brain is materially an organ like any other, that is to say elaborated from substances present in the diet (sometimes exclusively), for long it was not accepted that food can have an influence on brain structure, and thus on its function. Lipids, and especially omega-3 fatty acids, provided the first coherent experimental demonstration of the effect of diet (nutrients) on the structure and function of the brain."

Quickly, omega-3 fatty acids, in particular DHA from fish oil, swept the nutritional world with promise of their remarkable benefits. According to one expert, quoted in an article called "Omega Medicine," from "Nutrition Action," the newsletter for the Center for Science in the Public Interest, in October, 2007, "it's one of the biggest success stories in decades," with "downsides ... so minimal that the burden of proof for a benefit doesn't have to be that high." 

Familiar television personality and heart doctor Mehmet Oz, M.D., calls Omega-3 one of the five critical nutrients to take, and says that "It's good for your joints, skin, vision, brain, heart, helps lower bad cholesterol levels and even boosts fertility. It's ... good for just about every single part of your body."

With this kind of versatility -- and publicity -- suddenly DHA the superstar food additive started being introduced to many items on grocery store shelves, from bread to milk to cereal. Then there were the nutritional supplements as well (e.g., fish oil capsules) which were sold over-the-counter in health food stores, probably gratifying the generations of mothers who attempted to push daily spoonfuls of cod liver oil on their unsuspecting, and frequently ungrateful children :-). 

But DHA has always been in its most effective form, apparently, when sourced directly from food itself -- primarily fatty fish from cold-water regions -- so Atlantic salmon, mackerel, and sardines are frequently mentioned as particularly good sources. Omega-3s are also found in flax seed, nuts and even certain kinds of algae, but DHA is sourced predominantly from fish and fish oil.

Science takes a closer look

A study published in the Journal of Nutritional Health and Aging in 2004 stated that "dietary omega-3 fatty acids are certainly involved in the prevention of some aspects of cardiovascular disease...and in some neuropsychiatric disorders, particularly depression."

An earlier French study from 2003 on lipids, depression and suicide reports as part of its literature review that "Some epidemiological data support the hypothesis of a relation between lower depression and/or suicide rates and a higher consumption of fish." While focusing on the ratio of fatty acids to one another in the blood, it reported, "In major depression, all studies revealed a significant decrease of the polyunsaturated omega 3 fatty acids ... In addition, two studies found a higher severity of depression when the level of polyunsaturated omega 3 fatty acids or the ratio omega 3/omega 6 was low." 

The findings of the current study, according to one of its authors, "add to an extensive body of research that points to a fundamental role for DHA and other omega-3 fatty acids in protecting against mental health problems and suicide risks." As the press release regarding this study notes:

"Previous studies have associated low levels of omega-3 fats or low dietary intake of seafood, with suicide, thoughts of suicide, and depression. Many, but not all, treatment studies also have reported mental health benefits of supplemental DHA, including reduced anxiety, depression and risk of psychosis."  

The benefits conceivably extend beyond suicide to general emotional wellness. Capt. Joseph R. Hibbeln, M.D., acting chief, Section of Nutritional Neurosciences, NIAAA Laboratory of Membrane Biochemistry and Biophysics remarks,

"... a previous placebo-controlled trial demonstrated that 2 grams of omega-3 fatty acids per day reduced suicidal thinking by 45 percent as well as depression and anxiety scores among individuals with recurrent self-harm. In a prior study we found that low blood levels of DHA correlated with hyperactivity of brain regions in a pattern that closely resembles the pathology of major depression and suicide risk. While omega-3 fatty acids are generally recommended by the American Psychiatric Association as an adjunctive therapy for mood disorders, more research is needed to establish a definitive role for their use in the stand alone treatment of depression."

With suicides up, the military looking for reversible risk factors

Generally speaking, DHA levels seem low in servicemembers, if this study is any indication -- which points to a deficiency of fish in their diet, and little supplementation in the form of fish oil capsules, for instance. From Army Col. (Dr.) Michael D. Lewis, lead author on the study, and assistant professor in the Department of Preventive Medicine and Biometrics at the UHSU:

“We were surprised to find just how low the levels of omega-3 fatty acids were in the entire sample. There still was a significant suicide risk when we stratified the population. When we compared the 1,400 samples with the lowest levels of DHA to the remaining 200, there was a 62 percent increased risk that the samples were from a documented suicide. We need to continue to evaluate these results with a well-designed interventional study, but this represents a potential simple nutritional intervention that warrants further investigation.” 

The takeaway for us from this study is that if supplementing with DHA -- in the form of an increased amount of dietary fish, of the right kind -- improves the situation for depression and suicide -- it sounds like it's a change very worth making. The upside is so large, and the downside so low that truly, what's the risk? (And the rest of the literature on omega-3 fatty acids and DHA suggest so many other phsyiological positives -- from heart health to joint pain -- that it only adds to the attractiveness of this option.)

Again from Capt. Hibbeln:

"The U.S. military invests a great deal of funds and effort to ensure that its troops receive optimal nutrition, especially in combat and deployment situations. This study presents new information on the potential usefulness of omega-3 fats in reducing risk for suicide and optimizing mental health, which can be taken into account when designing U.S. military diets." 

Anything that improves the situation with mental health and combats suicide -- even if it makes only a fraction of a difference -- seems to be worth doing. Let's hope the military tests this as an intervention to see how well it works, and ends up making a "dietary difference" in the ongoing fight against suicide.

Quotable Quotes -- Dietrich Bonhoeffer on Suffering and Sorrow

Dietrich Bonhoeffer was a Christian theologian, author and martyr, who was executed in a German concentration camp during the Second World War. Among his powerful writings are these two short sentences about suffering and empathy/compassion in action:

"Some of us suffer a great deal from having our senses dulled in the face of all the sorrows which these war years have brought with them."

- and -

"It seems to me more important actually to share someone's distress than to use smooth words about it." -- Dietrich Bonhoeffer.

Karl Menninger, M.D. on PTSD (Combat Stress) in WWII Veterans

We've briefly quoted Karl Menninger, M.D., before, here. But in scouring a book he wrote almost 50 years ago, we came across this extensive retelling of what he observed with World War II veterans and combat stress -- what we know today as PTSD.

It's interesting to read because there is both not much material readily available before the Vietnam War brought post-traumatic stress disorder into the common awareness, and also because the phenomenon of PTSD does seem to slightly "mutate" over time, perhaps because of the difference in the types of combat with each significant war. Menninger, a world-famous psychiatrist, brings up many important points in this passage -- and we wonder how many of them would still be considered true today.

(The context for the original work that he's citing here was performed when he was a member of a commision to study combat exhaustion in World War II veterans, appointed by the Surgeon General and his brother, Brigadier-General William C. Menninger.)

“In our studies of reactions to combat stress in World War II previously referred to, we were very much impressed with the way in which a set of forces began a phase of great stress and simultaneously aroused certain opposing forces which helped to maintain a balance. Then came more stress and more defense. Gradually the stresses seemed to become greater than the defenses, so that there occurred a lowering of achievement level, a partial retreat, the employment of emergency regulatory devices, evidences of threatened disorganization, and then, usually a recourse to medical aid.

With sedation and a few hours of rest many of these individuals were able to resume their former efficiency and return to the battle. Heroic and admirable as it was, this was not too difficult to explain. But other individuals had the same treatment and were not able to return to the front lines. Their symptoms persisted. This too we could understand. More time was required, more rest, more recuperation, further removal from the imminence of renewed combat stress.

But now comes the enigma. Many of these patients were sent back to the base hospital for care, nursing, protection, rest, and treatment. We saw some of them there, later. Many had improved or were improving; some had returned to duty (but usually not to combat duty). What impressed us most was that some of them were not better; they were under treatment of sorts, but they were worse. There was, for them, no more battle stress, no more physical exertion and prevail, no more threat of death. There was not even any considerable probability of further duty assignment. Bright, or at least safe and comfortable, situations lay ahead for them. Why did not the symptoms disappear?

In analyzing the nature of the stress they had undergone, we began to realize this was different from what would appear on the surface. In the beginning these men had experienced fear, fatigue, resentment, hunger, cold, and other things. But they were sustained, there, by many things, too: self-respect, pride-idealism, courage, devotion to duty, training, and habituation to routine. Moreover, there was a strong support from relations with comrades and officers and units. The sudden increment of stress which precipitated these symptoms was frequently the loss of one of these human supports by death or transfer. In other instances cumulative fatigue seemed to be the most important factor.

For these men, then, who did not respond to battalion aid-station treatment, the nature of the stress had changed; but it did not diminish quantitatively as the casual observer might have assumed. The threat of danger was gone, true, but so were the excitement and the routine activity. The weariness was gone, true, but so was the companionship of fellow soldiers. The unpleasant physical conditions were corrected, but in their place was the guilt feeling of abandoning one’s comrades and the fear of accusation of cowardice. Painfully disturbing was the dilemma that if one mastered his distress he would be sent back to duty, but if one admitted it he would be retired. A retirement could be cleared of all tincture of suspected cowardice only if it took the form of something called sickness. Efficient warfare and humane medical science are antithetical and sooner or later the antithesis shows up in the individual.”

-- Karl Menninger, M.D., “The Vital Balance: The Life Process in Mental Health and Illness.” New York: The Viking Press (1963).

Editor's note: The photo illustrates Polish soldiers involved in the Warsaw Uprising.

A Remarkable Quote from General Dwight D. Eisenhower about Who PTSD Affects

"You mustn't think of these people as just some sort of unfortunates . . . They are not — they are one of you. I saw a major general, one of the finest athletes of his time, definitely break — break because he could no longer sustain the agonies of combat. He could not talk to me without shaking, and he had to go home. This cannot be dismissed as not touching you personally." -- General Dwight D. "Ike" Eisenhower, U.S. president and five-star Army general.