The Suicide Epidemic

by Geoffrey Dardia

This first appeared in The Havok Journal on July 12, 2018.

In 2018, the Department of Defense witnessed record-breaking suicides in almost every branch of the Armed Forces; some units saw a 6-fold increase. That same year, in Special Operations–where suicides have historically been lower than other military units–USSOCOM’s suicide rates tripled. After nearly two decades of seemingly endless conflicts and deploying to over 80 countries, our Special Operations Forces (SOF) have been worn down and stretched thin to the point that we are experiencing significant losses of highly-seasoned special operators to disciplinary reasons, termination of service, medical boards, and non-inherited (sporadic) cancers and suicides.

Even though experts say suicide rates in the military are comparable to the civilian population, they have failed to take into consideration SOF members, who are highly trained and adapted to operate in austere environments: sometimes alone, often in direct close combat, and typically for 20 plus years, were less likely to take their own lives. What is driving so many to take their own lives? Let’s take a good look at the environment in which our forces operate.

How We are Trained to “Operate” – The Operations Process

As problem solvers, Unconventional Warriors must possess the ability to think outside the box and have a broad understanding of every aspect of their operational environment. Think of SOF as the “jack of all trades and master of none.” SOF members must be able to “analyze all conditions, circumstances and influences to plan, prepare, execute and assess operations within their operational environment. “Operations Process” (ADP 5-0). 

Our current model of healthcare (conventional medicine) is problem/disease-oriented, meaning that all the focus is on the “what”–what disease, what diagnostic code, what surgery, what drug to prescribe–and not the “why” (root causes). Medicine is learned and practiced in a very linear, rigid fashion where there is very little room for interpretation, let alone  “thinking outside the box.” Think of conventional medicine as a labor union. In a labor union, you are only allowed to look at and work on one part of a building that you have authorization for. Our medical system is organized in the exact same way: siloed and disjointed. Our medical providers are the best in the world, but they are bound to a system that is completely outdated, inefficient, compartmentalized, and profit-driven. The healthcare system in the United States is not focused on creating health; it is focused on managing diseases. 

If you apply the principles of the operation process and mission analysis to medicine, you will be able to clearly “define the operational environment, describe the threats, evaluate the threats and develop courses of action/control measures” to protect people from those threats. In military language, this is referred to as the Intelligence Preparation of the Environment (IPE). If you apply these operating principles and processes to medicine, you get Unconventional Medicine. 

Another major gap we have in medicine is that “those that know (researchers and providers) don’t do, and those that do (patients) don’t know.” Most medical providers looking at broken SOF members have little to no experience in the Special Operations environment, and the majority of SOF members have little to no experience in medicine. How do we fill that gap? By everyone “understanding the operational environment and problem.”

If medical providers and care teams knew “where to look, what to look for, what to look with and what to expect to see” when evaluating and treating our warfighters, we would be able to resolve underlying health conditions that are taking their toll on service members and veterans.

Disjointed and Compartmentalized Health Care (Disease Care) 

Suicide is not a problem exclusive to military and veteran populations. First responders such as policemen, firemen, hospital workers, and EMTs are all experiencing similar rates of cancer, suicide, and other occupational-related health conditions, which are all directly associated to their lifestyle and environments. If we know that the conditions, circumstances, and influences of suicide are driven by lifestyle, environmental, and genetic factors, shouldn’t we be embracing a form of medicine that is focused on lifestyle, environment, and genetics instead of disease management?

People are continuing to slip through the cracks of a problem-oriented, target fixated, medical/scientific research community that somehow, in 2020, still operates in a complete vacuum, siloed off from one another. Imagine for a second that you were trying to read a map looking through a drinking straw. You wouldn’t have any idea what you were looking at! In the tactical world, imagine clearing a house while your eyes were glued to your optic; you won’t notice anything or anyone else around you as you were making your way through one of the most dangerous environments possible. This is known as target fixation. 

Prior to September 11th, 2001, our intelligence communities were siloed and operating in a complete vacuum similar to the way our medical system operates now. We had over a dozen intelligence agencies collecting information, but many of them were not sharing it with the other organizations. Most of the intelligence agencies had bits and pieces of information that could have been compiled to create a clear picture of an impending attack, but they failed to communicate with each other. This goes back to looking at a map through a drinking straw: if you get target fixated, you miss the big picture. Al Qaeda identified the vulnerabilities in our intelligence services and exploited them by carrying out the 911 attacks that killed over 3000 Americans. After 911, the United States unified all 16 intelligence agencies into the Intelligence Community (IC) and appointed a Director of National Intelligence (DNI). 

Just like our intelligence community prior to 911, our medical system is completely compartmentalized and disjointed. We have a system where medical doctors work in separate specialties finding bits and pieces of information but fail to see the big picture; these are known as gaps. Conventional medicine treats body parts and systems as if they were completely isolated from the rest of the body. 

If you become ill, especially if it is a complex illness, you could spend up to four years trying to nail down a solid diagnosis. You end up going around in circles with all of the specialty referrals, misdiagnoses, provider turnovers, and crazy work schedules. As we say in the military, “you get bounced around like a ping pong ball.” When you do finally get a diagnosis, you end up with the prescription drug smorgasbord, also known as the zombie cocktail. The zombie cocktail is the equivalent of throwing darts at the problem; prescribe enough medications, and hope that maybe one of them will do something beneficial. 

Providers tell you to take your prescription in hopes that it will work, and if it doesn’t, they just tell you to try another one until something sticks. There is nothing precise about that. If our military forces conducted operations the same way we currently practice medicine, we would be out of a job. Frustration, helplessness, and hopelessness, combined with dozens of prescriptions, TBI, PTSD, chronic stress, alcohol abuse, and insomnia, is a ticking time bomb for suicide.

It is time that we tackle health issues the same way we fight in Special Operations, Joint, Combined, Unconventional, and with precision. We can implement precision medicine to find, fix, and finish diseases the same way we target our enemies. Our healthcare system is suffering the same vulnerabilities our IC suffered prior to 911: it is compartmentalized and failing to adapt to a rapidly changing, asymmetric threat. 

Health Crisis in the United States (Metabolic Dysfunction)

The United States is facing a full-blown health crisis. Nearly 40% of Americans are considered obese, and nearly 70% are considered overweight. Obesity, diabetes, heart disease, Alzheimer’s, cancer, and other metabolic diseases are bogging down the health care system and leaving a lot of Americans with crippling medical debt. As of 2019, over 137 million Americans were struggling with medical debt, and to put it into perspective, that is nearly half of the entire population of the United States. Medical debt is also a major contributing factor to suicide. 

In addition to affecting our wallets, the healthcare crisis is impacting our national security. Approximately 70-80% of American citizens are ineligible to serve our country because of low IQ, health reasons (physical/mental), and criminal records. Out of that remaining 20 % that are eligible, only a fraction will volunteer to serve. From that small percentage, how many will be fully qualified to serve in Special Operations units? All these conditions, circumstances, and influences are tied to the environment and lifestyles of most Americans. To solve this problem, we need a form of medicine that is focused on optimizing people’s lifestyles and the environment they live in.

Instead of being target fixated on individual conditions, we should be focused on what all of these “conditions, circumstances and influences” in our “operational environment” have in common. 

Loss of Mission, Purpose, and Focus

As the wars in Afghanistan and Iraq have winded down, we have found our most battle-hardened warriors chained indoors to computers, cell phones, sync meetings, Powerpoint presentations, calendars, and the inbox of their Outlook accounts. The addiction to combat cannot be satisfied in windowless offices where the sun never shines. The service member who once possessed the complete sense of mission, purpose, and focus necessary to fight a well-determined enemy suddenly finds themself armed with nothing more than a mouse, keyboard, and computer, fighting a clock against unrealistic expectations and deadlines. This clear loss of mission, purpose, and focus is also a major contributing factor to suicide. Lacking a clear mission, purpose, and focus, while facing illnesses or injuries that prevent service members from ever going to combat again, can be a death sentence for some.

The Environment at Home (Garrison Life)

Service members are usually struggling with horrible relationships strained by deployments, professional development schools, training events, divorces, child custody battles, alimony, and in some cases taking care of special needs kids. Imagine trying to balance all of those at the same time without a robust support network. A lot of service members are also hiding medical issues and self-medicating so they are not ripped off teams and sent to staff jobs, which can be 10 times more stressful than deploying in some cases. Other service members are even being sexually assaulted or harassed by people who are supposed to be responsible for them (MST).

Believe it or not, most military suicides are people who have never deployed into combat. They are people who have been ostracized by their peers for being a “turd” or “never seen real combat.” They are people who lack a clear sense of mission, purpose and focus. They are people with poor job satisfaction. They are people who are misunderstood. They are people who become isolated and cut off from the world. They are people who are overwhelmed by personal, financial, and family struggles. They are people who feel helpless and hopeless. They are people who have disciplinary issues hanging over them. They are people who are trying to escape constant pain, self-doubt, lack of identity, suffering, guilt, shame, and addiction. They are people who went into the military to find a sense of belonging because they had no parental role models growing up. They are people who are thrown into a medical system that often calls them “malingerers.” They are people who have had undiagnosed brain injuries. They are people who have undiagnosed sleep disorders. They are people being told by medical providers who never stepped one foot onto the field of battle to “suck it up.” They are people who are told by medical providers or leadership that “it’s just all in your head.” The keyword here is “people.” We need to look at the whole person.

Physiological Risk Factors for Suicide

The majority of DOD-funded suicide research is based on psychological rather than physiological risk factors. How could suicides be increasing if we have tripled the amount of money in suicide research and suicide prevention programs? A good guess would be that we are once again target fixated on the psychological risk factors while overlooking the physiological ones. The Department of Defense has dumped millions of dollars into researching psychological risk factors and implemented countless prevention measures, yet suicide numbers are continually increasing. 

Psychology is the only medical field where you do not have to have a physical examination prior to making a diagnosis and prescribing medications. No other field of medicine is going to ask you a series of questions and then perform a procedure or prescribe medications without some sort of physical examination. Why is this the case?

As more medical discoveries are being made, we are learning that conditions such as depression, anxiety, insomnia, bipolar disorders, ADHD, and other behavioral health-related conditions have underlying physiological manifestations (TBI, hormone imbalances, toxic exposures, autoimmune disorders, chronic inflammation, low-grade infections ETC.). Studies have shown that people diagnosed with a brain injury are 9 times more to kill themselves and according to the CDC, “Suicide Is Top Cause of Deaths Tied to Traumatic Brain Injury.”

The body and mind are directly connected, and if you want to heal one, you must heal the other. This is critically important, and it bears repeating. If someone is having issues with behavior (mind), they are most likely having issues with their body (health). Imagine having everything in your life the way you want it, but still feeling like you are dragging around a dead, hollow body. When you finally are at the end of your rope and you go and ask for help, you are told: “it is all in your head.” In a community that does not self-identify, show any type of vulnerability, or ask for help, being told that “it’s all in your head” can be a death sentence.

Sleep disorders and Suicidal Ideation

Since 2003, insomnia rates in the military have increased by 650%. Studies have also shown that people with insomnia are twice as likely to commit suicide. Recent studies have also shown that nearly 85% of service members had some type of sleep disorder, 51% have obstructive sleep apnea while 25% had insomnia. Obstructive sleep apnea significantly increases the risk of heart attacks, stroke, and type 2 diabetes. Today’s service members are living off energy drinks, coffee, pre-workout, and every other over the counter stimulant to keep pace throughout the day, and when they do finally lay down to go to sleep, their minds are going 100 MPH in a 100 different directions. Sleep is crucial for physiological and psychological repair, and if you are not sleeping, you are not repairing.

Functional, Personalized, Lifestyle Medicine (FPL) – Final Protective Line Against Chronic Illness

In the end, it all boils down to people. People are the center of gravity, not only in the military but in the entire world. The environment affects everyone; nobody is immune from it, and that is why we are seeing the same types of health conditions in those who work in the same type of environment. If we continue to focus our resources on looking at diseases, we will continue to lose more people. If we truly want to put a dent in suicide, we must have a full “situational understanding” of how your lifestyle, environment, and genes affect your, mind, body, and spirit.

Again, it is time we embrace a form of medicine that provides our current model with a new lens for looking at problems and a new operating system for solving them. We need a system that connects all the existing modalities and resources together to better serve the people, not the institutions which govern them all. Functional, personalized, lifestyle medicine addresses the root causes of dysfunction by addressing the effects of our operational environment and all of its conditions, circumstances, and influences.

Conclusion

What is driving so many Special Operations members to commit suicide? The current suicide epidemic is being fueled by the conditions, circumstances, and influences in the Operational Environment. These conditions, circumstances, and influences include; TBI, sleep disorders, toxic exposures, alcohol abuse, prescription drug usage, chronic stress, ruined relationships, financial hardships, helplessness, hopelessness, poor job satisfaction, metabolic dysfunction, frustration with a disjointed health care system and loss of a clear mission, purpose and focus. 19 years of conflict with no clear end state is taking its toll on the force. The SOF community is the most overworked and overexposed community in the United States Armed Forces.

Brain health and function are the most influential, physiological risk factors associated with suicide. If Suicide is the leading cause of death associated with Traumatic brain injury, providers need to put more focus on the physiological risk factors of suicide. 

Knowing the strong correlation between TBI and suicide, military leaders, medical providers, and researchers should be directing more resources into “preventative medicine checks and services” (PMCS) for service members. 

The first SOF truth is “Humans are more important than hardware.” Our hardware has regularly scheduled checks and services (PMCS), our humans do not. The first SOF imperative is to “understand the operational environment.” Most medical providers do not fully understand the operational environment in which SOF operates. Most SOF members do not fully understand how their health is affected by their operational environment. “Those that know don’t do and those that do don’t know.”

References: 

https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2524845

https://www.cdc.gov/traumaticbraininjury/pubs/tbi_report_to_congress.html

https://www.sciencedaily.com/releases/2017/06/170612094032.htm

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3543057/

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2757484