PART

4

Psychological Issues for Active Duty Women

FOURTEEN

Suicide-Related Ideation and Behaviors in Military Women

MARJAN GHAHRAMANLOU-HOLLOWAY, BRIANNE GEORGE, JAIME T. CARRENO-PONCE, AND JACQUELINE GARRICK

Beginning with Deborah Samson, who in 1776 enlisted under the name “Robert Shurtliff” in order to fight for the United States in the Revolutionary War, women have been an important part of our nation’s military history (Freeman & Bond, 1992). There are approximately 214,098 active duty women serving in the US military (comprising 14.6% of all branches), with an additional 118,781 in the Reserve and 470,851 in the National Guard (Women in the Military Service for America Memorial, 2013). Military service, while challenging and rewarding for many, may expose the individual to a number of physical (e.g., sleep deprivation, injury), psychological (e.g., anticipation about deployment, trauma exposure), and psychosocial stressors (e.g., relationship and/or parenting issues)—all of which can serve as risk indicators for thoughts about death and dying.

Many of the stressors associated with military service may affect women differently than men. Moreover, military women, as compared to their military male and female civilian counterparts, may face additional unique stressors. Results of the 2011 DoD Health Related Behaviors Survey of Active Duty Military Personnel (Barlas, Higgins, Pflieger, & Diecker, 2013) indicate that military women attribute “a lot” or “some” stress, over the past 12 months, to the following top six life events: (1) being away from family and friends (46.6%); (2) change in work load (45.5%); (3) responsibilities and family/personal responsibilities (38.0%); (4) having to undergo a permanent change of station (37.1%); (5) problems with coworkers (32.4%); and (6) being deployed (30.3%).

In recent years, increasing attention has been paid to the psychological stressors most relevant to military women, yet there continues to be a lack of general dissemination of clinical observations and research on suicide-related ideation and behaviors among military women. Military women, compared with their civilian counterparts, have a threefold increased risk for suicide (Cassels, 2009). An analysis of 1990–2004 suicide mortality rates among military women in the US Air Force indicates that both enlisted and Officer women have higher suicide deaths compared to their general population counterparts (Yamane & Butler, 2009). This risk continues after military discharge, as female veterans are 79% more likely to die by suicide than civilian women (Cassels, 2009; McCarthy et al., 2009). I believe this is of those who attempt suicide, not 79% of the population. One explanation for the higher observed rates of suicide in military women is related to their access, familiarity, and use of firearms as compared to their civilian counterparts, who may choose other methods such as drug overdose (Cassels, 2009). Factors that are significantly associated with firearm use in women include the following: “being older, married, white and a veteran; residing in areas with higher rates of firearm availability; having an acute crisis; having experienced the death of a relative or friend; being depressed; and having relationship problems” (Kaplan, McFarland, & Huguet, 2009, p. 322).

The aims of this chapter are twofold: (1) to educate military and civilian mental health providers on the important public health problem of suicide-related ideation and behaviors among military women; and (2) to provide a series of recommendations on assessment, management, and treatment of suicide-related ideation and behaviors among military women.

National Data on Women

The Centers for Disease Control and Prevention (CDC) maintain national injury- and violence-related statistics. The most current 2010 national fatal injury report (CDC, 2013) indicates that suicide is the second leading cause of death in women aged 15–24 years, the third leading cause of death in women aged 25–34 years, and the fourth leading cause of death in women aged 35–44 years. In 2010, a total of 8,087 women died of suicide in the United States (age-adjusted rate of 4.99 per 100,000). Female suicides account for approximately 21% of all national suicides. Poisoning (37%), firearms (30%), and suffocation (24%) are the three most common methods of suicide for women. In terms of race, the highest 2010 suicide rates for women aged 25–64 years were among non-Hispanic Whites (8.98 per 100,000), followed by American Indian/Alaskan Natives (8.36 per 100,000). An interesting fact is that suicides occur at a higher rate than homicides (i.e., 5.15 crude rate versus 2.22 per 100,000) for women of all ages when homicide gets most of the media attention.

A recent CDC report (2011) presents national data on suicidal thoughts and behaviors among adults over the age of 18 for 2008–2009. Approximately 1.2 million adult women, reflecting 1.0% of the US adult female population made suicide plans in the past year; nearly 616,000 adult women, reflecting 0.5% of the US adult female population, made a suicide attempt in the past year. An estimated 4.6 million adult women, reflecting 3.9% of the US adult female population, had suicidal thoughts in the past year.

Department of Defense (DoD) Data on Military Women

Currently, the DoD Suicide Event Report (DoDSER; Luxton et al., 2012) is a standardized suicide surveillance effort implemented among all military branches of service. Overall, a total of 52 military women have been reported as having died by suicide between 2008 and 2011. While the total number of suicides for these four recent years (i.e., 2008–2011) has been reported, the DoDSER reports do not provide an estimated annual rate of suicide for military women. Authors of the report indicate that a relatively small count of military women who die of suicide each year results in stability issues in rate estimations. There is statistical merit to the practice of not calculating rates when incidents of mortality are less than 20 per year (as is the case with suicide in military women). Rates, incorporating events with such low frequencies, risk dramatic changes in the statistically derived rate of suicide from year to year with minimal changes to the actual number of female suicides.

The DoDSER for calendar year 2011 shows that approximately 16 military women died by suicide—this count reflects 5.32% of all suicides during the year. The 2011 overall demographics indicate that 14.86% of DoD Service members were women during the same calendar year. In general, given the small counts of suicides among military women, there is also no basis for making any conclusions about the observed “suicide by service” percentages.

The DoD Suicide Prevention Office (DSPO) has provided the following additional information on 2011 suicides among military women based on the DoDSER collected information. Approximately two out of every five military women who died by suicide were under the age of 25, Caucasian, and married. All were enlisted Service members at the time of death. About a third used a non-military issued gun, about half were diagnosed with a mood disorder, and approximately 87% did not have a history of deployment.

In the 2011 DoDSER, women accounted for 26.5% of suicide attempts in the military. The DoDSER purposely does not provide rates of suicide attempts, as the Services have implemented different standards for including an attempt in the DoDSER, and attempts may be underreported, making the consistency of attempt rates questionable. In this case, three out of every five military women who attempted suicide were under the age of 25 and Caucasian, half were married, and 73% were junior enlisted. Almost 75% of the attempts were made by drug overdose.

Failed relationships were reported in 50% of the suicide attempt cases. Approximately 75% of the women did not have a history of deployment. A greater proportion of women who attempted suicide were African American (29% female, 15% male) and had a history of physical (32% female, 18% male), emotional (35% female, 18% male), and/or sexual abuse (42% female, 9% male).

Sex Differences in Suicide-Related Thoughts and Behaviors

Sex differences in suicide deaths have been well documented in the general civilian population, with men dying four times more frequently¹ than women (Beautrais, 2006). Of the 38,364 (12.08 per 100,000)² suicide deaths among American adults in 2010, approximately 30,277 (19.95 per 100,000)³ were men, while only about 8,087 (4.99 per 100,000)⁴ were women (CDC, 2013). Suicide deaths in the US military also show a higher proportion of male suicides than female. Of the 301 US military suicide deaths in 2010, 94.7% were men.

In terms of suicide attempts and sex differences, women attempt suicide with three times greater frequency (CDC, 2013). In the World Health Organization (WHO) multinational survey (Nock et al., 2008), for those individuals who reported ideation, women had a significantly higher conditional probability of (1) making a future attempt, (2) making an attempt without a lifetime plan, or (3) making an attempt with a lifetime plan. Suicide attempts in the military present a slightly different picture in terms of sex differences. Nearly a quarter (26.5%) of 935 DoD 2011 documented suicide attempts were made by women—indicating that for every military female suicide attempt, there were three military male suicide attempts. One should keep in mind, however, that women comprise only 14.6% of the military (Luxton et al., 2012).

Finally, in terms of suicidal thoughts, among the adults in the United States who endorse suicide ideation, 3.8 million are men (3.5% of all US men) but 4.6 million (3.9%) are women (CDC, 2011). Systematic tracking of suicide ideation among military personnel is not currently occurring within the DoD. However, the 2011 DoD Health Related Behaviors Survey of Active Duty Military Personnel (Barlas, Higgins, Pflieger, & Diecker, 2013) shows that 13.4% of military women, compared with 11.8% of military men perceived a higher sex-related stress due to suicide ideation since joining the military.

Moreover, while we do not have much information about sex differences in suicidal thoughts for military women versus men, the civilian literature provides a helpful starting point for identifying potential sex differences in the onset, sustainment, and exacerbation of suicidal thoughts. The civilian literature indicates that females are more likely than males to experience suicidal thoughts as a way of coping with feelings of depression (Harlow, Newcomb, & Bentler, 1986). Psychiatric diagnoses that are most predictive of suicide ideation in women include post-traumatic stress disorder (PTSD), social anxiety, generalized anxiety, and panic disorders (Cougle, Keough, Riccardi, & Sachs-Ericcson, 2009). For women with PTSD, a greater prevalence of suicide ideation is noted with comorbid depression (Cougle, Resnick, & Kilpatrick, 2009). Additionally, a history of forced sexual intercourse, illegal drug use (other than cannabis), and exposure to violence are recognized as risk factors for suicide ideation in women specifically (Legleye et al., 2010). Women who are younger, who experience perceived workplace harassment, who are working with inadequate resources, and who experience professional burnout are also at risk for suicide ideation (Fridner et al., 2009). Psychiatric disorders, sexual harassment or abuse, and work-related stresses may all present similar risk factors for female Service members and may represent unique risk factors for this military subgroup.

Finally, men and women in the general population appear to differ in the trajectory from suicide ideation to suicide attempts. Baca-Garcia and colleagues (2010) found that the occurrence of suicide ideation without subsequent attempts was higher in women than in men. More specifically, Caucasian women between 18 and 64 years of age had the highest comparative risk of suicide ideation without a subsequent attempt when compared to other groups. However, there continues to be a lack of knowledge about whether these research findings correspond to the experiences of military women.

In the sections below, a brief review of risk and protective factors for suicide, pertaining to civilian and military women, is presented. While the scope of the scientific literature on military women and suicide risk is limited, the information presented here provides a solid foundation for best understanding the types of life experiences that may predispose women to develop a wish to die.

Demographic Factors

In a representative cross-national study of 84,850 adults, female sex, younger age (18–34 years), lower educational attainment, being unmarried, and the presence of a mental disorder served as the strongest risk factors for suicidal behaviors—and these factors appeared to be universal across 17 participating countries (Nock et al., 2008). In a cohort study of 87,257 women and 70,570 men (aged 15–89) receiving services through a health maintenance organization (HMO), the following factors were found to be significantly associated with suicide attempts in women: age 15–24 years, Caucasian race, 12th grade or less education, history of emotional problems, and history of family problems. The following factors were found to be significantly associated with suicide deaths in women: age 15–24 years, Asian race, Caucasian race, being separated/divorced, prior inpatient hospitalization for suicide attempt, and history of emotional problems.

Trauma-Related Factors

General Population

Adverse childhood experiences, including neglect, parental divorce/separation, witnessing domestic violence, sexual and/or physical abuse, and other traumatic events significantly impact suicide-related risk in adulthood (Afifi et al., 2008; Brent, Baugher, Bridge, Chen, & Chiappetta, 1999; Brown, Cohen, Johnson, & Smailes, 1999; Felitti et al., 1998). Risk of at least one suicide attempt among adults with a history of adverse childhood experiences increases two to five times compared with adults without such history (Dube et al., 2001); further, the odds of ever making a suicide attempt increases sharply for those with seven or more adverse childhood experiences (adjusted OR = 31.1, CI 95% [20.6–47.1]).

In terms of sex differences, Afifi and colleagues (2008) found that for men, physical abuse and witnessing domestic violence in childhood were associated with suicide ideation in adulthood, while childhood physical and sexual abuse were associated with a suicide attempt in adulthood. On the other hand, for women, childhood sexual and physical abuse were associated with suicide ideation in adulthood, while any experience of adverse childhood experience was associated with a suicide attempt in adulthood. In addition, military women who receive psychiatric care for suicide-related thoughts and behaviors have demonstrated a significantly higher likelihood of documented histories of childhood sexual abuse, adulthood sexual assault, adulthood physical assault, and pregnancy loss (Cox et al., 2011).

Military

A recent review by Zinzow and colleagues (2007) provides necessary information for mental health practitioners in regard to trauma for military women. This review indicates that military women (1) have higher rates of lifetime trauma than civilian women; (2) have higher rates of childhood trauma than civilian women (and that these traumas may be more severe); and (3) are at a higher risk for “cumulative trauma exposure” due to increased rates of trauma prior to military service and subsequent increased risk for trauma exposure during military service (Zinzow et al., 2007). Military women, compared to their male counterparts, are more likely to have survived multiple types of abuse during childhood (Dansak, 1998). Some implications of these higher trauma exposure rates include higher rates of anxiety, particularly PTSD, depression, medical and psychological service utilization, and psychological as well as physical health problems (Murdoch, Pryor, Polusny, Anderson, & Gackstetter, 2007; Zinzow et al., 2007), which can all serve as important indicators for suicide risk for women in uniform.

In addition, Zinzow and colleagues note that military women have increased rates of adult sexual assault—many of these events are “in-service” assaults (victim and assailant are both Service members). Military sexual assault survivors may have to continue to live and work with the perpetrator, particularly if on a deployment, and the survivor may have unique stigma concerns regarding how reporting the crime will affect one’s career (Zinzow et al., 2007). One study found that almost half of the women in their sample experienced sexual and/or physical assault during their military service, and that these women were more likely to have subsequent physical or emotional health problems (Sadler, Booth, Cook, & Doebbeling, 2003).

The DoD has a zero tolerance policy for sexual harassment of military members, as established by DoD Directive 1350.2, DoD Military Equal Opportunity (MEO) Program. This directive provides clear policy for how violations should be handled and what services should be available to victims. Despite these efforts, sexual harassment continues to occur and can cause significant psychological effects. Military women have been found to be the victims of sexual harassment with greater frequency than military men, as in the civilian population, and both women and men who experience this harassment have been found to endorse more negative mental health symptoms and higher scores on a depression measure (Murdoch, Pryor, Polusny, Anderson, & Gackstetter, 2007; Street, Gradus, Stafford, & Kelley, 2007).

In addition, compared to their civilian counterparts, military women are at higher risk of being exposed to traumas resulting from combat, natural disasters, and major accidents (Zinzow et al., 2007). There may also be sex differences in exposure and reaction to these types of traumas within the military. Hourani, Yuan, and Bray (2003) describe the most prevalent trauma for men as witnessing major accidents, and for women, as witnessing a major disaster. Military men are at risk for more physical symptoms of stress related to their trauma exposures, whereas military women have twice the risk for developing mental health problems following exposure to a traumatic event.

While minimal research exists on sex differences in combat exposure and reactions to combat for Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) Veterans, two solid reviews have made significant contributions to the literature (Boyd, Bradshaw, & Robinson, 2013; Street, Vogt, & Dutra, 2009). Street and colleagues (2009) show that although male Service members are more likely to be exposed to combat, approximately 12% of women deployed to OIF and OEF have experienced “moderate levels of combat,” and that a far greater percentage (around 40%) of women have reported coming under mortar or artillery fire. There is also some evidence that combat-related PTSD may be underdiagnosed in female Veterans, though this finding is in need of further exploration with Veterans of the current conflicts (Pereira, 2002).

Finally, women have often been observed as having higher rates of PTSD following trauma exposure in a variety of populations, including victims of sexual assault, combat Veterans, and civilians exposed to war and torture (Tolin & Foa, 2006; Johnson & Thompson, 2008). In fact, women have rates of PTSD that are twice as high as men, PTSD tends to last longer in women than in men, and the symptoms tend to result in poorer health among women versus men (Simmons, 2007). In addition, this effect has been shown even after controlling for type of trauma (Breslau & Anthony, 2007; Tolin & Foa, 2006). PTSD has been shown to be associated with suicide attempts even after adjusting for sociodemographic, mental disorders, and severity of physical disorders (Sareen, Cox, Stein, Afifi, Fleet, & Asmundson, 2007).

Psychiatric Factors (Summarizing General Population and Military Literature)

A review of 4,203 suicides among women aged 15–44 indicates that the most common precipitating circumstances associated with female suicides across 16 US states (2003–2007) are a current mental health problem (60%), having been treated for a mental health problem (54%), current depressed mood (44%), and past/current intimate partner relational problems (36%) (Ortega & Karch, 2010). A more detailed description of a number of psychiatric factors, identified as contributors to suicide risk, is provided below.

ANXIETY AND MOOD DISORDERS

PTSD and panic disorder are predictive of suicide risk among men, whereas PTSD and panic disorder, along with social anxiety disorder and generalized anxiety disorder, are predictive of suicide risk among women (Cougle, Keough, Riccardi, & Sachs-Ericcson, 2009). The diagnosis of major depressive disorder places both men (OR = 9.86, CI 95% [5.08–19.14]) and women (OR 5.00, CI 95% [3.19–7.83]) at greater risk for suicide attempts (Zhang, Mckeown, Hussey, Thompson, & Woods, 2005). Nightmares, a symptom of PTSD that negatively impacts the quality of sleep, have been associated with increased risk of suicide (Bernert & Joiner, 2007). Among individuals with a recent suicide attempt, frequent nightmares were associated with an increased risk for a subsequent attempt among men (3.9 times) and women (1.7 times) and a significant increase in suicide ideation for both men (3.0 times) and women (1.6 times) (Susansky, Hajnal, & Kopp, 2011). Krakow and colleagues (2000) examined sleep disturbance among female sexual assault survivors who had PTSD and found that women who had greater levels of suicide ideation had signs of breathing-related sleep disorders.

PREGNANCY, POSTPARTUM DEPRESSION, AND/OR CHILD LOSS

Pregnancy creates unique challenges for military women. Appolonio and Fingerhut (2008), based on their review of the literature, highlight unique stressors for military women during pregnancy. These stressors include working longer hours and later into their pregnancies, receiving less support, facing an ongoing struggle to balance work and family demands, and experiencing stigma about reporting issues resulting from pregnancy or new motherhood. Rates of postpartum depression in active duty military samples are roughly equivalent to rates in civilian populations, though these authors note that military women may have more barriers to care, including less awareness, less education, and increased stigma. In a recent study (Do, Hu, Otto, & Rohrbeck, 2013), 9.9% of all active duty military women who delivered a baby were diagnosed with postpartum depression during the one-year postpartum. Military women with postpartum depression compared with those without, after adjusting for various covariates, had 42.2 times the odds of being diagnosed with suicidality in the postpartum period (Do, Hu, Otto, & Rohrbeck, 2013). Notably, postpartum psychosis increases the risk of suicide among civilian women by 7-fold during the first year after childbirth and 17-fold over the next several years (Appleby, 1991; Appleby, Mortensen, & Faragher, 1998). Finally, women in the general population who experience abortion as a traumatic life event have also shown to be at risk for suicide ideation and behavior—as increases in depression, anxiety, and substance use disorders are experienced as well (Furgusson, Horwood, & Ridder, 2006).

SUBSTANCE USE DISORDERS

When compared to military men, women have been found to be similar in their use of drugs, but have reported lower rates of alcohol consumption than men (Bray, Fairbank, & Marsden, 1999). A recent study (Medical Surveillance Monthly Report, 2011) on alcohol-related diagnoses for US Armed Forces in 2001–2010 indicates that military women had a rate of 9.1% (compared with 14.5% in military men) for acute cases of alcohol related disorders and a rate of 6.5% (compared with 10.7% in military men) for chronic cases of alcohol-related disorders. The association between alcohol-related disorders and suicide outside the military has been well established since the 1980s (Center for Substance Abuse Treatment, 2008). Younger women with alcohol-related problems are twice as likely to attempt suicide, compared with older women (Gomberg, 1989)—therefore, young military women with an alcohol-related disorder should be considered as a high-risk group for suicide ideation and/or behaviors. Female Veteran outpatients with a history of military sexual assault, compared to those without, are found to have higher rates of alcohol abuse and depression (Hankin et al., 1999). Higher rates of alcohol and drug use subsequently predict having a PTSD diagnosis (Nunnink et al., 2010), which, as noted earlier, is yet another risk factor for suicide.

As stated above, substance-use disorders are often noted among individuals who have suicide-related thoughts and behaviors, with alcohol involved in approximately one-third of all suicide deaths in the general population (Karch, Crosby, & Simon, 2006). Alcohol or drug abuse conveys over a six times greater risk of suicide attempts (Molnar, Berkman, & Buka, 2001), and the link between impulsivity, substance abuse, and suicide has been widely noted in risk literature for suicide (Koller, Preuss, Bottlender, Wenzel, & Soyka, 2002; Mann, Waternaux, Haas, & Malone, 1999; Sher, Oquendo, & Mann, 2001; Sher, 2006).

EATING DISORDERS

Requirements to maintain fitness standards per service regulations, which include measurement of body composition, may pose a unique challenge to military women at risk for disordered eating. Though subject to the same types of standards as military men, military women, compared to their male counterparts, have reported higher levels of body dissatisfaction and report higher depressive symptoms associated with their weight (Carlton, Manos, & VanSltyke, 2005; Kress, Peterson, & Hartzell, 2006). Military women also show significantly higher rates of eating disorder, not otherwise specified, than civilian women, perhaps as a result of the pressure to attain and maintain fitness and weight standards in the military (McNulty, 2001). Military women who express a higher drive for thinness and greater body dissatisfaction are at a greater risk for developing an eating disorder (Lauder & Campbell, 2001). Additionally, women exposed to combat may be at particular risk for disordered eating. Military women who experienced combat versus those who did not were 1.8 times more likely to develop new disordered eating and 2.4 times more likely to lose a large amount of weight (Jacobson et al., 2008). Women with eating disorders have shown considerable risk for suicide-related behaviors (Franko et al., 2004).

PERSONALITY DISORDERS

The co-occurrence of personality disorders contributes a greater risk of suicide, independent of Axis I diagnoses, among both civilian men and women (Schneider et al., 2006). Cluster B personality disorders (i.e., dramatic) are independent predictors of suicide death in women, while cluster C personality disorders (i.e., avoidant) are independent predictors of suicide death in men (Schneider et al., 2006). Specifically, borderline personality disorder (BPD) poses significant increased risk for suicide in women; however, younger age (≤35 years) and BPD together are associated with increased suicide risk for both men and women (Qin, 2011). The potential increased suicide risk that these disorders present to military personnel has yet to be formally evaluated. Studies identifying such links may be particularly challenging in a population where personality disorders are likely underdiagnosed in both men and women.

HISTORY OF SUICIDE ATTEMPT

Individuals with multiple suicide attempts are at the greatest risk of eventual death by suicide (Hawton & Fagg, 1988; Kelley, Goldston, Brunstetter, Daniel, Ievers, & Reboussin, 1996; Pfeffer, Klerman, Hurt, Kakuma, Peskin, & Siefker, 1996). For individuals discharged from inpatient psychiatric hospitalization, the first month following hospitalization is the period of greatest risk for suicide death (Goldacre, Seagroatt, & Hawton, 1993), and current suicide ideation, along with depression, conveys increased risk of repeated suicide attempts (Lewinsohn, Rohde, & Seeley, 1994). For women with a history of suicide attempt(s), there is a six times greater risk of suicide attempt. Among women, suicide ideation, greater suicide attempt lethality, hostility, fewer reasons for living, borderline personality disorder, and nicotine use increase suicide attempt risk beyond the impact of prior attempt (Oquendo et al., 2007).

For military members, mental health hospitalizations have been associated with risk of suicide following discharge, especially if the Service member has a history of injury or alcohol use (Bell, Harford, Amoroso, Hollander, & Kay, 2010). The risk for suicide subsequent to a suicide attempt–related hospitalization is noteworthy among female Veterans. A retrospective cohort study on Veterans who had received inpatient care after a suicide attempt, during 1993–1998, at US Veterans Affairs facilities has shown that suicide is the leading cause of mortality (accounting for 25%) among the sample of female Veterans (Weiner, Richmond, Conigliaro, & Wiebe, 2011).

Occupational- and Interpersonal-Related Factors

Unemployment is a predictor of suicide risk for men; however, this has not been consistently identified as a risk factor for women (Qin, Agerbo, & Mortensen, 2003) and is not directly applicable to military women, who are obviously employed. What is important to understand here is that while men have an increased risk for suicide attempts when unemployed, women display the higher risk when faced with workplace problems. Factors predictive of suicide ideation in women facing occupational difficulties include younger age, perceived workplace harassment, working with inadequate resources, and occupational burnout (Fridner et al., 2009).

Professional risk factors are salient in understanding military-related suicide risk. Occupational and work dissatisfaction among military members play a role in suicide-related behaviors. For men in the US Air Force (USAF), for instance, dissatisfaction with USAF life in general is significantly associated with suicide ideation, while differences in satisfaction with work relationships are associated with suicide ideation among USAF women (Langhinrichsen-Rohling, Snarr, Slep, Heyman, Foran, & United States Air Force Family Advocacy Program, 2011). Additional military-related occupational risk factors include access to firearms and exposure to workplace trauma (Mahon, Tobin, Cusack, Kelleher, & Malone, 2005; Violanti, 2004).

The workplace problems experienced by women may be linked to another risk factor for suicide—that is, interpersonal problems. For women, dealing with interpersonal crises or loss of any significant relationship conveys an increased risk of ideation and attempts; this risk has been seen for women across their life span and independently of their culture (Bhugra & Desai, 2002; Cheng et al., 2010; Kingree, Thompson, & Kaslow, 1999). Furthermore, women who are victims of domestic violence that has involved physical injuries are at elevated risk for anxiety, depression, and suicide ideation (Fergusson, Horwood, & Ridder, 2006). Most recently, Gutierrez and colleagues (2013) have presented qualitative findings on female Veterans’ deployment-related experiences. Having a sense of failed belongingness, burdensomeness, and acquired capability for suicide were observed as themes emerging from the interviews conducted with these women. These factors have been presented as a contemporary model for suicide risk (Joiner, 2005) and have been consistently supported in the scientific literature as serving as risk indicators for suicide (Bryan, Cukrowicz, West, & Morrow, 2010; Van Orden, Witte, Gordon, Bender, & Joiner, 2008).

Suicide risk may be attenuated by the presence of protective factors, which may be social, psychiatric, and/or health related. On a positive note, women are seen as generally more emotionally expressive and open to seeking help, as well as identifying and using more social supports than men (Barbee, Cunningham, Winstead, Derlaga, Yankeelov & Druen, 1993; Gianakos, 2002; Maris, Berman, & Silverman, 2000). During times of emotional distress, men are less likely to express a need for help and may avoid their problems or use unhealthy coping strategies (e.g., alcohol) in an attempt to reduce their distress (Gianakos, 2002; Wimer & Levant, 2011). Greater distress levels and lower expressiveness among men have been tied to negative coping responses associated with the perceived threat to their masculinity (Burns & Mahalik, 2011). The general stigma and avoidance related to help seeking in the military is not surprising, given the overrepresentation of men in service (85%) and the masculine normative behaviors associated with military service (Burns & Mihalik, 2011).

In addition, positive family relationships, a sense of familial connection, and social support (Borowsky, Ireland & Resnick, 2001; Hovey & King, 1996) serve as socially protective factors for suicide. Perceived social support appears to lessen and protect against suicide ideation (Chioqueta & Stiles, 2007; Hovey, 1999). Satisfaction in personal relationships and a sense of usefulness to one’s family and friends are also associated with lower suicide ideation risk (Rowe, Conwell, Schulberg, & Bruce, 2006). For female physicians, meetings to discuss stressful workplace situations result in a lower risk of suicide ideation (Fridner et al., 2009). For individuals with chronic medical problems, risk for thoughts of suicide may be mitigated by feelings of happiness despite the medical conditions (Hirsch, Duberstein, & Unutzer, 2009). Unit cohesion and support from military leaders in the unit could play a crucial role for military members surviving a trauma; both unit cohesion and leader support are significantly associated with fewer health problems for soldiers exposed to trauma, both sexual and non-sexual in nature (Martin, Rosen, Durant, Knudson, & Stretch, 2000). Overall, social support and healthy interpersonal relationships appear to attenuate suicide ideation for both men and women.

A foundation of knowledge of the unique life experiences and health-related challenges of military women is essential in order to provide optimal evidence-based interventions and to advance the science of sex differences and suicide within DoD and civilian settings. Based on the information presented in this chapter on suicide-related thoughts and behaviors among women—particularly women who serve our nation—the following practice and research recommendations are provided for behavioral health providers and scientists:

1. Conduct a suicide risk screening and assessment at every intake session using psychometrically sound measures such as the Columbia Suicide Severity Rating Scale (C-SSRS; Posner et al., 2006) or the Suicide Status Form (SSF; Jobes, 2006), which is a collaborative assessment, treatment-planning, and documentation source for interviewing a patient about suicide-related risk and protective factors. The SSF has been used for many years within the US Air Force and is currently mandated for usage with at-risk patients based on the new Air Force Guide for Suicide Risk Assessment, Management, and Treatment (2013). The C-SSRS has a current military version (available for free at http://www.cssrs.columbia.edu/) that you may find extremely helpful. Do not assume that since military women are not demonstrating suicide deaths at a similar rate to their male counterparts that they are not at risk for suicide-related ideation and behaviors. Pay close attention to specific risk indicators for suicide ideation and behaviors among military women—for instance, traumatic life events, psychiatric problems, history of self-injurious behaviors with and without intention to die, postpartum depression, relational and/or occupational problems. Allow for sufficient time to best understand the specific biopsychosocial stressors that may place your female military patient at risk for suicidal thoughts and subsequent behaviors.

2. Consider the fact that military women, in general, have greater knowledge about weapons and are significantly more likely than their civilian counterparts to have ready access to lethal means such as firearms. For military women at risk for suicide, ensure that you have a discussion about availability to lethal means and address the removal of and/or restriction of access to such means and the conditions under which the lethal means would be returned to the individual. Depending on the imminence of the suicide threat, you are encouraged to consider collaborative work with family members, trusted peers, military police, and/or the Service member’s command to ensure safety.

3. Collaborate with the patient to prepare an individualized, hierarchically arranged, written list of coping strategies (i.e., a safety plan) to implement in future distressing circumstances. Discuss thoroughly the patient’s prior experiences, specifically, cognitions, emotions, and/or behaviors that precipitate self-injury at times of crises. Make sure that the safety plan, at the very least, contains contact information for the provider, the on-call provider (if available), the local 24-hour emergency department, and at least one reliable suicide hotline number, as well as information on how to best limit access to lethal means. Contact information for Military Crisis Line’s (1-800-273-TALK [8255] or 00800-1273-TALK [8255] in Europe, 24 hours a day, 7 days a week) suicide crisis hotline must be provided, along with name and address of the nearest Emergency Department. Check on the patient’s willingness to follow the safety plan and help problem-solve perceived obstacles in implementation. Refer to the Safety Planning Intervention guide provided by VA (http://www.mentalhealth.va.gov/docs/VA_Safety_planning_manual.pdf) for constructing safety plans (Stanley & Brown, 2008, 2012).

4. Remain mindful of the stigma, harassment, and possible ridicule within the military environment that many military women may experience because of how their suicide-related behaviors may be perceived by others. Within the military, suicide-related behaviors may be perceived and labeled as malingering—this may be more pronounced for women. “Women are still seen as weak, whiny, hormonal, and incapable” (Blank, 2008, p. 19), and such negative perceptions may lead to a minimization or dismissal of their symptoms. Therefore, work collaboratively with your female military patient in order to assist her to overcome organizational, cultural, and/or interpersonal challenges within the military—and thus to feel empowered about her skills, work functions, and overall contributions.

5. Remember that perceived barriers to care may play an important role concerning the timely delivery of mental health treatment to military women. Owens and colleagues (2009) report that over 40% of female Veterans studied reported needing psychological services but not utilizing these services, most often citing long waiting periods and prior bad experiences within VA healthcare system. Of the women who sought treatment from a non-VA mental health provider, most indicated feeling some stigma going to the local VA, and/or not feeling “welcome” there. Fontana and Rosenheck (2006) studied women admitted to VA’s Women’s Stress Disorders Treatment Team for treatment of their PTSD and found comfort to be a potential important factor in treatment adherence. The women generally reported feeling “somewhat comfortable” from the start of their treatment, and for those for whom this was their first contact with VA, comfort increased as exposure to treatment increased. For these women, level of comfort showed some associations with treatment compliance, though only slightly associated with outcomes. In another recent study, “ease of use” of the facility, as well as variables such as physician sensitivity and logistics of care, was predictive of VA utilization (Vogt et al., 2006). Stigma concerns, as well as the importance of comfort and sensitivity, should therefore be a focus of particular attention for providers who work with military women.

6. Provide psychoeducation to your female patients about career-related implications associated with seeking psychological care on a voluntary preventative basis versus those associated with seeking psychological care when mandated by command. A retrospective chart review (Rowan & Campise, 2006) was conducted using 1,068 cases of active duty USAF Service members seen in eight USAF behavioral health clinics during a one-year period. The investigators reported that self-referred USAF personnel, as compared with commander-mandated members, were less likely to have their confidentiality broken and to experience career-impacting recommendations. Of course, certain medical and psychiatric conditions may have significant impact on Service members’ careers, leading to administrative separation. Providers may face the difficult decision of determining the fitness and suitability of military women who have a history of suicide thoughts and behaviors. However, openly discussing concerns about career-related implications of seeking mental healthcare may help your female military patients understand that mental healthcare does not lead to separation from the military, but that this outcome may occur if their psychiatric symptoms have exacerbated, requiring further evaluation of their fitness for duty. Similarly, suicide-related thoughts and behaviors that result in hospitalization do not warrant a mandatory separation from military service. In a previous study of military members hospitalized for suicide-related reasons, nearly half the sample were returned to full duty status (Ritchie et al., 2003).

7. Promote and engage in research studies that advance our understanding of the unique needs of military women who experience suicide-related ideation and/or behaviors. Beautrais (2006, p. 153) writes the following: “One reason for the lack of investment in female suicidal behavior may be that there has been a tendency to view suicidal behavior in women as manipulative and nonserious (despite evidence of intent, lethality, and hospitalization), to describe their attempts as ‘unsuccessful,’ ‘failed,’ or attention-seeking, and generally to imply that women’s suicidal behavior is inept or incompetent (Canetto & Lester, 1995; Murphy, 1998).” Given the relatively low number of military women who die by suicide, some may argue that DoD resources should primarily be focused on preventing male suicides. However, military women, while underrepresented in the suicide death statistics, are expected to be overrepresented in the suicide ideation and attempt categories. DoD suicide prevention efforts and population-level surveillance cannot solely focus on suicide deaths (fatal events) and must consider ideation and attempts (non-fatal events) as other important areas for inquiry and prevention. Since the positions that military women hold are just as impacting on unit readiness as are those of their male counterparts.

8. When preparing scientific presentations, publications, and/or reports, conduct statistical analyses and present your findings on sex-related differences pertaining to suicide-related ideation and behaviors among military women. As repeatedly noted, this is an area of research inquiry that has not received much attention and is in desperate need for growth. It would be very helpful for DoD reports such as the DoDSER to provide a summary section on findings specifically pertaining to military women, so that the important discoveries pertaining to these individuals are not simply lost in the numbers. Funding of studies on suicide-related thoughts and behaviors among military women would also contribute to the advancement of science in this important understudied area.

This chapter has provided an overview of suicide-related ideation and behaviors among military women and a series of recommendations for behavioral healthcare providers and scientists. From recruits to Veterans, women are expanding their ranks in our nation’s military history. As the nature of women’s involvement in the military evolves, providers across various DoD, VA, and civilian healthcare settings have an increasing responsibility to recognize, understand, and respond to the psychological issues these women encounter. While efforts to address behavioral healthcare needs of military Service members as a whole have been outstanding, there is still a great deal of mental health research disparity in relation to issues pertaining to military women. Providers, researchers, and policymakers within the DoD are strongly encouraged to pay closer attention to the unique needs of this subgroup.

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of Defense.

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¹ China is a notable exception, where women outnumber men in suicide deaths (WHO, 2013).

² Age adjusted

³ Age adjusted.

⁴ Age adjusted.