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Killing in combat and suicide risk

Published online by Cambridge University Press:  23 November 2012

T.R. Rice*
Affiliation:
Department of psychiatry, Mount Sinai School of Medicine, 1, Gustave L. Levy Place, Box 1230, New York10029, United States
L. Sher
Affiliation:
Department of psychiatry, Mount Sinai School of Medicine, 1, Gustave L. Levy Place, Box 1230, New York10029, United States James J. Peters Veterans' Administration Medical Center, 130, West Kingsbridge Road, Bronx, New York10468, United States
*
Corresponding author. Tel.: +1 718 584 9000x6821; fax: +1 718 741 4703. E-mail address: Timothy.Rice@mssm.edu (T.R. Rice).

Abstract

Type
Letter to the editor
Copyright
Copyright © European Psychiatric Association 2012

Military combat veterans constitute a large population in which standard practices of suicide risk assessment and prevention may not apply [Reference Rice and Sher8]. Studies suggest that military veterans may differ from their civilian peers in their risk responsiveness to established clinical factors [Reference Rice and Sher8]. Veterans are additionally exposed to stressors to which civilians remain naïve. Identification and clinical responsiveness to these factors can save lives [Reference Bryan, Cukrowicz, West and Morrow1].

The act of killing in combat is one such stressor which recent research suggests may raise suicide risk. Combat killing is a prevalent act; contemporary estimates in Iraq war veterans range from 32 to 40% [Reference Maguen, Lucenko, Reger, Gahm, Litz and Seal4]. An increased risk was first identified among Vietnam veterans who expressed guilt over killing [Reference Fontana, Rosenheck and Brett2]. Killing irrespective of guilt was subsequently found to be associated with Post-Traumatic Stress Disorder (PTSD) symptoms, a well-known risk factor for suicidality [3,4]. This association held after controlling for the effect of witnessing another's act of killing [Reference VanWinkle and Martin9]. A direct association with suicidal ideation has now been found [Reference Maguen, Luxton, Skopp, Gahm, Reger, Metzler and Marmar5] and confirmed to be significant independent of comorbid disorders and adjusted levels of combat exposure [Reference Maguen, Metzler, Bosch, Marmar, Knight and Neylan6]. As suicidal ideation and suicide attempts are both strong independent risk factors for completed suicide [Reference Rice and Sher8], these data strongly suggest that killing in combat increases the risk of completed suicide.

Nearly all healthcare providers care for military veterans: Worldwide, the vast majority veterans receive their care outside of veteran-specialized healthcare systems [Reference Rice and Sher8]. When concern for suicidality arises, all providers should inquire into veteran status and tailor risk assessment practices accordingly. Though controversy remains whether veterans as a group are at an increased risk of suicide as compared to their civilian peers [Reference Miller, Barber, Young, Azrael, Mukamal and Lawler7], certain risk factors within this group are better established [Reference Rice and Sher8]. A history of combat killing is both prevalent and readily identifiable. Incorporating this risk factor into standard suicide risk assessment practices in veterans appears empirically prudent.

Asking about a history of killing in combat provides the attentive clinician a window into the experiential content of combat narratives. Additional suicide risk factors may be spontaneously revealed within these narratives, such as re-experiencing symptoms or guilt. Discussion may serve as a seamless and less stigmatized entry to the identification of clinical disorders such as depression or PTSD. Attention to a history of killing in combat develops and enriches our healthcare for these deserving individuals.

References

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