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Suicidal and Homicidal Soldiers in Deployment Environments

Suicidal and Homicidal Soldiers in Deployment Environments Guarantor: MAJ Jeffrey V. Hill, MC USA ... Suicidal and homicidal soldiers present one of the most fre-

MILITARY MEDICINE, 171, 3:228, 2006

Suicidal and Homicidal Soldiers in Deployment Environments

Guarantor: MAJ Jeffrey V. Hill, MC USA
Contributors: MAJ Jeffrey V. Hill, MC USA; CPT Robert C. Johnson, MSC USA; CPT Richard A. Barton, MSC USA

Suicidal and homicidal soldiers present one of the most fre- thoughts of harming themselves or others. At the other end of
quent and challenging scenarios for deployed mental health the spectrum are those who have already attempted or have
providers. A chart review of 425 deployed soldiers seen for imminent plans to hurt themselves or others.
mental health reasons found that 127 (nearly 30%) had con-
sidered killing themselves and 67 (nearly 16%) had considered Each case presents a dilemma to the deployed provider. On
killing someone else (not the enemy) within the past month. Of one side of the dilemma is the need to establish safety and
these, 75 cases were considered severe enough to require treatment.18–24 On the other side is the need to conserve the
immediate intervention. Interventions included unit watch, fighting force. Depletion of the fighting force can occur through
comprehensive treatment, and medical evacuation. Of the 75 death, wounding, or evacuation of the soldier. “Evacuation syn-
dangerous soldiers, 5 were evacuated out of theater. The rest dromes,” observed in many conflicts, are increases in numbers
were returned to duty. Evacuation to a hospital in the rear is of soldiers presenting to medical providers with symptoms
often the quickest and most risk-free option but is seldom the known to result in removal from the battlefield. For example,
best choice for maintaining the fighting force. This article after it became known that sleepwalking would disqualify a
presents several case examples and describes methods for soldier from duty in Vietnam, there was an epidemic of sleep-
dealing with suicidal and homicidal soldiers during deploy- walkers.25 Many soldiers have told us that it is common knowl-
ment. edge among their peers that suicidal or homicidal thoughts or
behaviors usually result in withdrawal from duty and discharge
Introduction from the military. Some soldiers experiencing problems adjust-
ing to the military lifestyle report these symptoms to facilitate
S uicides and homicides within the military have been of in- their discharge from service. However, suicides and homicides
terest for many years. Within the military, rates tend to do occur in the military, underscoring the importance of thor-
fluctuate below the norm for a comparable nonmilitary popula- ough evaluation and treatment of all such soldiers.1–11
tion and seem to be inter-related with social factors affecting the
general population. Some of this overall lower rate of suicide Given the current high level of interest in suicide and homi-
may be related to screening and disqualification of soldiers with cide prevention throughout the military, a soldier reporting sui-
mental health problems. During the summer of 2003, there was cidal or homicidal thoughts can expect to immediately become
a sharp increase in Army suicides, specifically among those the center of attention of his or her command.26,27 Incredible
involved in Operation Iraqi Freedom (OIF) I, which triggered a efforts to ensure safety are applied by command members and
widespread response throughout the military. OIF II began for medical personnel. Given the necessity of maintaining the fight-
the 1st Infantry Division early in 2004 and ended early in 2005. ing force, the dilemma for the deployed provider is whether to
The mental health providers throughout the Iraqi theater evacuate the soldier or to attempt to rehabilitate the soldier in
worked aggressively to prevent similar problems during OIF II. theater.17 Evacuation of the soldier is often the easiest solution
This article describes the approach used throughout the 1st and relieves the provider and the command of the responsibility
Infantry Division and specifically at Forward Operational Base to safeguard and to treat the soldier. However, such evacuations
(FOB) Speicher to treat both suicidal and homicidal soldiers. A may deplete the fighting force and lead to evacuation syn-
full review and discussion of the literature on military suicides is dromes. Treating such a soldier in theater is always a risky
beyond the scope of this article but is readily available venture in which the mental health provider takes a professional
elsewhere.1–16 risk, knowing that he or she may face blame and punishment for
a bad outcome. The emotional impact on the provider of taking
In OIF II, mental health providers come from a variety of such risks each day is not insignificant.
disciplines, including psychiatrists, psychologists, social work-
ers, occupational therapists, chaplains, and enlisted mental There are advantages and disadvantages of treatment in the
health technicians.17 They are dispersed throughout the area of deployment environment. Factors that tend to make treatment
operations and function together or individually. One of the more difficult are the availability of weapons, geographical and
most common and difficult scenarios for such providers is that logistical distance from providers, and operational require-
of dangerous patients. Dangerous patients can be defined as ments. Factors that have improved treatment capability in the
those who present to the provider with some degree of suicidal or deployment environment include the ability to search and re-
homicidal risk. The risk varies through a spectrum of serious- move weapons from soldiers and their living space, the ability to
ness. At one end of the spectrum are those who never have control the soldiers’ environment through unit watch or other
interventions, and the prohibition of and relative difficulty of
1st Infantry Division, Operation Iraqi Freedom II, Tikrit, Iraq. obtaining and using substances of abuse or dependence.28,29
The views expressed in this article are those of the authors and do not reflect the
official policy or position of the 1st Infantry Division, the Department of the Army, the Chart Review of Dangerous Patients in OIF II
Department of Defense, or the U.S. government.
This manuscript was received for review in January 2005. The revised manuscript FOB Speicher served as a major support and supply base
was accepted for publication in August 2005. during OIF II. Therefore, the soldiers populating the base were

Military Medicine, Vol. 171, March 2006 228

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Suicidal and Homicidal Soldiers 229

for the most part involved in support operations (e.g., truck Seventy-five of these cases were deemed severe enough to
require immediate mental health intervention. Of these 75 se-
drivers, vehicle maintenance personnel, medics, and cooks). vere cases, 15 (20%) were from Army reserve components, 59
(79%) were from active duty Army units, and 1 (1%) was from an
The Aviation Brigade was also based and treated at FOB active duty Air Force component. Twenty-two (29%) were from
combat units, and 53 (71%) were from support units. The aver-
Speicher. Soldiers in combat units based near FOB Speicher age age of these soldiers was 26 years, with a SD of 6.9 years and
a range of 19 to 48 years. Of these soldiers, 43 (57%) were
also received care at the division mental health section there married and 28 (37%) were single (4 had unknown status). Male
subjects accounted for 63 (84%) and female subjects 12 (16%).
and represented approximately one-fourth of the population Enlisted ranks from E1 to E5 represented 66 soldiers (88%) and
ranks above E5 represented 9 (12%). Diagnoses were 47% ad-
served. justment disorders, 19% depressive and dysthymic disorders,
8% combat operational stress and post-traumatic stress disor-
Between February 8 and December 25, 2004, 491 soldiers der, 5% other anxiety disorders, and 7% no diagnosis. The
remaining 14% represented various other psychiatric diagnoses
were evaluated by the FOB Speicher division mental health in a number of categories.

team, consisting of the first author, a board-certified psychia- Sixty-one of the soldiers were suicidal and 21 were homicidal.
Seven were both suicidal and homicidal. Of these 75 soldiers, 70
trist, and three enlisted mental health technicians. Of the 491 (94%) were treated in theater and returned to duty, whereas 5
(6%) were evacuated out of theater. One returned to theater after
soldiers, 425 completed standardized intake paperwork, includ- treatment in Germany. Twenty-nine were placed on unit watch,
which usually lasted 4 days to 1 week. Five soldiers carried a
ing the following questions. (1) In the past week, I have had disabled weapon (firing pin removed to render it nonfunctional).
Therefore, of the total of 491 soldiers seen, only 5 (1%) were
thoughts of ending my life (never, rarely, sometimes, frequently, evacuated for suicidality or homicidality. Ninety-nine percent of
all soldiers evaluated were returned to duty.
or almost always). (2) In the past month, have you thought of a
Treatment in Theater
specific plan to kill yourself (yes or no)? (3) In the past month,
To avoid unnecessary evacuations from theater, a full spec-
have you wanted to kill someone (yes or no)? (4) In the past trum of mental health treatment was established at FOB
Speicher. In most cases, this allowed the soldiers to continue
month, have you thought of a specific plan to kill someone (yes duty while being treated. Each soldier was evaluated and an
individual treatment plan was constructed, which might include
or no)? patient education, supportive therapy, cognitive therapy, com-
mand consultations, medication trials and management,
A chart review was conducted to determine how many soldiers and/or group (stress, anger, conflict resolution, depression,
combat operational stress, or social skills) treatment. These
reported suicidal or homicidal thoughts. Positive answers to interventions were provided through protocols with the psychi-
questions 2 to 4 acknowledge suicidal plans, homicidal atrist overseeing care of the patients and with classes, initial
thoughts, and homicidal plans, respectively. In question 1, the screening, and supportive counseling being performed mostly
answer “sometimes” or more was considered positive. In addi- by enlisted mental health specialists. A critical part of every
tion, soldiers reporting suicidal or homicidal thoughts, plans, or treatment plan was the safety plan. Safety plans included a
actions in the initial interview or subsequent sessions were tiered approach based on the severity of the soldier’s suicidal or
considered positive. Homicidal statements concerning killing homicidal thoughts or intent. At lower levels of intervention, a
the enemy as part of the soldier’s mission were common but not soldier might simply be instructed to talk to the chaplain or to
included in the database. Three soldiers reported homicidal visit mental health services when thoughts occurred. Higher
feelings toward nonmilitant Iraqi civilians. Question 1 asked levels of treatment might involve removal (or inactivation) of the
about symptoms in the past week and occurred in a different soldier’s weapon and ammunition, frequent appointments,
portion of the intake paperwork. Questions 2 to 4 reported and/or unit watch. The unit watch, as described below, was the
symptoms during the past month. Because this study was ret- primary means of ensuring safety for more severely suicidal or
rospective, standardization of the questions’ time frame and homicidal soldiers. When safety and treatment can be provided
structure was not possible. in theater, there is virtually no reason to evacuate a soldier out
of theater.
Of the 425 patients reviewed, 96 (23%) were from Army re-
serve components, 324 (76%) were from active duty Army units, Unit Watch
and 5 (1%) were from active Air Force components. Eighty-two
(19%) were from combat units and 343 (81%) were from support The unit watch, a powerful and controversial method of en-
units. The average age of treated soldiers was 27 years, with a suring safety, proved invaluable in maintaining the fighting
SD of 6.9 years and a range of 19 to 56 years. Of these soldiers,
215 (51%) were married and 210 (49%) were single. Male sub-
jects accounted for 308 (72%) and female subjects for 117 (28%).
Enlisted ranks from E1 to E5 represented 358 soldiers (84%)
and ranks above E5 represented 67 soldiers (16%) seen in the
clinic. Diagnoses were 34% adjustment disorders, 16% depres-
sive and dysthymic disorders, 13% combat operational stress
and post-traumatic stress disorder, 5% other anxiety disorders,
and 12% no diagnosis. The remaining 20% represented various
other psychiatric diagnoses in a number of categories. One hun-
dred twenty-seven of the 425 soldiers had thought of ending
their lives within the past week. Eighty-one had a specific sui-
cidal plan. Twenty-six had acted in a suicidal manner (e.g.,
placing a weapon to their head, loading ammunition in the
weapon, or taking an overdose). Sixty-seven had desired to kill
someone else (not the enemy). Thirty-six had formed a plan to
harm someone else. Eleven had acted on the plan to some
degree (e.g., loading ammunition into their weapon or pointing
the weapon at someone else).

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230 Suicidal and Homicidal Soldiers

force. Unit watches have been used for many years in the mili- vehicle. Because of the soldier’s potential for violence and phys-
tary.30 Military mental health providers are usually trained in ically threatening strength, two unit guards stayed with the
their appropriate use. The unit watch protocol guides com- patient. The soldier’s squad, tasked with providing unit guards,
mands in how to conduct a unit watch (Fig. 1). rotated two new guards every 12 hours. The guards were sent in
required two-vehicle convoys, resulting in two vehicles driven by
Some soldiers do poorly on a unit watch. This may be attrib- two drivers, each with a codriver, driving 1 hour to reach the
utable to unresolved mental illness, hostile unit reaction to the hospital, where they changed the guards, usually their codriv-
soldier, or the soldier’s ulterior motives. To maximize the healing ers, and returned to base. Therefore, during the convoy, at least
capabilities of the watch, commands are instructed to ensure seven soldiers (including the patient) of the 11-person squad
that the soldier is kept busy, is not stigmatized by the unit, and were occupied in ensuring the patient’s safety. This effectively
receives caring and supportive treatment by fellow soldiers.31 prevented an entire squad from accomplishing its mission.
Although this may seem more easily said than done, experience
shows that the majority of soldiers treated in theater under Malingering
conditions of unit watch do recover and return to full duty
within 2 weeks. Mental health care continues until deemed no Many soldiers presenting with dangerous tendencies demon-
longer necessary. strate some component of malingering. For the most part they
recover and return to full duty. Cases 2 and 3 provide examples.
Mental health teams reevaluate a soldier on unit watch every
2 to 3 days, with the goal of discontinuing the watch as soon as In case 2, a 25-year-old enlisted soldier presented to the clinic
it is no longer needed. Unit watches are costly to commands, escorted by command after the soldier related plans to commit
which must arrange an escort for the soldier 24 hours per day suicide with a pill overdose. On evaluation, it was evident that
and 7 days per week. Command acceptance of unit watch rec- the soldier did not intend to take the pills but rather desired to
ommendations can be strengthened by reminding the command be discharged from the military. The soldier was placed on a unit
of the potential of losing the soldier to suicide or medical evac- watch with reassessment every 2 to 3 days and continued to
uation. Even when a soldier is evacuated, the unit may need to report strong suicidal ideation until the 14th day of the unit
send an escort to provide for the soldier’s safety during travel. One watch. At that time, the soldier said, “I guess this isn’t getting
example of the manpower cost to the command of a suicidal soldier me anywhere. I might as well stop saying it.” The soldier denied
occurred in a previous operation and is described in case 1. further suicidal intent and served honorably for the remaining 9
months of deployment. Notably, earlier that day the commander
In case 1, a 24-year-old suicidal soldier was brought to the met with the psychiatrist and expressed the unit’s inability to
combat support hospital from another base ϳ1 hour away by continue the watch. The psychiatrist had agreed to recommend
a return to the rear if the situation did not improve.
Fig. 1. 1st Infantry Division (1ID) unit watch command instruction form. SSN,
Social Security number; NCO, noncommissioned officer; PT, physical training. In case 3, an enlisted 20-year-old soldier presented to the
clinic after threatening to kill command members or other sol-
diers. During evaluation, the soldier expressed the desire to get
out of the military and threatened to destroy people and things
if not released from duty. The soldier’s stated motive was to
convince the command that the soldier was mentally unstable
and thus to receive an administrative discharge from the mili-
tary. Upon learning that there would be no discharge from the
military, the soldier went on a rampage, damaging critical
equipment and making homicidal threats. In the court martial,
the soldier was found guilty of malingering in addition to van-
dalism, disrespect, and dereliction of duty and was sentenced to
the full penalty.

There is often some ulterior motive in the presentation of
mental health patients. Because such patients frequently re-
cover, however, the diagnosis of malingering and subsequent
prosecution should be used only in cases in which it is obviously
the primary issue and harm has been done. Otherwise, clini-
cians risk ignoring significant mental health disease and con-
tributing to a bad outcome. Sometimes suicidal or homicidal
soldiers are not mentally ill. For example, a soldier threatening
to kill a member of the chain of command may be motivated
more by revenge, anger, or other agendas, rather than a mental
disorder. In such cases, treatment through legal channels may
be more appropriate than treatment through medical chan-
nels.32 Alternatively, anger and plans for revenge can be related
to a mental illness and require treatment through medical chan-
nels.

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Suicidal and Homicidal Soldiers 231

Suicide Case Reports the deployment environment, where almost everyone demon-
strates some sadness or stress, it becomes extremely difficult to
As mentioned earlier, suicides do happen in the military.8–10 predict who will actually commit suicide. Case 5 occurred dur-
ing OIF II. Although it occurred in an immensely more violent
Cases 4 to 6 describe three completed suicides that occurred theater where soldiers died almost every day, the profound ef-
fects on unit morale and potentially related outbursts within
within the 1st Infantry Division during the first author’s 3-year weeks underscore the impact of a suicide on unit morale. As in
case 6, the soldier was performing additional duty at the time of
tour. None of these soldiers had communicated intent or sought the suicide, underscoring a potential relationship between the
mental health care. additional stress of disciplinary action and suicidal acts. Case 6,
which also occurred in Iraq, suggests a possible conception by
In case 4, a 20-year-old, single, junior enlisted soldier was soldiers that mental health workers are more interested in sui-
found with a gunshot wound to the head after failing to show for cidal soldiers or suicidal completion than in soldiers undergoing
a planned formation. The soldier was well liked and widely intense battle, sacrifice, and loss.
known throughout the unit and base. During the psychological
postmortem investigation, unit members recalled no verbal or The vast majority of soldiers treated for suicidal or homicidal
other indication of the soldier’s suicidal plans. The soldier had tendencies have a successful outcome. Case 7 illustrates one
never sought treatment with mental health agencies. Unit mem- such situation.
bers speculated that the suicide resulted after an e-mail argu-
ment with a significant other. Of note, the entire unit had been In case 7, a 35-year-old Army reservist presented during OIF
psychiatrically screened before deployment 3 months earlier. At II after lying in bed with an M16 rifle barrel held in the soldier’s
the screening time, this soldier indicated no mental health prob- mouth. On evaluation, the service member demonstrated a deep
lems or suicidal thoughts. melancholic depression, with no hope of ever recovering. A unit
watch was started and the weapon was disabled by removing the
In case 5, a 21-year-old enlisted soldier serving in Iraq was bolt from it. The soldier was treated with an antidepressant and
found in a portable toilet with a self-inflicted bullet wound to the weekly therapy. Over the next few weeks, the soldier showed
head. The shot was heard by nearby workers, who rushed to the remarkable mood improvement, became nonsuicidal, and was
scene and found the soldier dead. The soldier was undergoing returned to full duty. Months later, this soldier continued to
nonjudicial punishment for misbehavior and had just received mention gratefulness for the care provided, for subsequent re-
further counseling by the command. After reporting for addi- covery, and for the ability to complete the tour of duty in Iraq.
tional duty, the soldier went to the portable toilet and inflicted a
gunshot wound to the head. This soldier had never received Conclusions
mental health care and had not verbalized suicidal intent.
Suicidal and homicidal soldiers can be quite common during
This death had an immense effect on the morale of the unit, deployment, and their treatment is challenging. Some aspects of
for which there were no combat deaths during the deployment. treatment are easier to accomplish in the deployment environ-
Unit members and those at the scene were treated through ment, such as preventing substance abuse, providing supervi-
critical event debriefing (CED), as described in Army Field Man- sion, and, in some locations, ensuring prompt mental health
ual 8-51 and the Textbook of Military Medicine.33,34 Although care.11,28,29 However, some deployment factors, such as weapon
controversial in the medical literature, such debriefings were availability, unit mission requirements, and malingering, in-
standard throughout OIF II, expected by commands, and usu- crease the difficulty of providing safety and care. Unit watches
ally appreciated by participants. Within 2 weeks, three soldiers were used successfully during deployments to Kosovo and Iraq,
from three separate units presented after angry outbursts or providing safety during treatment. Unfortunately, suicides do
assault. Upon investigation, it was noted that all three of these occur in the military. Three examples included in this article
soldiers had been on site or had known the suicide victim but were unforeseen and untreated. There are many examples of
had not been included in the CED. successful treatment in theater. One such example is cited.

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