A military suicide prevention program in the Israeli Defense Force: a review of an important military medical procedure

Workplace interventions to prevent suicide: A scoping review

OBJECTIVES

To map organisational interventions for workplace suicide prevention, identifying the effects, mechanisms, moderators, implementation and economic costs, and how interventions are evaluated.

BACKGROUND

Suicide is a devastating event that can have a profound and lasting impact on the individuals and families affected, with the highest rates found among adults of work age. Employers have a legal and ethical responsibility to provide a safe working environment for their employees, which includes addressing the issue of suicide and promoting mental health and well-being.

METHODS

A realist perspective was taken, to identify within organisational suicide prevention interventions, what works, for whom and in what circumstances. Published and unpublished studies in six databases were searched. To extract and map data on the interventions the Effect, Mechanism, Moderator, Implementation, Economic (EMMIE) framework was used. Mechanisms were deductively analysed against Bronfenbrenner's socio-ecological model.

RESULTS

From 3187 records screened, 46 papers describing 36 interventions within the military, healthcare, the construction industry, emergency services, office workers, veterinary surgeons, the energy sector and higher education. Most mechanisms were aimed at the individual's immediate environment, with the most common being education or training on recognising signs of stress, suicidality or mental illness in oneself. Studies examined the effectiveness of interventions in terms of suicide rates, suicidality or symptoms of mental illness, and changes in perceptions, attitudes or beliefs, with most reporting positive results. Few studies reported economic costs but those that did suggested that the interventions are cost-effective.

CONCLUSIONS

It seems likely that organisational suicide prevention programmes can have a positive impact on attitudes and beliefs towards suicide as well reducing the risk of suicide. Education, to support individuals to recognise the signs and symptoms of stress, mental ill health and suicidality in both themselves and others, is likely to be an effective starting point for successful interventions.

Contributing Factors to Israeli Soldiers' Adaptation to Military Noncombat Positions

OBJECTIVE

Adjusting to a military environment is a complex process, with unique demands and various stressors placed on conscripts. In this study, we examined the unique and combined contribution of the independent variables that constitute an individual soldier's personal resources-the meaningfulness of the military role and the match between expectations and the job itself; cognitive flexibility; social support; and seeking help from a mental health officer (MHO)-to the adaptation (dependent variable) of noncombat soldiers to military service.

METHOD

The study group comprised 200 Israel Defense Forces noncombat soldiers aged 18-23 years (Meanage = 20.046 years, SD = 0.951). Of them, 107 (53.3%) had consulted a MHO. The remaining soldiers who had not consulted an MHO (n = 93, 46.5%) served as the comparison group. Research tools included the work and meaning questionnaire, the Cognitive Flexibility Scale, the Medical Outcomes Study (social support) questionnaire, and adaptation to the army questionnaire.

RESULTS

Adaptation to service was found to relate positively to the meaningfulness of the military role, cognitive flexibility, and social support. Social support partially mediated the relation between cognitive flexibility and adaptation to service. Additionally, soldiers who had consulted an MHO had lower levels of cognitive flexibility and social support, and they adapted less well to service compared to the comparison group.

CONCLUSIONS

The study indicates that soldiers who seek help have lower resources. Additional personal and environmental variables that contribute to the adjustment of soldiers in noncombat positions were also identified.

Risk Factors Associated With Various Severities of Suicidal and Non-Suicidal Self-Harm Among Israel Defense Forces Soldiers-A Nested Case-Control Study

OBJECTIVE

Severe suicide attempt is a major risk factor for completed suicide. The aim of the present study was to focus on suicide behavior and timing to gain better understanding of these populations.

METHOD

The nested case-control retrospective study based on medical records of 246,866 soldiers, who demonstrated suicide attempts of varying severity, including death by suicide were compared with soldiers who did not demonstrate such behavior.

RESULTS

Risk for death by suicide was associated with males, military seniority of less than 12 months. High frequency of visits with mental health care professionals was associated with being severe suicide attempters (SAs). Moderate suicide attempts were associated with being a male, visiting a primary care physician frequently, and belonging to one of the two latest immigrant groups in Israel (Ethiopians and former Soviet Union). Mild suicide attempts were associated with having a psychiatric diagnosis on the enlistment day, visiting a mental health care professional at high or average frequency, visiting a primary care physician at high or average frequency, being a male, and being born in the former Soviet Union. While the proportion of males demonstrating suicidal behavior was higher than the females', severe SAs were higher among females. There was a clear tendency of female suicide attempters at all levels to act toward the end of their military service.

CONCLUSIONS

Although half of the SAs were females, their characteristics may be similar to those of the male SAs, contrary to the sex differences in suicide behavior among civilians.

An effective suicide prevention program in the Israeli Defense Forces: A cohort study

Objective

To evaluate the effectiveness of the IDF Suicide Prevention Program, implemented since 2006.

Design

Quasi-experimental (before and after) cohort study.

Participants

Two cohorts of IDF mandatory service soldiers: the first inducted prior to (1992–2005, n = 766,107) and the second subsequent to (2006–2012, n = 405,252) the launching of the intervention program.

Exposure

The IDF Suicide Prevention Program is a population-based program, incorporating: reducing weapon availability, de-stigmatizing help-seeking behavior, integrating mental health officers into service units, and training commanders and soldiers to recognize suicide risk factors and warning signs.

Main outcome measure

Suicide rate and time to suicide in cohorts before and after exposure to the Suicide Prevention Program.

Results

Trend analysis showed lower suicide rates in the cohort after intervention. The hazard ratio for the intervention effect on time to suicide was 0.44 (95% CI = 0.34–0.56, P < .001) among males. Lower risk was associated with: male gender; born in Israel; higher socio-economic status; higher intelligence score; and serving in a combat unit (HR = 0.43: 95% CI = 0.33–0.55).

Conclusions

There was a 57% decrease in the suicide rate following the administration of the IDF Suicide Prevention Program. The effect of the intervention appears to be related to use of a weapon, and being able to benefit from improved help-seeking and de-stigmatization. Future efforts should seek to extend the program's prevention reach to other demographic groups of soldiers. The success of the IDF program may inform suicide prevention in other military organizations and in the civilian sector.

The effect of the Suicide Prevention Program (SPP) on the characteristics of Israeli soldiers who died by suicide after its implementation

BACKGROUND

Suicide is major cause of death in the IDF. The Suicide Prevention Program (SPP) led to significant reduction in yearly rates of suicide. A study regarding demographic changes of those who died by suicide was done to further investigate its affect.

METHOD

Nested case control retrospective study based on medical and HR data gathered between 1992 and 2016. Participants were divided into four groups: soldiers who died by suicide and non-suicidal soldiers, before and after SPP implementation.

RESULTS

Multivariate analysis with suicide as the binary logistic dependent variable before and after implementation of the SPP among four groups revealed that before SPP the OR was higher for males (OR, 7.885; 95% CI, 5.071-12.259;p < 0.001) compared to after (OR, 3.281; 95% CI, 1.600-6.726; p = 0.001). For support unit soldiers the values before SPP were OR, 14.962 and 95% CI, 8.427-26.563 (p < 0.001) while after SPP they were OR, 6.304 and 95% CI, 3.334-11.919 (p < 0.001). After SPP, OR was higher for psychiatric diagnosis at recruitment (OR, 5.830; 95% CI, 2.046-16.612; p =  0.001) than before SPP (OR, 2.422; 95% CI, 1.526-3.842; p < 0.001).For soldiers from Ethiopian ethnicity, after SPP values were higher (OR, 8.130 and 95% CI, 2.868-23.047 (p < 0.001) compared to before (OR, 3.522; 95% CI, 1.2891-6.650; p < 0.001). For those of Druse religion before values (OR, 4.027; 95% CI, 2.211-7.331; p < 0.001) were significant but not after.

CONCLUSIONS

While the SPP succeeded in reducing risk of suicide in situational factors, dispositional risk factors were not affected by the SPP. The OR decreased in critical masses and rose in unique and smaller groups.

Military hazing and suicidal ideation among active duty military personnel: Serial mediation effects of anger and depressive symptoms

BACKGROUND

Military hazing is one of most serious problems affecting suicidal ideation (SI) among active duty personnel, but has received limited research attention. Studies on hazing and SI indicate anger and depressive symptoms as mediators for SI.

METHODS

A sample of active duty military personnel (N = 944) completed an offline survey, consisting of the revised Conflict Tactics Scale-2, Composite International Diagnostic Interview Screening Scale, and revised Columbia Suicide Severity Rating Scale. Frequency, bivariate correlation, and serial mediation analyses were conducted to assess the serial effects of military hazing on SI, mediated via anger and depressive symptoms.

RESULTS

Military hazing, anger, depressive symptoms, and SI were positively related to each other in bivariate analyses. In serial mediation analyses, hazing was found to be a significant predictor of higher levels of anger, consequently triggering depressive symptoms, which, in turn, were associated with greater SI.

LIMITATIONS

Study limitations included the use of cross-sectional data with the use of retrospective self-report.

CONCLUSION

Hazing in the military is prevalent (17.6%), and SI is associated with serial effects of hazing, anger, and depressive symptoms with full mediation path. Findings suggest that policies that address reducing hazing and implementing clinical interventions specifically focused on symptoms of anger and depression may be important for decreasing SI in military personnel.