Suicide in peacekeepers: risk factors for suicide versus accidental death

UN peacekeeper health and risk factors --- a systematic scoping review

BACKGROUND

Conflicts, natural disasters, and complex emergencies present substantial health challenges to United Nations (UN) peacekeepers deployed in mission areas. This scoping review aims at summarizing previous research on the health of UN peacekeepers and identifies issues for further investigation.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews, we systematically searched Web of Science, PubMed, EMBASE, Scopus and China National Knowledge Infrastructure (CNKI) for English and Chinese literature published from April 1997 to November 2023. A data charting form was developed by two reviewers to extract relevant themes and provided narrative descriptions.

RESULTS

We screened 1079 de-duplicated records and included 143 studies in this scoping review. There were 112 studies on the health status of UN peacekeepers, with more than half on mental health problems such as stress and anxiety. Many studies explored the health status of UN peacekeepers in African countries deployed from mainly U.S., Canada, U.K., China, Australia and Norway. There were 39 studies on the health risk factors of UN peacekeepers, including natural environmental, social environmental, psychological, behavioral lifestyle, biological factors and health service factors. There were 62 articles on the health protection of UN peacekeepers, mainly based on previous deployment experience, with a lack of theoretical guidance from global health perspectives. This scoping review found that health problems of UN peacekeepers are complicated, and whose impacts are cross-border. Social environmental factors were explored the most among health risk factors. Disease prevention measures, medical and health measures, and psychosocial measures were the main health protection for UN peacekeepers.

CONCLUSIONS

This scoping review highlighted that health problems of UN peacekeepers were typical global health issues with complicated and cross-border health risk factors. Therefore, comprehensive strategies could be taken from global health perspectives, including multi-phases (before-deployment, during-deployment, and post-deployment), multi-disciplines (public health, medicine, politics, health diplomacy, and others), and multi-levels (the UN, host countries, troop-contributing countries, the UN peacekeeping team, and UN peacekeepers).

Suicides between 2010 and 2014 in the German Armed Forces-Comparison of Suicide Registry Data and a German Armed Forces Survey

BACKGROUND

The last 10 years have seen an increase in the number of suicides in the US Armed Forces. Accordingly, the topic of suicides in the German military has received a lot of attention in media and science alike.

METHODS

This study retrospectively examined all suicides (N = 107) committed by active, nonretired German military personnel from 2010 to the end of 2014, analyzing archived medical records. In a second step, these data were compared to a representative German Armed Forces survey conducted in 2012 (N = 1,549).

RESULTS

The following risk groups for suicide were identified: male (OR = 9.6), single (OR = 7.8), aged over 45 years (OR = 4.0), short period of service (<2 years; OR = 2.7), and low level of education (OR = 2.2). Surprisingly, military personnel with little experience in deployments abroad (<2 missions) showed double the risk (OR = 2.0) compared to those who had been deployed more than once.

DISCUSSION

Multiple robustness checks show that being single, aged over 45 years, and having obtained a low level of education exhibit the most robust effects on suicide risk.

CONCLUSION

Efforts should be made to develop and evaluate risk group-focused prevention programs. We conclude, that further studies should be initiated to show differences of risk groups between lethal and nonlethal suicidal behavior.

German research perspectives on suicidality and the rationale for future multinational suicide prevention projects among military service personnel

As a result of scientific publications indicating that the last two decades have seen an increase in the number of suicides in the US Armed Forces, the topic of suicide in the military of other countries, such as Germany, has also received a lot of attention in media and science alike. Risk factors for suicidal behaviour and suicide were identified in several research projects in the US, Canada, the UK, and Germany. Until now, German suicide research among military service personnel has mainly focused on epidemiological aspects of suicides and suicidality, individual risk factors, sub-groups at risk for suicide, suicides and deployment abroad, and associations of suicide and suicide attempts with acute mental disorders. The key findings are summarized in this review article. Efforts should be made to develop and evaluate risk group-focused and occupation-focused prevention and intervention programs. Future multinational studies should address potential differences between risk groups for fatal and non-fatal suicidal behaviour.

Army Soldiers and Suicidal Thoughts: The Impact of Negative Relationship Dynamics Moderated by the Dissolution of Romantic Relationships

Suicide among United States active-duty Army soldiers rapidly increased over the past two decades. Using a sample of 322 soldiers from the Army STARRS study, the researchers examined if romantic relationship factors (i.e., hostile disagreements and relationship distress) were linked with suicidal thoughts in Army soldiers, and if these associations were moderated by a recent separation or divorce. Hostile disagreements and relational distress were both significantly associated with higher rates of suicidal ideation. These associations were significantly amplified in magnitude when in the context of a recent separation or divorce. Implications include novel assessment, prevention, and treatment efforts focused on romantic relationships that may reduce the likelihood of soldiers experiencing thoughts of suicide.

The Wellbeing of Italian Peacekeeper Military: Psychological Resources, Quality of Life and Internalizing Symptoms

Working as a peacekeeper is associated with the exposure to acute and/or catastrophic events and chronic stressors. Hence, the meager literature about peacekeepers' wellbeing has mainly analyzed Post-Traumatic Stress Disorder (PTSD). This study aims to deep the analysis of the wellbeing of peacekeepers military. Based on the few studies on this population, we hypothesized that Italian peacekeeper military officers and enlisted men (n = 167; 103 males, 6 females, 58 missing) exhibit lower levels of internalizing symptoms (i.e., PTSD, depression, general anxiety, obsessions, and somatization) as compared to a control group (n = 60; 32 males, 28 females). Moreover, we hypothesized that peacekeepers have higher levels of psychological resources (i.e., self-efficacy, self-esteem, social support) and quality of life (i.e., higher life satisfaction and lower general stress). We compared the groups by means of MANOVAs on the subscales of the Psychological Treatment Inventory (PTI; Gori et al., 2015). We found that Italian peacekeepers have lower internalizing symptoms and higher levels of self-efficacy and self-esteem than the control group; however, no statistically significant differences were observed on perceived social support. Finally, peacekeepers have a higher quality of life: scores reflect higher life satisfaction and lower distress than the control group. This study is in line with previous literature supporting the claim that Italian peacekeeper military officers have sufficient psychological resources for coping with the stressful situations implied in peacekeeping missions. Future studies should deepen the analysis of the military's psychological characteristics by comparing war veterans and peacekeeper military.

Suicide Among Military Personnel and Veterans Aged 18-35 Years by County-16 States

INTRODUCTION

Suicide among military personnel and young Veterans remains a health concern. This study examined stateside distribution of suicides by U.S. county to help focus prevention efforts.

METHODS

Using 2005-2012 National Violent Death Reporting System data from 16 states (963 counties, or county-equivalent entities), this study mapped the county-level distribution of suicides among current military and Veteran decedents aged 18-35 years. This study also compared incident circumstances of death between decedents in high-density counties (i.e., counties with the highest proportion of deaths) versus those in medium/low-density counties to better understand the precipitators of suicide in counties most affected. Last, this study identified potential military and Veteran Health Administration intervention sites. All analyses were conducted in 2015.

RESULTS

Within the National Violent Death Reporting System participating states, an estimated 262 (33%) current military suicides occurred in just ten (1.0%) counties, and 391 (33%) Veteran suicides occurred in 33 (3.4%) counties. Mental health and intimate partner problems were common precipitating circumstances, and some circumstances differed between cases in high- versus those in medium/low-density counties. Multiple potential intervention sites were identified in high-density counties.

CONCLUSIONS

These findings suggest that military and Veteran suicides are concentrated in a small number of counties. Increased efforts at these locales might be beneficial.

Total and cause-specific mortality of Finnish military personnel following service in international peacekeeping operations 1990-2010: a comprehensive register-based cohort study

OBJECTIVES

To estimate total and cause-specific mortality after international peacekeeping deployments among the Finnish military peacekeeping personnel in comparison to the general population of similar age and sex.

DESIGN

A register-based study of a cohort of military peacekeeping personnel in 1990-2010 followed for mortality until the end of 2013. Causes of death were obtained from the national Causes of Death Register. The standardised mortality ratio (SMR) for total and cause-specific mortality was calculated as the ratio of observed and expected number of deaths.

SETTING

Finland (peacekeeping operations in different countries in Africa, Asia and in an area of former Yugoslavia in Europe).

PARTICIPANTS

14 584 men and 418 women who had participated in international military peacekeeping operations ending between 1990 and 2010.

INTERVENTIONS

Participation in military peacekeeping operations.

MAIN OUTCOME

Total and cause-specific mortality.

RESULTS

209 men and 3 women died after their peacekeeping service. The SMR for all-cause mortality was 0.55 (95% CI 0.48 to 0.62). For the male peacekeeping personnel, the SMR for all diseases was 0.44 (95% CI 0.35 to 0.53) and for accidental and violent deaths 0.69 (95% CI 0.57 to 0.82). The SMR for suicides was 0.71 (95% CI 0.53 to 0.92).

CONCLUSIONS

Even though military peacekeeping personnel are working in unique and often stressful conditions, their mortality after their service is lower compared with the general population. Military peacekeeping personnel appear to be a selected population group with low general mortality and no excess risk of any cause of death after peacekeeping service.

International military operations and mental health--A review

BACKGROUND

Volunteering in international military missions has been scrutinized for its effects on mental health. Different kinds of exposures to traumatic events are associated with a variety of mental disorders, mainly heightened rates of post-traumatic stress disorder (PTSD) and alcohol abuse.

AIMS

Based on the literature we discuss risk and protective factors concerning the psychological well-being of soldiers attending to international military operations.

METHODS

A systematic literature search was carried out using relevant search terms to identify the articles for this review.

RESULTS AND CONCLUSIONS

The ability to recognize and treat acute stress reactions during deployments is important. Post-deployment psychosocial support and services have a role in lowering barriers to care, diminishing stigma and also in recognizing individuals who suffer from psychological distress or psychiatric symptoms, to connect them with appropriate care. Further investigation of gender differences and the role of stigmatization is warranted. Most of those participating in international military operations are repatriated without problems, but repeated exposure to combat situations and other stressors may affect mental health in various ways. Stigmatization is still a barrier to care.

Autonomy as a Prospective Predictor of Perceived Burdensomeness and Thwarted Belongingness Through Symptoms of Depression

This study examined the relationship between sociotropy, autonomy, depression symptoms, perceived burdensomeness, and thwarted belongingness in a sample of 113 undergraduate students. A prospective design with three time points was utilized to determine whether personality styles and depression symptoms play a role in the development of perceived burdensomeness and thwarted belongingness, two interpersonal suicide risk factors. Time 1 autonomy predicted depression symptoms at Time 2; Time 2 depression symptoms predicted thwarted belongingness and perceived burdensomeness at Time 3. Results suggest depression symptoms mediate the relationship between autonomy and thwarted belongingness, and autonomy and perceived burdensomeness. This study contributes to understanding how the presence of specific personality traits may lead to depression symptoms, which in turn leads to perceived burdensomeness and thwarted belongingness. Clinical implications, including assessment of autonomy, and perceived burdensomeness and thwarted belongingness, are discussed.

Precipitating circumstances of suicide among active duty U.S. Army personnel versus U.S. civilians, 2005-2010

To help understand suicide among soldiers, we compared suicide events between active duty U.S. Army versus civilian decedents to identify differences and inform military prevention efforts. We linked 141 Army suicide records from 2005 to 2010 to National Violent Death Reporting System (NVDRS) data. We described the decedents' military background and compared their precipitators of death captured in NVDRS to those of demographically matched civilian suicide decedents. Both groups commonly had mental health and intimate partner precipitating circumstances, but soldier decedents less commonly disclosed suicide intent.

Occupational trauma and mental illness--combat, peacekeeping, or relief work and the national co-morbidity survey replication

OBJECTIVE

Peacekeepers, relief workers, and military members experience multiple traumas, and trauma is believed to increase risk for psychiatric distress. We examined whether combat and/or peacekeeping or relief work was associated with subsequent mental illness.

METHODS

Using data from the US National Co-morbidity Survey Replication (n = 2383), we estimated whether combat, peacekeeping, or relief work was associated with increased prevalence of mental illness through bivariate cross-tabulations and multivariate logistic regression.

RESULTS

Combat was associated with increased subsequent posttraumatic stress disorder (PTSD) and alcohol or drug issues more than peacekeeping or relief work.

CONCLUSIONS

Combat, alone or combined with peacekeeping/relief work, appears to be a risk factor for subsequent PTSD and issues with drugs and alcohol. Peacekeeping/relief work without combat does not appear to be associated with these diagnoses.

CLINICAL SIGNIFICANCE

We found an association between combat and subsequent PTSD and drug and alcohol issues. Absent combat, peacekeeping, or relief work were not associated with mental illness. Previous diagnoses and trauma exposure may increase potential for subsequent mental health problems.

The next generation of psychological autopsy studies. Part I. Interview content

The psychological autopsy (PA) is a systematic method to understand the psychological and contextual circumstances preceding suicide. The method requires interviews with one or more proxy respondents (i.e., informants) of decedents. The methodological challenges that need to be addressed when determining the content of these research interviews for PA studies are described and recommendations are made for meeting these challenges in future PA investigations. Ways to improve the data collected about mental disorders and life events--domains that are assessed in almost all PA studies--are discussed at length. Other understudied content areas considered include the role of personality traits, medical illness and functional limitations, availability of lethal agents, medications, and select distal variables including child maltreatment and family history of mental disorders and suicide. The benefits and challenges to using common protocols across studies are also discussed.

Psychological and marital distress in spouses of Vietnam veterans: importance of spouses' perceptions

Spouses of combat veterans with PTSD have greater psychological and marital distress than spouses of veterans without PTSD; however, few studies have examined how variables related to the spouses (e.g., cognitions) may play a role in their own distress. The current study examined spouses' perceptions of combat veterans' PTSD symptom severity in 465 spouses of veterans from the National Vietnam Veterans Readjustment Study. Spouses' perceptions of veterans' symptom severity were positively associated with spouses' psychological and marital distress; furthermore, spouses' perceptions fully mediated the effects of veterans' self-reported PTSD severity on spouses' distress. Additionally, for spouses who provided complete data with regard to their perceptions of veterans' PTSD, distress was highest when they perceived high levels of symptoms but veterans reported low levels. These results highlight the importance of interpersonal perceptions in intimate relationships and provide preliminary groundwork for future research on cognitions in spouses of combat veterans with PTSD.

Overcoming the fear of lethal injury: evaluating suicidal behavior in the military through the lens of the Interpersonal-Psychological Theory of Suicide

Suicide rates have been increasing in military personnel since the start of Operation Enduring Freedom and Operation Iraqi Freedom, and it is vital that efforts be made to advance suicide risk assessment techniques and treatment for members of the military who may be experiencing suicidal symptoms. One potential way to advance the understanding of suicide in the military is through the use of the Interpersonal-Psychological Theory of Suicide. This theory proposes that three necessary factors are needed to complete suicide: feelings that one does not belong with other people, feelings that one is a burden on others or society, and an acquired capability to overcome the fear and pain associated with suicide. This review analyzes the various ways that military service may influence suicidal behavior and integrates these findings into an overall framework with relevant practical implications. Findings suggest that although there are many important factors in military suicide, the acquired capability may be the most impacted by military experience because combat exposure and training may cause habituation to fear of painful experiences, including suicide. Future research directions, ways to enhance risk assessment, and treatment implications are also discussed.

Suicide-associated comorbidity among US males and females: a multiple cause-of-death analysis

OBJECTIVE

To describe physical and mental comorbidity among male and female suicides in the US. This research replicates a seminal Australian study, which permits inference on comparative cause-of-death data quality.

DESIGN AND SETTING

National cross-sectional study of suicides and unintentional injury decedents (comparison group) using Multiple Cause of Death (MCOD) public use files for 1999-2003.

MAIN OUTCOME MEASURES

Prevalence of medical conditions; relative odds of suicide-associated comorbidity.

RESULTS

For 14% of male suicides and 19% of female suicides, comorbidity was shown on their death certificates. Respective prevalences for mental and physical comorbidity were 7.2% and 7.1% for males and 10.0% and 9.3% for females. Mean numbers of psychopathologies mentioned were virtually identical for male and female suicides (1.22 and 1.21) for whom comorbidity was registered. Mean mentions of physical disease were lower for male suicides: 1.64 vs 1.77. Multiple medical conditions were registered for 4% of male suicides and 6% of female suicides. Suicides manifested excess comorbidity for depression and mood disorders (adjusted odds ratio (AOR) = 34.6, 95% CI = 32.41 to 36.92), schizophrenia (AOR = 2.5, 95% CI = 2.16 to 2.88), and cancer (AOR = 2.1, 95% CI = 1.93 to 2.19), but unexpectedly no excess comorbidity for HIV.

CONCLUSIONS

The US system of death certification appears to be less fastidious than the Australian system. Although comorbidity patterns were very similar, only half as much psychopathology was reported for US suicides as for Australian suicides. A questionable deficit of comorbid physical disease was also documented for US suicides. Findings have important implications for medical training, as well as for suicide surveillance, policy, and prevention.