Beyond Mental Health: Discussing Environmental and Non-Clinical Factors in Suicide with Commanders

By Maggie Baisley, Ph.D.
September 21, 2022

Air Force photo by Barry Bena

Often, discussions around suicide prevention focus on mental health services and diagnoses. Despite programmatic efforts to reduce suicidal behavior in the military, rates remain stagnant.¹ In response, the Department of Defense is considering more comprehensive prevention efforts. Regarding these efforts, an important consideration is that many service members commit suicide without receiving a diagnosis of mental illness or interacting with mental health services. For example, a precedent Clinician’s Corner Blog describing the U.S. Navy’s Deep Dive investigation into suicide events, he noted: “With respect to clinical providers, the Deep Dives revealed that approximately half of the decedents had a history of behavioral health care , with only about a third of the total decedents having seen behavioral health services. care during the year preceding their death. “If we address the military population as a whole, rather than using an individual clinical perspective, we may be better able to help all service members at risk for suicide, regardless of their health history mental.

Some experts suggest focusing more on suicide prevention on an environmental and demographic level, such as looking at ways to increase the financial security of communities.^{2 to 4} In both civilian and military communities, a number of environmental factors lead to suicidal thoughts and behaviors. For example, a meta-analysis identified unemployment as a risk factor for suicide.⁵ Commanders and other military leaders have influence and insight into the lives of military personnel in a way unique to most other workplaces and therefore can function as gatekeepers as well as primary influencers of well-being in their environment. “Gatekeepers” refer to “individuals in a community who have direct contact with large numbers of community members as part of their regular routine” and can serve as responsive bystanders to mitigate risk.⁶ As another example, the term “minority stress” has been used to rephrase the comparatively higher prevalence of suicide risk among transgender veterans.⁷ This term helps draw attention to environmental factors of distress and suicide risk, rather than pathologizing transgender identity itself.

Clinical providers are in a unique position to consult and advise commanders to be proactive in suicide risk management, beyond the command directing high-risk individuals to mental health services. Clinical providers in the military health system communicate regularly with commanders regarding specific servicemembers as well as unit health. For more information on the relationship between clinicians and commanders and its impact on mitigating suicide risk, consider reviewing another previous article. Clinician’s Corner blog on the subject. These interactions provide opportunities to educate and collaborate with commanders on available preventative practices and interventions, beyond commander-directed mental health referrals. Additionally, this clinical support tool for suicide prevention can be shared with leaders:

The references

1. Department of Defense. (2021). Annual report on suicide: calendar year 2020. https://www.dspo.mil/Portals/113/Documents/CY20%20Suicide%20Report/CY%202020%20Annual%20Suicide%20Report.pdf?ver=0OwlvDd-PJuA-igow5fBFA%3D%3D
2. Blanco, C., Wall, M.M., & Olfson, M. (2021). A population-wide approach to suicide prevention. JAMA, 325(23), 2339-2340. https://doi.org/10.1001/jama.2021.6678
3. Lund, C., Brooke-Sumner, C., Baingana, F., Baron, EC, Breuer, E., Chandra, P., Haushofer, J., Herrman, H., Jordans, M., Kieling, C. , Medina-Mora, ME, Morgan, E., Omigbodun, O., Tol, W., Patel, V. and Saxena, S. (2018). Social determinants of mental disorders and the sustainable development goals: a systematic review of journals. Lancet psychiatry, 5(4), 357-369. https://doi.org/10.1016/S2215-0366(18)30060-9
4. Christensen, H., Cuijpers, P. and Reynolds, CF, III. (2016). Changing the direction of research on suicide prevention: a necessity for a real impact on the population. JAMA Psychiatry, 73(5), 435-436. https://doi.org/10.1001/jamapsychiatry.2016.0001
5. Milner, A., Page, A., & LaMontagne, A.D. (2014). Cause and effect in studies of unemployment, mental health, and suicide: A meta-analytic and conceptual review. Psychological Medicine, 44(5), 909-917. https://doi.org/10.1017/S0033291713001621
6. Burnette, C., Ramchand, R., and Ayer, L. (2015). Custodian training for suicide prevention. Rand Health Quarterly, 5(1), 16.
7. Tucker, RP, Testa, RJ, Reger, MA, Simpson, TL, Shipherd, JC, & Lehavot, K. (2019). Current and military-specific gender minority stressors and their relationship to suicidal ideation among transgender veterans. Suicide and life-threatening behavior, 49(1), 155-166. https://doi.org/10.1111/sltb.12432

Dr. Baisley is a contract psychologist and scientific advisor to the Defense Health Agency’s Center of Excellence in Psychological Health. She served in the military and worked as a clinician in both DOD and VA settings. She advocates to ensure health care equity for historically marginalized communities and to optimize the health care system to provide appropriate care to all service members.