Suicide occurs when a person takes his or her own life. By definition, suicide is fatal and it affects not only those who die from or attempt suicide, but families and communities as well. In the United States, it is the 11th leading cause of death in the general population. Over 32,000 people die from suicide in the United States each year (CDC 2007b). Men are 4 times more likely than women to die from suicide, although women are more likely to attempt suicide. Accidental death is considered to be death resulting solely through violent, external, and accidental means.

Primary studies provided the basis of the committee’s findings on the relationship between deployment-related stress and suicide. Primary studies had to meet the criteria established in Chapter 2. Primary studies were considered to be studies in which exposure was determined by deployment status or studies that used a diagnosis of PTSD as a marker of war-related trauma. Primary studies also included those in which the cause of death was confirmed through at least one supplemental source, for example, through linkage of death-certificate data to the National Death Index or by a qualified nosologist or medical-review team that was blinded to subjects’ deployment status. Secondary studies typically had methodologic limitations, such as assessment of suicidal behaviors solely on the basis of self-report data. Most of the secondary studies did not confirm causes of death through a supplemental source. Understanding of the relationship between deployment-related stress and suicide or accidental death is hampered by the use of different case definitions for suicide or accidental death among cohorts of veterans. Suicide is an outcome that is rare even in the highly vulnerable population being considered here, so studies with low statistical power would have limited ability to establish an association between it and deployment-related stress. Primary studies are summarized in Table 6-13.

Primary Studies

The committee identified seven primary articles (Boehmer et al. 2004; Bullman and Kang 1996; CDC 1987; Kang and Bullman 1996, 2001; Kaplan et al. 2007; Thomas et al. 1991) and one government report (MHAT 2006a) relevant to determining whether there is a relationship between deployment-related stress and suicide or accidental death.

The VES is a major comprehensive study of the health of Vietnam veterans, an initial historical cohort of 9324 Vietnam-theater veterans who were compared with 8989 Vietnam-era veterans who served in the military during the Vietnam War but were deployed in Korea, Germany, or the United States. To be included in the study, veterans had to be male U.S. Army veterans who initially entered military service from 1965 to 1971, served a single term of enlistment, and were discharged alive in enlisted pay grades E-1 through E-5; participants were randomly selected from military personnel files of veterans discharged after 1971.

The first component of the VES to be completed was an assessment of mortality (CDC 1987). Nearly complete ascertainment of vital status of both veteran cohorts was obtained with multiple methods. In addition to determination of cause of death through inspection of all death certificates by persons blinded to the veterans’ Vietnam status, a medical review board, also blinded to Vietnam status, independently coded the underlying causes of all 426 deaths by using data from additional sources, including physicians, hospital records, autopsy records, and coroner and law-enforcement files. In the first followup period, which began at discharge from

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