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Why the military can’t get suicide prevention right

Last Friday, the Inspector General of the Department of Defense released a report called the Suicide Event Report Data Quality Assessment. I had no idea what the assessment was about but I am devoted to suicide prevention and intrigued by data so I gave the 100-page report a read.

When an active service member commits suicide or attempts suicide, a Suicide Event Report is compiled. The report is an investigation of the suicide and circumstances leading up to it. It is a sort of psychological autopsy that is supposed to provide military leaders with reliable information on suicide risk factors that will assist in designing effective suicide prevention efforts.

The IG decided to investigate how Suicide Event Reports are compiled after finding a high number of  “don’t know/data unavailable” responses to questions in the 2011 Annual Report – the most recent year available.  Here are the questions that received the most “don’t know/data unavailable” reponses:


You would think that these are among the most important questions in determining why someone committed suicide. So, why couldn’t the folks assigned to complete these reports answer these questions?

Turns out that while the IG was trying to answer that question it discovered another “particularly serious suicide prevention problem that presented a substantial and specific danger to public health and safety.”

What was that problem? Seems the Department of Defense wasn’t sharing medical records and health surveillance information with the Veteran’s Administration for the purpose of suicide prevention. This is a big deal because the VA’s Veterans/Military Crisis Line has been the primary crisis line not only for vets but also for active, retired and reserve service members. Last year it answered more than 3,300 calls.

Of course, the VA has the medical records of vets it cares for. However, when an active duty, retired or reservist calls the crisis line, the crisis line staff have no access to the caller’s medical or mental health history. They don’t know what – if any – prescription drugs the caller is or has been on.

“Knowing medical suicide risk factors is critical for Crisis Line personnel to conduct a risk assessment and to make decisions related to appropriate intervention,” the IG wrote in the report.

What this also means is that the Crisis Line staff is not able to provide the same level of coordinated care for service members as they deliver to vets in the Veteran’s Health Administration.

shutterstock_141031000The IG recommended the DOD share healthcare information with the VA by identifying data sources and developing a process to share that information.

The Principal Deputy for the Under Secretary of Defense for Personnel and Readiness offered a stunning Dilbertian response, saying the “recommendation is premature and that facilitating improvement requires careful consideration of broader questions to develop a holistic approach to improve performance where needed.”

In other words, “Meh, we’ll think about it.”

The IG, sounding as ticked off as an IG is allowed to be in a report, noted that the Under Secretary offered “no plan or timeline for sharing relevant data with the Military Crisis Line,” and reminded the reader they had shared their concern with senior leadership in the Defense Health Agency on Jan. 27, 2014 and briefed senior leadership in the Office of the Under Secretary of Defense for Personnel and Readiness on April 18, 2014.

“We identified this as a particularly serious suicide prevention issue that required action,” the IG wrote, adding that “additional comments are required that describe the specific actions the Defense Health Agency will take to accomplish this recommendation..”

Good luck with that.

The thing that astounds me about this predicament is that we’re dealing with the military – which has some of the most advanced communications systems on the planet. I mean, a guy at the CIA’s headquarters in Langley, Virginia can tell a drone half a world away when to fire a rocket.

So, you’re telling me you can’t share some medical records? It’s not like it’s illegal. In 2008 the National Defense Authorization Act actually required the DoD and VA to “accelerate the exchange of health care information.”

Call me naive but I just assumed that the Defense Health Agency and VA talked to each other and shared this kind of information. Why would you even create a system that doesn’t allow and encourage this?

Especially when it could save the lives of those who protect our’s.

Soldier in counseling image available from Shutterstock.






Why the military can’t get suicide prevention right

Christine Stapleton

Christine Stapleton has been a journalist for 35 years. She is now an investigative reporter for The Palm Beach Post. In 2006, began writing a blog for PsychCentral called Depression on My Mind. Her latest blog, Addiction Matters, draws on her 19 years of sobriety and her coverage of the drug treatment industry in South Florida.

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APA Reference
Stapleton, C. (2014). Why the military can’t get suicide prevention right. Psych Central. Retrieved on June 4, 2020, from


Last updated: 19 Nov 2014
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