A Systems Approach to Suicide Prevention in the CF

The foregoing sections make it clear that the CF is already heavily involved in activities with potential suicide preventive effects. In some areas, though, added attention may further strengthen its program, while at the same time providing other benefits to the CF (e.g., improved mental health care).

How does the CF’s approach stack up against a benchmark program? In 1999 the US Air Force implemented a multi-faceted community-based suicide prevention program [122]. The program included a number of different interventions (ANNEX B). In 2004, they reported that their suicide rates had declined significantly, and they identified other apparent benefits of the program (decreases in homicide, accidental deaths, and more severe forms of family violence) [122].

The program evaluation consisted principally of a comparison of pre- and post-program suicide rates. This design has methodological weaknesses, particularly for outcomes like suicide rates that fluctuate for incompletely understood reasons. Critics have pointed out that suicide rates were declining in the US general population at the same time [123;124]. The authors countered [125] that the rates in the general population did not decline as much as they did in the USAF and that the general population decrease was due to factors that would not have been as important in the Air Force population(specifically, decreases in unemployment and hard drug use).

There may also be some “regression to the mean” occurring—suicide prevention programs tend to get implemented when suicide rates are spiking, at times due to random variation, so the apparent decrease in rates in subsequent years may simply reflect further random variation. However, more recent data from the USAF refutes this in that data through 2008 show that the suicide rate has remained lower than the pre-program rates. Finally, proponents of the program point out that similar programs in a broad variety of settings have shown some evidence of benefit, albeit less convincingly [19].

For the CF’s purposes, there will likely never be a more definitive study of population-based suicide prevention programs in a military organization drawn from a culture similar to our own. 1 Evidence-wise,this is as good as it is likely to get. Military organizations will have to make decisions on suicide prevention programming using scientific data that has potentially important limitations.

The CF’s suicide prevention program is compared to the USAF program in ANNEX B. Most of the elements of the USAF program have already been implemented in the CF. In some cases (e.g.,confidentiality protections), the CF has gone far beyond the USAF standard, and there are additional targets for suicide prevention that the CF is addressing (e.g., improving clinical interventions for suicidal patients).

One intervention that the CF is not currently pursuing is yearly briefings to commanders on available mental health resources. The Panel did not view this as an essential strategy, and there was concern that this could risk trivializing the whole issue. Mandatory yearly training tends to turn valuable health education into a perfunctory exercise. Instead, this information on sources of care could be rolled into the overall mental health training approach for CF leaders. The frequency of any particular element of the programming should be driven by demonstrable educational needs rather than a desire to demonstrate due diligence. Periodic surveillance of the level of awareness of different programs informs the need for targeted awareness campaigns; this information is already being collected in the biennial Health and Lifestyle Information Survey.

The other intervention that is not part of the CF’s current approach is the so-called “hands-off” investigative interview policy. The Panel recommended that the CF consider adopting such a policy given the importance of disciplinary action as a trigger for suicidal behaviour.

Several interventions that are part of the USAF suicide prevention program are already being addressed in the CF, but further attention might lead to better outcomes. These include:

  • Leader education on mental health and suicidality during career courses: The CF is in the process of developing and implementing a comprehensive mental health education program; only one module has been developed so far, but others are expected to be completed over the next few years.
  • Rank-and-file education focussing on buddy aid: This is also being developed, with the target periods being during recruit training, pre-deployment training, and post-deployment reintegration.
  • Suicide surveillance: As noted earlier, there are some opportunities for improvement in the CF’s suicide surveillance system.

 

  • Recommendation 55: Leader education on available mental health services should be integrated into the CF’s comprehensive mental health education program. The frequency of this training should be guided by demonstrable educational needs rather than any fixed schedule.
  • Recommendation 56: “Buddy aid” mental health skills should also be integrated into the CF’s comprehensive mental health education program.

 


 

1 Reasons for this include: 1) Only a limited number of military organizations have enough suicides each year to be able to detect the sorts of modest benefits that suicide prevention programs are likely to offer; 2) Enthusiasm for suicide prevention is strong enough that developing and implementing a control condition would be difficult or impossible; 3) Suicide has strong cultural influences, and only a limited number of countries have cultures similar enough to our own that results seen elsewhere would be generalizable to the CF; and 4)The military is a tightly knit organization, meaning that it would be impossible to completely prevent some spill-over of the suicide prevention program into the control condition.

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