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Can Letters Prevent Military Suicides?

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For many soldiers deployed abroad in distant countries, the sense of isolation and danger can be overwhelming. It is hardly surprising that military suicides have risen astronomically since the beginning of the respective missions to Iraq and Afghanistan with a recent study showing an 80 per cent increase in suicides among U.S. soldiers during the period from 2004 to 2008 alone.

While some of these suicides can be linked to post-traumatic stress resulting from combat, nearly a third of military suicides occur in soldiers with no combat experience at all. According to the study's lead researcher, Michelle Canham-Chervak, "this study suggests that an army engaged in prolonged combat operations is a population under stress, and that mental health conditions and suicide can be expected to increase under these circumstances. By establishing that soldiers who are diagnosed with a mental health disorder or substance abuse are at greater risk of suicide, we then have a place to target our prevention strategies."

To help curb the rising military suicide rate, a new pilot project has been established by the National Center for Telehealth and Technology (T2) and the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE). Titled the Caring Letters Project (CLP), the new project involves sending brief letters to discharged inpatients considered to be at high risk for suicide following hospitalization.

The Caring Letters concept was first developed by psychiatrist Jerome Motto, who, along with fellow clinician Alan Bostrom, found that sending periodic letters to randomly selected high-risk outpatients who refused treatment led to lower suicides compared to a control group.

The letters themselves were designed to be brief and non-demanding, simply expressions of concern showing potentially suicidal patients that they were not alone. Following the success of Motto and Bostrom's 2001 research project as well as follow-up studies, a 2008 World Health Organization study on a random sample of more than 1,800 people who attempted suicide found significantly fewer suicide deaths in those who received personalized contact.

The point of the project was to test the feasibility of extending the Caring Letters model to other military treatment settings and to find whether letters or email messages worked better. After a structured treatment program with standardized testing to measure suicide potential, the person who attemped suicide was then discharged from the program.

As part of the outpatient follow-up, the patient received a personalized letter every two weeks for the first month after discharge. Over the next two years, patients in the program received up to eleven additional letters. Most of the letters were sent in the first year and dropped to one letter every three months in the second year. The format of the letter followed the basic form included in the following sample letter:

Dear [Participant],
We appreciated the opportunity to get to know you during your stay at Madigan Army Medical Center (MAMC). We hope things are going well for you.
We remember how you said you like hiking around the South Puget Sound. With the return of the summer weather, we hope you're getting a chance to get out there, and maybe explore some new trails. Anyway, we just wanted to send a quick e‐mail to let you know we were thinking about you and wishing you well.
If you wish to drop us a note, we would be glad to hear from you.
Sincerely,
Sara & Laura

While the letter was handwritten, both the letters and the email messages contained the same content and were supplemented with information taken from clinical interviews with the patient. They were all signed by the researcher and the head psychiatric nurse and included contact information and links to mental health resources such as suicide hotlines and substance abuse centres.

To ensure that anyone in crisis could get help as quickly as possible, a special safety plan was set up so that researchers could refer study participants to inpatient psychiatric staff as needed. The letters also included a note saying that an immediate response might not be possible but that they should contact one of the crisis numbers provided if they needed help quickly.

So how successful is the pilot project? The project results were recently published in the journal, Crisis, using a sample of 110 former inpatients who had agreed to participate in the research project (20 women and 90 men with an average age of 29). Although the hospital primarily dealt with active duty military personnel, nine of the participants were dependants of military personnel while another nine were either National Guard, activated Reserve, or retired.

Over half of the patients had reported suicidal thinking or had actually planned suicide before being admitted to hospital while 27 of the participants had attempted suicide. They stayed an average six days in hospital before being discharged and the main diagnosis was depressive disorder. There was no control group used in the study and all discharged patients who agreed to be in the study received the caring letters. To date, 436 letters have been sent out with 72 per cent of participants opting to receive email messages rather than handwritten letters.

While the Caring Letters Project is still ongoing, early results are promising. Though only 27 responses to the hundreds of letters sent out were received, they were all extremely positive statements about the program.

A common theme in the responses was expressing gratitude that someone was thinking of them. To date, no adverse problems have been reported and the safety plan has not been put into use. Still in its very early stages, the Caring Letters Project appears to be an effective way of helping potentially suicidal military personnel using existing health care staff. Unfortunately, measuring whether letters can prevent military suicides will likely require a more widescale research project across multiple treatment settings with a much larger sample of participants.

Will the use of letters help prevent the worrying rise in military suicides? Caring Letters can reach service members no matter where they are in the world, even in deployment settings where mental health professionals are not typically found. Since potentially suicidal service personnel often refuse treatment, letters can also be a non-obtrusive way to remind them that help is available.

While the Caring Letters approach is only one part of a much broader strategy to prevent military deaths, even a simple reminder that service personnel can get the help that they need may very well be the difference between life and death.

Here is more information on the Caring Letters Project (PDF)