The tragedy of suicide is deeply understood by Maj. Gen. Mark Graham, whose 21-year-old son killed himself in 2003 after struggling with depression. A top ROTC cadet at the University of Kentucky, Kevin Graham planned to become an Army doctor. But he quit taking his medication because he didn't want the Army to find out about his illness.
Eight months later, a roadside bomb in Iraq took the life of Gen. Graham's other son, Jeff.
"Both of my sons died fighting different battles," says Graham, commander of the Army's Division West and Fort Carson, Colo. "They were both heroes to us, both great young men."
Years went by before Graham spoke publicly about what happened. Today, he is part of the Army's intensive push to reduce a historic spike in soldier suicides. He is encouraging people to talk frankly about the stigmas associated with mental health care and suicide.
"People think if you talk about suicide, you'll cause somebody to do it," Graham says.
"And that is not the case. We've got to be able to talk about it in order for people to know it's OK to come forward and get help, so we can prevent these suicides from happening. We have to educate people to know it's a sign of strength, not weakness, to get help."
These are messages the military urgently hopes the troops will heed. More than 600 soldiers and Marines killed themselves between 2003 and 2008 – the equivalent of a battalion task force. Another 141 soldiers reportedly had taken their own lives by the end of July – 62 are still under investigation – putting the Army on track to have a record number of suicides for the fifth consecutive year.
"We have got to do better," Army Vice Chief of Staff Gen. Peter W. Chiarelli said after the suicide data was released. "We are trying every remedy and seeking help from outside agencies that are experts in suicide prevention. There isn't a reasonable suicide-prevention tool out there the Army won't potentially employ."
Mobile behavioral health teams have become a part of each brigade at Fort Carson, one of the world's largest Army bases. That makes it routine business for a soldier to seek help. "You go see the S-1 for a personnel action, to the medical clinic to get your stuff done, or go by and see the behavioral health guys," Graham says. "So it's OK. It's accepted by the soldiers and leaders."
Over the past several months, the Army also has dramatically increased its suicide-prevention efforts. All 1.1 million soldiers were pulled from their normal duties over a six-week period last spring to learn ways to recognize suicidal behavior and help fellow soldiers who are distressed or showing signs of suicide. This includes asking troubled soldiers if they are considering, or have ever considered, taking their own lives. "Normally if they have, they will tell you," Graham says. "When they do, you don't just say, ‘Hey, you need to go get help.' You take them to get help, right then."
Annual suicide-prevention training will be provided Army-wide, emphasizing the common causes of suicidal behavior and the critical role Army leaders, friends, co-workers and families play in helping soldiers. In addition, the Army established a suicide-prevention task force that made dozens of improvements to programs and recruited additional psychological and behavioral health counselors, says Army spokesman Wayne V. Hall.
A Comprehensive Soldier Fitness program is also being used throughout the Army, Army Reserve and National Guard that better balances mental health with physical health and fitness. A similar program is planned for family members and civilians who work for the Army. Chaplains also are leading relationship-strengthening programs for soldiers and families called Strong Bonds. A separate effort, known as Battlemind, helps troops and families prepare for the stresses of war and identify potential mental-health issues. The Navy and Marine Corps have likewise stepped up their suicide-prevention efforts.
Life or Death Mission. Last November, the Army contracted with the National Institutes of Mental Health to conduct a five-year, $50 million study on soldier suicides that will help guide future prevention efforts. The Army faces the challenge understanding that it is daunting, long-term and unpredictable.
"Suicide is one of the most complex public-health problems," says Dr. Mark Kaplan, a professor of community health at Portland State University who served on VA's Blue Ribbon Work Group on Suicide Prevention last year. "With all that we've learned, the suicide rate has not changed that much over time. The bottom line is there's so much we don't understand."
That's true for all suicides, military or otherwise, in part because of a lack of data. The National Center for Health Statistics estimates there are 33,000 U.S. suicides each year. But, Kaplan says, "We might be underestimating suicides in the general population by 25 to 50 percent."
Because of the lack of comprehensive data, Kaplan and other researchers are wary of drawing conclusions about what's happening in the military. "The evidence regarding combat-related experience seems to be mixed," Kaplan says. "There's often a lag time between combat exposure and post-traumatic stress disorder. Even World War II veterans, 40 years later, might experience the toll of PTSD."
Soldier suicides over the past six years illustrate how difficult it is to find definitive answers. The Army acknowledges repeated deployments may be contributing to the overall increase in numbers, but that's only part of the issue. Roughly 40 percent of soldiers and 35 percent of Marines who have taken their own lives since 2003 never deployed to Iraq or Afghanistan. A recent Army study also concluded that the majority of American soldiers in Iraq and Afghanistan who killed themselves did so during their first deployment.
Suicides aren't just occurring among soldiers serving in the global war on terror.
"We have other veterans trying to commit suicide – guys who served in Vietnam, Korea, World War II, the Gulf War and Panama," says Jim Deremo, The American Legion's department service officer in North Dakota. He helped start Courage Carries On, a suicide-prevention campaign that reaches out to veterans and active-duty servicemembers in his state. Deremo says he sees an increase in PTSD among veterans after they retire. "When you are busy working and raising a family," Deremo says, "you don't have time to think about it."
The problem is often traced back to the Civil War, when soldiers were allowed to take their guns home. "That's when we see the rise in the number of suicides by firearms," Kaplan says. He points to a June 1865 New York Times obituary detailing how the man who fired the first shot on Fort Sumter later turned his gun on himself.
"Ownership and possession of firearms is very high among people who successfully complete suicide," Kaplan says. "Suicide involving guns provides a very limited window to intervene."
Pain vs. Death. Tammy Schroeder has reached for a gun many times.
"The pain is so bad that death is the only alternative," says Schroeder, who has fought suicidal urges since she was raped while serving in the Air Force in 1983.
"When you are sticking a gun in your mouth, you think, ‘This is utopia ... the pain is going to be over.' Unless you've been where I've been, you can't understand it."
Schroeder plunged into depression and started self-medicating with alcohol and prescription drugs after the 1983 trauma. She lost her marriage, her 2-year old and her infant. "It's not what he did to me," she says of the perpetrator. "It's what he took from me."
Two decades later, Schroeder finally told her story to a fellow veteran at the South Dakota American Legion's Mid-Winter Conference. That woman, Terry Towns, was office manager for the Sioux Falls Vet Center and connected Schroeder with counselors. It saved her life.
"I got such outstanding care," says Schroeder, who now lives in Minnesota and is featured in the Courage Carries On campaign as someone who sought help and benefited. Even today, she keeps the telephone numbers for suicide-prevention hotlines on her refrigerator.
Although it took Schroeder years to seek counseling, most male soldiers never reach out. "So many people who are returning after multiple deployments are men who don't want to talk about their problems," Kaplan says. The stigma of mental illness remains powerful. So the question for the military is, "How do you educate young soldiers to seek help?"
"I think the way we get rid of the stigma is that we continue to educate others and talk about it, and let people know there is help, there is care for you out there," Graham says. "Going to behavioral doesn't mean someone is crazy. It means something is wrong."
It's important to note that psychological problems are not always the issue. Many military suicides involve younger soldiers who have relationship problems or financial problems and easy access to firearms. "Men feel very uncomfortable when the ground shifts under them, when they don't feel like the captain of their destiny," Kaplan says.
"They succumb to a sense of shame, a loss of control. Suicide is a way of taking control over their life." Financial and family issues could be dealt with by social workers instead of psychiatrists or psychologists, which also reduces the stigma associated with getting help, he adds.
People who deal with soldiers on a daily basis agree. "The majority of our folks who are in crisis have marital problems or financial problems, not psychological problems," says Lt. Col. Ross Waltemath, who runs the Crisis Intervention Office for the Indiana National Guard in Indianapolis. "When soldiers go to Iraq two or three times, the risks may accumulate, and if alcohol is added, you get a bad coping mechanism."
Unemployment is a significant factor among the soldiers the Indiana Guard's crisis-intervention team is called to help. The jobless rate in some pockets of northern Indiana has reached more than 17 percent. Forty-six of the 182 soldiers from the 1538th Transportation Company who just returned home to Elkhart, Ind., are unemployed, most because a factory closed while they were deployed. "It doesn't take long for them to start saying, ‘How am I going to feed my family?'" Waltemath says.
Transition Assistance. Kaplan thinks a more seamless transition from the military to VA and civilian life can reduce the stress on soldiers who are demobilizing or leaving the service.
Travis Rhoads knows this territory firsthand. He re-enlisted in 2007, following a three-year break from the Army, after finding it difficult to support his wife and four children as a truck driver for a soft-drink company. He tried to kill himself four months into his combat tour in Iraq.
Rhoads was shipped home and enrolled in a pilot program designed to expedite the handoff of servicemembers from DoD to VA. Instead, it took a tedious year for him to make his way through the system, get the required medical exams and receive a disability rating so he could be placed on long-term temporary medical leave from the Army. The delays, paperwork shuffles and uncertainty exacerbated his anxiety and made it impossible to find employment.
"There I am, trying to juggle so much with finances and my medical board, keep my treatment going and keep my sanity," Rhoads says. "I don't know how many times I had to ask, ‘Where's my paperwork? Who has my paperwork?' I'm exhausted."
Some state National Guard offices are addressing this as well. The Indiana and Minnesota Guard conduct three mandatory "Yellow Ribbon" weekends over a three-month period soon after soldiers come home. Members of the Guard must attend with their families and are seen by medical, employment, education and financial specialists, among others, who can get them an appointment at VA and enrolled to receive GI Bill benefits. "We really focus on the family members and train them to know how to get a hold of us," Waltemath says. "Eighty percent of the phone calls we get when a soldier is in crisis are from the wife, the husband, the mother or father, or a sibling."
Adele Kubein knows the importance of family involvement. She watched her daughter go through a frustrating three-year transition from the military to VA after she came home from Iraq in 2004 with a broken leg, a traumatic brain injury and a battered, suicidal mind. "She was a total wreck. I went to the barracks and there she was at the end of the hall with a cane, bent over and crying," Kubein says. "If my daughter had not had a pushy mother, things would have taken much longer, and she would never have had the financial wherewithal to survive."
Kubein believes the counseling offered by the Returning Veterans Project saved her daughter's life. A group of counselors based in Oregon that provides services at no charge to servicemembers and families, Returning Veterans arranged for a therapist with combat experience in Vietnam to care for her daughter.
"Normally, I am not a proponent of privatization," says Kubein, whose daughter was a .50-caliber gunner and field mechanic with the Oregon Army National Guard in Iraq for 10 months at the beginning of the war. "But the troops need to have a safe alternative for counseling, somewhere they know the Army can't have access to their records. That's the only way they are going to work through what they have seen and done."
Such concerns resonate with the people who established Courage Carries On. Despite assurances from the military, many servicemembers still believe seeking counseling will hurt their careers, Deremo says. And some veterans, especially from the Vietnam era, refuse to go to VA because of they way they were treated when they first returned from the war.
"We wanted to offer them something totally outside the government where they could be referred to counseling services," says Deremo, who receives many calls for help from families of servicemembers or veterans who have tried to commit suicide.
"Despite all that the military is doing, despite all that VA is doing, the word is not getting to everybody," he says.
The North Dakota American Legion launched Courage Carries On in February. It features five veterans, including Schroeder, talking about how they needed and began getting help. It encourages people to call 2-1-1 – a private mental health referral service in North Dakota – or the national suicide hotline. It is designed for anyone who has served and is suffering, not just combat veterans. Posters have gone up in bars, churches, laundry mats and other locations. Public service announcements are playing on TV and radio. Billboards followed. The bottom line message: "You had the courage to put on the uniform and go serve your country," Deremo says. "Now you have to have the courage to make a phone call so you can get better, so your family can get better."
"Don't wait 23 years to get help like I did," Schroeder adds. "You hurt so many other people." For her, there's an equally pressing reason to make the call whenever she's feeling her worst. "If I kill myself," she says, her thoughts turning back to the man who assaulted more than two decades ago, "he's won."
Ken Olsen is a freelance writer and frequent contributor to The American Legion Magazine.