In fact, the number of 2004 suicides, to that point, was almost four times that of airmen killed in combat during the Iraq war.

After several years of generally declining suicide rates, the sudden upward surge sparked major concern and strong interest in prevention.

“We must take action now to reverse this devastating trend,” declared James G. Roche, Secretary of the Air Force, and Gen. John P. Jumper, USAF Chief of Staff, in an Oct. 25 memorandum sent out to all Air Force commanders.

Air Force headquarters urged units to re-emphasize programs initiated in the mid-1990s, when the suicide rate was even higher.

Those programs had brought down the number of self-inflicted deaths and won praise from civilian experts.

No one knows what has caused the recent suicide spike, but Air Force officials warn that war in Iraq and other combat operations have drained unit attention away from prevention efforts.

“You can only pay attention to so many things simultaneously,” said Lt. Col. Rick L. Campise, chief of the Air Force Suicide Prevention Program in the Office of the Surgeon General, and then you lose track of the problem. “So I think, unfortunately, that is what has happened with suicide prevention.”

High Stress

Jumper points to another potential cause—stress in today’s Air Force.

“Our jobs are inherently stressful,” said the Chief of Staff. “This is a fact of our profession. We have over 30,000 airmen deployed across the globe, with over 7,000 of them in a combat environment. Many airmen are now on their sixth deployment in 10 years. Those at home face increased work hours, inconsistent manning, and a continuous workload. More stress comes from uncertainty. ... We are taking steps to mitigate some of these factors, but stress will always be a concern.”

While the number of suicides might seem small, the 2004 figures represented a one-year rate increase of about 43 percent. Suicide is now the No. 2 cause of death in the Air Force—behind accidents but ahead of illness and homicide.

Researchers investigating the causes of the suicides say that they can find nothing unusual to report. “Everyone has a theory, but we don’t have any evidence at this time,” said Campise, a clinical psychologist.

The search has been slowed to some extent by bureaucracy. When an airman dies, the USAF Office of Special Investigations takes six to nine months to complete its investigation. OSI must wait for the airman’s unit and county coroner to file reports. Moreover, OSI agents must interview the victim’s friends, family members, and any others with evidence.

“Some of the data we have on cases is incomplete,” said Campise, “but the data we have at this time indicates that people are killing themselves for the same reasons they have for the past 25 years in the Air Force.”

What are those reasons?

“Failed romance is the No. 1 cause,” said Campise, who noted that it plays a role in more than 60 percent of cases.

Other causes include work and financial and legal problems, as well as substance abuse. The reasons seem to remain constant. “You have the same themes cropping up again,” noted Campise.

Air Force officials may not be able to fully account for the recent surge in self-inflicted deaths, but they do know a great deal about the phenomenon itself. Campise noted, for example, that males are five times more likely than females to take their own lives.

“There are all kinds of theories about why,” said Campise, “but it’s not just in the military. It’s across the world.”

The only apparent exception to this general rule, he noted, can be found in China.

Also highly predictable, remarked Campise, are the preferred means for committing suicide. He said death by gunshot ranks No. 1; firearms are used in more than 55 percent of suicides in the military (a mirror image of society as a whole). Other common means are hanging and drug overdose.

New Factor

In the past, age has not been a critical factor in Air Force suicide rates, but that seems to have changed in 2004. That year, members aged 17 through 24 years accounted for about half of all the suicides, although the age group makes up 37 percent of the force.

So far, no suicides have been reported among airmen in Iraq. However, one sergeant from the New Hampshire Air National Guard took his own life one day after returning from six months of duty in the war zone. That case still is being investigated.

The Air Force’s suicide prevention program was born in the 1990s.

“Everybody had just assumed they were doing a good enough job,” said Campise. “They felt, ‘We have chaplains available. We have other people available, so people should just make use of these things.’ ”

Then, in the early 1990s, the Air Force experienced an increase in suicides, a development that got the leadership’s attention.

Gen. Thomas S. Moorman Jr., the vice chief of staff at the time, called in the surgeon general, Lt. Gen. Charles H. Roadman II, and ordered immediate action in support of suicide prevention.

According to Campise, “The surgeon general came back and said, ‘You know, I have looked into this suicide stuff, and it’s not a medical problem. It’s a community problem, and if we want to handle it, everyone in the Air Force needs to be involved, not just the Medical Corps.’ ”

The surgeon general formed a study group, tapping representatives of 15 Air Force functional areas and experts from the Centers for Disease Control and Prevention in Atlanta and from academia.

This group set up USAF’s formal prevention program. The Chief of Staff has formal authority, but direct responsibility for implementing it falls on two groups—the Integrated Delivery System (IDS) and the Community Action Information Board (CAIB).

The program USAF instituted in 1996, following a record-high suicide rate, helped send the numbers down. Officials hope a renewed focus will do the same this time.

The 11-Step Program

The group developed 11 initiatives as the basis of the prevention program. Now included in AFPAM 44-160, these initiatives cover: community awareness; leadership involvement; investigative interview policy; professional military education; epidemiological database; delivery of community preventive services; community education and training; critical incident stress management; integrated delivery system; limited patient-psychotherapist privilege; and unit risk factor assessment.

Using the community approach, IDS agencies first try to handle problems locally.

All of the helping organizations meet on a monthly basis. These include chaplains, medics, operations personnel, health and wellness workers, and representatives of the family support center.

These individuals try to solve problems on the base. If that proves impossible, they go up the line to the CAIB chaired by the wing commander or the vice commander for that wing. If that doesn’t work, the problem moves up to the major command, which also has its own IDS and CAIB. Then comes the Air Force CAIB and Air Force IDS. At that level, the problem will be reviewed by three- and four-star generals.

The most recent Air Force-level CAIB was held Sept. 8.

“The report we were getting from the field was that a lot of people aren’t even aware of the 11 initiatives any more,” said Campise. “It is hard to implement something you aren’t even familiar with.”

The group asked permission to draft a memo from the Chief of Staff to the entire Air Force saying, “Listen, I want all you guys to go down and look at your 11 initiatives and how each installation is implementing those,” Campise said.

The results of the inquiries were to be completed and submitted to Air Force headquarters by Jan. 7. The Air Force hopes to have concrete answers to some questions within a couple of months.

After initial launch of the program in 1996, the Air Force’s suicide rate fell dramatically. From a 1994 high of almost 17 self-inflicted deaths per 100,000 members, it plunged to 5.6 per 100,000 in 1999. Since then, however, it has been inching up. As of Nov. 9, 2004, it was 14.6 per 100,000.

When analyzing these numbers, it is important to keep them in perspective. Even today’s high Air Force rate comes in at roughly half that in the civilian sector, when adjusted for age and gender.

The Army reported a surge of suicides during 2003, when 24 soldiers deployed to Kuwait and Iraq took their own lives. That was a rate of 17.3 per 100,000. The overall Army rate for the year was 12.8 per 100,000, slightly higher than the Air Force rate. The Navy rate also has hovered around 12 per 100,000 in recent years but began inching up last year.

The other services also have prevention programs, but Campise believes that the Air Force approach is different. He noted that the Air Force program has not one or two but 11 different points of leverage to help prevent suicides.

Focus on Prevention

“The programs which always have failed have concentrated on the person who is currently suicidal and needs to get to the hospital,” said Campise. “The Air Force’s program is a creative prevention model which means that you don’t wait until people are suicidal to start tending to them. You start tending to them when they have problems at work, when they are having relationship problems, financial problems, legal problems. You take care of those problems long before they get suicidal.”

The service is neither relying entirely on the original program nor discarding it in favor of something new.

“It’s a matter of going back to what we know has worked in the past,” said Campise, “and it’s also a matter of coming up with new products or activities that will re-emphasize an aspect of it.”

One initiative concerns leader involvement. The Air Force has proposed a workshop to teach commanders how to collaborate with mental health personnel for the good of the troops.

Another entails development of workshops to help front-line supervisors recognize when someone is in trouble and how they should respond.

The Air Force effort draws on some of the world’s most knowledgeable suicide experts. For example, the president of the American Association of Suicidology, David Rudd of Baylor University, consults with the Air Force on its programs.

In the effort to help those in trouble, supervisors and co-workers often are hindered by a natural reluctance to pry into the private affairs of another person. Theoretically, however, co-workers and supervisors are supposed to know an individual well enough to detect such telltale signs as a sloppy uniform or poor work, without having to actually ask prying questions.

Jumper thinks it is time to remind the force that all airmen must look out for one another—to be good wingmen.

“This problem,” he said, “cannot be solved through programs and training sessions alone. It’s going to take an effort from the whole force, from our commanders and supervisors to every airman in the force.”

Everyone a Wingman

In a recent message to the Air Force, the Chief of Staff stated the fundamental truths:

“Commanders—you bear the responsibility for the total welfare of our greatest asset—airmen. You are responsible for their physical, emotional, social, and spiritual well-being. Use your base resources. You should know when your airmen need help and where to send them to get it.

“Supervisors—you are our first line of defense. Like commanders, you are responsible for the well-being of the people you supervise. It is you who look every airman in the eye every day. It is you who can spot the first signs of trouble and you who are in the best position to listen and engage.

“Airmen—be good wingmen. Take care of yourself and those around you. Step in when your wingman needs help. Signs of stress and suicide should not be dismissed. Neither should senseless risks to life and limb because of improper safety and irresponsible behavior.”

In July 2004, the Air Force revised its instruction directive (AFI 41-210) to improve the flow of information between commanders and support agencies and still protect members’ privacy rights.

“Confidentiality continues to be seen as a double-edged sword,” said Campise. “We have to maintain a balance between a patient’s privacy and a commander’s need for information that allows [him or her] to make decisions that ensure the safety of the airman and the success of the mission.”

Officials concede that they may never discover why the suicide rate has risen so sharply in recent months. Although the prevention program apparently reduced the earlier rate, they are not sure what caused the 1990s spike, either.

Campise said that it is difficult, if not impossible, to prove a chain of causation.

“All you can do is find correlations,” he said. “We know there is a correlation between being male and committing suicide, but you can’t say that just because you are male, that causes you to commit suicide. And we know that if you are divorced, you are twice as likely to commit suicide, but we can’t say that being divorced causes you to commit suicide because there are a lot of divorced people who don’t commit suicide.”

Even without knowing the cause, however, officials hope that new attention to the prevention program will lead, if not to a cure, to another reduction in numbers.