Feature Article
Implications for future use
Can it be generalized beyond the Air Force? Is it transferable to non-military populations? What are its implications for effective ways to address stigma - at-large and in specific populations?
Just what are the next steps when it comes to making the most of the U.S. Air Force Suicide Prevention Program and its recent publication in the “British Medical Journal?”
Next steps: Within the Air Force
As the USAF suicide prevention program enters its seventh year, trying to sustain a global program and high quality interventions is the goal.
Lt. Col. Rick L. Campise, Ph.D., suicide prevention manager for the Air Force, cites a number of new and ongoing initiatives to keep suicide prevention “top of mind” within USAF staff . These include public forums - both within and outside the Air Force - plus and leadership directives and memos.
Campise also attends as many suicide prevention meetings as he can each year to spread the good news of USAF suicide prevention program and results.
“I went to about 15 conferences last year,” he recalls. “It creates a buzz.”
That buzz has gotten results - and media attention - as Campise cites major media coverage of the USAF program by “U.S. News & World Report,” Associated Press and French television, among others.
Next steps: For future research
Although risk factors for suicide are fairly well known, little research exists - until publication of this “British Medical Journal” study - on what might prevent suicide.
“Community-based approaches to health promotion present methodological challenges to study design and evaluation. The 'noise' of real world environments often results in effect sizes smaller than expected. But this is not the case with the USAF study,” the study's authors say in the “British Medical Journal.” “In contrast, we found reductions in risk similar to those seen after community interventions for HIV prevention that have also targeted changing social norms.”
Yet a causal relation between suicide decline and the USAF program has not been established conclusively, nor have the components that might have been most responsible for that decline been identified, notes Kerry L. Knox, Ph.D.
Additionally, replication studies in other populations are called for, say authors of the BMJ study, who advocate testing the USAF suicide prevention strategy in other occupation-related communities such as law enforcement or large corporations to determine whether the program can be effective in other populations.
Additionally it may be useful to study the impact of increased use of prescribed antidepressants during the second half of the 1990s - and its potential effect on de-stigmatizing seeking help for mental health problems.
The USAF is involved in its own research of the program as well.
“We conducted empirically based research on eight different USAF bases regarding the career impact of help seeking behaviors,” notes Campise, who adds that he and a colleague are writing a paper based on this research study; its publication is pending.
Campise is also collaborating with prominent suicidologists, tapping the USAF suicide prevention database to learn more about successful interventions.
“We're looking to see if there are sub-types of suicidal individuals that we're successfully intervening with, and those that we're not successfully intervening with,” notes Campise. “It's putting our database to work.”
Next steps: For communities beyond the Air Force
A five-year study funded by the National Institute of Mental Health is now under way to evaluate each of the USAF program's components and how to best adapt them to other populations. Leading this study is Knox.
Aditionally, the USAF has acted as consultants to other entities formulating their own suicide prevention programs. These include the National Parks Service, U.S. Air Marshals, Slovenia Department of Public Health, British Army in Northern Ireland and Australian Department of Defense. And the USAF has presented ideas at California State University on how to effectively translate elements of its suicide prevention program to civilian populations.
Yes, but ... Are these results transferable?
It’s the $64,000 question. Are these findings - obtained from a unique population like the U.S. Air Force - transferable to other communities? Some say yes.
“Novel interventions are often first tested in restricted populations,” notes Kerry L. Knox, Ph.D., a researcher with the University of Rochester study of the USAF prevention program. “We were able to eliminate key confounders for risk of suicide such as socioeconomic status and access to health care.”
Knox and colleagues note that diversity does exist within the Air Force community as to education level, financial resources, rank, job description and installation assignment.
“But year-to-year variations in the composition of this population are minimal,” she adds. “So we were able to do this type of cohort study looking at the population both before and after the program was implemented.”
Researchers note that key lessons and overarching principles derived from this program may be adaptable to select communities that are more tightly organized. These could include police, fire fighters, other branches of armed services, larger corporations, states or smaller countries, and schools and universities.
Despite proponents’ accolades, naysayers aren’t so sure about generalizing about results from the USAF study for other populations.
Even University of Rochester researchers offer some limitations.
“Differences exist in the characteristics of active Air Force personnel and the U.S. civilian population,” says Knox. “All have completed secondary school, are employed and housed, and have comprehensive healthcare benefits including mental health care.”
“Since 1974 members have been screened for mental illness before entry,” notes Lt. Col. Rick L. Campise, Ph.D., suicide prevention manager for the Air Force. “Use of illicit drugs, a risk factor for suicide, is approximately 90 percent less frequent than in the civilian population after adjusting for age and sex. And all members have a commander or a first sergeant whose job it is to be interested in each member's health and well-being.”
The suicide rates in the U.S. also declined in second half of the 1990s, researchers point out.
“But this decline is extremely small compared to that measured in the Air Force,” notes David A. Litts, O.D., retired USAF colonel and a member of the team that developed the Air Force prevention program. “Low unemployment and decline in drug use would not be expected to have been a factor for the special population in the Air Force. But increasing use of antidepressants may have a context.”
COMMONALITIES BETWEEN THE USAF AND CIVILIAN COMMUNITIES
• Identifiable leaders that can influence community norms and priorities
• Human services including health care that are delivered through a web of community agencies and organizations that are not well connected
• Elements of a common identity shared among community members who at the same time are a collection of widely diverse individuals
• An established network of gatekeepers - people who open gates to provide resources for individuals in need
DISTINCTIONS THAT MAKE THE USAF UNIQUE
• Leadership authority is especially concentrated and hierarchical
• All members work for the same employer
• Housing and health care - including mental health care - are universally available
• Population is pre-screened for serious brain disorders
• Gatekeeper network is unusually well organized
NOTE: These distinctions have likely sped the implementation of the program and increased its penetration.
WHAT MAY BE TRANSFERABLE FROM THE USAF TO CIVILIAN COMMUNITIES
• Leveraging community leaders to change cultural norms
• Engaging and training established networks of gatekeepers
• Improving coordination of broadly diverse human services
• Providing educational programs to community members
