Suicide and Life-Threatening Behavior 31(1) Spring 2001 103 2001 The American Association of Suicidology

Are UN Peacekeepers at Risk for Suicide?ALBERT WONG, MD, MICHAEL ESCOBAR, PHD, ALAIN LESAGE, MD,MICHEL LOYER, MA, CLAUDE VANIER, MD, AND ISAAC SAKINOFSKY, MD

Media reports connecting UN peacekeeping duties by Canadian soldiers totheir subsequent suicide prompted this study of peacekeeping as suicide risk. In acase-control design we retrospectively compared 66 suicides in the Canadian mili-tary between 1990 and 1995 with two control groups: (a) 2,601 controls randomlyselected from the electronic military database and (b) 66 matched controls withcomplete personnel and medical data. We found no increased risk of suicide inpeacekeepers except among a subgroup of air force personnel. Here confoundingindividual factors, isolation from supports, and possibly inadequate preparationfor deployment elucidated their suicides. Theater of deployment (e.g., Bosnia) didnot affect the suicide rate. Military suicides experienced psychosocial stresses andpsychiatric illness more often than their matched controls. We conclude that al-though peacekeeping per se does not increase overall suicide risk, military life-styles may strain interpersonal relationships, encourage alcohol abuse, and con-tribute to psychiatric illness and suicide in a minority of vulnerable individualsirrespective of peacekeeping assignment. Careful selection, and preparatory mili-tary training that encourages intragroup bonding and mutual support, may protectagainst suicide risk.

Even as we enter the 21st century there mor. Peacekeeping duty seems here to stay;between 1992 and 1994 the number of UNseems no end to endemic regional conflicts.

Military forces of UN member nations will peacekeepers mushroomed internationallyfrom 11,500 to 72,000 (Trager, 1994).foreseeably be indispensable to monitoring

peace agreements, such as those recently po- Surprisingly little is known about theimpact of peacekeeping on the peacekeepersliced in Bosnia-Herzegovina, the Middle

East, Rwanda, Somalia, Kosovo, and East Ti- themselves. Several studies have highlighted

ALBERT WONG, MD, is Research Fellow in the Department of Psychiatry and the Institute ofMedical Sciences, University of Toronto, Toronto, Ontario, Canada. MICHAEL ESCOBAR, PHD, is Asso-ciate Professor in the Department of Public Health Sciences, University of Toronto, Toronto, Ontario,Canada. ALAIN LESAGE, MD, is Associate Professor, MICHEL LOYER, MA, is Research Associate, andCLAUDE VANIER, MD, is Psychiatrist-in-Chief at the Louis-H. Lafontaine Hospital, Fernand-SeguinResearch Center, University of Montreal, Montreal, Quebec, Canada. ISAAC SAKINOFSKY, MD, is pro-fessor in the Departments of Psychiatry and Public Health Sciences, University of Toronto, Toronto,Ontario, Canada.

This research was supported by Department of National Defense (Canada) Contract 5784-18(DHPP 3). Special thanks are due to Lieut.-Col. Martin Tepper (Ret.), Col. Ruth MacKenzie, Messrs.Richard Mitchell, Ron Nitschke and Stephane Pharand, Capt. Krista Simonds, Capt. Stephanie McKin-non, Sgt. Clara Frey, Cpl. Dana Beattie, Mme. Christiane Montgiraud, and Ms. Joan Santiago.

Address correspondence to Isaac Sakinofsky, Suicide Studies Program, Clarke Division, Centerfor Addiction and Mental Health, 250 College St., Toronto, Ontario, Canada, M5T 1R8, E-mail: isaac.sakinofsky@utoronto.ca.

104 PEACEKEEPING AND SUICIDE

the prevalence of posttraumatic stress disor- vice over five years preceding these media re-ports.der (PTSD) in military combatants and

peacekeepers (Carlstrom, Lundin, & Otto,1990; Jones, 1985; Litz, King, King, Or-sillo, & Friedman, 1997; Litz, Orsillo, Fried- METHODman, Ehlich, & Batres, 1997; MacDonald,Chamberlain, Long, Pereira-Laird, & Mir- Subjectsfin, 1998; McCarroll, Ursano, & Fullerton,1995; McCarroll, Ursano, Fullerton, & All 66 deaths in the Canadian forces

between January 1990 and June 1995 certi-Lundy, 1993; McCarroll, Ursano, Fullerton,et al., 1995; Orsillo, Roemer, Litz, Ehlich, & fied as suicides were investigated. Sixty (91%)

were among enlisted personnel; two wereFriedman, 1998; Rosebush, 1998; Solomon,Neria, Ohry, Waysman, & Ginzburg, 1994). captains, one was a major, and one was a col-

onel; 63 of 66 (95%) were males. Mean ageNo study to our knowledge has focused spe-cifically on the relationship between peace- was 30.4 (SD = 7.4, range = 19–51) years.

The anglophone-to-francophone ratio waskeeping duties and suicide, although severalreports have shown that in general suicide is 1.4 : 1. Army personnel (56%) made up the

largest group, followed by air force personnelless frequent in military populations thancomparable civilian groups. Reports from the (30%) and navy personnel (14%). Single per-

sons (47%) predominated; 41% were mar-United States and Scandinavia consistentlyindicate that the prevalence of military sui- ried, and 12% divorced or separated. The

majority (62%) was childless. Fifty-two per-cide has remained half to two thirds that ofthe age-comparable general public (Kawa- cent were in combatant “trades” such as

pilots, infantry, or artillery. Twenty-four sui-hara & Palinkas, 1991; Rothberg, Fagan, &Shaw, 1990; Rothberg & Jones, 1987; Roth- cides (36%) had experienced at least one 6-

month tour of peacekeeping duty in 1 orberg & McDowell, 1988; Schroderus, Lonn-qvist, & Aro, 1992). Suicide was the third more of 29 countries from Afghanistan to the

former Yugoslavia.cause of death (13%) in military personnel,after unintentional injuries and diseases (Hel-mkamp & Kennedy, 1996). Lower rates of Comparisonssuicide in the military of many countries maybe explained on grounds of selection and First, the overall military suicide rates

were compared with age- and sex-compara-screening, and on a structured and supportivesocial environment. Rothberg and colleagues ble data for Canada and, for francophones,

also for Quebec. Then two control groups(Rothberg, Bartone, Holloway, & Marlowe,1990) named this combination the “healthy were selected: (a) A 1 in 26 sample (n =

2,601) of computerized personnel records inworker effect.”In the spring of 1995 a stream of dis- the database of serving military personnel

(total = �67,000) was randomly selected byturbing news reports focused public concernin Canada on accounts of military personnel computer-generated random numbers. This

yielded an unmatched computerized recordwho committed suicide during or followingUN peacekeeping duties in Bosnia. Urgent group (UCRG). (b) A matched control group

(MCG) of living military personnel (n = 66)questions were raised by policy makers aboutthe possible role of peacekeeping duties in was constructed, whose complete hard-copy

files were reviewed. Potential matches werecausing their suicides. This study is an at-tempt to resolve the question of the role of selected by computer for the following vari-

ables: gender, age (within 5 years), rank (offi-peacekeeping duty as a potential risk factorfor suicide; it investigates the 66 suicides that cer, noncommissioned officer [NCO], en-

listed person), first language English oroccurred in the Canadian forces regular ser-

WONG ET AL. 105

French, marital status, and military occupa- test. Statistical packages used were SASPROC FREQ, PROC CATMOD, andtion (“trade”). Informed consent and ethics

review at the two universities were obtained PROC PROBIT. Where odds ratios are pre-sented below, their 95% confidence intervalsbefore inclusion in the study.are placed in parentheses.

Living Matched Case-Control Study.WeData Analysisreviewed the complete hard-copy personneland medical files of the suicide cases andUnmatched Computerized Record Group

(UCRG). The 2,601 randomly selected MCG controls, including the military in-quests (called summary investigations) on theUCRG records, composed of serving mem-

bers from all branches of the military, includ- suicides. These inquests, similar to U.S.Army psychological autopsies discussed bying naval personnel, were compared with

those of the 66 suicides. However, because it Rothberg (1998), inquired into the personalhistory, health, social problems, and militarywas often unclear whether or not a naval ves-

sel had been supporting a peacekeeping oper- service of the deceased and their possible re-lationship to the death, as well as adjudicat-ation during the assignment of a subsequent

naval suicide, a separate comparison was also ing whether it was a suicide or accident. Insome cases there were additional reports suchdone excluding naval personnel (n = 2,107).

Both analyses are presented in Table 1. The as a UN or joint command investigation.Best estimate diagnoses according to thesize of the sample (3.85% of the entire serv-

ing force) empowered reasonably accurate es- fourth edition of the Diagnostic and StatisticalManual of Mental Disorders were first inde-timation of the entire regular force popula-

tion, the standard error of the log (odds pendently made by two psychiatrists (A. W.and I. S.) and differences resolved by discus-ratio) being off by only 1–2% from that

which would have been obtained using the sion. Simple Kappa coefficients before discus-sion (95% confidence limits) were: adjustmententire service population; consequently infer-

ences obtained from this analysis could be ex- disorder 0.68 (0.51,0.86); major depressive ill-ness, 0.67 (0.49,0.84); anxiety disorder, 0.79trapolated to the entire service population.

The major analytical methods were log-lin- (0.40,1.19); PTSD, 0.66 (0.04,1.28); substancedisorder, 0.72 (0.55,0.89); personality disor-ear modeling and logistic regression. First,

the individual variables were examined for der, 0.66 (0.47,0.86); and psychotic disorder,1.00 (1.00,1.00). Case and control groupspossible transformations and simple two-way

tables were examined to look at the marginal were compared on psychiatric symptoms, sub-stance abuse, best estimate diagnoses, post-relationships between two different variables.

Then a log-linear hierarchical model analysis ings, life event stresses, personality profile,and combat/peacekeeping experiences. Stan-was performed to look for associations and

higher order interactions between different dard statistical methods for paired data (Mc-Nemar and Mantel-Haenszel chi-square test,variables. We estimated basic frequencies,

did pairwise comparisons (Pearson’s chi- paired t test and frequency distribution) werenot used because our results were “extreme”square), looked for possible confounders and

for more complex structures by log-linear hi- and the usual normal approximation wouldnot be accurate in the tail of the distribution.erarchical model analysis (likelihood ratio

statistic). The resulting interactions were Instead of the usual asymptotic methods, ex-act methods based on the cumulative bino-subjected to a series of logistic regression

analyses (Wald test). A subanalysis of air mial distribution were employed (Agresti,1990; Mosteller, 1952). To calculate the cu-force personnel, looking at the relationship

between suicide and peacekeeping, control- mulative binomial distribution distributionwe (M. E.) adapted a computer code pub-ling for military occupation or trade, was car-

ried out using the Cochran-Mantel-Haenszel lished in Fortran (Press, Flannery, Teukol-

TABLE1

SelectedDemographicCharacteristicsofRegularForceSample(UCRG)andSuicides

Army,Air,&

Navy

Army&AirOnly

UCRG

Suicides

pUCRG

Suicides

pDemographic

(n=2,601)

(n=66)

Value,df

Value

a(2,107)

(57)

Value,df

Value

Gender:%males

89.39%

(2,325)95.45%

(63)

2.528,df

=1

.112

88.99%

(1,875)96.49%

(55)

3.239,df

=1

.072

%Age

18–24

11.26%

(293)13.64%

(9)

1.694,df

=4

.792

10.06%

(212)10.53%

(6)

1.556,df

=4

.817

25–29

21.41%

(557)24.24%

(16)

21.17%

(446)21.05%

(12)

30–34

29.49%

(767)31.82%

(21)

30.14%

(635)36.84%

(21)

35–39

19.95%

(519)15.15%

(10)

21.21%

(447)17.54%

(10)

>40

17.88%

(465)15.15%

(10)

17.42%

(367)14.04%

(8)

FirstlanguageFrench

28.49%

(741)42.42%

(28)

6.091,df

=1

.014

30.47%

(642)42.11%

(24)

3.527,df

=1

.060

Maritalstate

Single

22.96%

(595)46.15%

(30)

32.282,df=2

.001

21.90%

(460)44.64%

(25)

30.486,df=2

.001

Married

71.84%

(1,862)40.0%

(26)

72.33%

(1,519)39.29%

(22)

Divorced/Separated

5.21%

(135)13.85%

(9)

5.76%

(121)16.07%

(9)

Widowed

0.0%

0.0%

0%(0)

0%(0)

Childless

45.02%

(1,171)62.12%

(41)

7.592,df

=1

.006

43.52%

(917)61.40%

(35)

7.203,df

=1

.007

Rank

<Corporal

5.23%

(136)21.21%

(14)

38.210,df=5

.001

3.80%

(80)

17.54%

(10)

33.077,df=5

.001

Corporal

48.75%

(1,268)56.06%

(37)

50.55%

(1,065)59.65%

(34)

NCO

23.95%

(623)13.64%

(9)

23.07%

(486)12.28%

(7)

Officer

<Captain

4.23%

(110)

3.03%

(2)

4.22%

(89)

3.51%

(2)

Captain

10.88%

(283)

3.03%

(2)

11.39%

(240)

3.51%

(2)

>Captain

6.96%

(181)

3.03%

(2)

6.98%

(147)

3.51%

(2)

Highschoolnotcompleted

16.92%

(440)36.36%

(24)

16.939,df=1

.001

17.23%

(363)36.84%

(21)

14.627,df=1

.001

Anypeacekeepingservice

32.95%

(857)36.36%

(24)

0.339,df

=1

.560

39.01%

(822)42.11%

(24)

0.223,df

=1

.637

Yugoslavia(former)

11.23%

(292)12.12%

(8)

0.052,df

=1

.820

13.38%

(282)14.04%

(8)

0.020,df

=1

.887

Somalia

1.54%

(40)

1.52%

(1)

0.000,df

=1

.988

1.85%

(39)

1.75%

(1)

0.003,df

=1

.957

Rwanda

0.85%

(22)

1.52%

(1)

0.337,df

=1

.561

1.00%

(21)

1.75%

(1)

0.317,df

=1

.574

Anyforeignservice

65.05%

(1,692)54.55%

(36)

3.115,df

=1

.078

62.87%

(1,325)54.39%

(31)

1.714,df

=1

.191

Note.Inthistableforlackofspaceonlyselectedlevelscanbeshownforsomecategories.UCRG,unmatchedcomputerizedrecordgroup;

NCO,noncommissionedofficers.

a ThesepvaluesobtainedbyunivariateanalysishavenotbeenadjustedformultipletestingbytheBonferronimethodandmustbetreated

withcaution.Interdependenceofvariableshasbeenadjustedforinthemultivariateanalysesshowninthesubsequenttables.

WONG ET AL. 107

sky, & Vetterling, 1989) and checked imple- rate per 100,000 of 33.9 (3.3, 64.4), similarto age-comparable males in Quebec (36.3).mentation of the code with the execution of

the same function in a commercial softwareprogram, S-Plus (S-Plus User’s Guide, 1998). Peacekeeping Experience

There was no excess of suicide in theoverall peacekeeping group including thoseRESULTSassigned to duty in recent trouble spots (seeTable 1). There were no suicides amongMode of Deaththose navy personnel identified as on apeacekeeping mission and the results areGunshot or explosives were used in 27

suicides (40.9%), hanging in 18 (27.3%) sui- negative whether or not naval personnel areincluded in the analysis. There was no in-cides, and carbon monoxide poisoning in 9

(13.6%) suicides. Less common methods in- creased risk for army peacekeepers (OR =0.53 [0.28,1.05]), even after single status andcluded drug overdoses or poisoning in five

(7.6%) suicides. One soldier immolated him- failure to complete high school (possible riskfactors) were added to the model. However,self with gasoline, another stabbed himself to

death, one jumped, another fatally injected in the air force subgroup the probability ofsuicide was raised (OR = 3.43; Table 2).himself, and two drowned. In one case the

cause of death was attributed to an “unusual Peacekeeping remained a significant risk fac-tor even after single marital state and lowtoxin possessing proteolytic activity possibly

acquired abroad.” Two cases were murder- rank category (possible confounders) wereincluded in the model, the odds ratio risingsuicides, one involving a man and his chil-

dren, and the other a man and his spouse. to 5.31 (1.92, 14.72). To explain this findingwe scrutinized the records of each of the airforce suicides. None of the nine air forceComparison of Suicide Rate with

Canadian Population peacekeepers had been potential combat-ants—seven were aircraft technicians, onewas a cook, and one was a finance clerk (Coch-The suicide rate (95% confidence lim-

its) among the males (n = 63) was 12.2 (9.2, ran-Mantel-Haenszel, n.s.). There were nostresses, psychiatric diagnoses or circum-15.2). Because it was 26.2 per 100,000 for

age-related Canadian males (1990–1994), the stances discoverable that were unique to thepeacekeeper air force suicides or more fre-male military rate was half that of the compa-

rable civilian group. Female military suicides quent. In six of nine cases their suicides wereassociated with relationship problems (in-constituted 4.5% of the total suicide group

(half the expected 10.6%, but not signifi- cluding pending separations, or divorce withloss of custody of children). One was undercantly different). In the all-branches sample,

francophones, nonmarried (including single legal investigation, and two were pending re-lease complicated by psychiatric problems.and divorced/separated) or childless persons,

those with less than high school completion, Relationship discord was similarly present in9 of 11 air force nonpeacekeeper suicidesor lower rank than corporal were overrepre-

sented. NCOs and officers at captain or (χ2 = 1.626, df = 1, p = .202). The proportionsof psychosocial problems identified in thehigher rank were underrepresented among

the suicides (see Table 1). The excess among suicides were similar among army, navy, andair force personnel.francophones no longer held significance

when the Bonferroni correction was appliedor only the army and air services were in- Temporal Relationshipcluded in analysis (see Table 1). There were26 male francophone suicides aged 19–38 One soldier blew himself up with a

grenade while serving in the Golan and an-years and an outlier aged 49, that is, a suicide

108 PEACEKEEPING AND SUICIDE

TABLE 2Risk of Suicide in Peacekeepers by Service

Regular Forces Suicides with Odds Ratiowith Peacekeeping Peacekeeping (95% Confidence

Regular Service Experience (%) Experience (%) Intervals)

Air Force 19.2 45.0 3.43 (1.42, 8.41)Navy 7.1 0 —Army 55.9 40.5 0.53 (0.28, 1.05)

would end their relationship; he ap-other died by self-inflicted gunshot inpeared torn between his sense of dutyRwanda. The close temporal proximity of and his desire to save their relationship.these two suicides to peacekeeping missions He was then given two options [by his

was unusual; most suicides among former Commanding Officer]: “Stay here, sortout his problems with his girl friend,peacekeepers occurred years later. Eight sui-get out of the Army and do whatevercide victims served in the former Yugoslaviashe wanted him to do, sort out his life;as peacekeepers and committed suicide 1–3 or, I told him, he could grow up, faceyears later; one served in Somalia and died 2 his problems. . . . I told him he had 24

years later, and three died 7 and 8 years after hours to decide. . . . The next day, hecame in and said that he was going toUN service in Israel. One soldier died 4 years[peacekeeping theater].” The implica-after service in Namibia, two died 3 yearstion was stay home and be a wimpafter the Gulf War, two died 4 and 5 years whose career would be in trouble orafter service in Egypt, and two died 1 and 5 come along and be a good soldier. Be-

years following a tour in Haiti. ing placed in this “lose-lose” situationwas likely very stressful.

Narrative Inquest ReportsMatched Case-Control Comparison

Although there was little evidence toPsychosocial problems in each cate-suggest that as a group peacekeepers were at

gory were identified more often among therisk for suicide, qualitative information in thesuicide victims than their matched controlsnarrative records suggests that active UN(Table 3). Relationship problems were iden-duty could have placed particular individualstified most commonly, followed by conflictsunder severe stress and strain, as exemplifiedover their military jobs, with the military sys-in these extracts from military inquest re-tem, and with their pending release. We ex-ports:plored whether absence on UN duties might

He tripped a [type of] anti-personnel have exacerbated relationship difficulties, butmine that did not explode. . . . Long found the frequency of those having prob-hours in [UN peacekeeping mission]. . . . lems with loved ones was similar betweenRelentless schedule. . . . There was no

peacekeepers (75.0%) and nonpeacekeepersbreak for us since coming back. (Com-(71.4%; χ2 = 0.098, df = 1, p = .754). Paradox-ment by fellow soldier to investigators)ically, substance abuse (including alcohol)

In retrospect it appears that the chain was identified in 29.2% of peacekeeper sui-of command may not have served this cides and twice the proportion (57.1%) ofmember well. Here was a young soldier nonpeacekeeper suicides (χ2 = 4.80, df = 1,who was having significant problems

p = .028).with his common-law wife and fearedthat going to [peacekeeping theater] Positive best estimate diagnoses were

WONG ET AL. 109

TABLE 3Military Suicides and Matched Controls (MCG): Psychosocial Problems

Binomial/McNemar Test

Odds Ratio(95% Confidence

Problem Suicides Controls Pairsa Intervals) p Value

Relationship 48 (72.7%) 4 (6.1%) 45,1 45.0 (7.68,1816.39) <.001Release pending 21 (31.8%) 0 (0%) 21,0 43.0 (5.21, ∞) <.001Conflict with the system 27 (40.9%) 5 (7.6%) 25,3 8.3 (2.54,43.12) <.001Financial 8 (12.1%) 1 (1.5%) 8,1 8.0 (1.07,354.99) .039b

Military job 28 (42.4%) 5 (7.6%) 26,3 8.7 (2.66,44.74) <.001Legal 7 (10.6%) 3 (4.6%) 7,3 2.3 (0.53,13.98) .344Grief 2 (3.0%) 1 (1.5%) 2,1 2.0 (0.104,117.99) 1.000Other 7 (10.6%) 3 (4.6%) 7,3 2.3 (0.53,13.98) .344

aPairs on which the cumulative binomial distributions were calculated: The first figure indi-cates matched pairs with positive exposure in the suicide case, none in the control. The secondfigure indicates pairs with no exposure in the case, positive exposure in the control.

bWhen the Bonferroni test for multiple comparisons is applied, this p value loses its signifi-cance (<.00625 required).

more prevalent among the suicides (Table 4). in Bosnia. None of the air force suicides metPTSD criteria.Adjustment disorders were found in two

thirds of suicides, and mood disorders and/ Previous Suicidalityor a substance disorder in over one third ofsuicides. Two suicides and three controls met A previous suicide attempt (likely un-

derstated in both categories) was document-criteria for PTSD, all formerly peacekeepers

TABLE 4Military Suicides and Matched Controls (MCG): Best Estimate Psychiatric Diagnoses

Binomial/McNemar Test

Odds RatioSuicides Controls (95% Confidence

Diagnosis (66) (66) Pairsa Intervals) pb

Adjustment disorder 44 (66.7%) 4 (6.1%) 41,1 41.0 (6.96,1658.47) <.001Mood disorder 28 (42.4%) 5 (7.6%) 25,2 12.5 (3.12,108.89) <.001Substance disorder 32 (48.5%) 2 (3.0%) 30,0 61.0 (7.64,∞) <.001Anxiety disorder 3 (4.6%) 0 (0%) 3,0 7.0 (0.41,∞) .250PTSD 2 (3.0%) 3 (4.6%) 2,3 0.7 (0.06,5.82) 1.00Personality disorder 22 (33.3%) 4 (6.1%) 22,4 5.5 (1.87,21.95) <.001Psychotic disorder 4 (6.1%) 1 (1.5%) 4,1 4.0 (0.40,196.99) .375Prior attempts 14 (21.2%) 1 (1.5%) 13,0 27.0 (3.05,∞) <.001

APairs on which the cumulative binomial distributions were calculated: The first figure indi-cates matched pairs with positive exposure in the suicide case, none in the control. The secondfigure indicates pairs with no exposure in the case, positive exposure in the control.

bWhen the Bonferroni test for multiple comparisons is applied the criterion p value for signif-icance is <.00625.

110 PEACEKEEPING AND SUICIDE

ed in 14 (21%) of the cases and one of the failure at recruitment to detect concealed in-formation concerning personal and psycho-controls (see Table 4); the mean number of

prior attempts (0.32 in the cases, 0.015 in the logical difficulties, posthumously discoveredfrom interviews with schoolteachers and schoolcontrols) was also significantly different

(paired t = 3.375, p = .001). Warning signs records (Apter et al., 1993).Although PTSD and other effects of(chronic threats, police reports, verbal threats,

or notes) were documented in 19 (28.8%) military stressors on mental health have beenwell studied in UN peacekeepers (Carlstromsuicide cases, and alcohol was present in the

blood postmortem in 27 (47.4%) of the cases et al., 1990; Litz, King et al., 1997; Litz, Or-sillo et al., 1997; MacDonald et al., 1998; Or-where it had been estimated; other sub-

stances were present in 9 (16.1%) suicide sillo et al., 1998), this is the first study to ad-dress the specific question of suicide risk incases.peacekeepers.

Our finding of an overall military sui-cide rate half that of Canadian civilians con-

DISCUSSION firms the findings of other studies (e.g., Ka-wahara & Palinkas, 1991; Rothberg, Fagan,et al., 1990; Schroderus et al., 1992). Franco-In this study no significant evidence

linked peacekeeping duties in the overall mil- phones may have been overrepresented inthe overall sample, but the difference did notitary population with suicide. However, in-

creased risk was present in the subgroup of attain statistical significance, probably be-cause of small numbers. Only single maritalair force peacekeepers. This could be ex-

plained by personal factors (e.g., relationship status (a risk factor) was disproportionatelypresent among them and their rates equaledproblems) not directly related to peacekeep-

ing duties and not more frequent than among that of (mostly francophone) Quebec, pro-posing a cultural factor.air force suicides who had done no peace-

keeping. We found on further inquiry that Certain of the narrative military in-quest reports suggest that in particular in-air force practice had been to deploy air force

personnel for peacekeeping duties as re- stances peacekeeping service generated uniqueoccupational stress which may have contrib-quired, without the elaborate selection and

preparation for peacekeeping duties afforded uted as a negative life event to suicides in vul-nerable individuals, although not affectingarmy personnel. Thus army service people

were protectively bonded together by prepa- the group as a whole. If true, how long wouldsuch an effect persist? The impacts of dis-ratory training, but air force personnel lacked

this support. Furthermore, the majority of air turbing military experiences (e.g., handlingmortuary material) may result in PTSDforce peacekeeper suicides were single and

from the lowest ranks, and may have experi- ( Jones, 1985; McCarroll, Ursano, & Fuller-ton, 1995) lasting for years (Solomon et al.,enced oppressive loneliness and isolation in

the unfamiliar environment (Rothberg, 1991). 1994; McCarroll et al., 1993). Conceivably,peacekeeping stress might exacerbate an un-The absence of an overall association

between peacekeeping experience and suicide derlying psychiatric problem (e.g., a soldierdepressed over a failing relationship), and themay be explained by the selection criteria for

active duty missions, which include evidence effects might persist beyond completion ofthe posting. Peacekeeping duties in particu-of good general adjustment and mental and

physical health—the “healthy worker effect” larly traumatic environments, where atrocit-ies diminish the value of human life, may(Rothberg, Bartone, et al., 1990). However,

screening and selection processes are notori- conceivably alter personal concepts of thevalue of life in vulnerable individuals amongously imperfect, and in the case of air force

personnel were less elaborate than for their the peacekeepers, lowering their own thresh-olds for suicide when subsequently con-army confreres. An Israeli study reported

WONG ET AL. 111

fronted by depression or adversity. Hall problems. Substance abuse, usually alcohol,was identified in one third of the suicides; the(1996) suggested the term deployment malad-

justment to qualitatively distinguish peace- relationship between alcohol abuse and sui-cide in the military is well documented (Al-keeping stress reaction from “battle fatigue”

seen in conventional war. These hypotheses, lebeck & Allgulander, 1990; Clark, Campag-nari, & Jones, 1985; Rossow & Amundsen,if true, would apply only to a susceptible mi-

nority, not to the group as a whole. The 1995). Also, the greater frequency of psychi-atric disorder among the military suicides ac-unique stresses undergone by peacekeepers

are inherent in their jobs (e.g., witnessing cords with other studies of military suicide(Marttunen et al., 1996).atrocities, separation from loved ones) and

mostly inevitable. However, the impact on The major limitation of the study wasits retrospective nature, an inherent problemfamily life can conceivably be reduced by in-

creasing the intervals between overseas post- in studying suicide. Also, although personneland medical files were available for both theings to a minimum of 1 year, allowing sol-

diers more time with their families. Careful suicides and controls, military inquest datawere available only for the suicides. In theselection and pretraining, and deployment

stress management programs are also poten- MCG study the Kappa values for agreementbetween the two raters before consensus maytially helpful.

Relationship problems were prevalent be considered low by some readers.Prevention of suicide in the military isin the majority of our overall military sui-

cides, supporting U.S. Army (Rothberg, Fa- impeded by the “macho” soldier culture,which deters a soldier from admitting emo-gan, et al., 1990; Rothberg & McDowell,

1988) and Finnish findings (Marttunen, Hen- tional difficulty, perceiving it as weakness.Soldiers also know that applicants with ariksson, Pelkonen, Schroderus, & Lonnqvist,

1996). We found a comparatively lower prev- known history of psychiatric illness are ex-cluded from recruitment and released fromalence in the matched controls than in the

suicides, but the question remains whether service earlier (Fragala & McCaughey, 1991).Consequently, psychiatric and social difficul-military lifestyles generally put strain on rela-

tionships (Bercuson, 1996). Alcohol may also ties may be concealed from helping agencieswithin the services. This problem requiresplay a role. The suicide narratives we re-

viewed showed clearly that although the mili- direct confrontation and reeducative pro-grams so that mental health and social prob-tary system officially discourages alcohol

abuse, social life on a military base is cen- lems can become destigmatized in militarysettings and suicide thereby be prevented.tered on drinking, and alcoholic excess

seemed to play a part in some relationship

REFERENCES

Canada’s army, the airborne, and the murder in So-AGRESTI, A. (1990). Categorical data analy-malia. Toronto: McClelland & Stewart.sis. New York: Wiley.

CARLSTROM, A., LUNDIN, T., & OTTO,ALLEBECK, P., & ALLGULANDER, C.B. (1990). Mental adjustment of Swedish soldiers(1990). Suicide among young men: Psychiatric ill-in South Lebanon in 1988. Stress Medicine, 6, 305–ness, deviant behavior and substance abuse. Acta

Psychiatrica Scandinavica, 81, 565–570. 310.CLARK, M. A., CAMPAGNARI, K. D., &APTER, A., BLEICH, A., KING, R. A.,

KRON, S., FLUCH, A., KOTLER, M., & COHEN, JONES, L. M. (1985). The major causative role ofethanol and the minor role of other drugs in theD. J. (1993). Death without warning? A clinical

postmortem study of suicide in 43 Israeli adoles- deaths of military personnel in San Diego County,California. Military Medicine, 150, 487–491.cent males. Archives of General Psychiatry, 50, 138–

142. FRAGALA, M. R., & MCCAUGHEY, B. G.(1991). Suicide following medical/physical evalua-BERCUSON, D. (1996). Significant incident:

112 PEACEKEEPING AND SUICIDE

tion boards: A complication unique to military ORSILLO, S. M., ROEMER, L., LITZ, B. T.,EHLICH, P., & FRIEDMAN, M. J. (1998). Psychiat-psychiatry. Military Medicine, 156, 206–209.

HALL, D. P. (1996). Stress, suicide, and ric symptomatology associated with contemporarypeacekeeping: An examination of post-missionmilitary service during Operation Uphold De-

mocracy. Military Medicine, 161, 159–162. functioning among peacekeepers in Somalia. Jour-nal of Trauma and Stress, 11, 611–625.HELMKAMP, J. C., & KENNEDY, R. D.

(1996). Causes of death among U.S. military per- PRESS, W. H., FLANNERY, B. P., TEU-KOLSKY, S. A., & VETTERLING, W. T. (1989).sonnel: A 14-year summary, 1980–1993. Military

Medicine, 161, 311–317. Numerical recipes: The art of scientific computing(FORTRAN version). Cambridge: Cambridge Uni-JONES, D. R. (1985). Secondary disaster

victims: The emotional effects of recovering and versity Press.ROSEBUSH, P. A. (1998). Psychological in-identifying human remains. American Journal of

Psychiatry, 142, 303–307. tervention with military personnel in Rwanda.Military Medicine, 163, 559–563.KAWAHARA, Y., & PALINKAS, L. A. (1991).

Suicides in active-duty enlisted navy personnel. ROSSOW, I., & AMUNDSEN, A. (1995). Al-cohol abuse and suicide: A 40-year prospectiveSuicide and Life-Threatening Behavior, 21, 279–290.

LITZ, B. T., KING, L. A., KING, D. W., study of Norwegian conscripts. Addiction, 90, 685–691.ORSILLO, S. M., & FRIEDMAN, M. J. (1997).

Warriors as peacekeepers: Features of the Somalia ROTHBERG, J. M. (1991). Stress and sui-cide in the U.S. Army: Effects of relocation onexperience and PTSD. Journal of Consulting and

Clinical Psychology, 65, 1001–1010. service members’ mental health. Armed Forces andSociety, 17, 449–458.LITZ, B. T., ORSILLO, S. M., FRIEDMAN,

M., EHLICH, P., & BATRES, A. (1997). Posttrau- ROTHBERG, J. M. (1998). The Army psy-chological autopsy: Then and now. Military Medi-matic stress disorder associated with peacekeeping

duty in Somalia for U.S. military personnel. cine, 163, 427–433.ROTHBERG, J. M., BARTONE, P. T., HOL-American Journal of Psychiatry, 154, 178–184.

MACDONALD, C., CHAMBERLAIN, K., LOWAY, H. C., & MARLOWE, D. H. (1990). Lifeand death in the US Army. In Corpore sano, Jour-LONG, N., PEREIRA-LAIRD, J., & MIRFIN, M. K.

(1998). Mental health, physical health, and stres- nal of the American Medical Association, 264, 2241–2244.sors reported by New Zealand Defence Force

peacekeepers: A longitudinal study. Military Medi- ROTHBERG, J. M., FAGAN, J., & SHAW, J.(1990). Suicide in United States Army personnel,cine, 163, 477–481.

MARTTUNEN, M., HENRIKSSON, M., 1985–1986. Military Medicine, 155, 452–456.ROTHBERG, J. M., & JONES, F. D. (1987).PELKONEN, S., SCHRODERUS, M., & LONN-

QVIST, J. (1996). Suicide among military con- Suicide in the U.S. Army: Epidemiological andperiodic aspects. Suicide and Life-Threatening Be-scripts in Finland. Military Medicine, 162, 14–18.

MCCARROLL, J. E., URSANO, R. J., & havior, 17, 119–132.ROTHBERG, J. M., & MCDOWELL, C. P.FULLERTON, C. S. (1995). Symptoms of PTSD

following recovery of war dead: 13–15-month fol- (1988). Suicide in United States Air Force person-nel, 1981–1985. Military Medicine, 153, 645–648.low-up. American Journal of Psychiatry, 152, 939–

941. SCHRODERUS, M., LONNQVIST, J. K., &ARO, H. M. (1992). Trends in suicide rates amongMCCARROLL, J. E., URSANO, R. J., FUL-

LERTON, C. S., & LUNDY, A. (1993). Traumatic military conscripts. Acta Psychiatrica Scandinavica,86 , 233–235.stress of a wartime mortuary. Anticipation of ex-

posure to mass death. Journal of Nervous and Men- SOLOMON, Z., NERIA, Y., OHRY, A.,WAYSMAN, M., & GINZBURG, K. (1994). PTSDtal Disease, 181, 545–551.

MCCARROLL, J. E., URSANO, R. J., FUL- among Israeli former prisoners of war and soldierswith combat stress reaction: A longitudinal study.LERTON, C. S., OATES, G. L., VENTIS, W. L.,

FRIEDMAN, H., SHEAN, G. L., & WRIGHT, K. M. American Journal of Psychiatry, 151, 554–559.S-Plus user’s guide, data analysis products di-(1995). Gruesomeness, emotional attachment, and

personal threat: Dimensions of the anticipated vision. (1998). Seattle: Mathsoft.TRAGER, J. (1994). The people’s chronology.stress of body recovery. Journal of Traumatic

Stress, 8, 343–349. New York: Henry Holt.MOSTELLER, F. (1952). Some statistical

problems in measuring the subjective response to Manuscript Received: June 20, 1998Manuscript Accepted: January 13, 2000drugs. Biometrics, 8, 220–226.