MS. DIANE REHMThanks for joining us. I'm Diane Rehm. Tomorrow we mark Veterans Day as we do reflect on the sacrifices men and women in uniform have made for us. It's not just in the heat of the battle that soldiers are at risk. The rate of suicide is rising in both active duty members and also among veterans. Joining me to talk about this disturbing trend: Barbara van Dahlen from Give an Hour, Rajeev Ramchand from RAND Corporation, Jan Kemp of the Department of Veterans Affairs and Elspeth Cameron Ritchie from the District of Columbia's Department of Mental Health.

MS. DIANE REHMPlease join us, 800-433-8850. Send us your email to drshow@wamu.org. Feel free to join us on Facebook or Twitter. Good morning to all of you. Thank you for joining us.

MS. BARBARA VAN DAHLENGood morning.

DR. ELSPETH CAMERON RITCHIEGood morning.

MS. JAN KEMPGood morning.

REHMJan Kemp, I know the VA, the Department of Veterans Affairs, reports that a veteran takes his or her life every 80 minutes. What's the basis for that figure?

KEMPThanks, Diane, and thanks for having us on today. The -- one of the biggest problems we face in the veterans administration is actually having solid numbers about the number of veterans who die by suicide every year in the United States. We rely on the Center for Disease Control numbers that come in through the national death index, which come in through each state reporting system.

KEMPAnd not all states are required to report veteran status on their death certificates. So there is a small group of states, 16 of them, which do report this information, and we use that information to extrapolate what the total numbers probably look like. I think we have a pretty good estimate, but we don't know for sure.

REHMCould the actual numbers be even higher?

KEMPThey could. The states that report veterans' suicide are probably not our most heavily populated veteran states. So they might not be totally representative of the numbers out there.

REHMAnd, Rajeev Ramchand, you were asked by the Department of Defense to evaluate suicide rates among active service members. What were the findings?

MR. RAJEEV RAMCHANDThat's correct. We -- the DOD has a good sense, especially from the past decade, of what the rate is in the services among active duty, and that includes members of the reserve component and National Guard who have been activated. And, basically, we see that the rate was around 10 per 100,000, so it's still a relatively rare event. But starting at around 2005, the rate did start to increase.

REHMTo?

RAMCHANDSo, right now, in 2010, the last data I saw was that the rate in the DOD, broadly, is around 18 per 100,000. And it's highest in the Army, where it's around 22 per 100,000.

REHMNow, is there any indication from DOD why the numbers are highest within that branch of the service?

RAMCHANDThere isn't. We don't know for sure right now, and that wasn't something that we were charged to do in our study. I do know that the Army does have a significant research endeavor with the National Institute of Mental Health to look at this issue, specifically within that service.

REHMAnd what's the total number of individuals who have committed suicide in the past year? Do we have a sense?

RAMCHANDWe do have a sense. I mean, these rates are from a number -- and, you know, I don't have the number off the top of my head right now.

REHMOkay. And how would you say these rates compare with the general population?

RAMCHANDThat's a great question. The general population in the United States, we know up until 2008, so the rate has been 10 per 100,000 in the United States. But that's just a very crude comparison, and it's actually not a fair comparison because the military is disproportionately male. And we know males are more at risk for suicide. So the actual comparison is this adjusted rate that we calculated in our report. And that rate -- we would expect the military rate to be at around 20 per 100,000.

RAMCHANDSo in the past, from 2001 to 2005, it was actually much lower than what we would expect, given the demographic profile. But now, it has -- at least the 2010 numbers have matched the 2008 numbers. There's a lag -- as Jan was saying, there is a lag in the CDC's reporting of national suicide estimates, so we don't know 2010 numbers yet.

REHMElspeth Ritchie, talk about the risk factors in the military and for veterans. Are they different from the risk factors in the general population?

RITCHIEYes, absolutely. As you know, Diane, I retired from the Army last year and -- after spending 28 years in the Army and looked very closely at risk factors for especially Army soldiers. And we published a paper recently on the prevalence and risk factors associated with Army suicides. And, basically, Army suicides are very different from the suicides in the civilian population. In the civilian population, it is usually people with psychiatric disease who are prone to kill themselves.

RITCHIEIn the Army, the risk factors are pretty simple: the breakup of a relationship, and they are also getting in trouble at work and having a legal problem. And in the Army, if you have a legal problem, you have an occupational problem. And what we've seen over time is that these precipitants -- often very humiliating events are what precipitate a suicide. The other thing that's very important to talk about, and people don't in general, is that about 70 percent of Army suicides are committed by gun, by either the personal weapon back here or the service weapon in theater.

RITCHIEAnd I believe that we don't do nearly enough discussion about how dangerous it is to have the -- what I call the gun in the nightstand, the easily available gun there at a time when you might be having a fight with your wife or just found out that you're going to get in trouble.

REHMNow, as I understand it, a third of all suicides in the military are among those who have yet to deploy. What are the factors at work there?

RITCHIEWhat I believe is the most important factor there is not the individual deployment history, but the unit deployment history. So our bases with the highest, what we call up tempo, operations tempo are also those with essentially the highest suicide rate. So where we've had a high suicide rate for a number of years: Fort Carson, Fort Stewart, Fort -- not Fort Bragg so much anymore, Fort Campbell, Fort Riley. Those are all bases, and others, where the troops are constantly coming and going.

RITCHIEAnd what the leaders told me, when we went down to investigate suicides, is they don't know their troops anymore 'cause they're just so busy. They get back from theater, and, shortly after that, they're going to different deployments or different schools or different units. And so the new kid who comes in, that in the old days were being integrated with picnics and barbeques and unit runs, now isn't integrated in the same way 'cause it's just going so quickly.

REHMAnd, Barbara van Dahlen, I know you are a clinical psychologist and president at Give an Hour. Tell us about that organization.

DAHLENSure. About six years ago now, I founded Give an Hour. And the idea was, as I saw the wars unfolding -- my father was a World War II veteran, and I had a huge respect for the men and women who serve and what they were dealing with -- what was clear was that, even though there were tremendous strides being made in the Department of Defense and Veterans Affairs, it wasn't going to be enough. And the war was continuing, and tremendous stress we were seeing already at that point in 2005 when these numbers started to show signs of increasing.

DAHLENAnd so the idea was to ask civilian mental health professionals to literally give an hour a week of their time to provide free mental health care to the returning troops, their families, and now also their communities. So now we have over 6,000 mental health professionals throughout the country, and they've given out well over 42,000 hours. And now we're working in communities to help coordinate and connect the dots because, as I'm sure that we'll talk later this morning, the issue is about coordination and collaboration among all organizations that are doing this work.

REHMBut the concern, I would think, is not just with veterans coming back. It's with those who are on active duty.

DAHLENAbsolutely. And when I say returning, I mean folks who are in the military and coming whether back to their community from a deployment or finally separating from the military. You're absolutely right. So we offer services to anyone who is serving or who has served or their families since 9/11.

REHMAnd how many psychologists, psychiatrists do you have who are working with you?

DAHLENSix thousand throughout the country now and more every day that are joining once they find out that the need is clearly there.

REHMAnd can you give us an estimate as to how many servicemen and women you've seen as an organization?

DAHLENIt's hard to count because, often, our providers are in large groups at reintegration events. Plus our individual counselors are seeing people in individual sessions or family sessions, and so we count hours. So the 42,000 hours, about half of those -- maybe not quite half -- go to direct service, some to families, some to reintegration events, so it's a wide range.

REHMBarbara van Dahlen, clinical psychologist, president of Give an Hour. Short break, and we'll be right back.

REHMAnd welcome back. Of course, tomorrow is Veterans Day, a day we set aside to honor those who have served our country and those who are serving our country. Jan Kemp is with me. She is National Mental Health Program director for suicide prevention at the Department of Veterans Affairs. And suicide is our concern this morning. Jan Kemp, the suicide rate seems so much higher among veterans than active service soldiers. Why is it that veterans are so vulnerable?

KEMPI think we have to remember that veterans come in all ages. And especially the people that are seen in the VA, which are the ones that we know the most about and that we can track and look at their numbers, often have a series of difficulties over their lifespan. So we continue to work at them, and our numbers actually include two groups of people that we're extremely concerned about now as far as suicide. And one of those are our returning veterans and our newer veterans.

KEMPBut another group of people of concern are Vietnam-era veterans who continue to have problems and difficulties, but also are reaching that point in their life where they're starting to match the general population in a period of time when the suicide rates are high.

REHMBut that group would be older. The group coming back from Iraq, from Afghanistan, much, much younger. What are some of the problems there, Elspeth?

RITCHIEWe see a number of problems when people return, especially in the Guard and Reserve. There is the difficulty of fitting back in with the population who hasn't seen what you've seen. Our soldiers and other service members have seen incredible amount of atrocities, of combat. They've watched friends die. They've been at risk themselves. Everybody knows somebody who's wounded. I just got a very touching message this morning from Afghanistan, from a colleague of mine who saw an Afghan be shot and die despite everything they could do to try to save them.

RITCHIEThe difficulty is taking care of Iraqis and Afghan kids who may die. So they've seen a lot, been exposed to a lot. They come back here to a society that really doesn't understand them. And then one of the real concerns is, especially with the Reserve and Guard, if they can't get a good job -- if they've been the mayor of Iraqi village or have been in charge of logistics in Afghanistan and then they -- if they're lucky, are stocking shelves at Wal-Mart, what do they do?

RITCHIESo one of the points I really want to make for all your listeners is it's great to offer mental services, but it's even more important to think about jobs and employment. Anything that the folks out there can do to say, how can I help my young veteran who may be four years behind in terms of college and work experience, who's a little disconnected anyway, what can I do to plug that person back into the community and into employment? That is just so important.

REHMBarbara.

DAHLENAbsolutely. And one of the things that's happening, that is good news, there are many efforts right now underway where the goal is to coordinate efforts among communities, employers, educators, mental health profession.

REHMAnd what kind of success do you have?

DAHLENWell, they're just getting underway. There's an organization now, the Points of Light Institute, that is now implementing what's called the Community Blueprint Network. I was part of the creation of that, that initiative, and it's all about the heavy lifting of finding those in the communities who have jobs, those in the communities that want to provide education and having them work together, talk together, engage in action, so that it's not just -- we all want to help our veterans. But unless we give community members specific things that they can do, it's not happening.

REHMRajeev.

RAMCHANDYeah, I agree very much. We know from the scientific literature that unemployment is linked with suicide, that people who are unemployed have a higher rate of suicide. And we also know that veterans who return have a higher unemployment rate. So, you know, I echo the other panelists who talk about that. I did want to mention, though, also, that we don't know what the Reserve and National Guard suicide rate is, for many other reasons that Jan was talking about with the veterans.

RAMCHANDThe tracking, the processes to track suicides among non-activated Reserve and Guard are just not as fine-tuned as they are for the active duty population or for those who are already accessing care in the VA.

RITCHIEThough they are a lot better than they used to be.

RAMCHANDThat's right.

RITCHIEFive years ago, we had very little information. I really commend the effort to the senior leadership in the Army, the Department of Defense. Both developed task forces and also to try to get the numbers about the Reserve and the Guard. So you're absolutely right, it's not as good as it should be, but it's whole lot better than five, six years ago.

REHMBarbara van Dahlen, are there risk signs or common warning signs that community members, family members should be aware of?

DAHLENAbsolutely. And the VA and DOD are doing more and more, and organizations like ours, to get the word out to family members because it's often family members who see their loved ones struggling. In the unit, obviously, it's important, as Cam was saying, that the commanders and the leaders of those units recognize the signs, such as withdrawal or depressive indicators, frequent sort of discussions of, you know, suicide.

DAHLENPeople will make reference, too, you know, and often in a somewhat joking or sort of black humor way or withdrawing from their activities, withdrawing from friends. Substance abuse plays a huge role. We see that. That's often one of the pieces of the puzzle when you look back. So family problems, again, as a indication that the person is in need of increased support, giving their objects away, talking about, you know, if I'm not here next year, here's what I'd like you to do.

REHMSo what should a family member do if you begin to recognize those kinds of signs?

DAHLENWell, one of the things we get contacted often by family members that are saying, I'm afraid, I'm concerned, what should I do? We encourage them to get in touch with a mental health professional immediately, either through the VA's hotline, DOD if it's an active duty member. There's lots of channels there at their base, their installation, through given hours, so that they can, with a mental health professional, make some decisions immediately. If there's imminent danger, then, obviously, they call the police. They call 911 immediately to get some assistance.

REHMRajeev.

RAMCHANDYeah, I think that that's -- when we look at the evidence about how suicide can best be prevented, some of our strongest evidence is with evidence-based mental health care. Unfortunately, for the active duty population, there are still significant barriers to accessing that care. There's concern about negative career repercussions. So this is a huge issue, I think.

REHMWhat happens there, Elspeth, when someone on active military duty goes to a senior officer or a chaplain, or requests time with a psychiatrist or a psychologist? Isn't there a fear of loss of status?

RITCHIEThere absolutely is a fear, and there are two different discussions on this. One is how we need to eliminate stigma. And, personally, I don't think we're ever going to eliminate stigma. I think we can reduce it, and I think we can also make easy access care through either the chaplains or primary care. But there definitely is a fear, and, unfortunately, there are still policies in the Department of Defense which do penalize those who go to get treatment.

REHMGive me an example.

RITCHIEWell, for example, if you're started on a psychiatric medication, you're not supposed to deploy until you've been stable for at least three months. Well, nobody wants to stay behind while their unit goes over. Remember, it's an all-volunteer Army. People who are in after 10 years of war, they know they're going to deploy. By and large, they want to deploy. So there's apparently a black market for Prozac out there of people who want to get it on the quiet because they don't want to have to go through the military medical system.

REHMNow, Jan Kemp, give me an idea of what happens at the other end of that hotline when a veteran calls. What happens?

KEMPThe VA opened up the Veteran's Crisis Line in 2007. And since then, over half a million have called the hotline, seeking help. When they called, the phone is answered by a mental health professional who works for the VA, who does a brief kind of assessment of someone's safety status and how they're feeling and why they're calling. And then it helps them make some determinations about whether they need help right then. If they do, we get emergency services in their local community to go and get them and help them and get them to services.

KEMPOr we can make immediate referrals to the VA for the same-day service or next-day service. They will get a callback from a suicide prevention coordinator who works at the local facility and connect with them. Or if they're not interested in going to the VA or don't want to, we make referrals to organizations like Barbara, such as Give an Hour or other local organizations that we're familiar with.

REHMAnd how many professionals do you have answering those phones? Can you give us an idea of, say, how many callers you get in a week?

KEMPWe get over, actually, sometimes close to 1,000 calls a day. So it's a busy place. It's open 24/7. We have anywhere between 25 and 30 lines open, depending on what time of day it is. We've also learned that there are huge groups of veterans who would prefer to communicate with us over the computer, that this newer generation is much more apt to chat with us or text us, so we've opened up other lines of communication. We have a chat -- one-to-one chat service that's open 24 hours a day, seven days a week, and that's a very busy, busy place.

REHMElspeth.

RITCHIEAnother population that's important to teach and to talk about is actually the police and fire and emergency medical services because they're often the ones that respond to the family member or to somebody who's concerned about a vet. So in Washington, D.C., like many places, we now have a course where we treat -- teach -- excuse me -- teach metropolitan police officers about how to respond to veterans.

RITCHIEWe teach them about post-traumatic stress disorder and how to avoid what we call suicide by cop, the scary situation where a veteran puts himself in a position to be shot by police. And this crisis intervention training is spreading across the country. So if there's any police out there listening to this program, or, again, fire and emergency medical personnel, I'd encourage you to take advantage of some of these trainings.

REHMBarbara.

DAHLENAbsolutely. We have seen that throughout communities across the country where there is this disconnect. The first responders often don't recognize the signs and symptoms. Part of the Community Blueprint Network initiative that I was talking about includes a component in the behavioral health arena to train civilian first responders. Often, interestingly, first responders come from the military themselves, many policemen, many firemen.

DAHLENAnd so, in a way, it's a very willing audience if we get to them, if we work with them. But it is about connecting the dots in communities for all the people who can touch these veterans.

REHMBarbara Van Dahlen, she is a clinical psychologist, president of Give an Hour. And you're listening to "The Diane Rehm Show." We're going to open the phones now, 800-433-8850. We also have some emails here. We'll get to as many of your calls as possible. First to James in Jackson, Mich. Good morning to you.

JAMESGood morning, Diane. First, I really want to thank both you and your guests for your efforts to increase awareness in our community of our need to increase our support for those that have been supporting us, not just increase the levels of support, but increase our thinking about the scope of the different ways we can support them.

REHMIndeed. Thank you.

JAMESAnd I very much want to make sure that what I'm saying is not misinterpreted as not appreciating what's being done. I've heard -- this topic has been growing in the public awareness over the past few years. And yet I have not heard anything publicly addressed, although my associates, you know, from back in the day, the military, we talk about it, and even active personnel talk about this.

JAMESAnd that's this. The increased public plausibility from this raised awareness of the plausibility of active duty soldiers that are disturbed by what they've experienced, what they've been ordered to do, what they've witnessed, resolving -- resulting in dealing with this through by committing suicide makes silencing a disturbed soldier's concern through an orchestrated suicide an increasably (sic) -- an increasingly viable solution.

JAMESAnd it calls for an increased skepticism in all of our minds that want to support our soldiers when a finding that -- especially an active enlisted soldier's death who's been expressing and displaying being disturbed over something they directly experienced -- when that death is explained by suicide, there really needs to be a increased level of skepticism as to the reality of that suicide or...

REHMOkay. Wait just a second. Let me ask you what you mean by orchestrated suicide.

JAMESWell, in Vietnam, it was called friendly fire. You know, sometimes the quickest solution to prevent accountability and to prevent exposure is to just silence someone. So, I mean, I guess, to be blunt, somebody is killed, and they are no longer a problem. That person is dead because they were upset, and he killed himself. And what -- the issues they were raising, that was a...

REHMAll right. Okay. Let's take a look at this. Elspeth.

RITCHIEThe Army and the other services look at suicides very, very closely. Every unexplained death, which includes accident, homicide and suicide, is examined usually by the armed forces medical examiner's office. And I have looked at hundreds and hundreds of suicides, and I have not seen evidence of that. What I have seen -- and we see it quite often -- is that soldiers who have been exposed to combat become basically fatalistic. They become desensitized to violence, and sometimes they become rather indifferent. But I have not seen what the caller is talking about.

REHMWell, but let's face it. There have been numerous cover-ups of friendly fire killings, and the Department of Defense has come out with admissions way after the fact of friendly fire killings. So, you know, that's what James is talking about, linking that with, perhaps, the idea of someone who might have complained and might have thought that the stress he or she was going through was far too much to take on. We've got to take a short break here. And when we come back, more of your calls, your email. I look forward to hearing from you.

REHMAnd we're back, talking about suicide among members and former members of the military. A listener asks, "If a soldier commits suicide, does his family get his VA benefits?" Jan Kemp.

KEMPI'd -- I'm not 100 percent sure of that answer, but they're eligible for VA benefits just as they would be regardless of the suicide. So if they were eligible for benefits for -- ordinarily, the suicide doesn't make a difference.

REHMShe goes on to say, "I am currently appealing a VA decision. They denied me and my two children any benefits. My late husband was suffering from PTSD, put on meds while on his second tour in Iraq. Six months after he came home, he wrecked his motorcycle and died instantly. He was found to have a high blood alcohol level. So VA ruled it willful misconduct, not in the line of duty. He was a good soldier for nine years, was planning on retiring from the Army. I feel the Army failed him." Elspeth.

RITCHIEWell, first of all, my deepest sympathies go out to that lady.

REHMIndeed.

RITCHIEThat is a tragic situation. When I was on the Army -- in the Army, I was involved in the question about appeals. And what I would encourage her to do -- it sounds like she started an appeal -- to continue that appeal because these cases are looked at very carefully. And in my personal opinion, not speaking for the Army, I think it's critically important to get the benefits to the families of those who died, whether by accident, homicide, combat or suicide.

REHMWhere can she turn to get the kind of legal help she may need in her battle against the VA?

DAHLENWell, there are some organizations now that are providing pro bono legal assistance. A good place to check might be the National Veterans Legal Services Program. They're based here in D.C. And if they don't have attorneys that could help with that specific case, although they probably do, they could direct her.

REHMAll right. A caller in Winchester, Va. Good morning, Deb.

DEBYes, Diane. I'm calling because I feel like the suicide problem in the military extends beyond the soldiers, to the families of the soldiers, specifically in our family. My husband's son was killed in Afghanistan a number of years ago. And this morning, we just came back from a counseling session through the VA. And I can't tell you how many times I have had concerns for my husband's safety. And I think that the problem right now is there's a ripple in a pond. And when a soldier is either wounded or killed, it not only affects the soldier but all of those in his circle who love him.

REHMDeb, I'm so sorry for your loss. And I can certainly understand her statement about the ripple effect. Barbara.

DAHLENAbsolutely. And I'm so glad that she's getting that counseling help, so they have a place to talk through. And we're hearing this over and over. Some family organizations, Blue Star Families and National Military Family Association, are taking a very serious look. Their concern is for spouses as well, that there are cases that are not tracked in the same way that our service members are tracked. So she's absolutely right.

DAHLENIt's children, too. As a child psychologist, we're very concerned about the impact on -- especially teenage children who are under stress because of the family's multiple deployment. And if there is a suicide in a family or a death in a family, it automatically increases that family's risk of all kinds of mental health reactions. And most families will heal, which is why we have to touch them, wrap ourselves around them. But if we don't reach them, and they're alone in this, that's when things can really turn desperate.

REHMElspeth.

RITCHIEI'd like to pick up on one theme here, which is how devastating a suicide is for those family members. And sometimes, somebody who's suicidal thinks, oh, my family will just be better off without me. That's so wrong, so not true. Suicides reverberate across generations. They affect many, many people. So if anybody out there is thinking about suicide, I just encourage them all the different ways to get help. Military OneSource is another one that we just mentioned. Don't do that for your family -- to your family.

REHMAll right.

RITCHIEGet help.

REHMTo Birmingham, Ala. Good morning, Mike. Mike, are you there? All right. Let's go to Jerry in Baltimore, Md.

JERRYWell, if we focus on the young person in today's society, youth is a time of ambition, desire to get ahead. So jobs are hard to get in the civilian sector, so they enlist in the service. And I was just wondering if you can factor in the economic situation and how it affects the sense of loss and disappointment that would lead to suicide.

REHMJerry, are you a member or a former member of the military?

JERRYNo, ma'am. The closest I got to the military was I was in the Maryland State Guard many years ago.

REHMI see. I see. Rajeev.

RAMCHANDThere is a correlation between economic factors and suicide. It's still a big debate in -- out there in the literature. So, as I said before, unemployment increases the risk for suicide. But there's a notion that during periods of high unemployment, that risk is actually attenuated. So it's less because being unemployed isn't as stigmatized when many of your friends are at stake. So the research is still ongoing into this area as to how economic factors really kind of play in to affect suicide rates.

REHMAll right. To Fort Lewis, Wash. Good morning, Rob.

ROBGood morning, Diane. Thanks for having me.

REHMSurely.

ROBI'm an active duty Army staff sergeant. I've been in the Army for about nine years. I have two year-long deployments, and I've seen this issue pretty close. Now, from my perspective, there is a serious issue in the Army culture here, specifically the upper echelons. There's a lot of hubris and a lot of arrogance with regards to their decision-making. Now, the Army attempts to address suicide through training, and it's not that simple. For example, my unit deployed in '09 to 2010.

ROBThen, after we got back from Iraq, within a month, they announced our next deployment to Afghanistan, which is within a month right after getting back. Now, the trainings for these are breakneck speed. Every month, there's some kind of three-week FTX, which is a field training exercise where you're away from your family. And the Army have mission first, and they really mean that. They don't really -- from our perspective as soldiers, we do not see the Army leaders as caring about how our families are dealt with during this time.

REHMElspeth.

RITCHIEI think Fort Lewis has really gone above and beyond the call of duty. They've been deployed over and over, as have soldiers from a number of other units. And they'll transfer from Fort Campbell to Fort Lewis, so it's sort of out of the frying pan and into the fire. So I think the sergeant is absolutely right about the high up-tempo, which I referred to earlier.

RITCHIEHaving spent a lot of time in the halls of the Pentagon, I think the higher echelons do care and do want to do everything they can. But there's kind of a sense of we've had two wars to fight, and you've got a finite number of soldiers, other service members to fight the war with. So I believe that the senior Army leadership and DOD leadership is very conscious of it, but they're really between a rock and a hard place.

ROBOkay. Thank you.

REHMThanks for calling. Let's go to Orrville, Ohio. Good morning, Sharon.

SHARONHi. Good morning.

REHMGo right ahead.

SHARONI just -- Hi. I was going to say, about 30 years ago, my brother committed suicide in the military, in the Army. And he also -- he came from, basically, a very dysfunctional military family. Because I was a military brat, and, well, we traveled all over, but my father actually had some psychological issues. And he was in a couple of the wars, you know, Vietnam and Korea. And my question is, does the military screen people, or can they screen people before they allow them to enlist to find out, you know, does this person, you know, come from a dysfunctional background?

SHARONWould they have a good support, you know, base? You know, I mean, it makes sense that they would be more likely to commit suicide or have problems.

REHMRajeev.

RAMCHANDThere is screening for mental disorders, typically severe mental illness. One problem with suicide is -- one risk factor we have is depression, for example, and as Elspeth was talking about earlier, precipitating events like relationship breakup and whatnot. But these are very common events, and, actually, they're not very predictive of suicide. So it's estimated that 3 percent of those with depression will go on to die by suicide. So this is kind of a current Institute of Medicine estimate for that risk. So if you screen people from depression, the majority of those are not at risk for dying by suicide.

RAMCHANDSo it's not clear then if you're -- given our manpower issues and our recruiting issues whether -- what we would do with that information if they did screen positive. And more than that, people with depression who are properly treated can function very well.

REHMBarbara.

DAHLENAnd this caller raises a very critical issue to think about and talk about and work on in terms of intervention. This family -- her family that she's talking about, 30 years ago, there wasn't a whole lot of attention to taking care of these folks...

REHMTrue.

DAHLEN...in or outside of the military. What we do know, and what these points about risk factors -- they're cumulative. They sort of build on each other, so that the more we get in from a number of different points -- primary care physicians, pediatricians, faith-based opportunities, employers -- the more likelihood that we will have families that are properly supported so it does not elevate to suicide. Depression will be treated and addressed, and the family will heal.

REHMSharon, thanks for calling. So sorry about your loss. To Paul in Raleigh, N.C. Good morning you're on the air.

PAULGood morning, Diane.

REHMHi.

PAULI'm glad that you all brought this subject up today. I spent 15 years in the Marine Corps. And after my career in the Marine Corps, I got my master's degree in psychology, and I'm working on my Ph.D. towards clinical psychology.

REHMGood for you.

PAULThank you. My dissertation is actually on this subject. One of your panelists had made mention that the stigma -- there's -- we seem to have a problem with the stigma. And one of the things that I found in the Marine Corps, and in other military branches, in that your SRB, which is your service record book, tends to get to your next duty station before you do. As soon as you start seeing counseling, taking some type of medication, everything, it goes into your medical record book and your service record book.

PAULThat gets there before you, so that stigma about who you are gets to your next command before you ever get there. My dissertation wants to cover -- of I want to cover my dissertation to require everybody in the military to, at some point, on a monthly basis, annual basis, quarterly basis, some way to take counseling, to seek out, even if it's just a sit and talk. That way there's no stigma. If everybody has to seek counseling, then you can't hold it against one person.

PAULSo you have a good majority of the military that maybe don't need the counseling, and that's fine. So they get to sit down for 30 minutes and talk to a counselor. It's no big deal. But individuals that actually do need the counseling will get the help they need.

REHMInteresting thoughts. And you're listening to "The Diane Rehm Show." Elspeth.

RITCHIEThe Army has actually tried things like that, as have the other services. For example, at Fort Lewis, where the other caller was from, they had a program that everybody who returned received counseling. It's a challenge because a lot of soldiers don't want it. And then you have the question of, if you're short on counselors already, are you really making the best use of those counselors? So it's a debate with -- that the Army and other services have been having. So far, doing that has not driven the suicide rate down at Fort Lewis. It's still up there.

RITCHIEBut, you know, the Army and the Department of Defense have tried all sorts of things. One of the points I'd like to make is that it's going to be larger than just the Army, the Department of Defense or the VA. Half the soldiers who get out and other service members don't go to the VA. So I think it's important for the community as a whole to really be engaged. There are some great projects out there, as Barbara mentioned. One called Coming Home Project is a retreat, et cetera.

RITCHIEOne of the important things to do is not to assume that veterans are 60-year-old men with ponytails and Harley David (sic) jackets or 21-year-olds with high and tights. Ask everybody if they're a veteran. Ask middle-aged ladies like me. Ask grandparents and -- because, you know, a lot of our soldiers are from all walks of society, and they would appreciate being asked if they're a veteran. And then, again, thanking them for their service is great, but doing something concrete, like offering them a job, is really, really, great.

REHMRajeev.

RAMCHANDAnd just to follow up with what Elspeth was saying, employers need to know that, you know, suicide is very rare, still, on the -- in the military population. I don't want to minimize the attention focused on it, but it is rare. We know 20 percent of service members who previously deployed have some diagnosable mental condition, but may be functioning. But that also means that the majority don't have that.

RAMCHANDSo employers need to -- the stigma goes the other way. We need to make sure that people are aware that, you know, a lot of these veterans who are coming back have really good skills to get employed.

REHMSo are you saying that potential employers may look unfavorably at hiring a veteran because of these concerns?

RAMCHANDI think that that's one concern that we've heard about, and I think that's something that we're worried about.

REHMYou know, there's one other thing I want to ask you about. One recommendation in the report is for doctors to notify unit leaders if they think the soldier is a risk to him or herself. Doesn't that kind of breach that doctor-patient relationship?

RAMCHANDThe doctor-patient relationship, especially with the military mental health counselor, isn't -- confidentiality isn't guaranteed in the military.

REHMIt's not protected.

RAMCHANDIt's not.

REHMReally?

RAMCHANDSo it doesn't breach that. But it -- that lack of confidentiality, we think, is one reason that service members -- like, I think it was Paul who was talking about it -- are so reluctant to seek mental health care. So that recommendation is something that I think needs a little bit more -- a little bit of thought.

RITCHIELet me jump in there, having been an Army psychiatrist for so long. In general, we do preserve confidentiality as much as we're able to. If the service member is a danger to self or others, we're going to, usually, have to notify command and hospitalize that patient. That's actually pretty similar to the civilian world, where, if the patient is dangerous, you need to notify somebody.

REHMWell, let's hope that this program has provided people with information they can use, whether it's a member of the family, whether it's a veteran feeling that way. I thought your comment about think about the impact on your family is so important. Dr. Elspeth Cameron Ritchie, Jan Kemp, Rajeev Ramchand, Barbara Van Dahlen. We'll have your website on the -- on our website. And you'd like to give a number, very quickly.

DAHLEN1-800-273-8255.

REHMThanks for being here.