Chapter 1: Understanding the Silent Message of Suicide

Suicides often communicate a powerful message to those left behind: "This individual found life unbearable and lost hope for change. Now, they've found peace." Many are reluctant to grasp this message, often shaming the deceased or deeming the act sinful. However, a few are able to hear and reflect on the implications.

For some soldiers, particularly those already grappling with immense stress, this message can become an irresistible call. It intertwines with the impulsivity common among youth and the accessibility of weapons in combat zones, leading to increased risks.

In 2008, I served as the sole psychiatrist at a U.S. Army base located near Mosul, Iraq, where approximately four thousand soldiers from various units lived. I was part of an Army Combat Stress Control Unit (the military term for a mental health team) that operated throughout northern Iraq. Our local team included myself, two social workers, and three enlisted technicians.

Our primary objective was to keep soldiers functional and engaged with their tasks. Evacuating someone from Iraq was always a last resort and challenging to execute. Such a decision had to be made by a doctor—nurses, psychologists, or social workers could not make that call. It also required the approval of the soldier's commanding officer and the provision of at least one other soldier to accompany the evacuated individual to a military hospital in Germany. There were no psychiatric facilities available for U.S. personnel in Iraq or Kuwait.

The process often left me feeling frustrated. I had to persuade commanding officers that a mental health issue, unlike a visible injury, necessitated the removal of a soldier. Then, I needed to convince medical and logistical staff that a soldier with mental health challenges could be safely evacuated on a standard flight. In our sector, Army medical leadership was hesitant to use medical helicopters for mental health evacuations, believing the situation didn't warrant the resources.

I had been in Iraq for two months before my patient took his own life. During that time, I coordinated two medical evacuations for severe suicidal thoughts that did not respond to our team's treatment.

In the week following Darren's suicide, I arranged for three soldiers to be evacuated. All were my patients, and it felt as though we were conceding defeat in our work together. They had understood the message behind his suicide and found it compelling. Fortunately, the company commanders recognized the heightened risk of mental health crises following Darren's death and did not question my recommendations.

One of the soldiers worked in the same unit as Darren. He suffered from PTSD due to previous deployments and believed returning to Iraq would alleviate his symptoms. Unfortunately, many soldiers with PTSD mistakenly thought that returning to combat would heal their disconnection from life back home. Instead, this soldier found that being back in a war zone intensified his feelings of despair. He approached me a few days after the suicide, visibly agitated, expressing that he understood why Darren had chosen to end his life. The clarity of Darren's choice frightened him, leading him to feel cornered. I worried that if I didn't facilitate his evacuation, he might harm himself or others. His company commander shared my concerns and agreed to send him home.

The second soldier was a medic at the base's small clinic. I had been treating her for about a month when she confided that she had seen Darren's face shortly before his death and thought he appeared peaceful. She envied him for having escaped his troubles, and the image of his perceived tranquility haunted her. Despite my efforts to support her, we both felt overwhelmed by her growing hopelessness.

The third soldier had never met Darren but had heard about his suicide. She had been diagnosed with borderline personality disorder years earlier, a diagnosis that typically disqualified soldiers from service. However, the demands of the Iraq war led to a decline in recruitment and retention rates. She struggled to form friendships in Iraq, and Darren's suicide inspired her to consider death as a less painful alternative to living. She contemplated walking into a minefield at the edge of our base. Her sincerity shocked me, and I promptly informed her commanding officer that she was among those most likely to attempt suicide. He concurred with my assessment.

The evacuation process for all three soldiers took several days of phone calls and paperwork. I believed that military leaders intentionally made the process cumbersome to deter frequent evacuations. There was a pervasive fear among non-mental health leaders that soldiers would seek to leave if the process was perceived as too easy. This attitude reflected their biases against mental illness and their frustration with soldiers who either threatened or completed suicide.

Days after Darren's death, the base chaplain proposed holding a memorial service. However, the chain of command hesitated. Typically, the death of a soldier in Iraq warranted a public memorial with gun salutes. Darren's superiors were reluctant to acknowledge the suicide, fearing its implications and wanting to suppress its message.

Many soldiers in his unit expressed their discontent with this decision. Eventually, two weeks posthumously, a memorial was permitted, but it was a small, private affair, limited to members of his company. Our Combat Stress Control Team, including myself, was not invited.

Our supervisor worked diligently to ensure that two of our technicians could attend the memorial for support, but I was still excluded. To me, this exclusion felt like an implicit accusation of guilt. My presence might remind others of Darren's suicide, suggesting that they too might contemplate rejecting their duties and existence.

I longed for the chance to grieve Darren with others, to collectively say farewell. The denial of this opportunity frustrated me deeply, and a part of me feared they might be right—it was my fault. If so, I should have hidden away in shame to prevent the perceived contagion of suicide.

As a Navy psychiatrist embedded with an Army unit, I had learned that Army leaders often touted their "open door policy," allowing soldiers to voice their concerns. Yet, I witnessed the discomfort this policy caused for many leaders, who found it challenging to accommodate such visits.

I asked my supervisor to reach out to the brigade commander's office again, expressing my desire to utilize their open door policy to discuss the situation. I requested an appointment.

Within a day, I received approval to attend Darren's memorial service. Months later, during a meeting about another topic, I respectfully inquired why I had initially been excluded from attending his funeral. The brigade commander feigned ignorance, suggesting that perhaps one of his aides had made the decision. Ultimately, I would never know the true reason.

The memorial took place in a makeshift chapel with seating for fifty, yet it was standing room only, with over one hundred soldiers from his company present. The chaplain played recorded music and shared memories of Darren, who was remembered as a comedian and a beloved member of his unit. Tears streamed down my face as I mourned alongside them.

In those moments, I recalled Darren sitting across from me in our clinic a few hours before his suicide. We had made eye contact, but he hadn't asked to speak with me. Later, I learned he had come for the anger management class I had suggested, though he ultimately skipped it. He returned to his unit and took his life just as they prepared for a mission. I can only wonder if he had already made the decision or if something triggered an impulsive action. All we had left were his last words on a note: "Sorry Sarge, I just can't see the light at the end of the tunnel no more."

I still possess the program from his memorial service. I sometimes glance at it, but it remains too painful to confront.

As I fought to attend his memorial and to evacuate severely ill soldiers, I continued to treat others, helping them process their feelings about Darren's suicide and their own mental health risks. In the ensuing weeks, our team also prepared for three inspections, prompted by the suicide. The sheer number of inspections created an atmosphere that suggested something terrible emanated from our clinic. Perhaps the suicide was our fault, and military leaders needed to ensure we weren't perpetuating it. Our commanding officer arrived from a nearby base to provide support and assess our care. The senior Army psychiatrist in Iraq also conducted an inspection, likely wishing to find some lingering trace of suicide in our clinic. The final inspection I vividly recall focused entirely on my care of Darren.

This senior psychiatrist, a reservist, was unknown to me from Navy hospitals in the States. Before his arrival, our commanding officer reassured me that I had nothing to worry about, as others had reviewed my notes and deemed everything appropriate. The review was supposed to consist solely of record examination and interviews. However, he deviated from the intended scope, interviewing other providers in our clinic, as well as Darren's commanding officer and unit friends. My supervisor described him as a bull in a china shop.

His interview with me spanned several hours over the course of a week. He scrutinized my notes and a questionnaire Darren had filled out, probing me line by line about my interpretations: "He checked here that he's married. What did he mean?" At times, he appeared to contest my explanations of my own notes. Ultimately, he concluded that I had provided appropriate care and adhered to the standard procedures.

While this finding was professionally relieving, personally, I still held myself accountable for Darren's death and the fallout that ensued on the base. Fortunately, shortly after the investigation cleared me, my command granted me four days of Rest and Relaxation in Qatar. I coordinated the trip with a fellow Navy psychiatrist stationed in another part of Iraq. It was comforting to share our experiences and struggles. While he hadn't lost any patients, he faced the constant threat of mortars and rockets, with explosions occurring near his quarters. Our time together provided some much-needed respite.

Upon returning from Qatar, I was left alone with my thoughts of Darren. I feared what would come next for my remaining patients. Over the subsequent months, no one pressured or scrutinized me more than I did myself. I grappled with ensuring others felt their lives were manageable. Thankfully, there were no further suicides, but the pressure to prevent them weighed heavily on me. I failed to realize at the time that much of that pressure was unwarranted, as, similar to my colleague facing incoming rockets, the decision to commit suicide largely lay beyond my control.

Years have passed, and I have worked to process the effects of my deployment. Like many in the military, I had suppressed my emotions, but they still influenced me. Upon returning from Iraq, I experienced suicidal thoughts and developed inexplicable medical issues. I dealt with feelings of isolation, irritability, and nightmares. The challenges faced by my PTSD patients mirrored my struggles, including my own battles with stigma.

Research indicates that nearly 60% of service members with mental health concerns do not seek treatment, often due to stigma. Even after returning to Walter Reed, I never considered accessing mental health care for myself, as I didn't want to be perceived as a psychiatrist in need of psychiatric help, despite advocating for my colleagues and subordinates to seek therapy for their daily struggles. This phenomenon likely extends to other professions, such as law enforcement and aviation. The weight of shame remains significant, and as stigma persists, military suicides continue.

Nearly a decade later, upon my retirement from the Navy, a psychologist evaluating me remarked, "You know you have it too, right?" I was reluctant to accept that I had PTSD resulting from my experiences and from hearing the traumatic stories of countless service members over twenty years. Even as someone who fought against stigma within the military, I grappled with it personally. Yet, I eventually embraced the reality of my own PTSD and prioritized self-care. Sharing my experiences has proven therapeutic, dispelling feelings of helplessness and reinforcing the notion that I can effect change. For a long time now, the message of suicide no longer resonates with me. I see light at the end of my tunnel, and I know that with continued effort, I can reach it.

Chapter 2: Reflections on Mental Health in the Military

The first video, "Iraq War Veteran's Suicide Letter Describes Trauma of War, Abandonment by Gov't," delves into the profound emotional struggles faced by veterans and the impact of their experiences on mental health.

The second video, "Iraq War Veterans, 20 Years Later: 'I Don't Know How to Explain the War to Myself' | Op-Docs - YouTube," offers insights from veterans reflecting on their experiences and the lasting effects of war on their mental well-being.