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HEALTH SCENARIO

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Staff Sergeant P. was a 34-year-old veteran of the United States Army, having served two tours of duty in Operation Enduring Freedom in Afghanistan. During his second tour of duty, his squadron of nine soldiers was attacked with an improvised explosive device, resulting in the deaths of two soldiers and injuries to three others, including Staff Sergeant P. The explosion resulted in a traumatic brain injury (TBI) to Staff Sergeant P., which produced persistent headaches, trouble concentrating, fatigue, sleep disturbance, irritability, depression, and anxiety. He was evaluated by an Army physician and found to be unfit for military service, ultimately resulting in a medical discharge.

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Upon returning from military service, Staff Sergeant P. married his high school girlfriend and was employed as a security guard. He had difficulty adjusting to civilian life and began experiencing recurrent nightmares, emotional detachment, and conflict with his wife and coworkers. He began abusing alcohol and a variety of other substances. Staff Sergeant P. was seen at a Department of Veterans Affairs clinic and diagnosed with posttraumatic stress disorder (PTSD) for which he was prescribed cognitive behavioral therapy.

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Persistent violent outbursts led first to Staff Sergeant P.’s termination from work and then to his separation and eventual divorce from his wife. He became increasingly isolated, with few friends, diminishing financial resources, and few prospects for employment. On the first anniversary of his divorce, he ended his life with a self-inflicted gunshot wound.

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CLINICAL BACKGROUND

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Suicide is the 10th leading cause of death in the United States, accounting for nearly 40,000 fatalities or about 1.5% of all deaths. Globally, suicide is the 16th most common cause of death, with an estimated million lives lost to it each year. The risk of suicide is highly age dependent, rising rapidly in the teen years and continuing to rise through young adulthood, peaking in the 45 to 54-year age group. For persons age 15 to 24 years, suicide trails only unintentional injuries and homicide as a cause of death, and among those age 25 to 34 years, suicide is second only to unintentional injuries as a cause of death.

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Although females are more likely than males to have had suicidal thoughts, completed suicides are four times more likely among males than among females. Non-Hispanic whites have the highest death rate from suicide followed by American Indians/Alaska Natives, with comparatively low rates among blacks, Hispanics, and Asian Americans. Suicide rates declined over the latter years of the 20th century but have increased steadily since the year 2000. The largest increases over time have been seen among adults age 45 to 64 years, with decreases observed among elderly adults.

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Among males, firearms are the most common method of suicide (56%) followed by suffocation or hanging and then poisoning. In contrast, among females, poisoning is the most common method (37%) followed in turn by ...

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