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U.S. Navy Suicide Deep Dive: Missed Opportunities and Recommendations

By Navy Lt. Cmdr. Stephanie M. Long, Ph.D., MSCP, ABPP, MSC
Sept. 14, 2020

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The Navy conducts an annual Multidisciplinary Suicide Case Review, commonly referred to as the Deep Dive, during which a board of experts reviews all suicides from a calendar year. It is organized by the Navy’s Suicide Prevention Program, which is housed in the Office of the Chief of Naval Operations' 21st Century Sailor Office. For each suicide death, files reviewed include the Department of Defense Suicide Event Report record, medical records, personnel files, law enforcement reports, autopsy reports, and toxicology files. The purpose of the Deep Dive is threefold: to understand the unique experiences of sailors who died by suicide, to identify missed intervention opportunities, and to make recommendations for improvements in Navy suicide prevention efforts.

The board is comprised of a variety of individuals, including OPNAV N17 staff, Navy and Marine Corps Public Health Center epidemiologists, suicidologists, mental health providers, Naval Criminal Investigative Service special agents, Fleet and Family Support Center program managers, and command representatives (both officer and enlisted). All of these individuals provide diverse perspectives as suicide case files are reviewed, maximizing our collective ability to identify factors that contributed to sailors' deaths, as well as provide recommendations to prevent such deaths in the future.

Suicide can be incredibly difficult, and often impossible, to predict. Sailors who have seemingly few risk factors for suicide may attempt to take their lives, just as sailors who have multiple risk factors for suicide may never attempt to take their lives. In reviewing the deaths of sailors during the Deep Dive, however, there appears to be frequent missed opportunities to intervene. Most commonly, the pattern we noticed involved sailors disclosing some pertinent, suicide-related information to at least one individual, usually a family member or significant other. That one person, however, may not have the context to understand the importance of the information divulged to them or they may be unsure what to do with the information. Specifically, family members and/or significant others may hesitate to share divulged information with command or with others because of concerns for the sailor's career.

Identifying missed intervention opportunities has led to valuable recommendations to improve policies, programs, processes, and practices. For example, gatekeeper training was developed for certain communities (Ombudsmen, schoolhouse instructors, legal personnel and Transient Personnel Unit staff) who were likely to come into contact with those at risk. The training helps heighten awareness in these communities that the sailors and family members they interact with may be at increased risk for suicide. This training also reinforces recommendations regarding what to do when personnel in these communities are approached by a sailor who shares suicide-related information. Another change recommended by the Deep Dive board was to install collapsible shower rods in barracks to create safer environments for sailors.

With respect to clinical providers, Deep Dives have revealed approximately half of the decedents had any history of behavioral health care, with only approximately one-third of the total decedents having seen behavioral health care in the year prior to their deaths. However, almost all decedents had a visit within the Military Health System 90 days before their death, many of them within 30 days prior to their death. We recommend all clinicians regardless of their specialty, be mindful that anyone can be at risk for suicide, and to conduct universal screening (i.e., with all patients, every time) to further bolster our suicide prevention efforts. Additionally, it is critical that providers directly, compassionately ask patients about their emotional health and well-being while maintaining eye contact. This one small ACT of taking the time to ask this question may make a critical difference in the life of that sailor. Suicide is the second leading cause of death in our sailors and, while this may be one of a litany of questions providers ask their patients, asking this question in an empathic way may lead a sailor to ask for help when they may otherwise not.

The Navy's Suicide Prevention Program is made up of individuals who are passionate about saving lives. Most of us have been touched by suicide in some way and have a strong desire to ease the pain of those who have lost family members, friends, and/or shipmates to suicide. We are all moved to better understand why some sailors have died by suicide so that we may develop better policies and programs to prevent as many sailor suicides as possible. We encourage all sailors, including providers and leaders, to reach out to OPNAV N17 for needed suicide prevention and intervention support and information.

Lt. Cmdr. Long is the U.S. Navy's suicide prevention subject matter expert. She has a master's and doctorate in clinical psychology, as well as a post-doctoral master's in clinical psychopharmacology. She has worked with service members in multiple settings, including in a deployed Joint Task Force environment, an intensive outpatient program, an addiction treatment facility, and on an aircraft carrier. 

Last Updated: May 24, 2024
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