Photo: Freelance Photo: Courtesy US Army Photo: Courtesy Photo Photo: Courtesy US Army Photo: BOB OWEN, STAFF / SAN ANTONIO EXPRESS-NEWS Photo: BOB OWEN, Rowen@express-news.net / SAN ANTONIO EXPRESS-NEWS Photo: BOB OWEN, Rowen@express-news.net / SAN ANTONIO EXPRESS-NEWS Photo: Courtesy US Army Photo: Courtesy Photo: Courtesy US Army Photo: Courtesy Photo Photo: COURTESY CINDY WALTON

The mounting toll of military suicides since 2003 — an intractable problem highlighted again Friday with a murder-suicide at Joint Base San Antonio-Lackland — has surpassed the number of troops killed in Iraq.

The latest Pentagon statistics on suicides in all service branches, combined with previously-released data compiled by the San Antonio Express-News, brought the total to 4,839 for the years 2003 through 2015. In the same period, 4,496 American were lost serving in Iraq.

The shooter at Lackland’s Medina Annex, identified as Technical Sgt. Steven D. Bellino, a 342nd Training Squadron student, killed the unit’s commander, Lt. Col. William “Bill” Schroeder, after a brief struggle that allowed a senior non-commissioned officer to escape, according to one account. Bellino was being escorted to a disciplinary hearing early Friday and was armed with two Glock pistols, sources said. The Air Force has not described a motive.

Years of research have yielded a good understanding of suicide risk factors, the Defense Suicide Prevention Office and other experts say.

But the numbers remain stubbornly high — defying myriad programs, a $50 million research effort called the Army Study to Assess Risk and Resilience in Servicemembers, or STARRs, and creation of a Pentagon office in 2012 to deal with the issue.

Last year’s toll of 475 suicides is the highest since 2012. The Army, Air Force and Marine Corps saw increases in self-inflicted deaths in 2015, while the Navy reported a drop-off.

"I think we're making progress, but I think it's slow," said Alan Peterson, professor of medicine and director of the largest military-related PTSD research consortium, based at the UT Health Science Center San Antonio. “I think we have a lot of ideas about additional ways to intervene, and I think we’re now at the point where we need to start implementing some of these ideas.”

The problem often has been associated with the Army, which carried the heaviest burden of the Iraq war and saw a doubling in the number of self-inflicted deaths from 2004 to 2008. The Marines and Air Force also experienced modest increases over that period. Suicides in the Navy remained relatively stable until spiking in 2012 and 2014.

The Army created a partnership with the National Institute of Mental Health to find researchers who could design and implement a large study. The resulting STARRs initiative brought investigators from Harvard Medical School, the Uniformed Services University of the Health Sciences, University of Michigan, and University of California.

The Pentagon suicide office said most prevention research in recent years has focused on identifying and predicting risk factors. The problem is using what is known in a way that works.

The Air Force’s suicide prevention program manager, Lt. Col. David Linkh, said suicide rates have gone up among all demographics and age groups, with young enlistees at the greatest risk.

“There’s always some level of speculation,” he said. “It’s an imperfect science and we don’t have a clear answer as to why rates are rising.”

Some clues, many questions

Army Capt. Jonathan Muniz was a soldier’s soldier, an enlistee who joined in 1993 and became an officer with a chest full of ribbons.

A physician’s assistant, he survived a grueling competition to win the Expert Field Medical Badge, which tests a soldier’s combat and medical skills over a period of days. Typically, only one in every six soldiers passes. The Army said he spent 23 months in Iraq and Afghanistan over the years, earning the coveted Combat Medical Badge.

He was 42 when he shot himself in Killeen on the evening of Jan. 8, 2015, leaving behind a wife and son who live in San Antonio.

His wife declined to be interviewed. An obituary in the Express-News described him as a man of accomplishment — commissioned as a first lieutenant 11 years after he enlisted and earning a bachelor’s degree from the University of Nebraska Medical Center.

“Jonathan loved his family far and wide, but especially his wife and son. He was passionate about helping others,” his obituary stated. “He was an avid reader, enjoyed watching movies, and absolutely loved music.”

Muniz was part of another bad year for the Army in which 274 active-duty, reserve and National Guard soldiers died by their own hand. It wasn’t the highest total since 2003 but a significant increase from 2014.

The risk of suicide follows people after they leave the military. A study of 1.3 million veterans who had been on active duty during the Iraq and Afghanistan wars, 317,581 of whom deployed, found higher suicide rates than the U.S. population.

That’s a dramatic turnaround from before the two wars, when suicide rates among active-duty and former military personnel were 20 to 30 percent lower than for all Americans.

Study predicts suicides

A study Peterson helped craft showed that one form of therapy reduced suicide attempts by 60 percent among 150 active-duty soldiers at high risk of killing themselves — an event he calls a major milestone in clinical care.

The Pentagon is taking steps to spread lessons from the trial and some think the program should be expanded immediately but others have called for more study, he said.

Another study released just 10 days ago also shows promise. It suggests health-care providers could intervene before troops kill themselves by monitoring their online comments on social media accounts to identify those at risk.

Researchers obtained records for 1,400 service members, half of whom had died by suicide in 2010 or 2011 and half from other causes.

Combing through the posts of 315 people who had publicly available social media data, they found patterns in comments when categorized into five major risk variables — stressful life events dubbed “triggers,” negative beliefs and thoughts, negative emotions or feelings; physical complaints and concerns, and behaviors that undermined the victims’ ability to cope. Some three dozen indicators of risk were among the variables.

A trigger, for example, included relationship problems, significant loss, and legal or financial woes. Those at long-term risk revealed “triggering events” on social media and also expressed negative emotions and beliefs — a pattern that strengthened as the victim got closer to his or her self-inflicted death.

“Six months before someone dies by suicide they say, ‘I had an argument with my significant other’ and then a couple of Facebook posts later they’ll say, ‘Man, it really sucks. I feel terrible,’” said Craig Bryan, assistant professor of clinical psychology at the University of Utah and a former faculty member at the UT Health Science Center in San Antonio, who led the study.

“As they get closer to dying, a month away, they say, ‘I had yet another argument with my spouse,’ and then right away after that they say, ‘It’s unbelievable, she’s so unfair, I’m a total loser and I can’t take this anymore, I have to do something about this, this is the worst day of my life,’” he added. “So it’s like all the sudden, it’s not just saying, ‘I feel bad,’ it’s like ‘I feel bad and it’s horrible and I can’t take this and I’m a horrible person.’”

The study described a growing consensus that insomnia, agitation and social withdrawal are warning signs of an imminent suicide.

More research on social media, with larger sample sizes, is needed, the authors said. But while conceding that privacy concerns are a hurdle in such research, they called for asking troops to be part it, even if it influences their social media behavior. They urged the Pentagon to integrate publicly available social media data into its suicide-prevention programs, saying it could save lives.

“We’re very excited with the results, to say the least. But we’re trying to be cautious about not over-interpreting them,” Bryan said. “This is that first step where we think this is a new way of approaching suicide prevention using newer data analytic techniques that are not very commonly used amongst researchers.”

Not related to combat

It was thought that war-zone tours played a role in suicides, but that isn’t so clear anymore. Army demographic summaries, which had been released to the media until the past few years, showed that roughly two in every three soldiers committing suicide had served one or more deployments. But the study, co-authored by VA health scientist specialist Tim Bullman and released in November, reached an unexpected conclusion.

“We included both deployed and non-deployed veterans, and what we found out is that there is no deployment effect, that service in Iraq and Afghanistan is not associated with this increased risk of suicide,” Bullman added. “It looks instead that just military service in general is associated with increased risk of suicide.”

Bullman’s study in the Annals of Epidemiology noted that a recent analysis tracked an elevated suicide risk among currently and previously deployed soldiers. But other studies didn’t make the same connection.

Suicide rates for Iraq and Afghanistan veterans receiving care at VA facilities, moreover, were not that different from patients of other wars when adjusted for their psychiatric conditions and other demographic variables, such as whether they were male or female and where they lived. Still, veterans returning from the desert are more at risk of suicide if they have a major depressive disorder and PTSD.

A study of 212,664 former active-duty troops who served in Iraq and Afghanistan also showed their suicide risk in 2005 was a third higher than the general population. Researchers discovered that the suicide rate was highest for them during the first three years back in the United States.

But war veterans actually had a slightly lower suicide rate than military personnel who had never deployed.

If that strikes some familiar with the long war’s impact on veterans as counterintuitive, it also underscores the complexity of today’s all-volunteer force. Researchers agree the latest generation of veterans is different from those of the past. A larger percentage of the military has gone to war — and not just for one tour. Many have returned for two, three and four tours.

Large numbers of National Guard and Reserve troops have deployed in both Iraq and Afghanistan, again for multiple tours. More women have been in the fight. Many have lost friends and seen others injured. Many wrestle with PTSD.

But that isn’t the only complication. With most of the force finally home and safe, soldiers in particular are facing the possibility of losing their jobs. That is especially true for those struggling with health and weight problems, or even passing a PT test.

Given the many variables, Peterson, the Strong Star Consortium director in San Antonio, said it’s hard for anyone to know who might fall victim to suicide, unless they’re already known as high-risk cases.

“When you’re looking at the population as a whole, it is a real significant challenge to figure out which out of 10,000 people is going to be the person who might commit suicide in a one-year time frame,” he said. “I don’t know if it is too complicated, but it is very complicated, so there’s not an easy solution.”

sigc@express-news.net