In 2008, the United States Army woke to an alarming discovery: Its soldiers were killing themselves at a startling rate. The suicide rate in the armed forces used to be well below that of civilians in the US population, but by 2008 the suicide rate in the army had surpassed the rate for civilians, even threatening to overtake the rate of combat deaths.
In response, the Pentagon implemented a raft of measures, including the establishment of a suicide prevention task force. There were also suicide prevention programmes in most army posts, and training in emotional resiliency to cope with the stress of deployment and combat. The Pentagon also initiated the Army Study to Assess Risk and Resilience in Service members (or Army Starrs). It was the largest study of suicide risk and resilience ever conducted among military personnel.
The US Army is also trying to change the culture of soldierly machismo that views psychological problems as indicative of personal weakness. "Getting help for emotional problems should be as natural as seeking help for a sprained ankle," said General Peter Chiarelli, the army vice-chief of staff.
Similar problems have occasionally surfaced in Singapore. In July last year, 23-year-old national serviceman, Private Ganesh Pillay Magindren of the 24th Battalion Singapore Artillery, took his own life.
Unimaginable pain
The writer William Styron who suffered from depression, once wrote: "Suicide remains a tragic and dreadful act, but its prevention will continue to be hindered, and the age-old stigma against it will remain, unless we can begin to understand that the vast majority of those who do away with themselves - and of those who attempt to do so - do not do it because of any frailty, and rarely out of impulse, but because they are in the grip of an illness that causes almost unimaginable pain."
Pte Ganesh was diagnosed with schizophrenia and was, in all likelihood, in great pain before that final act. We may never know what made him take this extreme action. Was it some symptom of his illness, or was it - as is generally assumed - precipitated by the punishment that was meted out to him for his various infractions? Or was it a combination of these and other factors?
Schizophrenia is a serious mental illness. It occurs roughly in about 1 per cent of the general population. It has often been said that one in 10 of those affected eventually kill themselves. But this figure is lower than that of those with major depressive disorder, another common mental illness.
Straits Times senior writer Andy Ho, in his article on Sunday, suggested that young men with schizophrenia ought to be exempted from national service.
However, one must not make the erroneous assumption that the diagnosis of schizophrenia is synonymous with an inability to cope with stressful or demanding tasks and situations. The truth is that schizophrenia has varying outcomes. Recent studies have suggested that in some cases, long-term medication might not be necessary.
Nor is the illness so bleakly hopeless. People do get better, if not recover. Consider Professor John Nash, the Princeton University mathematician and Nobel Prize laureate. After a stellar early career, he was stricken with schizophrenia and fell precipitously into a state where he was unable to function.
Prof Nash spent his time wandering aimlessly on the Princeton campus grounds - as so dramatically depicted in the book and movie A Beautiful Mind. It was only after he accepted treatment that he regained his mental health and resumed teaching at the university.
I have among my patients a number of young men with schizophrenia who have successfully completed national service and emerged from it stronger and more confident. But they do need close monitoring. They also need - especially when things get tough - that feeling of safety that comes from knowing that there are people who understand them and their illness, and to whom they can turn to for help.
Through the cracks
Sometimes, however, some do fall through the cracks.
I have had patients who killed themselves - most times seemingly inexplicably. Often, I would offer to see the family as a way of bringing some "closure", although I must admit that I have difficulty in understanding exactly what that means. Selfishly, these meetings are also a means of seeking some absolution for my own guilt.
I remember one such session with the mother of a patient, an intelligent young man with schizophrenia.
He killed himself in his bedroom using a method he learnt from a suicide site on the Internet. The mother - a middle-aged lady whose face was worn with grief - sat with me while I tried to answer her few questions.
But I couldn't quite answer her most pressing question. That unknowable "why" was like a boundless void and we lapsed into silence. Having nothing more to ask, she left. I don't think I gave her a modicum of solace.
As professional caregivers, we so often do not give enough consideration to those family members who have to deal with the loss. Author Julian Barnes described it in his book Flaubert's Parrot. "You come of it as a gull comes out of an oil slick," he wrote, "you are tarred and feathered for life."
Pte Ganesh's father said that the family is "all broken up". Research has shown that suicide-bereaved parents and family members report eddying feelings of shame, anguish and disbelief as they struggle to make sense of the suicide. They also experience a wall of silence: Being stonewalled by others and silencing themselves as they are afraid of being judged - a sense of uneasiness which accentuates their sense of isolation and abandonment.
Demystifying suicide
"Every suicide is as different and as unique as the people themselves," said Gen Chiarelli in testimony in the US Senate. "And the reality is there is no one reason a person decides to commit suicide. That decision reflects a complex combination of factors and events."
While that is true, we cannot afford to mystify suicide as something beyond our comprehension and control.
Following the few cases of sudden death in otherwise fit young servicemen while training, the Singapore Armed Forces has put in place a more vigorous system for the pre-enlistment screening for any potentially risky heart problems. The challenge now might be how to minimise, if not prevent, potential suicides in an inclusive, non-discriminatory and non-stigmatising way.
Thousands of young men are enlisted every year to serve the country. They will be the ones who - should it become necessary - will put themselves in harm's way to defend the rest of us. So we do owe them something.
The writer is the vice-chairman on the medical board (research) at the Institute of Mental Health.
