Spec. 4 James Christian “Frosty” Paquette attended Irmo High School and finished at Chapin High School. He overcame a serious head trauma from a car accident in April 1990. He went on to be a Corrections Officer with the S.C. Dept. of Corrections, then earned a two‐year degree from Midlands Technical College and became a licensed electrician. He entered the South Carolina. Army National Guard in 2006 and spent a tour in Afghanistan. Specialist Paquette transferred to the regular Army where he was stationed at Fort Wainwright, Alaska, as a wheeled vehicle mechanic.

Paquette, deeply troubled at having accidently killing a young boy during a firefight in Afghanistan, sought in‐patient psychiatric care three years after his combat tour.  He was by then stationed at Fort Wainwright, Alaska.  He was, as reported by his wife, suicidal by then.  Upon leaving in‐patient treatment he returned to duty and should have been stepped down to the intensive outpatient care program on base where he would have continued therapy and been closely monitored.  However, just three weeks after putting his uniform back on James Paquette was dead.  He was 40 years old.

On April 18, 2019, Webcenter11 News in Fairbanks, Alaska, interviewed Joseph Pecko, the team lead for the Behavioral Health Epidemiological Consultation or BH EPICON team.  That team sent to Fort Wainwright after a surge in Army suicides occurred which compelled Alaska Representative Don Young to petition the Army to take meaningful action.

Pecko offered the EPICON team will review the two confirmed suicides as well as four additional and presumed suicides which the Army is still investigating.  The team will also study the unique aspects of being stationed at Fort Wainwright, to include “the isolation and winters” and how these factors influence suicide.

Specialist James Paquette took his life in July 2011, one of the hottest months of the summer in Fairbanks. According to Air Force behavioral health professionals at Eielson Air Force Base, just 30 minutes down the highway from Fort Wainwright, the most critical seasonal change of the year that brings with it a higher number of suicide attempts and successes, is Spring break‐up, not winter.  The reasons for this are compelling and counter the myth that winter plays a significant factor in both civilian and military suicide.

The EPICON team might also do some checking with the Alaska Department of Health and Social Services. Alaska has suffered one of the highest suicide rates in the nation ever since it was a U.S. territory.  The Ak‐DHSS retains a remarkable data bank of studies and reports, as well as recommendations, regarding all aspects of living and working in Alaska with the specter of suicide in mind.  In its most current report the department offered, in part, “The economic and human cost of suicidal behavior to individuals, families, communities, and society makes suicide a serious public health problem. Alaska had the second highest age‐adjusted suicide rate in the nation in 2016, the most recent year for which national data are currently available. 
Suicide cost Alaska a total of $249,000,000 of combined lifetime medical and work lost cost in 2014, or an average of $1,491,017 per suicide death.”

EPICON Alaska can access the governor’s select committee’s work as well as the comprehensive state plan on suicide detection, intervention, and prevention. If the Army’s behavioral health teams at both Joint Base Elmendorf Richardson and Fort Wainwright were already actively in partnership with the state’s experts, to include sharing information and interacting in each other’s programs and projects to include sharing resources, it is fair to say Representative Young’s demand for tangible action would not have been necessary.  And neither would be the “Let’s reinvent the wheel” approach represented by the Army sending BH EPICON to Fort Wainwright.

The Statewide Suicide Prevention Council http://dhss.alaska.gov/suicideprevention/Pages/default.aspx advises the governor and legislature on issues relating to suicide. In collaboration with communities, faith‐based organizations, and public‐private entities, the Council works to improve the health and wellness of Alaskans by reducing suicide and its effect on individuals and communities.

A comprehensive state plan addressing goals and strategies to prevent suicide developed by the council can be found at: https://www.sprc.org/sites/default/files/Recasting-the-Net-Promoting-Wellness-to-Prevention-Suicide-2018–2022.pdf.

“He [Specialist Brown] felt there was hope for him when he was told he would be processed for separation for his medical condition his health needs would be transferred to the VA. The last week at the hospital he learned this was not going to happen. He would be court martialed, kicked out of the Army, turned over to civilian authorities and not receive any medical benefits. This caused a change in his progress and he became suicidal, informing me of how he would commit suicide, when and where.  He informed me he had transferred all his life insurance over to his mother along with power of attorney but would not talk to her; he refused phone calls from her.” – Pastoral Counselor

Two weeks before his being discharged against the strong recommendations of his behavioral health team at Madigan Army Medical Center’s psychiatric unit (5 North) and the senior most addictionologist at the JBLM Substance Use Disorder Clinical Care (SUDCC) program, Specialist Matthew Brown requested to speak with his chaplain.

Brown had been properly diagnosed as being actively suicidal prior to his transfer from 5 North to a private sector program felt to be better suited in managing his care and treatment.  Along with his suicidal ideation the 21‐year old infantryman was co‐diagnosed with major depressive disorder and pre‐existing PTSD aggravated by military service.  There were strong indications of a possible diagnosis for borderline personality disorder, this concern documented by the soldier’s active duty therapist. According to the Mayo Clinic, hospitalization when borderline personality disorder is suspected is the preferred means to “keep you safe from self‐injury or address suicidal thoughts or behaviors”.

Note: Borderline Personality Disorder (BPD) is a rampant behavioral health challenge in the Armed Services and Coast Guard.  Dr. Holly O’Reily is a clinical psychologist and Lead on Traumatic Stress and Sexual Assault at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.  She describes one aspect of BPD as being “…a pervasive pattern of unstable personal relationships, self‐image, affect and impulsivity. The hallmark feature is a heightened fear of abandonment and recurrent suicidal ideation and self‐harm. Although, this PD is more common in women, men may also be diagnosed with BPD. Individuals with BPD report significant relationship problems and intense emotions. I encourage clinicians to be patient, be fair and consistent and to help them improve their emotion regulation and coping skills.”

Brown’s experienced therapist on 5 North had explained her observations and concerns to me during the transfer process to private sector care.  She was hopeful he could be stabilized and then successfully discharged from service with the category of discharge that would see his medical care/treatment continued in the VA medical system.

For the past 4–5 years now, BPD has been a significant co‐occurring diagnosis in the military, affecting a larger population of female service members than male.  The Air Force, in specific, sees its younger female service members so affected.  Care and treatment for BPD must take place parallel to care and treatment for co‐occurring behavioral health or substance issues, and this is extremely difficult in the current military medicine system for several reasons.

When the chaplain, who had been working with Matt since his admission as a patient, wrote his report he noted the meeting was to specifically address “grief, loss, and suicidal ideation”.  Since his enlistment in 2015, Brown’s marriage had ended, his personal finances were upside down, and he’d lost his six‐month old son.  In addition, the distraught soldier shared his having had a seizure prior to going in‐patient.  He’d gone to a civilian doctor about this event afterward, not wanting the Army to know and possibly discharge him with no means of support.

When they met Brown told the chaplain he’d made up his mind to take his own life and had planned how and where he would do so once returned to Joint Base Lewis McChord.  He’d changed his military life insurance benefit of $400,000 so that it would go to his mother.  Upon advising her of this he refused to take her phone calls.  He was done.

On August 2, 2018, Matthew Brown, using the handgun he’d retrieved from a friend he’d left it with, shot himself in‐quarters.

All the above was known to the military behavioral health providers involved in any way with his case.  Still, they allowed for his brigade commander to proceed with court martial proceedings against Brown so that he might be made “an example of”.

In 2012, the Department of Defense announced a total of 349 suicides among its active duty population had occurred.  The financial compensation to those made beneficiaries totaled $139,600,000 dollars.  When coupled with the $100,000 lump sum death paid out per case, a sum in 2012 of $34,900,000 dollars, the overall financial tragedy cost of suicide was a staggering $174,500,00 dollars!

This amount does not include the additional cost to the military of pre‐medical / behavioral health care and treatment per affected service member. Nor the untracked costs per family and friends left behind for their own counseling and therapeutic needs.  The latter pointed out by the Watson Institute at Brown University as part of the ongoing strategy at DoD to “increasingly off‐load the burden of care for service members’ health onto their families and communities, and mainly onto female spouses.”

“This update just scratches the surface of the human consequences of 17 years of war. Too often, legislators, NGOs, and the news media that try to track the consequences of the wars are inhibited by governments determined to paint a rosy picture of perfect execution and progress. The US has made some effort to increase transparency, but there are a number of areas — the number of civilians killed and injured, and the number of US military and veteran suicides, for instance — where greater transparency would lead to greater accountability and could lead to better policy.”

Credit:Human Cost of the Post‐9/11 Wars: Lethality and the Need for Transparency November 2018

Neta C. Crawford, Watson Institute, Brown University 

SSG Michael Mantenuto enlisted in the Army in 2010.  Athletic, ambitious, and looking to maximize his military career opportunities he came in under the 18‐Xray program which allowed him to enlist for a Special Forces military occupational specialty.

Married with two children, Mantenuto began military life at the ripe old age of 29.  Two brief careers, one as a pro hockey player and the other as an actor, had not panned out as he’d hoped.  With financial challenges motivating his decision to enlist he was successful given nearly two years’ of being clean and sober.  An alleged honors violation saw him dropped from the Special Forces Qualification Course and reassigned to a unit in the 82^ndAirborne Division, historically known as “The Jump’ in Junkies”.  As he waited out his appeal Mike slipped back into addictive habits, rejoining the SFQC class he graduated from in July 2013. That weekend he was arrested in Wilmington, NC, while under the influence.

Assigned to the 1^stSpecial Forces Group at Fort Lewis, Washington, Mantenuto took to the life of a “Green Beret” like a duck to water.  His work ethic, honed by years of playing hockey to include the Division One level in college, was impeccable.  He made rank rapidly and was well‐liked among his peers in Group.  However, pre‐existing behavioral health and substance issues saw Mike go to his commander.  “He told them he needed help,” his now widow told me.  “He told them they could pull his [SF] tab and take away his green beret if they wanted to but he had to get help.”

In May, on his birthday, SSG Mantenuto entered a 28‐day dual diagnosis in‐patient program in Portland, Oregon. When he graduated, he returned to Fort Lewis where he co‐founded an informal peer support group with several others, he’d been in‐patient with.  His experience in Portland had been unlike the other rehab programs he been through as a civilian.  It was, as his widow offered, the fellowship and sharing in a group setting that really helped him with his own challenges.

In 2016, again on an operational detachment or A‐team, re‐enlisted to in part take advantage of a hefty bonus for doing so, and then deployed overseas for several months.  While in‐transit he experienced a blackout event in the Maldives Islands brought about mixing prescription Ambien with alcohol. Ambien used extensively by U.S. Special Operations Forces during long flights overseas and back, or to re‐adjust the operational sleep cycle so they can sleep during the day and execute their missions at night, is not alcohol‐friendly.

Per their January 23, 2018 report (Patterns of zolpidem use among Iraq and Afghanistan veterans: A retrospective cohort analysis), PloS One, a highly regarded scientific journal, offered the following:

“Iraq and Afghanistan war veterans (IAVs) may be particularly vulnerable to zolpidem exposure given their behavioral and medical risk factors for adverse health outcomes, including suicide, accidental overdose from prescription medications, and motor vehicle accidents.”

“The rates of abuse and dependency for zolpidem are comparable to benzodiazepines and are especially concerning in patients with mental health conditions and substance use disorders. On this basis, zolpidem is classified as a Schedule IV controlled substance in the U.S. along with benzodiazepines.”

In short, the Army’s prescribed method, as distributed by Special Forces team medics who have the required DEA documentation to do so regarding regulated medications, of using Ambien/zolpidem as liberally as it is, was placing a soldier with Mantenuto’s medical and behavioral health history in extreme jeopardy.  After the Maldives incident, which was quietly swept under the rug, Mantenuto requested and was granted an assignment with the unit’s K9 team.  It was a position he grew to love, and he was constantly training and working with his dog as a result.

He was also overseeing the development and presentation of his W.A.R. program, a peer support program within 1^stGroup that was gaining wide popularity and endorsement on JBLM to include official input and assistance from MAMC’s behavioral health leadership.  Two weeks before taking his own life Mike requested to leave the K9 team.  He kept his reason between himself and his family, telling close friends from rehab like Wendy Wilson‐Heid, who repeated their conversation in a UK Daily Mail article“…shortly before his death, he transferred out of the K‐9 Unit, which he had loved that it wasn’t ‘enough’.  She told DailyMail.com: “I didn’t get into him about why that had happened. He just said [to me], ‘I need to get my life together and I couldn’t do it by doing that.’”

However, Mantenuto’s widow shared her husband’s decision with NewsRep.  “The guys on the team were giving him a bad time.  They didn’t know if they could trust him.” The team’s trust had to do with their own alcohol and substance use and Mike’s dual role as both a K9 handler and W.A.R. advocate at Group Headquarters where he had an office.  “He told them they didn’t have to worry about him saying anything, and he knew they were joking around, too.  But it hurt him, and he was having his own problems too.  He left the team so they would be comfortable again.”

Peer pressure killed Mike Mantenuto, as well. It furthered his isolation at the unit. With his since‐childhood cultural development as a hockey player Mantenuto knew, and feared, being cut from a team.  Any team. With his behavioral health and substance challenges, and record of embarrassing himself and Special Forces due to substance related incidents, he was vulnerable to the horrific experience of self‐isolation and what it brings with it.

From a November 2018 report on just this subject rendered by Public Medicine.gov –

Suicidal thoughts and behaviors and social isolation: A narrative review of the literature.

BACKGROUND:

“Social isolation is one of the main risk factors associated with suicidal outcomes. The aim of this narrative review was to provide an overview on the link between social isolation and suicidal thoughts and behaviors.”

CONCLUSIONS:

“Data from the observational studies suggest that both objective social isolation and the subjective feeling of loneliness should be incorporated in the risk assessment of suicide. Interventional studies targeting social isolation for suicide prevention are needed.”

On the morning of his death SSG Mantenuto left his family quarters on Fort Lewis in civilian clothing, his handgun and three loaded magazines with him.  In his daypack was his passport and military ID card.  He did not take his wallet.  Along with his official identification were assorted papers and print‐outs from the addiction rehab sites he frequented.  There was also a book on Christianity he was reading.  The Jeep he drove was registered in his wife’s name and was a 2005 model.  The Mantenutos were living on base and taking every opportunity to save a bit here and there.

Mike had decided to leave the Army after his current enlistment.  He planned to return to Massachusetts, specifically Gloucester, where he’d been a commercial fisherman prior to his acting career.  He wanted to buy his own fishing boat.  He just wanted to go back home and lead a quieter, and hopefully more stable, life with his family.

That dream vanished as his surely as did the best practices care and treatment he should have been provided at JBLM / Madigan Army Medical Center.

At Saltwater State Park, 25 miles from Fort Lewis, a favorite getaway for Mantenuto with its driftwood covered shoreline and majestic view of Puget Sound and Vashon Island, he parked where he could take in the entire view.  Shortly thereafter he scribbled a three‐line note, adjusted the driver’s seat so he could lean back comfortably, and then shot himself through the mouth.  Death was instantaneous.

The Jeep was impounded and had to be recovered from the impound lot.  Before it was released to be driven home Mike’s wife had to clean the interior of her husband’s blood, bone fragments, and brain tissue.  Their son’s bicycle was in the vehicle at the time of his father’s death.

His widow received a lump sum death gratuity of $100,000.  The money meant to help with expenses as the family would no longer be “in the Army” along with their loved one.  An additional $400,000, Mike’s SGLI insurance, would come later.  It was enough to get the family back home and re‐established. Two years after the fact much of Mantenuto’s belongings had yet to be unpacked.  His passing still too painful to comprehend.

A White Star Family is one who had a close relative that served in the military and lost them to suicide. Whether they were active duty, reserve, or retired from the military, the sole purpose of this program is to honor those service members and provide proper care and support to the families.

By the close of 2018, 321 members of our Armed Forces had taken their lives.  One hundred and thirty‐eight of these suicides, the dominant metric overshadowing all the other Services’ numbers, were Army.  Only the Marine Corps has begun tracking/combining its suicide numbers with its Reserve component, enforcing the Marine culture of one military family and ethos.  The financial payout for 138 self‐inflicted deaths was $69,000 million dollars, or $500,00 dollars per life lost while wearing an Army uniform.

https://www.military.com/daily-news/2019/01/30/active-duty-military-suicides-near-record-highs-2018.html

How many of these deaths in 2018, which includes Matthew Brown’s, could be directly connected to the incompetence, malfeasance, ignorance, and deliberate compromise of standing Army‐wide behavioral health and substance dependency policies, guidelines, and best practices would be an interesting question to have answered.  The next step would be that of accountability.  Who, for example, involved with Specialist Brown’s care and treatment, and responsible for his safety after he was diagnosed as actively suicidal, has been reprimanded?  Relieved of command?  Why was the investigation into Brown’s suicide in August of 2018 put on the back burner until the new year?  His was an alleged to be a straightforward death by self‐inflicted gunshot wound. That, in my experience, as was the case when the Des Moines Police Department conducted its investigation of SSG Mantenuto’s suicide, a 3–5-page report with photos plus the corner’s report as to Cause of Death.

And why is the USASOC investigation into Mike’s suicide, two years after the fact, now only recent closed?  And why had the Department of Defense stepped in on USASOC and taken over FOIA release responsibility (damage control?) where its being shared with the Media is concerned?

It is fair to say a percentage of successful suicides, not to mention attempts which are not necessarily known about or tracked, are a direct result of both commanders and health care professionals failing to do their jobs correctly.  When we kill our own its hard to make a case for better education, training, and “just raise your hand if you need help” sales pitches from the same folks who are screwing up.

The tsunami of military service suicide has necessarily given birth to the White Star Family program.  Once a service member takes his or her own life the clock begins ticking where the surviving family is concerned.  They are no longer “military dependents” and they are processed as swiftly as possible out of military life.  Per KILL22’s website, the program provides the needed safety net for those families the Military off‐loads back into the civilian sector.

“A White Star Family is one who has lost a loved one to suicide who served in the military or as a first responder.  22KILL Honors the sacrifices of both the service member and their family by providing outreach and support programs.  These include family counseling and workshops, resource education, need assessments, peer retreats, and other services as necessary.”

“Suicide is also an urgent and growing problem among the veterans of the post‐9/11 wars. Although it is difficult to tell how many of these suicides are by post‐9/11 war veterans, because the VA does not disaggregate by war, there were more than 6,000 veteran suicides each year from 2008–2016, a rate that is 1.5 times greater than that of the non‐veteran population.” – The Costs of War, Watson Institute, Brown University, November 2018

Data from the DoDSER system allow us to learn about the risk factors and events leading up to military suicide. These are the actionable facts that will help us to fine tune DoD’s suicide prevention programs to reduce the occurrence of military suicide in the future.

• Personally owned firearms continued to be the most common method of suicide within the DoD, accounting for 58.9 percent of all suicides. Military issued firearms accounted for 2.3 percent of suicides.
• Drug and alcohol overdose were the most common method of attempted suicide, accounting for 56.8 percent of recorded suicide attempts.
• Nearly a quarter (23.4 percent) of those individuals who died by suicide communicated about their thoughts or desire to take their own life in the 90 days prior to their death in a manner other than a suicide note. This included talking, writing, or texting/e‐mailing others about these thoughts.
• Over half of the individuals who died by suicide did not have a documented behavioral health diagnosis. This doesn’t mean that these individuals were not struggling with behavioral health issues or major stressors in their lives, but rather that they did not seek care for those issues. This is important for understanding how stigma surrounding help‐seeking for behavioral health issues can have major consequences.
• Relationship problems are a common occurrence preceding suicide. We found that 39.5 percent of cases had experienced a failed relationship within 90 days of the suicide event. Primarily these involved romantic partners, but also included close friends and family.
• Over 58 percent of individuals who died by suicide had contact with the Military Health System in the 90 days prior to their death. This contact included primary care appointments, pharmacy visits, behavioral health appointments, or any other contact with MHS health care staff – Credit: Department of Defense Annual Report on Military Suicide, 2018

The Way Ahead –

Each of the four successful suicides presented in this article might have been prevented.  Fact.  That the clear warning signs and behavioral indicators leading to detection and then intervention in each instance were either intentionally disregarded or unintentionally missed is evident.  If intentionally ignored for agendas other than that of soldier/patient safety – as I propose was the case with Matthew Brown and Michael Mantenuto.  When those responsible and in uniform in the Army, or any of the other Services where such a betrayal can be shown to have occurred, behavioral health, substance dependency, and line unit commanders should be officially reprimanded at the very least.  Additional disciplinary options include demotion, transfer, and if the investigation shows deliberate and intentional disregard for the patient’s life – negligent homicide charges should not be out of the question.

The missed cues in the deaths of Specialist Paquette and Specialist Naugle are tragic but fixable.  In Paquette’s case, a benefits clerk not having been properly educated to alert his/her supervisor of a soldier asking if his insurance would be paid if his death was by suicide can be re‐trained.  In Naugle’s case a more vibrant and shorter fuse avenue to in‐patient care and treatment must be put in place, especially in Oregon which has the highest Guard suicide rate, year after year, of any other state in the union.

SGLI and death gratuity benefits must continue to be paid out to those loved ones and families affected by suicide.  The financial price tag is high – but the hard right over the easy wrong must be adhered to give these families will never be the same again.  And, sadly, as is the Armed Services’ policy, their ties to the military community of family, friends, and the safety the military community offers is taken away from them as soon as possible.

Relocation costs, monthly bills, psychological care and treatment for the survivors’ benefit, unexpected debt or expenses, vocational training or re‐training for a spouse left behind, all of these and more are due to a White Star family.

And maybe, just maybe, the millions upon millions upon millions of dollars currently being paid out yearly for Active Duty, National Guard, Reserves, and Veteran suicide will become so unacceptable that accountability and consequences become the metrics that begin to drive the daily self‐inflicted death toll down.

“When you think about accountants, who would want to be an accountant? But, what would we do without accountants? Whether it’s soldiers or garbage men or doctors, everyone has the thing that they love.” — Fred Willard

Mr. Walker’s final installment in this series will address suicide among our female service members.