After Spc. Freddy Hook, a medic with the Army's 82nd Airborne Division, killed himself in 2010, the trail of possible causes seemed long.
He had used illegal drugs: Was it the demons of addiction? His rocky relationship with his fiancée? A wrenching deployment to earthquake-ravaged Haiti or the prospect of an impending tour in Afghanistan?
As with most of suicides plaguing the military today, no one will know for sure.
"There are so many factors," said his mother, Theresa Taylor, of Lafayette, La. "Everything that was important to him was having problems."
Of the crises facing U.S. troops today, suicide ranks among the most emotionally wrenching - and baffling. Over the course of nearly 12 years and two wars, suicide among active-duty troops has risen steadily, hitting a record of 350 in 2012. That total was twice as many as a decade before and surpassed not only the number of U.S. troops killed in Afghanistan but also the number who died in transportation accidents last year.
Even with the withdrawal from Iraq and the pullback in Afghanistan, the rate of suicide within the military has continued to rise significantly faster than within the general population, where it is also rising. In 2002, the military's suicide rate was 10.3 per 100,000 troops, well below the comparable civilian rate. But today the rates are nearly the same, above 18 per 100,000 people.
And according to some experts, the military might be undercounting the problem because of the way it calculates its suicide rate.
Yet although the Pentagon has commissioned numerous reports and invested tens of millions of dollars in research and prevention programs, experts concede they are little closer to understanding the root causes of why military suicide is rising so fast.
"Any one variable in isolation doesn't explain things," said Craig J. Bryan, associate director of the National Center for Veterans Studies at the University of Utah. "But the interaction of all of them do. That's what makes it very difficult to solve the problem. And that's why we haven't made advances."
An emerging consensus among researchers is that, just as among civilians, a dauntingly complex web of factors usually underlie military suicide: mental illness, sexual or physical abuse, addictions, failed relationships, financial struggles. Indeed, the most recent Pentagon report of suicides found that half of the troops who killed themselves in 2011 had experienced the failure of an intimate relationship and about a quarter had received diagnoses of substance abuse.
Studies have also found that certain patterns of suicide among civilians seem intensified within the military. Among civilians, young white males are one of the most likely groups to kill themselves. In the military that group, which is disproportionately represented, is even more likely to commit suicide. Among civilians, firearms are the most common means; in the military, as might be expected, guns are used even more often, in 6 of every 10 instances.
Deployment and exposure to combat can act as catalysts that worsen existing problems in a service member's life, like drug abuse, or cause new ones, like post-traumatic stress disorder or traumatic brain injuries, which might contribute to suicidal behaviour. Indeed, a study published this week in the medical journal JAMA Psychiatry found that troops with multiple concussions were significantly more likely to report having suicidal thoughts than troops with one or no concussions.
Yet deployment and combat by themselves cannot explain the spiking suicide rates, researchers say. Pentagon data show that in recent years about half of service members who committed suicide never deployed to Iraq or Afghanistan. And more than 80 per cent had never been in combat.
"This probably is the keenest misconception the public has: that deployment is the factor most related to the increased rates of suicide," said Cynthia Thomsen, a research psychologist at the Naval Health Research Center in San Diego.
Another question lingers: Is the current trend unique or typical of war throughout the ages? Because detailed figures on military suicides were not collected until after Vietnam, it is impossible to know, although many experts believe that suicides rose during and after the two World Wars, Korea and Vietnam.
What is known is that since 2001, more than 2,700 service members have killed themselves, and that figure does not include National Guard and reserve troops who were not on active duty when they committed suicide.
Suicide among veterans has also risen somewhat since 2001, to an estimated 22 a day, according to the Department of Veterans Affairs.
Just 12 years ago, when the rate of military suicide was so much lower, many experts believed that military culture insulated young people from self-harm. Not only did it provide steady income and health care, structure and a sense of purpose, the reasoning went, military service also screened personnel for criminal behaviour as well as for basic physical and mental fitness.
But a decade of war has changed that perception.
"There is a difference between a military at war and a military at peace," said Dr. Jonathan Woodson, assistant secretary of defence for health affairs. "There is no doubt that war changes you."
THE LOVED ONES' QUESTION
The Pentagon's 2011 annual report on suicide, the most recent available, paints this picture: About 9 of 10 suicides involved enlisted personnel, not officers. Three of four victims did not attend college. More than half were married. Eight in 10 died in the United States. Most did not leave notes or communicate their intent to hurt themselves.
Each of those suicides comes with its unique set of circumstances, its own theory as to why. But in the voices of loved ones left behind, themes echo. Surprise. Confusion. A relentless question: Could we have done more?
Cpl. Wade Toothman of the Marine Corps deployed to Iraq, where a good friend was killed, and then to Afghanistan, where a roadside bomb blew out one of his eardrums.
After he left the Marines in 2011, he complained of chronic headaches, a possible symptom of a traumatic brain injury. But he did not seek treatment. His mother also worried that he had post-traumatic stress. But he denied it and refused to see a doctor, saying he feared that the diagnosis would make it impossible to get a job.
"People will say I'm crazy," he told her.
Experts say the months just after a service member leaves the military can be a particularly disorienting and even dangerous time. Once cocooned in close-knit units, new veterans must learn to be individuals again, freer yet often more alone, surrounded by a society that knows little about military life.
Once back in his tiny Oklahoma hometown, Prue, Toothman got bored and moved to Hawaii, where he had been based. But he could not find work, returned to Oklahoma, took a prison-guard job that he hated and talked idly of re-enlisting.
"He was having a hard time being a civilian," said his mother, Louise Toothman.
She did not realize just how hard. One October weekend in 2012, she went with her son to shop for groceries and pick up the tags for his new pickup truck. He seemed content.
"He was making plans," she said.
Two days later, he killed himself with a shotgun she had given him as a gift.
After his death, she began to uncover clues. Medical records showed that despite his denials about post-traumatic stress, the Marine Corps had treated him for the disorder, including by prescribing him antidepressants.
He also left behind an anguished note that made his mother believe he could not forget seeing a close friend killed in Iraq.
"I've held a lot of guilt and anger and sadness inside for a very long time," he wrote her. "I was too ashamed and proud to say it to you."
"I stopped drinking and tried dealing with it on my own and I failed," he continued. "I'm sorry I let you down. I was really hoping for some crazy, noble, heroic death. I love you and there's nothing you or anyone could do. This is my decision. I'm sorry I wasn't strong enough."
Louise Toothman wept as she read his words.
"If I had known these things, I would have acted differently," she said. "I would have been right there."
Don Lipstein knows that feeling.
His son, Petty Officer 2nd Class Joshua Lipstein, had been a heavy drinker as a teenager growing up in Wilmington, Del. But motivated by the Sept. 11 terrorist attacks four years earlier, he enlisted in the Navy and joined a riverboat crew that seemed to give him a sense of fulfillment, his father said. He made plans to make the Navy a career.
But during his second Iraq tour, doctors discovered he had a brain tumour and sent him home. In late 2009, he underwent surgery that caused him to lose hearing in one ear. Assigned to a desk job, he seemed headed for a medical discharge. The prospect of losing a career he loved was wrenching.
In the ensuing months, his father recalls, he became dependent on opioid pain killers. He told his father he was not addicted, just self-medicating. But Don Lipstein pushed him to enroll in a drug rehabilitation program. It did not help: Months afterward, Joshua Lipstein started using heroin.
Even the birth of a daughter did not seem to relieve his inner struggles. In March 2011, while he was awaiting his final discharge, he spoke to his father on the phone. Don Lipstein could hear the despondency; alarmed, he asked his son to unload his gun.
"Dad," he replied, "I can't do that." He killed himself soon after.
Don Lipstein, who speaks and counsels about suicide for the Tragedy Assistance Program for Survivors, a non-profit organization, says he does not blame the military for his son's death, noting how much he loved his work.
But he wonders whether commanders missed tell-tale signs - a problem the Pentagon acknowledges might be widespread. He wonders if he missed them, too.
"I didn't look at him as suicidal," he said. "Looking back, there were all kinds of stressors on his life. If I could have considered he was suicidal, could I have done something to prevent it?"
LOOKING FOR WHAT WORKS
For Kathryn Robinson, seeking treatment for her post-traumatic stress disorder and occasional thoughts about suicide was not an issue. Finding a program that worked was.
A member of the Army National Guard, she deployed to Iraq in 2007 as a combat videographer. There, a sniper shot off one of her fingers during a fierce firefight. After active duty, she isolated herself from friends and family and became dependent on antidepressants.
But unlike some veterans, Robinson, 45, who lives in Detroit, sought treatment repeatedly: a residential program for post-traumatic stress disorder, a women's trauma recovery program, horse therapy, song writing therapy, transcendental meditation, running.
Travel seems to work best of all, she said: "I call it trying to outrun the crazy."
Under intense pressure to expand and improve treatment and prevention programs, the armed services have hired additional mental health counsellors, conducted advertising campaigns to encourage troops to seek care and instituted resiliency programs to help them control stress through diet, exercise, sleeping habits, meditation or counselling. Commanders are being instructed on how to identify the tell-tale signs of suicidal behaviour as an early-warning system.
Yet the persistently high suicide rates have raised questions about which, if any, programs work. According to a 2010 report, the Department of Defence had nearly 900 suicide prevention activities, with multiple "inconsistencies, redundancies and gaps" in services.
Some experts say the Pentagon should focus on fewer programs that might have quicker impact. Some studies suggest, for instance, that simply improving sleeping habits can improve mental well-being. Others show that strengthening social connections, such as by having commanders or friends send "caring letters" to troubled service members, can prevent suicide.
But the stubborn nature of the problem is prompting more serious consideration of what suicide prevention experts call "means restriction," particularly reducing access to privately owned firearms.
"If we want to limit suicide, we should put means restriction at the front because it works," said Bryan of the University of Utah.
Indeed, the Pentagon is considering policies to encourage family members to take personal firearms away from suicidal service members. Commanders already have the authority to confiscate military-issue firearms from potentially suicidal service members.
But any such program is sure to be contentious and stir opposition from Second Amendment advocates. Woodson, the assistant secretary of defence for health affairs, said that the program would be voluntary but that details were still being developed.
Perhaps the biggest challenge facing the Pentagon is simply getting suicidal service members into treatment. Surveys show that despite campaigns to reduce stigma, many service members continue to believe that treatment will be ineffective or hurt their careers, said Dr. Charles Hoge, a psychiatrist at Walter Reed National Military Medical Centre.
"The problem isn't the specific treatments, but the fact that individuals aren't seeking care or are dropping out," Hoge said. "There's quite a bit of effort put into addressing stigma. But the fact remains that it is still a big problem."
For that reason, the Pentagon's first department-wide suicide prevention policy, to be released this year, will require "leaders to foster a command climate that encourages Department of Defense personnel to seek help," Jacqueline Garrick, acting director of the Defence Suicide Prevention Office, told Congress in March.
Theresa Taylor wonders whether any of that would have saved her son, Hook, who seemed to fall through one crack after another.
His family had a long history of military service. But his mother, an Air Force veteran, encouraged him to enlist because he was a bright underachiever who used drugs. The military, she hoped, would help him grow up.
For two years, he seemed to thrive as a medic with the 82nd Airborne Division. But in 2010, his life veered wildly off track. He seemed deeply affected by suffering he witnessed during a humanitarian mission to Haiti early that year. Over the following months, there were tensions with his fiancée. An arrest for driving 160 mph. A relapse into drug use.
When he visited his mother in Louisiana in October 2010, he seemed agitated, "not in a good place," she said.
He had begun taking antidepressants and seemed worried that his dream of joining the elite Army Rangers was becoming vanishingly distant. Adding to his stress, he was scheduled to deploy to Afghanistan the next March.
"He didn't want to go," Taylor said. "It didn't have to do with the war or the Army. He felt like he needed to get his life straight."
As Christmas approached, Taylor learned that he had asked his fiancée to enter into a suicide pact. She told his commanders at Fort Bragg, and they promised to put him on suicide watch.
But a mental health professional at the post decided that he was not suicidal and cleared him to go on holiday leave, Taylor said. Over the next day, he stabbed a drug dealer while trying to reclaim a Rolex watch, a cherished gift that he had traded for drugs, his mother said.
His sergeant, whom he told about the stabbing, took him to turn himself in. But on the way to the police station, Hook called his fiancée and said, "I'll see you on the flip side." Then he stepped from the car and shot himself using a pistol he had taken from a friend. He died Christmas Day at the age of 20.
Taylor acknowledged that many of her son's problems had predated enlistment. But she is haunted by a tape loop of questions about whether she, or her son's friends, or his commanders, could have done more to help him.
"There is enough blame for everyone to go around," she said. "The only reason you can blame anyone at all is that he was so young. If he was 40 and pulling these stunts, you'd say he should have learned. But he wasn't."
© 2013, The New York Times News Service