Contrary to popular belief, PTSD and exposure to combat don’t make service members more likely to commit suicide.

The past several years have seen a rash of news stories focusing on rising rates of suicide among U.S. soldiers. In fact, military suicides surpassed combat deaths in 2012. But as the American public grows weary of war, this topic has become increasingly politicized, obscuring the real picture of mental health problems in the military.

Cynthia LeardMann, Senior Epidemiologist at the Department of Deployment Health Research (DDHR), set out to investigate. She discovered that combat stress did not affect rates of soldier suicides, but instead that underlying mental health problems were to blame.

She used data from the Millennium Cohort, the largest longitudinal study of military service members in U.S. history. The Cohort includes more than 200,000 current and former military personnel across all branches of the armed forces. “This cohort study is perfectly positioned to study risk factors for suicide among military members and veterans,” said Dr. Nancy Crum-Cianflone, Director of the DDHR, in an interview with Healthline.

The study, published in the August issue of JAMA, showed that the suicide rate among active-duty military personnel recently rose sharply, from 10.8 suicides per 100,000 soldiers in 2005 to 16.3 per 100,000 in 2008. Since 2009, suicide rates have stabilized around 18 per 100,000. In comparison, according to the American Foundation for Suicide Prevention, rates in the civilian population rose from 10.4 in 2000 to 12.1 in 2010.

After applying statistical controls to account for education, race, age, and other factors, LeardMann made a surprising discovery. Exposure to combat stress, length of deployment, and total days deployed don’t affect military suicide rates at all.

Even individuals who had been diagnosed with Post-Traumatic Stress Disorder (PTSD) didn’t have higher suicide rates. Rather, suicide in the armed forces was predicted by the exact same factors that affect at-risk civilians: major depression, manic-depressive disorder, alcohol or substance abuse, and male gender.

“It is possible that this relationship may be different for those individuals already suffering from a mental health disorder who then experience an extremely stressful life event,” LeardMann cautions. “In addition, those with PTSD often have other associated conditions, such as depression and alcohol-related problems.”

Although the suicide rate has also risen in the civilian population—the paper correlates civilian suicide rates with economic hardship—rising rates of mental illness in the military likely account for the increased suicide rate in the armed forces.

Crum-Cianflone explains, “The recent increase in mental disorders may be due to cumulative stresses and increased tempo across both deployed and home-station environments among a military that has been involved in greater than a decade of war (the longest continuous combat engagement in U.S. history).” However, both LeardMann and Crum-Cianflone expect that deployment-related factors are and will continue to be unrelated to suicide rates.

In this light, the mental image of a farm-boy-turned-soldier sent to Iraq and freshly traumatized by violent combat, driving him to suicide, doesn’t hold up. With this new information, the military can better target those at the greatest risk for suicide: service members who already live with mental illness.

Current suicide prevention strategies include a focus on targeting service members exposed to the most combat. LeardMann’s study suggests that, instead, prevention should focus on identifying service members who are struggling with depression, alcohol abuse, and other mental health problems and providing them with the treatment they need. “While these strategies will not eliminate all suicides, these are the most important risk factors,” said Crum-Cianflone.

In an editorial published alongside the study, Dr. Charles Engel proposes another potential barrier to treatment. Engel, an associate professor of psychiatry at the Uniformed Services University of the Health Sciences and Colonel in the U.S. Army Medical Corps, offers an insider’s perspective.

He’s worried that military personnel with mental health problems might be afraid to seek treatment. “Clinical diagnosis of a mental disorder can result in military discharge, especially if resulting in significant occupational impairment,” Engel explains. “If a service member fears loss of job or career then they may be reluctant to seek care or assistance, especially from a mental health specialist.”

Part of this fear stems from looser rules regarding medical confidentiality. Among civilians, a psychotherapist may not break patient confidentiality unless he or she believes that there is an immediate threat to the patient’s life or to the life of another. The military should be no different, Engel feels.

“Unless there is an immediate threat to a combat mission, confidentiality standards should approximate civilian standards,” he states. If service members know they can trust their doctor or therapist, they are more likely to seek treatment.

Service members with depression face a more extreme version of the stigma that prevents many depressed civilians from seeking treatment. Engel concludes, “Stigma isn’t unique to the military and will likely remain a challenge for years to come, so the goal is to bring the right services to primary care and to the service member with needs.”