A military suicide prevention program in the Israeli Defense Force: a review of an important military medical procedure

The phenomenon of suicide during military service is not unique to the Israeli military and other armies. Soldiers’ age––adolescence––is a known factor contributing to suicide, in light of psychological processes of identity formation and self-definition, the stresses of military service, and above all, the availability of weapons. The stigma of seeking help deters some soldiers from getting the assistance they need when they need it most, thus contributing to the higher suicide rate. In the previous decade the IDF initiated intensive and structured preventive procedures aimed at reducing suicide rate among soldiers. The IDF’s Suicide Prevention Program (SPP) was grounded in professional knowledge and backed by military policy changes, both critical to the implementation and change processes. The SPP includes thorough psycho-education and guidance, supervision, greater accessibility of mental health officers, and lower accessibility of nonessential weapons. The SPP has succeeded in reducing the suicide rate by almost 50 %.

The aim of this article is to review the background of the design of the IDF’s SPP and its major components, leading to the current success.

Cognitive-Behavioural Therapy and Psychodynamic Psychotherapy in the Treatment of Combat-Related Post-Traumatic Stress Disorder: A Comparative Effectiveness Study

This study compared the effectiveness of two psychotherapy approaches for treating combat veterans with chronic post-traumatic stress disorder (PTSD): cognitive-behavioural therapy (CBT) and psychodynamic psychotherapy (PDT). These treatments are routinely used by the Unit for Treatment of Combat-Related PTSD of the Israel Defense Forces (IDF). IDF veterans with chronic PTSD were assigned to either CBT (n = 148) or PDT (n = 95) based on the nature of their complaint and symptoms. Psychiatric status was assessed at baseline, post-treatment and 8-12 months follow-up using the Clinician-Administered PTSD Scale, the PTSD Questionnaire, the Montgomery and Asberg Depression Rating Scale and the Psychotherapy Outcome Assessment and Monitoring System-Trauma Version assessment questionnaire. Both treatment types resulted in significant reduction in symptoms and with improved functioning from pre-treatment to post-treatment, which were maintained at follow-up. No differences between the two treatments were found in any the effectiveness measures. At post-treatment, 35% of the CBT patients and 45% of the PDT patients remitted, with no difference between the groups. At follow-up, remission rates were 33% and 36% for the CBT and PDT groups, respectively. The study recommends further randomized controlled trials to determine treatment efficacy. Copyright © 2015 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGE

Both cognitive-behavioural therapy and psychodynamic psychotherapy have to be treatments offered in clinics for treating PTSD. Therapists who treat PTSD should be familiar with cognitive-behavioural and dynamic methods. The type of treatment chosen should be based on thorough psychosocial assessment.

Characteristics of the suicidal soldier in the Israeli Defense Force-a review of literature

Suicide is the third leading cause of death among adolescents in most Western world countries. Similar findings have been reported among adolescents in Israel (including the Israeli army) in times of peace; nonetheless, suicide rate has decreased significantly in recent years.

In Israel, IDF service is mandatory and adolescents are obligated to serve by law. Therefore, the IDF is responsible under state and moral law to care for the physical and mental health of its soldiers. Additionally, there is an understanding that the Israeli soldiers represent a mentally healthy population as prior to their enlistment they undergo a series of tests and evaluations to determine their suitability for service. The IDF is one of the few organizations in the world that is comprised of the majority of a country’s healthy adolescent population. International literature defines this population (i.e., the adolescent population) as having the highest risk of suicidality. Moreover, the risk of suicide increases in the face of two additional circumstances within the context of military service: the army service as a stressor and the availability of weapons.

The IDF invests significant resources in delineating the characteristics of suicidal soldiers, realizing its importance for suicide prevention during military service. This article reviews studies regarding complete suicide cases of Israeli soldiers in the aim of characterising a ‘suicidal soldier’s profile’ to inform better screening and prevention policies.

A neurobehavioral account for individual differences in resilience to chronic military stress

BACKGROUND

Military training is a chronic stressful period that often induces stress-related psychopathology. Stress vulnerability and resilience depend on personality trait anxiety, attentional threat bias and prefrontal-limbic dysfunction. However, how these neurobehavioral elements interact with regard to the development of symptoms following stress remains unclear.

METHOD

Fifty-five healthy combat soldiers undergoing intensive military training completed functional magnetic resonance imaging (fMRI) testing while performing the dot-probe task (DPT) composed of angry (threat) and neutral faces. Participants were then stratified according to their bias tendency to avoidance (n = 25) or vigilance (n = 30) groups, categorized as high or low trait anxiety and assessed for post-stress symptom severity.

RESULTS

Avoidance compared to vigilance tendency was associated with fewer post-trauma symptoms and increased hippocampal response to threat among high anxious but not low anxious individuals. Importantly, mediation analysis revealed that only among high anxious individuals did hippocampal activity lead to lower levels of symptoms through avoidance bias tendency. However, in the whole group, avoidance bias was modulated by the interplay between the hippocampus and the dorsal anterior cingulate cortex (dACC).

CONCLUSIONS

Our results provide a neurobehavioral model to explain the resilience to post-trauma symptoms following chronic exposure. The model points to the importance of considering threat bias tendency in addition to personality traits when investigating the brain response and symptoms of trauma. Such a multi-parametric approach that accounts for individual behavioral sensitivities may also improve brain-driven treatments of anxiety, possibly by targeting the interplay between the hippocampus and the dACC.

Everyday functioning of male adolescents who later died by suicide: Results of a pilot case-control study using mixed-method analysis

OBJECTIVE

Previous research has shown a link between difficulties in everyday functioning and suicidality in adolescence. The majority of research in this field focuses on suicidal ideation and attempts, rather than on completed suicide. The main goal of this study is to better characterize everyday functioning among young men who later completed suicide. Based on previous literature, we hypothesized that the functioning of adolescents who died by suicide would be poor, compared to controls.

METHODS

The current study is a record-driven study, which examined summaries of screening interviews performed by the Israeli Defense Forces (IDF) of 20 male adolescents who later completed suicide, compared with 20 matched living controls. The current study is a pilot stage of a larger project. The study used unique data, collected as part of the IDF pre-induction process, in the months or years before the tragic outcome. The data were extracted by two psychologists, blinded to the participants׳ suicide or non-suicide outcome, using mixed-method technique, combining qualitative and quantitative analysis.

RESULTS

The main findings indicated that, in comparison with controls, male adolescents who later died by suicide were described as having more interpersonal difficulties, were more likely to be involved in violent behavior, had more difficulties in dealing with problems in everyday functioning and had an avoidant conflict resolution style.

CONCLUSIONS

Functional difficulties are apparent in a wide range of behavioral domains in adolescents who later complete suicide. These findings indicate a need for interventions that might assist young persons, and it is possible that such assistance might reduce the likelihood of suicide. However, because suicide is a rare outcome and these behavioral traits are common in adolescence, the presence of such traits might not be useful in identifying people at risk of suicide.

IQ and obesity in adolescence: a population-based, cross-sectional study

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

Low IQ is associated with high BMI in childhood. There are inconsistent findings on the association between low SES and high BMI. Youth with low IQ have been reported to have poorer health behaviors, such as poor nutrition and less physical activity.

WHAT THIS STUDY ADDS

Low IQ is significantly associated with obesity for both male and female adolescents, though more strongly for female adolescents. Physical activity has a mediating effect on the association between low IQ and obesity among both male and female adolescents, though more strongly for male adolescents. The association between low IQ and obesity is strongest among adolescents from high SES backgrounds.

BACKGROUND

Previous studies have shown an association between low intelligence quotient (IQ), high body mass index and low socioeconomic status (SES).

OBJECTIVES

This study examined the cross-sectional association between IQ and obesity, exploring the roles of gender, SES and physical activity in this association.

METHODS

Subjects were 235,663 male and 169,259 female adolescents assessed by the Israeli military draft board.

RESULTS

Low IQ was significantly associated with increased odds of obesity among male (odds ratio [OR] = 1.44, 95% confidence interval [CI] = 1.36-1.52) and female adolescents (OR = 1.61, 95% CI = 1.51-1.73); this association was significantly stronger among female adolescents. Sobel tests indicated that physical activity had a significant mediating effect on this association for male and female adolescents, although more strongly for male adolescents. Dividing the sample according to SES, the association between low IQ and obesity was strongest in the high SES group (male adolescents: OR = 1.26, 95% CI = 1.10-1.43, female adolescents: OR = 1.61, 95% CI = 1.38-1.89), even when controlling for physical activity.

CONCLUSIONS

The findings suggest that low IQ is associated with increased odds of obesity, particularly in female adolescents and in adolescents with high SES. Physical activity has a mediating effect on this association, although more strongly for male than for female adolescents. Public health measures on decreasing obesity might focus on these groups.

Cognitive function and the risk for diabetes among young men

OBJECTIVE

Diabetes is a risk factor for an accelerated rate of cognitive decline and dementia. However, the relationship between cognitive function and the subsequent development of diabetes is unclear.

RESEARCH DESIGN AND METHODS

We conducted a historical-prospective cohort study merging data collected at premilitary recruitment assessment with information collected at the Staff Periodic Examination Center of the Israeli Army Medical Corps. Included were men aged 25 years or older without a history of diabetes at the beginning of follow-up with available data regarding their general intelligence score (GIS), a comprehensive measure of cognitive function, at age 17 years.

RESULTS

Among 35,500 men followed for a median of 5.5 years, 770 new cases of diabetes were diagnosed. After adjustment for age, participants in the lowest GIS category had a 2.6-fold greater risk for developing diabetes compared with those in the highest GIS category. In multivariable analysis adjusted for age, BMI, fasting plasma glucose, sociogenetic variables, and lifestyle risk factors, those in the lowest GIS category had a twofold greater risk for incident diabetes when compared with the highest GIS category (hazard ratio 2.1 [95% CI 1.5-3.1]; P < 0.001). Additionally, participants in the lowest GIS category developed diabetes at a mean age of 39.5 ± 4.7 years and those in the highest GIS group at a mean age of 41.5 ± 5.1 years (P for comparison 0.042).

CONCLUSIONS

This study demonstrates that in addition to a potential causal link between diabetes and enhanced cognitive decline, lower cognitive function at late adolescence is independently associated with an elevated risk for future diabetes.

Borderline intellectual functioning is associated with poor social functioning, increased rates of psychiatric diagnosis and drug use--a cross sectional population based study

Borderline intellectual functioning is defined by the DSM IV as an IQ range that is between one to two standard deviations below the mean (71<IQ<84), and a considerable percentage of the population is included in this definition (approximately 13.5%). The few studies performed on this group indicate that borderline intellectual functioning is associated with various mental disorders, problems in everyday functioning, social disability and poor academic or occupational achievement. Using data from the Israeli military, we retrieved the social and clinical characteristics of 76,962 adolescents with borderline intellectual functioning and compared their social functioning, psychiatric diagnoses and drug abuse with those of 96,580 adolescents with average IQ (± 0.25 SD from population mean). The results demonstrated that the borderline intellectual functioning group had higher rates of poor social functioning compared to the control group (OR=1.9, 95% CI=1.85-1.94). Individuals with borderline intellectual functioning were 2.37 times more likely to have a psychiatric diagnosis (95% CI=2.30-2.45) and 1.2 times more likely to use drugs (95% CI=1.07-0.35) than those with average IQ. These results suggest that adolescents with borderline intellectual functioning are more likely to suffer from psychiatric disorders, poor social functioning and drug abuse than those with average intelligence, and that borderline intellectual functioning is a marker of vulnerability to these poor outcomes.

Primary health care utilization prior to suicide: a retrospective case-control study among active-duty military personnel

OBJECTIVE

About 45% of civilians who died by suicide had contact with a doctor within 1 month of death. Thus, educating primary care physicians (PCP) to detect and mitigate depression is an important suicide-prevention strategy. However, the PCP consulting rate before suicide has not been examined in a military population. We investigated the utilization of primary health care and mental health services by active-duty military personnel suicide cases prior to death in comparison to matched military controls.

METHOD

All suicides (N = 170) were extracted from a cohort of all active-duty Israeli military male personnel between 2002 and 2012. Applying a retrospective, nested case-control design, we compared primary care services utilization by suicide cases with demographic and occupationally matched military controls (N = 500).

RESULTS

Whereas 38.3% of suicide cases contacted a PCP within the last month before death, only 27.6% of suicide cases contacted a mental health specialist during their entire service time. The PCP contact rate within 1 month before death or index day did not differ between suicide cases and military controls (38.3% vs. 33.8%, χ²₁ = 1.05, P = .3). More suicide cases contacted a mental health specialist within service time than did military controls (27.6% vs. 13.6%, χ²₁ = 10.85, P = .001).

CONCLUSIONS

Even though PCP contact rate by military personnel who died by suicide is slightly lower than that reported for civilians who died by suicide prior to their death, it is higher than mental health specialist contact rate and higher than that by age-matched civilians who died by suicide. These results imply that PCPs education is a viable approach to suicide prevention in a military setting.

Attention bias variability and symptoms of posttraumatic stress disorder

Cognitive theories implicate information-processing biases in the etiology of anxiety disorders. Results of attention-bias studies in posttraumatic stress disorder (PTSD) have been inconsistent, suggesting biases towards and away from threat. Within-subject variability of attention biases in posttraumatic patients may be a useful marker for attentional control impairment and the development of posttrauma symptoms. This study reports 2 experiments investigating threat-related attention biases, mood and anxiety symptoms, and attention-bias variability following trauma. Experiment 1 included 3 groups in a cross-sectional design: (a) PTSD, (b) trauma-exposed without PTSD, and (c) healthy controls with no trauma or Axis I diagnoses. Greater attention-bias variability was found in the PTSD group compared to the other 2 groups (η(p)2=.23); attention-bias variability was significantly and positively correlated (r = .37) with PTSD symptoms. Experiment 2 evaluated combat-exposed and nonexposed soldiers before and during deployment. Attention-bias variability did not differentiate groups before deployment, but did differentiate groups during deployment (ηp2=.16); increased variability was observed in groups with acute posttraumatic stress symptoms and acute depression symptoms only. Attention-bias variability could be a useful marker for attentional impairment related to threat cues associated with mood and anxiety symptoms after trauma exposure.

Characteristics of soldiers with self-harm in the israeli defense forces

Suicide is the leading cause of soldier death in the Israeli Defense Forces (IDF) in peace time. Suicide attempt (SA) and non-suicidal self-injury (NSSI) are risk factors for death by suicide in civilian studies and therefore their predictive value needs to be determined in the military. All army screening, psychometric and demographic data on consecutive cases of IDF soldier self-harm during the years 2010-2011 were analyzed. The Columbia Suicide Severity Rating Scale was used retrospectively to classify self-harm as suicidal or NSSI. The Suicide Ideation Scale and the Suicide Intent Scale were scored retrospectively by trained clinical psychologists. A total of 107 soldiers reported self-harm during the study period, comprising 70 SA and 37 with NSSI. The most prevalent diagnosis was personality disorder (n = 48). Soldiers with any mood/anxiety disorders comprised the smallest group (n = 21) and included major depression, dysthymia, anxiety, and posttraumatic stress disorder. Soldiers with NSSI (n = 37) did not differ in any of the characteristics from those who attempted suicide (n = 70). Unlike the well-known female dominance in both SA and NSSI patients in other settings, males dominated this army sample in both groups. Soldiers with self-harm (both SA and NSSI) cannot be easily distinguished by any demographics or specific psychological attributes detectable at induction, and the scales used in suicide research cannot predict an attempt or NSSI. Unlike civilian samples, males dominated attempter and NSSI groups and the reason for this may be multifactorial. These retrospective findings, if replicated, indicate the need for different screening strategies at induction into the military.

Differentiating Army suicide attempters from psychologically treated and untreated soldiers: a demographic, psychological and stress-reaction characterization

BACKGROUND

Suicide is the leading cause of death in most armies during peace-time. The recent dramatic rise in suicides in the US Army further focuses attention on the causes of suicidal behavior in the military.

METHODS

This study investigated demographic characteristics, psychological profile and stress-related risk factors associated with suicide attempts in Israelis aged 18-21 years, who served in the Army in 2009. Soldiers who attempted suicide (N=60) were compared to soldiers treated by a mental health professional, but reported no suicidal behavior (N=58), and to controls (N=50).

RESULTS

Suicide attempters had lower socioeconomic status and less cognitive ability compared with treated soldiers and untreated control soldiers. Only 25% of the suicide attempters had received mental healthcare prior to the attempt. The majority of the attempts were non-lethal (86.2%), and only 5.2% used firearms. Attempters had more previous suicide attempts (37.9%) and deliberate selfharm incidents (19.3%), compared to almost no such behaviors in the other two groups. Following the suicide attempt, 77% were diagnosed with moderate to severe mental disorders, 44.8% personality disorders and 8.6% mood disorders. Attempters reported higher levels of general stress compared to their peers in the other two groups. Being away from home and obeying authority were especially more stressful in attempters.

CONCLUSIONS

Young soldiers are less prone to seek mental health assistance, despite suffering from higher levels of stress. Screening is required to detect soldiers at risk for suicidal behavior and preventive intervention will require active outreach.

Neural traces of stress: cortisol related sustained enhancement of amygdala-hippocampal functional connectivity

Stressful experiences modulate neuro-circuitry function, and the temporal trajectory of these alterations, elapsing from early disturbances to late recovery, heavily influences resilience and vulnerability to stress. Such effects of stress may depend on processes that are engaged during resting-state, through active recollection of past experiences and anticipation of future events, all known to involve the default mode network (DMN). By inducing social stress and acquiring resting-state functional magnetic resonance imaging (fMRI) before stress, immediately following it, and 2 h later, we expanded the time-window for examining the trajectory of the stress response. Throughout the study repeated cortisol samplings and self-reports of stress levels were obtained from 51 healthy young males. Post-stress alterations were investigated by whole brain resting-state functional connectivity (rsFC) of two central hubs of the DMN: the posterior cingulate cortex (PCC) and hippocampus. Results indicate a ’recovery’ pattern of DMN connectivity, in which all alterations, ascribed to the intervening stress, returned to pre-stress levels. The only exception to this pattern was a stress-induced rise in amygdala-hippocampal connectivity, which was sustained for as long as 2 h following stress induction. Furthermore, this sustained enhancement of limbic connectivity was inversely correlated to individual stress-induced cortisol responsiveness (AUCi) and characterized only the group lacking such increased cortisol (i.e., non-responders). Our observations provide evidence of a prolonged post-stress response profile, characterized by both the comprehensive balance of most DMN functional connections and the distinct time and cortisol dependent ascent of intra-limbic connectivity. These novel insights into neuro-endocrine relations are another milestone in the ongoing search for individual markers in stress-related psychopathologies.

Attention to threats and combat-related posttraumatic stress symptoms: prospective associations and moderation by the serotonin transporter gene

IMPORTANCE

Combat places soldiers at risk for posttraumatic stress disorder (PTSD). The excessive rates of PTSD and other adjustment disorders in soldiers returning home make it imperative to identify risk and resilience factors that could be targeted by novel therapeutic treatments.

OBJECTIVE

To investigate the interplay among attention to threat, combat exposure, and other risk factors for PTSD symptoms in soldiers deployed to combat.

DESIGN AND SETTING

Longitudinal prospective study of Israeli Defense Force infantry soldiers carried out in 2008 through 2010. Repeated measurements during a 1-year period included baseline and predeployment data collected in training camps and deployment data collected in the combat theater.

PARTICIPANTS

Infantry soldiers (1085 men; mean age, 18.8 years).

MAIN OUTCOME MEASURES

Postcombat PTSD symptoms. RESULTS Soldiers developed threat vigilance during combat deployment, particularly when they were exposed to high-intensity combat, as indicated by faster response times to targets appearing at the location of threat relative to neutral stimuli (P < .001). Threat-related attention bias also interacted with combat exposure to predict risk for PTSD (P < .05). Bias toward threat at recruitment (P < .001) and bias away from threat just before deployment (P < .05) predicted postcombat PTSD symptoms. Moreover, these threat-related attention associations with PTSD were moderated by genetic and environmental factors, including serotonin transporter (5-HTTLPR) genotype.

CONCLUSIONS AND RELEVANCE

Combat exposure interacts with threat-related attention to place soldiers at risk for PTSD, and interactions with other risk factors account for considerable variance in PTSD vulnerability. Understanding these associations informs research on novel attention bias modification techniques and prevention of PTSD.

Family history of schizophrenia and bipolar disorder as risk factors for autism

CONTEXT

The clinical and etiologic relation between autism spectrum disorders (ASDs) and schizophrenia is unclear. The degree to which these disorders share a basis in etiology has important implications for clinicians, researchers, and those affected by the disorders.

OBJECTIVE

To determine whether a family history of schizophrenia and/or bipolar disorder is a risk factor for ASD.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a case-control evaluation of histories of schizophrenia or bipolar disorder in first-degree relatives of probands in 3 samples—population registers in Sweden, Stockholm County (in Sweden), and Israel. Probands met criteria for ASD, and affection status of parents and siblings for schizophrenia and bipolar disorder were established.

RESULTS

The presence of schizophrenia in parents was associated with an increased risk for ASD in a Swedish national cohort (odds ratio [OR], 2.9; 95% CI, 2.5-3.4) and a Stockholm County cohort (OR, 2.9; 95% CI, 2.0-4.1). Similarly, schizophrenia in a sibling was associated with an increased risk for ASD in a Swedish national cohort (OR, 2.6; 95% CI, 2.0-3.2) and an Israeli conscription cohort (OR, 12.1; 95% CI, 4.5-32.0). Bipolar disorder showed a similar pattern of associations but of lesser magnitude.

CONCLUSIONS

Findings from these 3 registers along with consistent findings from a similar study in Denmark suggest that ASD, schizophrenia, and bipolar disorder share common etiologic factors.

The relationship between risk of hospitalization for schizophrenia, SES, and cognitive functioning

Although most studies find low socioeconomic status (SES) to be associated with prevalence of schizophrenia, incidence studies do not generally support this, and some even report an inverse association. The objective of the current historical prospective study was to examine the relationship between SES, cognitive functioning, and risk of hospitalization for schizophrenia in a population-based sample of Israeli adolescents. Subjects were 811 487 adolescents, assessed by the Israeli military draft board for socio-demographic factors and cognitive functioning. Data on later hospitalization for schizophrenia were obtained from a population-based hospitalization registry. Findings indicated that when simply examining SES and schizophrenia, lower SES was associated with greater risk of hospitalization for schizophrenia (Hazard Ratio [HR] = 1.193, 95% CI = 1.091-1.303). When dividing the cohort into low, average, and high cognitive functioning, SES did not influence the risk for schizophrenia among individuals with high and average cognitive functioning, whereas among individuals with low cognitive functioning, high SES was found to slightly increase the risk for schizophrenia (HR = 1.21, 95% CI = 1.03-1.42). One possible explanation for this finding might be that among individuals from low socioeconomic backgrounds, low IQ may reflect decreased opportunities related to SES, whereas among individuals from high SES backgrounds, low IQ might reflect risk for later psychopathology.

Battlefield-like stress following simulated combat and suppression of attention bias to threat

BACKGROUND

Acute stress disorder involves prominent symptoms of threat avoidance. Preliminary cross-sectional data suggest that such threat-avoidance symptoms may also manifest cognitively, as attentional threat avoidance. Confirming these findings in a longitudinal study might provide insights on risk prediction and anxiety prevention in traumatic exposures.

METHOD

Attention-threat bias and post-traumatic symptoms were assessed in soldiers at two points in time: early in basic training and 23 weeks later, during advanced combat training. Based on random assignment, the timing of the repeat assessment occurred in one of two schedules: for a combat simulation group, the repeat assessment occurred immediately following a battlefield simulation exercise, and for a control group, the assessment occurred shortly before this exercise.

RESULTS

Both groups showed no threat-related attention bias at initial assessments. Following acute stress, the combat simulation group exhibited a shift in attention away from threat whereas the control group showed no change in attention bias. Stronger threat avoidance in the combat simulation group correlated with severity of post-traumatic symptoms. Such an association was not found in the control group.

CONCLUSIONS

Acute stress may lead some individuals to shift their attention away from threats, perhaps to minimize stress exposure. This acute attention response may come at a psychological cost, given that it correlates with post-traumatic stress disorder (PTSD) symptoms. Further research is needed to determine how these associations relate to full-blown PTSD in soldier and civilian populations.