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Bigler ED. Neuroimaging as a biomarker in symptom validity and performance validity testing. Brain Imaging Behav 2015; 9:421-44. [DOI: 10.1007/s11682-015-9409-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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202
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Pease JL, Monteith LL, Hostetter TA, Forster JE, Bahraini NH. Military Service and Suicidal Thoughts and Behaviors in a National Sample of College Students. CRISIS 2015; 36:117-125. [DOI: 10.1027/0227-5910/a000300] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background: As a result of the post-9/11 GI Bill, increasing numbers of veterans are enrolling in college. However, little is known regarding suicidal outcomes among this group. In prior research, college student veterans reported high rates of suicidal ideation and attempt. Nonetheless, no research has examined whether military service is associated with increased suicide risk among college students. Aims: Our primary aims were to examine whether a history of military service was related to past-year suicidal ideation, plan, and attempt among college students. On the basis of previous research with college students, we hypothesized that students with a history of military service (i.e., current or prior) would report a higher percentage of past-year suicidal ideation, plan, and attempt. Our secondary aims were to examine the associations between military service and major depression and nonsuicidal self-injury. Method: Our sample included 3,290 college students with and without a history of military service who participated in the Healthy Minds Study in 2011 and 2012. Results: Military service was not significantly associated with past-year suicidal ideation, plan, or attempt. Students without a history of military service were more likely to report nonsuicidal self-injury. There was no significant difference in screening positive for major depression. Conclusions: These findings conflict with previous research that identified student veterans as being at elevated risk.
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Affiliation(s)
- James L. Pease
- Veterans Integrated Service Network 19 Mental Illness Research, Education and Clinical Center, Denver, Co, USA
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, Co, USA
| | - Lindsey L. Monteith
- Veterans Integrated Service Network 19 Mental Illness Research, Education and Clinical Center, Denver, Co, USA
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, Co, USA
| | - Trisha A. Hostetter
- Veterans Integrated Service Network 19 Mental Illness Research, Education and Clinical Center, Denver, Co, USA
| | - Jeri E. Forster
- Veterans Integrated Service Network 19 Mental Illness Research, Education and Clinical Center, Denver, Co, USA
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Co, USA
| | - Nazanin H. Bahraini
- Veterans Integrated Service Network 19 Mental Illness Research, Education and Clinical Center, Denver, Co, USA
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, Co, USA
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203
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Galynker I, Yaseen ZS, Briggs J, Hayashi F. Attitudes of acceptability and lack of condemnation toward suicide may be predictive of post-discharge suicide attempts. BMC Psychiatry 2015; 15:87. [PMID: 25884153 PMCID: PMC4403982 DOI: 10.1186/s12888-015-0462-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 03/30/2015] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Suicide attempts (SA) after psychiatric hospitalization continue to be a major cause of morbidity. Implicit measures may enhance our ability to assess suicide risk. In this context, we describe the first use of the Suicide Opinion Questionnaire (SOQ) to identify post-discharge suicide attempters. METHODS Adult psychiatric inpatients admitted for suicidality (N = 91) were administered a battery of measures including the SOQ, and forty were reached and reassessed for SA at two months post-discharge. Exploratory factor analysis (EFA) on items associated with suicidality was performed to identify latent constructs. Linear discriminant analysis (LDA) was used to optimize factor combination for suicide identification. Results were compared with explicit measures of suicidality, and logistic regression was used to control for other risk factors. Finally, a simplified 9-item scale was derived from the results and its performance compared to that of the linear discriminant function. RESULTS Twenty items differed between patients with and without SA at intake or follow-up. EFA on these identified two factors: suicide attempters indicated greater acceptability and less moral condemnation of suicide. The LDA-derived discriminant function and 9-item scale was significantly sensitive and specific for post-discharge SA. CONCLUSIONS Attitudes of acceptability and lack of condemnation toward suicide may constitute an implicit measure of suicidality that could contribute to risk assessment in a high-risk population.
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Affiliation(s)
- Igor Galynker
- Department of Psychiatry and Behavioral Sciences, Mount Sinai Beth Israel Medical Center, 1st Avenue @ 16th Street, 9-Fierman, New York, NY, 10003, USA.
| | - Zimri S Yaseen
- Department of Psychiatry and Behavioral Sciences, Mount Sinai Beth Israel Medical Center, 1st Avenue @ 16th Street, 9-Fierman, New York, NY, 10003, USA.
| | - Jessica Briggs
- Department of Psychiatry and Behavioral Sciences, Mount Sinai Beth Israel Medical Center, 1st Avenue @ 16th Street, 9-Fierman, New York, NY, 10003, USA.
| | - Fumitaka Hayashi
- Department of Psychiatry and Behavioral Sciences, Mount Sinai Beth Israel Medical Center, 1st Avenue @ 16th Street, 9-Fierman, New York, NY, 10003, USA.
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204
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Shelef L, Laur L, Fruchter E. Characteristics of the suicidal soldier in the Israeli Defense Force-a review of literature. DISASTER AND MILITARY MEDICINE 2015; 1:10. [PMID: 28265425 PMCID: PMC5329921 DOI: 10.1186/2054-314x-1-10] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 01/05/2015] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Leah Shelef
- Psychology Branch, Israeli Air Force, Kragujevac, Israel ; Mental Health Department, Israel Defense Force Medical Corps, Ramat Gan, Israel
| | - Lucian Laur
- Mental Health Department, Israel Defense Force Medical Corps, Ramat Gan, Israel
| | - Eyal Fruchter
- Mental Health Department, Israel Defense Force Medical Corps, Ramat Gan, Israel
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205
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Lusk J, Brenner LA, Betthauser LM, Terrio H, Scher AI, Schwab K, Poczwardowski A. A Qualitative Study of Potential Suicide Risk Factors Among Operation Iraqi Freedom/Operation Enduring Freedom Soldiers Returning to the Continental United States (CONUS). J Clin Psychol 2015; 71:843-55. [DOI: 10.1002/jclp.22164] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Jaimie Lusk
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc
- Veterans Integrated Service Network (VISN) 19 Mental Illness Research, Education, and Clinical Center (MIRECC)
- University of Denver, Graduate School of Professional Psychology
| | - Lisa A. Brenner
- Veterans Integrated Service Network (VISN) 19 Mental Illness Research, Education, and Clinical Center (MIRECC)
- University of Colorado Denver, Anschutz Medical Campus, Departments of Psychiatry, Neurology, and Physical Medicine and Rehabilitation
| | - Lisa M. Betthauser
- Veterans Integrated Service Network (VISN) 19 Mental Illness Research, Education, and Clinical Center (MIRECC)
- University of Colorado Denver, Department of Psychology
| | - Heidi Terrio
- Evans Army Community Hospital, University of Colorado Denver, Department of Psychology
- Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury
| | - Ann I. Scher
- Uniformed Services University of the Health Sciences
| | - Karen Schwab
- Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury
- Uniformed Services University of the Health Sciences
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206
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Street AE, Gilman SE, Rosellini AJ, Stein MB, Bromet EJ, Cox KL, Colpe LJ, Fullerton CS, Gruber MJ, Heeringa SG, Lewandowski-Romps L, Little RJA, Naifeh JA, Nock MK, Sampson NA, Schoenbaum M, Ursano RJ, Zaslavsky AM, Kessler RC. Understanding the elevated suicide risk of female soldiers during deployments. Psychol Med 2015; 45:717-726. [PMID: 25359554 PMCID: PMC4869515 DOI: 10.1017/s003329171400258x] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) has found that the proportional elevation in the US Army enlisted soldier suicide rate during deployment (compared with the never-deployed or previously deployed) is significantly higher among women than men, raising the possibility of gender differences in the adverse psychological effects of deployment. METHOD Person-month survival models based on a consolidated administrative database for active duty enlisted Regular Army soldiers in 2004-2009 (n = 975,057) were used to characterize the gender × deployment interaction predicting suicide. Four explanatory hypotheses were explored involving the proportion of females in each soldier's occupation, the proportion of same-gender soldiers in each soldier's unit, whether the soldier reported sexual assault victimization in the previous 12 months, and the soldier's pre-deployment history of treated mental/behavioral disorders. RESULTS The suicide rate of currently deployed women (14.0/100,000 person-years) was 3.1-3.5 times the rates of other (i.e. never-deployed/previously deployed) women. The suicide rate of currently deployed men (22.6/100,000 person-years) was 0.9-1.2 times the rates of other men. The adjusted (for time trends, sociodemographics, and Army career variables) female:male odds ratio comparing the suicide rates of currently deployed v. other women v. men was 2.8 (95% confidence interval 1.1-6.8), became 2.4 after excluding soldiers with Direct Combat Arms occupations, and remained elevated (in the range 1.9-2.8) after adjusting for the hypothesized explanatory variables. CONCLUSIONS These results are valuable in excluding otherwise plausible hypotheses for the elevated suicide rate of deployed women and point to the importance of expanding future research on the psychological challenges of deployment for women.
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Affiliation(s)
- A. E. Street
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | - S. E. Gilman
- Departments of Social and Behavioral Sciences, and Epidemiology, Harvard School of Public Health, Boston, MA, USA
| | - A. J. Rosellini
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - M. B. Stein
- Departments of Psychiatry and Family and Preventive Medicine, University of California San Diego, La Jolla, CA, USA
- VA San Diego Healthcare System, San Diego, CA, USA
| | - E. J. Bromet
- Department of Psychiatry, Stony Brook University School of Medicine, Stony Brook, NY, USA
| | - K. L. Cox
- US Army Public Health Command, Aberdeen Proving Ground, MD, USA
| | - L. J. Colpe
- Division of Services and Intervention Research, National Institute of Mental Health, Bethesda, MD, USA
| | - C. S. Fullerton
- Department of Psychiatry, Uniformed Services University School of Medicine, Center for the Study of Traumatic Stress, Bethesda, MD, USA
| | - M. J. Gruber
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - S. G. Heeringa
- Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
| | | | - R. J. A. Little
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - J. A. Naifeh
- Department of Psychiatry, Uniformed Services University School of Medicine, Center for the Study of Traumatic Stress, Bethesda, MD, USA
| | - M. K. Nock
- Department of Psychology, Harvard University, Cambridge, MA, USA
| | - N. A. Sampson
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - M. Schoenbaum
- Office of Science Policy, Planning and Communications, National Institute of Mental Health, Bethesda, MD, USA
| | - R. J. Ursano
- Department of Psychiatry, Uniformed Services University School of Medicine, Center for the Study of Traumatic Stress, Bethesda, MD, USA
| | - A. M. Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - R. C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
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207
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Maguen S, Skopp NA, Zhang Y, Smolenski DJ. Gender differences in suicide and suicide attempts among US Army soldiers. Psychiatry Res 2015; 225:545-9. [PMID: 25530416 DOI: 10.1016/j.psychres.2014.11.050] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 11/19/2014] [Accepted: 11/25/2014] [Indexed: 10/24/2022]
Abstract
In order to best tailor suicide prevention initiatives and programs, it is critical to gain an understanding of how service members׳ suicide risk factors may differ by gender. We aimed to better understand gender differences in suicide and suicide attempts among soldiers, including demographic, military, mental health, and other risk factors. We also examined risk factors uniquely associated with suicide and suicide attempts. We conducted a retrospective study of 1857 US Army soldiers who died by suicide or attempted suicide between 2008 and 2010 and had a Department of Defense Suicide Event Report. Female and male soldiers had more similarities than differences when examining risk factors associated with suicide. The only gender difference approaching significance was workplace difficulties, which was more strongly associated with suicide for female soldiers, compared to their male counterparts. Among suicide decedents, the most common risk factor was having a failed intimate relationship in the 90 days prior to suicide. Among those who attempted suicide, the most common risk factor was a major psychiatric diagnosis. Better understanding both gender differences and risk factors uniquely associated with suicide has critical prevention and public health implications as we work to better understand preventable mortality in our youngest generation of service members.
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Affiliation(s)
- Shira Maguen
- San Francisco VA Medical Center, San Francisco, CA, USA; Department of Psychiatry, University of California, San Francisco, San Francisco, CA, USA.
| | - Nancy A Skopp
- National Center for Telehealth & Technology, Defense Centers of Excellence for Psychological Health & Traumatic Brain Injury, Joint Base Lewis-McChord, Tacoma, WA, USA; Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Ying Zhang
- National Center for Telehealth & Technology, Defense Centers of Excellence for Psychological Health & Traumatic Brain Injury, Joint Base Lewis-McChord, Tacoma, WA, USA
| | - Derek J Smolenski
- National Center for Telehealth & Technology, Defense Centers of Excellence for Psychological Health & Traumatic Brain Injury, Joint Base Lewis-McChord, Tacoma, WA, USA
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208
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Goodwin L, Wessely S, Fear NT. The Future of "Big Data" in Suicide Behaviors Research: Can We Compare the Experiences of the U.S. and U.K. Armed Forces? Psychiatry 2015; 78:25-8. [PMID: 26168024 DOI: 10.1080/00332747.2015.1016783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The recent increased suicide rate in the U.S. military has received widespread academic and media attention (Nock et al., 2013). "Big data" has been defined as large, complex, and linkable information (Khoury & Ioannidis, 2014) that can be used to investigate such changes in incidence at a population level. "Big health data" can revolutionize the future of epidemiological research, and this commentary discusses a specific example of how it can be used to progress suicide research.
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209
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Ursano RJ, Heeringa SG, Stein MB, Jain S, Raman R, Sun X, Chiu WT, Colpe LJ, Fullerton CS, Gilman SE, Hwang I, Naifeh JA, Nock MK, Rosellini AJ, Sampson NA, Schoenbaum M, Zaslavsky AM, Kessler RC. Prevalence and correlates of suicidal behavior among new soldiers in the U.S. Army: results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Depress Anxiety 2015; 32:3-12. [PMID: 25338964 PMCID: PMC5113817 DOI: 10.1002/da.22317] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 08/21/2014] [Accepted: 08/23/2014] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The prevalence of suicide among U.S. Army soldiers has risen dramatically in recent years. Prior studies suggest that most soldiers with suicidal behaviors (i.e., ideation, plans, and attempts) had first onsets prior to enlistment. However, those data are based on retrospective self-reports of soldiers later in their Army careers. Unbiased examination of this issue requires investigation of suicidality among new soldiers. METHOD The New Soldier Study (NSS) of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) used fully structured self-administered measures to estimate preenlistment histories of suicide ideation, plans, and attempts among new soldiers reporting for Basic Combat Training in 2011-2012. Survival models examined sociodemographic correlates of each suicidal outcome. RESULTS Lifetime prevalence estimates of preenlistment suicide ideation, plans, and attempts were 14.1, 2.3, and 1.9%, respectively. Most reported onsets of suicide plans and attempts (73.3-81.5%) occurred within the first year after onset of ideation. Odds of these lifetime suicidal behaviors among new soldiers were positively, but weakly associated with being female, unmarried, religion other than Protestant or Catholic, and a race/ethnicity other than non-Hispanic White, non-Hispanic Black, or Hispanic. CONCLUSIONS Lifetime prevalence estimates of suicidal behaviors among new soldiers are consistent with retrospective reports of preenlistment prevalence obtained from soldiers later in their Army careers. Given that prior suicidal behaviors are among the strongest predictors of later suicides, consideration should be given to developing methods of obtaining valid reports of preenlistment suicidality from new soldiers to facilitate targeting of preventive interventions.
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Affiliation(s)
- Robert J. Ursano
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland,Correspondence to: Robert J. Ursano, Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814.
| | - Steven G. Heeringa
- Institute for Social Research, University of Michigan, Ann Arbor, Michigan
| | - Murray B. Stein
- Department of Psychiatry, University of California San Diego, La Jolla, California,Department of Family and Preventive Medicine, University of California San Diego, La Jolla, California,VA San Diego Healthcare System, San Diego, California
| | - Sonia Jain
- Department of Family and Preventive Medicine, University of California San Diego, La Jolla, California
| | - Rema Raman
- Department of Family and Preventive Medicine, University of California San Diego, La Jolla, California,Department of Neurosciences, University of California San Diego, La Jolla, California
| | - Xiaoying Sun
- Department of Family and Preventive Medicine, University of California San Diego, La Jolla, California
| | - Wai Tat Chiu
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Lisa J. Colpe
- National Institute of Mental Health, Bethesda, Maryland
| | - Carol S. Fullerton
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Stephen E. Gilman
- Departments of Social and Behavioral Sciences, and Epidemiology, Harvard School of Public Health, Boston, Maryland
| | - Irving Hwang
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - James A. Naifeh
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Matthew K. Nock
- Department of Psychology, Harvard College, Cambridge, Massachusetts
| | | | - Nancy A. Sampson
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | | | - Alan M. Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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210
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Ursano RJ, Kessler RC, Heeringa SG, Cox KL, Naifeh JA, Fullerton CS, Sampson NA, Kao TC, Aliaga PA, Vegella P, Mash HH, Buckley C, Colpe LJ, Schoenbaum M, Stein MB. Nonfatal Suicidal Behaviors in U.S. Army Administrative Records, 2004-2009: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Psychiatry 2015; 78:1-21. [PMID: 26168022 PMCID: PMC4503376 DOI: 10.1080/00332747.2015.1006512] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Although the U.S. Army suicide rate is known to have risen sharply over the past decade, information about medically documented, nonfatal suicidal behaviors is far more limited. Here we examine trends and sociodemographic correlates of suicide attempts, suspicious injuries, and suicide ideation among regular Army soldiers. METHODS Data come from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) Historical Administrative Data Study (HADS), which integrates administrative records for all soldiers on active duty during the years 2004 through 2009 (n = 1.66 million). RESULTS We identified 21,740 unique regular Army soldiers with a nonfatal suicidal event documented at some point during the HADS study period. There were substantial increases in the annual incidence rates of suicide attempts (179-400/100,000 person-years) and suicide ideation (557-830/100,000 person-years), but not suspicious injuries. Using hierarchical classification rules to identify the first instance of each soldier's most severe behavior, we found increased risk of all outcomes among those who were female, non-Hispanic White, never married, lower-ranking enlisted, less educated, and of younger age when entering Army service. These sociodemographic associations significantly differed across outcomes, despite some patterns that appear similar. CONCLUSION Results provide a broad overview of nonfatal suicidal trends in the U.S. Army during 2004 through 2009 and demonstrate that integration of multiple administrative data systems enriches analysis of the predictors of such events.
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211
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Kessler RC, Warner CH, Ivany C, Petukhova MV, Rose S, Bromet EJ, Brown M, Cai T, Colpe LJ, Cox KL, Fullerton CS, Gilman SE, Gruber MJ, Heeringa SG, Lewandowski-Romps L, Li J, Millikan-Bell AM, Naifeh JA, Nock MK, Rosellini AJ, Sampson NA, Schoenbaum M, Stein MB, Wessely S, Zaslavsky AM, Ursano RJ. Predicting suicides after psychiatric hospitalization in US Army soldiers: the Army Study To Assess Risk and rEsilience in Servicemembers (Army STARRS). JAMA Psychiatry 2015; 72:49-57. [PMID: 25390793 PMCID: PMC4286426 DOI: 10.1001/jamapsychiatry.2014.1754] [Citation(s) in RCA: 271] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
IMPORTANCE The US Army experienced a sharp increase in soldier suicides beginning in 2004. Administrative data reveal that among those at highest risk are soldiers in the 12 months after inpatient treatment of a psychiatric disorder. OBJECTIVE To develop an actuarial risk algorithm predicting suicide in the 12 months after US Army soldier inpatient treatment of a psychiatric disorder to target expanded posthospitalization care. DESIGN, SETTING, AND PARTICIPANTS There were 53,769 hospitalizations of active duty soldiers from January 1, 2004, through December 31, 2009, with International Classification of Diseases, Ninth Revision, Clinical Modification psychiatric admission diagnoses. Administrative data available before hospital discharge abstracted from a wide range of data systems (sociodemographic, US Army career, criminal justice, and medical or pharmacy) were used to predict suicides in the subsequent 12 months using machine learning methods (regression trees and penalized regressions) designed to evaluate cross-validated linear, nonlinear, and interactive predictive associations. MAIN OUTCOMES AND MEASURES Suicides of soldiers hospitalized with psychiatric disorders in the 12 months after hospital discharge. RESULTS Sixty-eight soldiers died by suicide within 12 months of hospital discharge (12.0% of all US Army suicides), equivalent to 263.9 suicides per 100,000 person-years compared with 18.5 suicides per 100,000 person-years in the total US Army. The strongest predictors included sociodemographics (male sex [odds ratio (OR), 7.9; 95% CI, 1.9-32.6] and late age of enlistment [OR, 1.9; 95% CI, 1.0-3.5]), criminal offenses (verbal violence [OR, 2.2; 95% CI, 1.2-4.0] and weapons possession [OR, 5.6; 95% CI, 1.7-18.3]), prior suicidality [OR, 2.9; 95% CI, 1.7-4.9], aspects of prior psychiatric inpatient and outpatient treatment (eg, number of antidepressant prescriptions filled in the past 12 months [OR, 1.3; 95% CI, 1.1-1.7]), and disorders diagnosed during the focal hospitalizations (eg, nonaffective psychosis [OR, 2.9; 95% CI, 1.2-7.0]). A total of 52.9% of posthospitalization suicides occurred after the 5% of hospitalizations with highest predicted suicide risk (3824.1 suicides per 100,000 person-years). These highest-risk hospitalizations also accounted for significantly elevated proportions of several other adverse posthospitalization outcomes (unintentional injury deaths, suicide attempts, and subsequent hospitalizations). CONCLUSIONS AND RELEVANCE The high concentration of risk of suicide and other adverse outcomes might justify targeting expanded posthospitalization interventions to soldiers classified as having highest posthospitalization suicide risk, although final determination requires careful consideration of intervention costs, comparative effectiveness, and possible adverse effects.
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Affiliation(s)
- Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Christopher H. Warner
- Department of Behavioral Medicine, Blanchfield Army Community Hospital, Fort Campbell, Kentucky
| | | | - Maria V. Petukhova
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Sherri Rose
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Evelyn J. Bromet
- Department of Psychiatry, Stony Brook University School of Medicine, Stony Brook, New York
| | - Millard Brown
- US Army Office of the Surgeon General, Falls Church, Virginia
| | - Tianxi Cai
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
| | - Lisa J. Colpe
- National Institute of Mental Health, Bethesda, Maryland
| | - Kenneth L. Cox
- US Army Public Health Command, Aberdeen Proving Ground, Maryland
| | - Carol S. Fullerton
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Stephen E. Gilman
- Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, Massachusetts10Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
| | - Michael J. Gruber
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | | | | | - Junlong Li
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
| | | | - James A. Naifeh
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Matthew K. Nock
- Department of Psychology, Harvard University, Cambridge, Massachusetts
| | | | - Nancy A. Sampson
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | | | - Murray B. Stein
- Department of Psychiatry, University of California, San Diego, La Jolla14Deapartment of Family and Preventive Medicine, University of California, San Diego, La Jolla15Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Simon Wessely
- King’s Centre for Military Health Research, King’s College London, London, United Kingdom
| | - Alan M. Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Robert J. Ursano
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Johnson LL, O’Connor SS, Kaminer B, Jobes DA, Gutierrez PM. Suicide-Focused Group Therapy for Veterans. ACTA ACUST UNITED AC 2014. [DOI: 10.1080/21635781.2014.963762] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Rings JA, Gutierrez PM, Forster JE. Exploring Prolonged Grief Disorder and Its Relationship to Suicidal Ideation Among Veterans. ACTA ACUST UNITED AC 2014. [DOI: 10.1080/21635781.2014.963758] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Pheister M, Kangas G, Thompson C, Lehrmann J, Berger B, Kemp J. Suicide prevention and postvention resources: what psychiatry residencies can learn from the Veteran's Administration experience. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2014; 38:600-4. [PMID: 24800730 DOI: 10.1007/s40596-014-0132-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 04/03/2014] [Indexed: 05/20/2023]
Abstract
Suicide risk assessment and coping with the loss of a patient through suicide are two of the more challenging aspects of psychiatry residency. Over the last decade, the Department of Veterans Affairs has focused on a significant effort into the development of a comprehensive suicide prevention. This article aims to describe the initiatives and resources in place at the VHA to help address the issue of suicidal behavior in veterans and how residency programs can use this to enhance teaching of suicide prevention and postvention.
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Nowrangi MA, Kortte KB, Rao VA. A Perspectives Approach to Suicide After Traumatic Brain Injury: Case and Review. PSYCHOSOMATICS 2014; 55:430-7. [DOI: 10.1016/j.psym.2013.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 11/19/2013] [Accepted: 11/21/2013] [Indexed: 10/26/2022]
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Mash HBH, Fullerton CS, Ramsawh HJ, Ng THH, Wang L, Kessler RC, Stein MB, Ursano RJ. Risk for suicidal behaviors associated with alcohol and energy drink use in the US Army. Soc Psychiatry Psychiatr Epidemiol 2014; 49:1379-87. [PMID: 24797397 DOI: 10.1007/s00127-014-0886-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 04/14/2014] [Indexed: 12/14/2022]
Abstract
PURPOSE Suicidal behaviors have increased in the US Army since 2005. To identify potential interventions for suicide risk, we examined the relationship between alcohol and energy drink use, independently and in combination, and rates of seriously considering and/or attempting suicide in US Army soldiers. METHODS This study used the DoD Survey of Health Related Behaviors Among Active Duty Military Personnel (DoD HRB), which sampled 10,400 Army soldiers, with 5,927 responses representing 508,088 soldiers. Use of energy drinks in combination with alcohol (A/ED) and average daily amount of alcohol consumption over the past 30 days and history of seriously considering and/or attempting suicide in the past year were assessed via self-report questions. RESULTS Six percent of Army service members reported either seriously considering and/or attempting suicide in the past year. Twenty-six percent of soldiers reported A/ED. Those who reported the highest level of alcohol use were more likely to have seriously considered and/or attempted suicide. Soldiers who reported daily A/ED were over three times more likely to have reported suicidal ideation or attempts, and even after adjusting for overall alcohol consumption and energy drink use alone remained approximately two times (OR = 1.99) more likely to report suicidality. CONCLUSIONS Combination alcohol and energy drink use and heavy alcohol use contribute to suicidality and may be targets for potential intervention to address suicide risk.
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Affiliation(s)
- Holly B Herberman Mash
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, MD, USA,
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Don Richardson J, Cyr KS, Nelson C, Elhai JD, Sareen J. Sleep disturbances and suicidal ideation in a sample of treatment-seeking Canadian Forces members and veterans. Psychiatry Res 2014; 218:118-23. [PMID: 24755040 DOI: 10.1016/j.psychres.2014.04.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Revised: 03/31/2014] [Accepted: 04/04/2014] [Indexed: 10/25/2022]
Abstract
This study examines the association between suicidal ideation and sleep disturbances in a sample of treatment-seeking Canadian Forces members and veterans, after controlling for probable posttraumatic stress disorder (PTSD), major depressive disorder (MDD), generalised anxiety disorder (GAD), and alcohol use disorder (AUD). Subjects included members and veterans of Canadian Forces seeking treatment at a hospital-based Operational Stress Injury Clinic (n=404). Sleep disturbances and nightmares were measured using individual items on the PTSD Checklist - Military Version (PCL - M), while the suicidality item of the Patient Health Questionnaire (PHQ-9) was used as a stand-alone item to assess presence or absence of suicidal ideation. Regression analyses were used to determine the respective impact of (1) insomnia and (2) nightmares on suicidal ideation, while controlling for presence of probable PTSD, MDD, GAD, and AUD. We found that 86.9% of patients reported having problems falling or staying asleep and 67.9% of patients reported being bothered by nightmares related to military-specific traumatic events. Neither sleep disturbances nor nightmares significantly predicted suicidal ideation; instead, probable MDD emerged as the most significant predictor. The clinical implications of these findings and their potential impact on treatment guidelines are discussed.
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Affiliation(s)
- J Don Richardson
- Parkwood Hospital Operational Stress Injury Clinic, St. Joseph׳s Health Care London, London, Ontario, Canada; Department of Psychiatry, Western University, London, Ontario, Canada; Department of Psychiatry and Behavioral Neuroscience, McMaster University, Hamilton, Ontario, Canada.
| | - Kate St Cyr
- Parkwood Hospital Operational Stress Injury Clinic, St. Joseph׳s Health Care London, London, Ontario, Canada
| | - Charles Nelson
- Parkwood Hospital Operational Stress Injury Clinic, St. Joseph׳s Health Care London, London, Ontario, Canada; Department of Psychology, Western University, London, Ontario, Canada
| | - Jon D Elhai
- Department of Psychology, University of Toledo, Toleldo, OH, USA; Department of Psychiatry, University of Toledo, Toleldo, OH, USA
| | - Jitender Sareen
- Deer Lodge Operational Stress Injury Clinic, Winnipeg, Manitoba, Canada; Department of Psychiatry,University of Manitoba, Winnipeg, Manitoba, Canada; Department of Psychology, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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Nock MK, Stein MB, Heeringa SG, Ursano RJ, Colpe LJ, Fullerton CS, Hwang I, Naifeh JA, Sampson NA, Schoenbaum M, Zaslavsky AM, Kessler RC. Prevalence and correlates of suicidal behavior among soldiers: results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry 2014; 71:514-22. [PMID: 24590178 PMCID: PMC4100464 DOI: 10.1001/jamapsychiatry.2014.30] [Citation(s) in RCA: 222] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The suicide rate among US Army soldiers has increased substantially in recent years. OBJECTIVES To estimate the lifetime prevalence and sociodemographic, Army career, and psychiatric predictors of suicidal behaviors among nondeployed US Army soldiers. DESIGN, SETTING, AND PARTICIPANTS A representative cross-sectional survey of 5428 nondeployed soldiers participating in a group self-administered survey. MAIN OUTCOMES AND MEASURES Lifetime suicidal ideation, suicide plans, and suicide attempts. RESULTS The lifetime prevalence estimates of suicidal ideation, suicide plans, and suicide attempts are 13.9%, 5.3%, and 2.4%. Most reported cases (47.0%-58.2%) had pre-enlistment onsets. Pre-enlistment onset rates were lower than in a prior national civilian survey (with imputed/simulated age at enlistment), whereas post-enlistment onsets of ideation and plans were higher, and post-enlistment first attempts were equivalent to civilian rates. Most reported onsets of plans and attempts among ideators (58.3%-63.3%) occur within the year of onset of ideation. Post-enlistment attempts are positively related to being a woman (with an odds ratio [OR] of 3.3 [95% CI, 1.5-7.5]), lower rank (OR = 5.8 [95% CI, 1.8-18.1]), and previously deployed (OR = 2.4-3.7) and are negatively related to being unmarried (OR = 0.1-0.8) and assigned to Special Operations Command (OR = 0.0 [95% CI, 0.0-0.0]). Five mental disorders predict post-enlistment first suicide attempts in multivariate analysis: pre-enlistment panic disorder (OR = 0.1 [95% CI, 0.0-0.8]), pre-enlistment posttraumatic stress disorder (OR = 0.1 [95% CI, 0.0-0.7]), post-enlistment depression (OR = 3.8 [95% CI, 1.2-11.6]), and both pre- and post-enlistment intermittent explosive disorder (OR = 3.7-3.8). Four of these 5 ORs (posttraumatic stress disorder is the exception) predict ideation, whereas only post-enlistment intermittent explosive disorder predicts attempts among ideators. The population-attributable risk proportions of lifetime mental disorders predicting post-enlistment suicide attempts are 31.3% for pre-enlistment onset disorders, 41.2% for post-enlistment onset disorders, and 59.9% for all disorders. CONCLUSIONS AND RELEVANCE The fact that approximately one-third of post-enlistment suicide attempts are associated with pre-enlistment mental disorders suggests that pre-enlistment mental disorders might be targets for early screening and intervention. The possibility of higher fatality rates among Army suicide attempts than among civilian suicide attempts highlights the potential importance of means control (ie, restricting access to lethal means [such as firearms]) as a suicide prevention strategy.
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Affiliation(s)
- Matthew K. Nock
- Department of Psychology, Harvard University, Cambridge, Massachusetts
| | - Murray B. Stein
- Departments of Psychiatry and of Family and Preventive Medicine, University of California, San Diego, La Jolla3VA San Diego Healthcare System, San Diego, California
| | | | - Robert J. Ursano
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Lisa J. Colpe
- National Institute of Mental Health, Bethesda, Maryland
| | - Carol S. Fullerton
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Irving Hwang
- Department of Health Care Policy, Harvard Medical School, Boston
| | - James A. Naifeh
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Nancy A. Sampson
- Department of Health Care Policy, Harvard Medical School, Boston
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Schoenbaum M, Kessler RC, Gilman SE, Colpe LJ, Heeringa SG, Stein MB, Ursano RJ, Cox KL. Predictors of suicide and accident death in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS): results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry 2014; 71:493-503. [PMID: 24590048 PMCID: PMC4124912 DOI: 10.1001/jamapsychiatry.2013.4417] [Citation(s) in RCA: 172] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multicomponent study designed to generate actionable recommendations to reduce Army suicides and increase knowledge of risk and resilience factors for suicidality. OBJECTIVES To present data on prevalence, trends, and basic sociodemographic and Army experience correlates of suicides and accident deaths among active duty Regular Army soldiers between January 1, 2004, and December 31, 2009, and thereby establish a foundation for future Army STARRS investigations. DESIGN, SETTING, AND PARTICIPANTS Analysis of trends and predictors of suicide and accident deaths using Army and Department of Defense administrative data systems. Participants were all members of the US Regular Army serving at any time between 2004 and 2009. MAIN OUTCOMES AND MEASURES Death by suicide or accident during active Army service. RESULTS The suicide rate rose between 2004 and 2009 among never deployed and currently and previously deployed Regular Army soldiers. The accident death rate fell sharply among currently deployed soldiers, remained constant among the previously deployed, and trended upward among the never deployed. Increased suicide risk was associated with being a man (or a woman during deployment), white race/ethnicity, junior enlisted rank, recent demotion, and current or previous deployment. Sociodemographic and Army experience predictors were generally similar for suicides and accident deaths. Time trends in these predictors and in the Army's increased use of accession waivers (which relaxed some qualifications for new soldiers) do not explain the rise in Army suicides. CONCLUSIONS AND RELEVANCE Predictors of Army suicides were largely similar to those reported elsewhere for civilians, although some predictors distinct to Army service emerged that deserve more in-depth analysis. The existence of a time trend in suicide risk among never-deployed soldiers argues indirectly against the view that exposure to combat-related trauma is the exclusive cause of the increase in Army suicides.
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Affiliation(s)
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Stephen E. Gilman
- Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, Massachusetts4Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
| | - Lisa J. Colpe
- National Institute of Mental Health, Bethesda, Maryland
| | | | - Murray B. Stein
- Department of Psychiatry and Family, University of California, San Diego, La Jolla7Department of Preventive Medicine, University of California, San Diego, La Jolla8Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Robert J. Ursano
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University School of the Health Sciences, Bethesda, Maryland
| | - Kenneth L. Cox
- United States Army Public Health Command, Aberdeen Proving Ground, Maryland
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Thompson JM, Zamorski MA, Sweet J, VanTil L, Sareen J, Pietrzak RH, Hopman WH, MacLean MB, Pedlar D. Roles of physical and mental health in suicidal ideation in Canadian Armed Forces Regular Force veterans. Canadian Journal of Public Health 2014; 105:e109-15. [PMID: 24886845 DOI: 10.17269/cjph.105.4217] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 04/05/2014] [Accepted: 02/12/2014] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Suicide in recent veterans is an international concern. An association between mental disorders and suicide has been established, but less information is available about an association between physical health problems and suicide among veterans. This study extends this area of inquiry by examining the relationship of both physical and mental health problems with suicidal ideation in a representative national sample of Canadian veterans. METHODS Subjects were a stratified random sample of 2,658 veterans who had been released from the Canadian Armed Forces Regular Force during 1998-2007 and had participated in the 2010 Survey on Transition to Civilian Life. Associations between physical and mental health and past-year suicidal ideation were explored in multivariable regression models using three measures of physical and mental health. RESULTS The prevalence of suicidal ideation was 5.8% (95% confidence interval [CI]: 5.0%-6.8%). After adjustment for covariates, ideation was associated with gastrointestinal disorders (adjusted odds ratio [AOR] 1.66, CI: 1.03-2.65), depression or anxiety (AOR 5.06, CI: 2.97-8.62) and mood disorders (AOR 2.91, CI: 1.67-5.07); number of physical (AOR 1.22, CI: 1.05-1.42) and mental conditions (AOR 2.32, CI: 2.01-2.68); and SF-12 Health Survey physical health (AOR 0.98, CI: 0.96-0.99 for each 1 point increase) and mental health (AOR 0.88, CI: 0.87-0.89). CONCLUSIONS Physical health was independently associated with suicidal ideation after adjustment for mental health status and socio-demographic characteristics. The findings underscore the importance of considering physical health in population-based suicide prevention efforts and in mitigating suicide risk in individual veterans.
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Ressler KJ, Schoomaker EB. Commentary on "The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)": Army STARRS: a Framingham-like study of psychological health risk factors in soldiers. Psychiatry 2014; 77:120-9. [PMID: 24865196 DOI: 10.1521/psyc.2014.77.2.120] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Although historically the Army suicide rate has been significantly lower than the civilian rate, in 2004, the suicide and accidental death rates began trending upward. By 2008, the Army suicide rate had risen above the national average (20.2 per 100,000). In 2009, 160 active duty Soldiers took their lives, making suicide the third leading cause of death among the Army population. If accidental death, frequently the result of high-risk behavior, is included, then more Soldiers died by their own actions than in combat in 2009. The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) was thus created in 2009 to begin to address these problems. The Army STARRS project is a large consortium of seven different studies to develop data-driven methods for mitigating or preventing suicide behaviors and improving the overall mental health and behavioral functioning of Army Soldiers during and after their Army service. The first research articles from the Army STARRS project were published in late 2013 and early 2014. This work has already begun to outline important facets of risk in the military, and it is helping to drive an empirically derived approach to improvements in understanding mental disorders and risk behavior and to improve prevention and support of mental health and resilience. The Framingham Heart Study, started in the 1940s, marked a watershed event in utilizing large cross-sectional and prospective longitudinal collaborative research to identify and understand risk factors for cardiovascular disease. The Army STARRS project, through its collaborative, prospective, and robust innovative design and implementation, may provide the beginning of a similar scientific cohort in mental disorders. The work of this project will help understand biological and psychological aspects of military service, including those leading to suicide. When coupled with timely feedback to Army leadership, it permits near real-time steps to diagnose, mitigate, and manage emerging mental health issues and the root causes of risk and resilience in Army Soldiers, with potential impact extending across many traumatized populations-not unlike a parallel process that has markedly improved survival and recovery from physical combat wounds.
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Ursano RJ, Colpe LJ, Heeringa SG, Kessler RC, Schoenbaum M, Stein MB. The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Psychiatry 2014; 77:107-19. [PMID: 24865195 PMCID: PMC4075436 DOI: 10.1521/psyc.2014.77.2.107] [Citation(s) in RCA: 195] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
UNLABELLED IMPORTANCE/OBJECTIVE: Although the suicide rate in the U.S. Army has traditionally been below age-gender matched civilian rates, it has climbed steadily since the beginning of the Iraq and Afghanistan conflicts and since 2008 has exceeded the demographically matched civilian rate. The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multicomponent epidemiological and neurobiological study designed to generate actionable evidence-based recommendations to reduce Army suicides and increase knowledge about risk and resilience factors for suicidality and its psychopathological correlates. This paper presents an overview of the Army STARRS component study designs and of recent findings. DESIGN/SETTING/PARTICIPANTS/INTERVENTION: Army STARRS includes six main component studies: (1) the Historical Administrative Data Study (HADS) of Army and Department of Defense (DoD) administrative data systems (including records of suicidal behaviors) for all soldiers on active duty 2004-2009 aimed at finding administrative record predictors of suicides; (2) retrospective case-control studies of fatal and nonfatal suicidal behaviors (each planned to have n = 150 cases and n = 300 controls); (3) a study of new soldiers (n = 50,765 completed surveys) assessed just before beginning basic combat training (BCT) with self-administered questionnaires (SAQ), neurocognitive tests, and blood samples; (4) a cross-sectional study of approximately 35,000 (completed SAQs) soldiers representative of all other (i.e., exclusive of BCT) active duty soldiers; (5) a pre-post deployment study (with blood samples) of soldiers in brigade combat teams about to deploy to Afghanistan (n = 9,421 completed baseline surveys), with sub-samples assessed again one, three, and nine months after returning from deployment; and (6) a pilot study to follow-up SAQ respondents transitioning to civilian life. Army/DoD administrative data are being linked prospectively to the large-scale survey samples to examine predictors of subsequent suicidality and related mental health outcomes. MAIN OUTCOME MEASURES Measures (self-report and administratively recorded) of suicidal behaviors and their psychopathological correlates. RESULTS Component study cooperation rates are comparatively high. Sample biases are relatively small. Inefficiencies introduced into parameter estimates by using nonresponse adjustment weights and time-space clustering are small. Initial findings show that the suicide death rate, which rose over 2004-2009, increased for those deployed, those never deployed, and those previously deployed. Analyses of administrative records show that those deployed or previously deployed were at greater suicide risk. Receiving a waiver to enter the Army was not associated with increased risk. However, being demoted in the past two years was associated with increased risk. Time in current deployment, length of time since return from most recent deployment, total number of deployments, and time interval between most recent deployments (known as dwell time) were not associated with suicide risk. Initial analyses of survey data show that 13.9% of currently active non-deployed regular Army soldiers considered suicide at some point in their lifetime, while 5.3% had made a suicide plan, and 2.4% had attempted suicide. Importantly, 47-60% of these outcomes first occurred prior to enlistment. Prior mental disorders, in particular major depression and intermittent explosive disorder, were the strongest predictors of these self-reported suicidal behaviors. Most onsets of plans-attempts among ideators (58.3-63.3%) occurred within the year of onset of ideation. About 25.1% of non-deployed U.S. Army personnel met 30-day criteria for a DSM-IV anxiety, mood, disruptive behavior, or substance disorder (15.0% an internalizing disorder; 18.4% an externalizing disorder) and 11.1% for multiple disorders. Importantly, three-fourths of these disorders had pre-enlistment onsets. CONCLUSIONS Integration across component studies creates strengths going well beyond those in conventional applications of the same individual study designs. These design features create a strong methodological foundation from which Army STARRS can pursue its substantive research goals. The early findings reported here illustrate the importance of the study and its approach as a model of studying rare events particularly of national security concern. Continuing analyses of the data will inform suicide prevention for the U.S. Army.
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Affiliation(s)
- Robert J. Ursano
- Center for the Study of Traumatic Stress, Department of Psychiatry, at the Uniformed Services University School of Medicine in Bethesda, Maryland
| | | | | | - Ronald C. Kessler
- Department of Health Care Policy at Harvard Medical School in Boston
| | | | - Murray B. Stein
- Departments of Psychiatry and Family and Preventive Medicine at the University of California San Diego in La Jolla, and with the VA San Diego Healthcare System
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Heeringa SG, Gebler N, Colpe LJ, Fullerton CS, Hwang I, Kessler RC, Naifeh JA, Nock MK, Sampson NA, Schoenbaum M, Zaslavsky AM, Stein MB, Ursano RJ. Field procedures in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Int J Methods Psychiatr Res 2013; 22:276-87. [PMID: 24038395 PMCID: PMC3992884 DOI: 10.1002/mpr.1400] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 07/15/2013] [Indexed: 01/19/2023] Open
Abstract
The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multi-component epidemiological and neurobiological study of unprecedented size and complexity designed to generate actionable evidence-based recommendations to reduce US Army suicides and increase basic knowledge about determinants of suicidality by carrying out coordinated component studies. A number of major logistical challenges were faced in implementing these studies. The current report presents an overview of the approaches taken to meet these challenges, with a special focus on the field procedures used to implement the component studies. As detailed in the paper, these challenges were addressed at the onset of the initiative by establishing an Executive Committee, a Data Coordination Center (the Survey Research Center [SRC] at the University of Michigan), and study-specific design and analysis teams that worked with staff on instrumentation and field procedures. SRC staff, in turn, worked with the Office of the Deputy Under Secretary of the Army (ODUSA) and local Army Points of Contact (POCs) to address logistical issues and facilitate data collection. These structures, coupled with careful fieldworker training, supervision, and piloting, contributed to the major Army STARRS data collection efforts having higher response rates than previous large-scale studies of comparable military samples.
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Affiliation(s)
| | - Nancy Gebler
- University of MichiganInstitute for Social ResearchAnn ArborMIUSA
| | | | - Carol S. Fullerton
- Center for the Study of Traumatic Stress, Department of PsychiatryUniformed Services University School of MedicineBethesdaMDUSA
| | - Irving Hwang
- Department of Health Care PolicyHarvard Medical SchoolBostonMAUSA
| | | | - James A. Naifeh
- Center for the Study of Traumatic Stress, Department of PsychiatryUniformed Services University School of MedicineBethesdaMDUSA
| | | | - Nancy A. Sampson
- Department of Health Care PolicyHarvard Medical SchoolBostonMAUSA
| | | | | | - Murray B. Stein
- Departments of Psychiatry and Family and Preventive MedicineUniversity of California San DiegoLa JollaCAUSA
- VA San Diego Healthcare SystemSan DiegoCAUSA
| | - Robert J. Ursano
- Center for the Study of Traumatic Stress, Department of PsychiatryUniformed Services University School of MedicineBethesdaMDUSA
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Kessler RC, Santiago PN, Colpe LJ, Dempsey CL, First MB, Heeringa SG, Stein MB, Fullerton CS, Gruber MJ, Naifeh JA, Nock MK, Sampson NA, Schoenbaum M, Zaslavsky AM, Ursano RJ. Clinical reappraisal of the Composite International Diagnostic Interview Screening Scales (CIDI-SC) in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Int J Methods Psychiatr Res 2013; 22:303-21. [PMID: 24318219 PMCID: PMC4027964 DOI: 10.1002/mpr.1398] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 07/15/2013] [Indexed: 11/06/2022] Open
Abstract
A clinical reappraisal study was carried out in conjunction with the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) All-Army Study (AAS) to evaluate concordance of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses based on the Composite International Diagnostic Interview Screening Scales (CIDI-SC) and post-traumatic stress disorder (PTSD) checklist (PCL) with diagnoses based on independent clinical reappraisal interviews (Structured Clinical Interview for DSM-IV [SCID]). Diagnoses included: lifetime mania/hypomania, panic disorder, and intermittent explosive disorder; six-month adult attention-deficit/hyperactivity disorder; and 30-day major depressive episode, generalized anxiety disorder, PTSD, and substance (alcohol or drug) use disorder (abuse or dependence). The sample (n = 460) was weighted for over-sampling CIDI-SC/PCL screened positives. Diagnostic thresholds were set to equalize false positives and false negatives. Good individual-level concordance was found between CIDI-SC/PCL and SCID diagnoses at these thresholds (area under curve [AUC] = 0.69-0.79). AUC was considerably higher for continuous than dichotomous screening scale scores (AUC = 0.80-0.90), arguing for substantive analyses using not only dichotomous case designations but also continuous measures of predicted probabilities of clinical diagnoses.
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Affiliation(s)
| | - Patcho N. Santiago
- Center for the Study of Traumatic Stress, Department of PsychiatryUniformed Services University of the Health SciencesBethesdaMDUSA
| | | | - Catherine L. Dempsey
- Center for the Study of Traumatic Stress, Department of PsychiatryUniformed Services University of the Health SciencesBethesdaMDUSA
| | - Michael B. First
- Department of PsychiatryColumbia UniversityNew YorkUSA
- New York State Psychiatric InstituteNew YorkUSA
| | | | - Murray B. Stein
- Departments of Psychiatry and Family and Preventive MedicineUniversity of California San DiegoLa JollaCAUSA
- VA San Diego Healthcare SystemSan DiegoCAUSA
| | - Carol S. Fullerton
- Center for the Study of Traumatic Stress, Department of PsychiatryUniformed Services University of the Health SciencesBethesdaMDUSA
| | | | - James A. Naifeh
- Center for the Study of Traumatic Stress, Department of PsychiatryUniformed Services University of the Health SciencesBethesdaMDUSA
| | | | - Nancy A. Sampson
- Department of Health Care PolicyHarvard Medical SchoolBostonMAUSA
| | | | | | - Robert J. Ursano
- Center for the Study of Traumatic Stress, Department of PsychiatryUniformed Services University of the Health SciencesBethesdaMDUSA
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Stein MB, Ursano RJ. Suicide among United States military personnel: determining the root causes. Depress Anxiety 2013; 30:896-7. [PMID: 24108488 DOI: 10.1002/da.22196] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Murray B Stein
- Departments of Psychiatry and Family & Preventive Medicine, University of California San Diego and VA San Diego Healthcare System
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Kaplow JB, Layne CM, Saltzman WR, Cozza SJ, Pynoos RS. Using multidimensional grief theory to explore the effects of deployment, reintegration, and death on military youth and families. Clin Child Fam Psychol Rev 2013; 16:322-40. [PMID: 23760905 PMCID: PMC4651441 DOI: 10.1007/s10567-013-0143-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
To date, the US military has made major strides in acknowledging and therapeutically addressing trauma and post-traumatic stress disorder (PTSD) in service members and their families. However, given the nature of warfare and high rates of losses sustained by both military members (e.g., deaths of fellow unit members) and military families (e.g., loss of a young parent who served in the military), as well as the ongoing threat of loss that military families face during deployment, we propose that a similar focus on grief is also needed to properly understand and address many of the challenges encountered by bereaved service members, spouses, and children. In this article, we describe a newly developed theory of grief (multidimensional grief theory) and apply it to the task of exploring major features of military-related experiences during the phases of deployment, reintegration, and the aftermath of combat death--especially as they impact children. We also describe implications for designing preventive interventions during each phase and conclude with recommended avenues for future research. Primary aims are to illustrate: (1) the indispensable role of theory in guiding efforts to describe, explain, predict, prevent, and treat maladaptive grief in military service members, children, and families; (2) the relevance of multidimensional grief theory for addressing both losses due to physical death as well as losses brought about by extended physical separations to which military children and families are exposed during and after deployment; and (3) a focus on military-related grief as a much-needed complement to an already-established focus on military-related PTSD.
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Affiliation(s)
- Julie B Kaplow
- Department of Psychiatry and Depression Center, University of Michigan, Rachel Upjohn Building, 4250 Plymouth Road, Ann Arbor, MI 48109-5765, USA.
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