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

Adjustment disorder in the Armed Forces: a systematic review

BACKGROUND

In the UK military, adjustment disorder (AjD) is reported as one of the most diagnosed mental disorders, alongside depression, in personnel presenting to mental health services. Despite this, little is understood about what may predict AjD, common treatment or outcomes for this population.

AIM

The systematic review aimed to summarise existing research for AjD in Armed Forces (AF) populations, including prevalence and risk factors, and to outline clinical and occupational outcomes.

METHOD

A literature search was conducted in December 2020 to identify research that investigated AjD within an AF population (serving or veteran) following the PRISMA guidelines.

RESULTS

Eighty-three studies were included in the review. The AjD prevalence estimates in AF populations with a mental disorder was considerably higher for serving AF personnel (34.9%) compared to veterans (12.8%). Childhood adversities were identified as a risk factor for AjD. AjD was found to increase the risk of suicidal ideation, with one study reporting a risk ratio of 4.70 (95% Confidence Interval: 3.50-6.20). Talking therapies were the most common treatment for AjD, however none reported on treatment effectiveness.

CONCLUSION

This review found that AjD was commonly reported across international AF. Despite heterogeneity in the results, the review identifies several literature gaps.

The Role of Past Suicidal Behavior on Current Suicidality: A Retrospective Study in the Israeli Military

Past suicide attempts are a significant risk factor for future suicidality. Therefore, the present military-based study examined the past suicidal behavior of soldiers who recently made a severe suicide attempt. Our sample consisted of 65 active-duty soldiers (61.5% males), between the ages of 18 and 28 years old (M = 20.4, SD ± 1.3). The inclusion criterion was a recent severe suicide attempt, requiring at least a 24 h hospitalization. This sample was divided into two groups, according to previous suicidal behavior, namely whether their first suicide attempt was before or after enlistment (n = 25; 38.5% and n = 40; 61.5%, respectively). We then examined the lethality and intent of the recent event in regard to this division. Four measures were used to assess the subjects' suicidal characteristics: the Columbia Suicide Severity Rating Scale, the Self-Harm Behavior Questionnaire, the Suicidal Behaviors Questionnaire-Revised, and the Beck Scale for Suicide Ideation. No significant difference in the severity of the suicide attempts (either actual or potential severity) were found between those who had suicide attempts before enlistment and those who had their first attempt in the service. As a matter of fact, most of the suicide attempts that occurred for the first time during military service had used a violent method (58.3%, n = 21). Finally, using multivariate analyses, we found that current thoughts and behavior, rather than past suicidality, was the strongest predictor for the lethality of suicide attempts.

Suicide among Ethiopian origin soldiers in the IDF - A qualitative view of risk factors, triggers, and life circumstances

BACKGROUND

Ethiopian soldiers in the IDF comprise an at-risk group for suicide. The study investigated the unique characteristics of these soldiers, compared with other suicides in the Israel Defense Forces (IDF).

METHOD

The research group included all (n = 36) male soldiers born an Ethiopian family, who died by suicide during their compulsory military service in the years 1990-2017. The control group included all (n = 55) non-Ethiopian soldiers who died by suicide during their military service in the years 2009-2013. Socio-demographic, military-service, and suicide-related variables were examined.

RESULTS

Logistic regression analysis revealed that risk for suicide among Ethiopian soldiers were being incarcerated in a military prison, belonging to a bereaved family, seniority in the military service, and avoidance of help-seeking (explaining 87.8% of the variance).

DISCUSSION

Ethiopian suicide soldiers have endured heavy environmental pressure, such as financial problems and family bereavement. These circumstances could lead to conflict with the soldier's military service, resulting in absence from service or even imprisonment. When the Ethiopian soldier's distress goes un-expressed in words or actions with others, the psychological crisis signs remain unapparent to those around him, and the risk for eventual suicide is high.

LIMITATIONS

The case analysis did not include retrieving information from family and relatives outside the military but was derived from archived material, collected primarily for legal purposes. This limitation was addressed by assembling objective variables and information collected prior to the suicide, along with post-mortem information collected by mental health personnel in their assessments.

Correlations between interpersonal and cognitive difficulties: Relationship to suicidal ideation in military suicide attempters

Background

Understanding suicidal ideation may help develop more effective suicide screening and intervention programs. The interpersonal and the cognitive-deficit theories seek to describe the factors leading to suicidal behavior. In the military setting it is common to find over- and under-reporting of suicidal ideation. This study sought to determine the relationship between these two models and determine to what degree their components can indirectly predict suicidal ideation.

Methods

Suicide attempters (n = 32) were compared with non-suicidal psychologically treated peers (n = 38) and controls (n = 33), matched for sex and age (mean 19.7 years). Pearson's analysis was used to quantify the relationship between the variables from the two models and hierarchal regression analysis was used to determine the explanation of suicidal ideation variance by these variables.

Results

Suicide attempters have more difficulties in problem-solving, negative emotion regulation and burdensomeness compared with their peers (P < .001). These variables are all closely correlated with each other and to suicide ideation (r > ± 0.5; P < .001). Prior suicide attempt, loneliness and burdensomeness together explain 65% (P < .001) of the variance in suicidal ideation.

Conclusions

Suicidal ideation is strongly correlated with components of interpersonal and cognitive difficulties. In addition to assessing current suicidal ideation, clinicians should assess past suicide attempt, loneliness and burdensomeness.

Personal and psychiatric characteristics among Druze soldiers attempting suicide during military service

BACKGROUND

A non-fatal suicide attempt is a strong predictor of suicide. This study aimed to examine personal characteristics and psychiatric diagnoses among Druze soldiers who attempted suicide during their military service.

METHOD

The research group (n = 180) included all Druze soldiers who had attempted suicide between the years 2008-2012 (This number encompassed 18.4% of all suicide attempts in the IDF during those years). Three control groups were examined: Jewish soldiers who had attempted suicide (n = 155), and two additional groups comprising Druze and Jewish combat soldiers who had not attempted suicide (n = 5,255 and n = 205,819, respectively).

RESULTS

While Druze soldiers were diagnosed with psychiatric conditions less frequently than their Jewish counterparts, the more prolonged time to diagnosis among Druze may account for increased severity at time of diagnosis, thus increasing the risk of suicide attempt. A multivariate analysis revealed that the odds of a suicide attempt among Druze soldiers were much higher than among Jewish soldiers (OR 20.53; p < .001). In addition, it was found that average and high socioeconomic levels, strong Hebrew language skills, and high intelligence levels were protective factors against attempted suicide (p < .001, R² = 0.217).

LIMITATIONS

The three control groups were samples, while the research group (Druze attempters) consisted of all instances of attempted suicide during the study period. Comparing only samples would have offered less statistical power; therefore, using all the records in the research group improved accuracy.

Depression and impulsiveness among soldiers who died by suicide: A psychological autopsy study

INTRODUCTION

Despite the accumulated knowledge about suicide, suicidal acts remain difficult to predict, and many suicides are acted out impulsively.

METHODS

We performed a psychological autopsy study based on inquiries about the deaths of all male soldiers aged 18-21 years who served in the Israeli army and died by suicide between 2009 and 2013 (n = 69). The study population was first divided into two groups: those who had depressive disorder (n = 31); and those who did not (n = 38). Socio-demographic characteristics of the subjects and the characteristics of the suicidal act were compared. Afterwards, the study population was re-divided by the presence or absence of impulsive personality traits (n = 22, and n = 47, respectively), and investigated for distinct suicidal behavior features.

RESULTS

No significant socio-demographic differences were found between the depressed and non-depressed suicide victims. The depressed group had showed more signs of planning the act (47% vs. 23%), and had expressed suicidal ideation in the days preceding the suicide (51.6% vs. 21%). One third of the subjects were found to have an impulsive personality trait, with significantly more histories of disciplinary issues, violence and cluster B personality disorders. Alcohol use during the act was significantly more prevalent among impulsive than non-impulsive subjects (45.4% vs. 14.9%).

CONCLUSION

Identification of distinct clinical groups of suicide victims among young males might help clinicians evaluate high risk cases, and may provide valuable opportunities to alleviate and prevent these events in the future.

Perceived Stress and Intent to Die in Young Soldiers Who Attempt Suicide

Abstract. Background: Intent to die is an important component of suicide risk assessment. The authors compared the predictive effect of two forms of stress – military and perceived – in intent to die by suicide among young adult Israeli soldiers with a history of suicide attempts. Depression, suicide ideation, and habituation/acquired capacity for suicidality served as covariates. Methods: Participants were 60 young adult soldiers in the Israeli Defense Force (ISF; aged 18–21 years), who made a suicide attempt during their military service. Study variables were assessed using self-report measures. Results: Intent to die by suicide correlated with suicide ideation, habituation/acquired capacity, depressive symptoms, and perceived stress. In a multiple regression analysis, perceived stress predicted intent to die (b = .44, p = .002) over and above the prediction by suicide ideation (b = .42, p = .013) and acquired capacity/habituation (b = .28, p = .023). Limitations: The cross-sectional design restricts causal inference. In addition, an exclusive reliance on self-report measures might have inflated shared method variance. Conclusions: Perceived stress captures a unique dimension of intent to die by suicide among young suicide attempters.

The contribution of the socio-demographic characteristics on suicidal ideation among Israeli soldiers

Background

Suicidal ideation is a risk factor for suicide attempt. The aim of the present study is to compare suicidal ideation of different groups with different distress.

Methods

100 soldiers, aged 18–21, divided into four research cohorts: soldiers who had carried out a suicide attempt (n = 40); soldiers with a psychiatric diagnosis (n = 20); soldiers having high severity adjustment difficulties (n = 20); and a control group of soldiers, having neither a history of mental health diagnosis, nor adjustment difficulties (n = 20). All completed the suicide ideation scale.

Results

Half of the attempters had a psychiatric diagnosis (depression or anxiety) on the day of their enlistment and 37.5 % of them had a specified personality disturbance. The attempters were characterized by previously-attempted suicide (p < .01). The lowest mean values (M = 1.95, SD = .67) were among the attempter (F = 3.173, df = 3, p = .02) in motivation for military service. The variable expressing low motivation for military service was the sole predictor of suicide ideation (p = .032).

Conclusions

Early diagnosis facilitated better monitoring by military mental health officers.

Dissociation and acquired capability as facilitators of suicide ideation among soldiers

BACKGROUND

The phenomenon of suicide and suicidal behaviors during military service is universal, with a recent dramatic rise in some armies.

AIMS

The aim of this study was to shed light on the role of dissociation and habituation as facilitators of suicidal behavior, beyond other well-established risk factors of stress, such as depression and hopelessness.

METHOD

The study group included 167 soldiers, aged 18-21 years divided into three research groups: soldiers who made suicide attempts, soldiers who were psychologically treated, and a control group of soldiers having no history of mental health treatment. All subjects completed a suicide ideation scale and instruments measuring stress, mental pain, bodily dissociation, and habituation.

RESULTS

Suicide attempters had higher levels of subjective stress as well as depression and hopelessness compared with the psychologically treated and control groups. Using regression analysis, suicide facilitators of dissociation and habituation explained a significant proportion of the suicidal ideation variance, above and beyond the contribution of stress, depression, and hopelessness. A combined effect of stress and facilitating factors amplifies the level of suicidal ideation among soldiers.

CONCLUSION

Identifying psychological facilitators of suicide-like dissociation and habituation may contribute to understanding suicidal behavior in soldiers and assist in developing effective suicide-prevention initiatives in the military setting.

Risk factors for suicide attempt among Israeli Defense Forces soldiers: A retrospective case-control study

BACKGROUND

A major risk factor for suicide is suicide attempts. The aim of the present study was to assess risk factors for nonfatal suicide attempts. Methods The study's cohort consisted of 246,814 soldiers who were divided into two groups: soldiers who made a suicide attempt (n=2310; 0.9%) and a control group of soldiers who did not (n=244,504; 99.1%). Socio-demographic and personal characteristics as well as psychiatric diagnoses were compared. Results The strongest risk factors for suicide attempt were serving less than 12 months (RR=7.09) and a history of unauthorized absence from service (RR=5.68). Moderate risk factors were low socioeconomic status (RR=2.17), psychiatric diagnoses at induction (RR=1.94), non-Jewish religion (RR=1.92), low intellectual rating score (RR=1.84), serving in non-combat unit (RR=1.72) and being born in the former Soviet Union (RR=1.61). A weak association was found between male gender and suicide attempt (RR=1.36). Soldiers who met more frequently with a primary care physician (PCP) had a higher risk for suicide attempt, as opposed to a mental health professional (MHCP), where frequent meetings were found to be a protective factor (P<0.0001). The psychiatric diagnoses associated with a suicide attempt were a cluster B personality disorder (RR=3.00), eating disorders (RR=2.78), mood disorders (RR=2.71) and adjustment disorders (RR=2.26).

LIMITATIONS

Mild suicidal behavior constitutes a much larger proportion than among civilians and may have secondary gain thus distorting the suicidal behavior data.

CONCLUSIONS

Training primary care physicians as gatekeepers and improved monitoring, may reduce the rate of suicide attempts.

Mental Disorders, Comorbidity, and Pre-enlistment Suicidal Behavior Among New Soldiers in the U.S. Army: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

We examined the associations between mental disorders and suicidal behavior (ideation, plans, and attempts) among new soldiers using data from the New Soldier Study (NSS) component of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS; N = 38,507). Most new soldiers with a pre-enlistment history of suicide attempt reported a prior mental disorder (59.0%). Each disorder examined was associated with increased odds of suicidal behavior (ORs = 2.6-8.6). Only PTSD and disorders characterized by irritability and impulsive/aggressive behavior (i.e., bipolar disorder, conduct disorder, oppositional defiant disorder, and attention-deficit/hyperactivity disorder) predicted unplanned attempts among ideators. Mental disorders are important predictors of pre-enlistment suicidal behavior among new soldiers and should figure prominently in suicide screening and prevention efforts.

Emotional regulation of mental pain as moderator of suicidal ideation in military settings

BACKGROUND

In the Israel Defense Forces (IDF) as well as in most armies throughout the world, the leading cause of death during peace-time is suicide. This study examines emotional regulation of mental pain as a contributor to suicidal ideation in soldiers.

METHODS

One hundred sixty-eight IDF soldiers (aged 18-21years, 59% males) completed the following self-report questionnaires: Scale for Suicide Ideation (SSI); Orbach & Mikulincer Mental Pain Scale (OMMP); and Emotional Regulation of Mental Pain questionnaire. Participants were divided into 3 groups: soldiers who attempted suicide (AS group, n=58), soldiers under treatment by a mental health professional and reporting no suicidal behavior (PT group, n=58), and controls (C group, n=50).

RESULTS

Suicide ideation, mental pain, and low emotional regulation were significantly higher in the suicidal group as compared to the two other groups (P<0.001). Mental pain was significantly related to more suicide ideation in soldiers with low ability to regulate mental pain (P<.001 for the interaction).

CONCLUSION

Emotional regulation of mental pain moderates the link between mental pain and suicide ideation. Soldiers with high mental pain and low regulation of mental pain exhibited higher suicidal ideation. These findings may assist in planning prevention programs in the army and similar settings.

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.