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Kennedy CJ, Kearns JC, Geraci JC, Gildea SM, Hwang IH, King AJ, Liu H, Luedtke A, Marx BP, Papini S, Petukhova MV, Sampson NA, Smoller JW, Wolock CJ, Zainal NH, Stein MB, Ursano RJ, Wagner JR, Kessler RC. Predicting Suicides Among US Army Soldiers After Leaving Active Service. JAMA Psychiatry 2024:2824097. [PMID: 39320863 DOI: 10.1001/jamapsychiatry.2024.2744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/26/2024]
Abstract
Importance The suicide rate of military servicemembers increases sharply after returning to civilian life. Identifying high-risk servicemembers before they leave service could help target preventive interventions. Objective To develop a model based on administrative data for regular US Army soldiers that can predict suicides 1 to 120 months after leaving active service. Design, Setting, and Participants In this prognostic study, a consolidated administrative database was created for all regular US Army soldiers who left service from 2010 through 2019. Machine learning models were trained to predict suicides over the next 1 to 120 months in a random 70% training sample. Validation was implemented in the remaining 30%. Data were analyzed from March 2023 through March 2024. Main outcome and measures The outcome was suicide in the National Death Index. Predictors came from administrative records available before leaving service on sociodemographics, Army career characteristics, psychopathologic risk factors, indicators of physical health, social networks and supports, and stressors. Results Of the 800 579 soldiers in the cohort (84.9% male; median [IQR] age at discharge, 26 [23-33] years), 2084 suicides had occurred as of December 31, 2019 (51.6 per 100 000 person-years). A lasso model assuming consistent slopes over time discriminated as well over all but the shortest risk horizons as more complex stacked generalization ensemble machine learning models. Test sample area under the receiver operating characteristic curve ranged from 0.87 (SE = 0.06) for suicides in the first month after leaving service to 0.72 (SE = 0.003) for suicides over 120 months. The 10% of soldiers with highest predicted risk accounted for between 30.7% (SE = 1.8) and 46.6% (SE = 6.6) of all suicides across horizons. Calibration was for the most part better for the lasso model than the super learner model (both estimated over 120-month horizons.) Net benefit of a model-informed prevention strategy was positive compared with intervene-with-all or intervene-with-none strategies over a range of plausible intervention thresholds. Sociodemographics, Army career characteristics, and psychopathologic risk factors were the most important classes of predictors. Conclusions and relevance These results demonstrated that a model based on administrative variables available at the time of leaving active Army service can predict suicides with meaningful accuracy over the subsequent decade. However, final determination of cost-effectiveness would require information beyond the scope of this report about intervention content, costs, and effects over relevant horizons in relation to the monetary value placed on preventing suicides.
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Affiliation(s)
- Chris J Kennedy
- Department of Psychiatry, Massachusetts General Hospital, Boston
| | - Jaclyn C Kearns
- National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts
| | - Joseph C Geraci
- Transitioning Servicemember/Veteran and Suicide Prevention Center (TASC), VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
- Center of Excellence for Research on Returning War Veterans, VISN 17, Doris Miller VA Medical Center, Waco, Texas
- Resilience Center for Veterans & Families, Teachers College, Columbia University, New York, New York
| | - Sarah M Gildea
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Irving H Hwang
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Andrew J King
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Howard Liu
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Alex Luedtke
- Department of Statistics, University of Washington, Seattle
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Brian P Marx
- National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts
| | - Santiago Papini
- College of Social Sciences, University of Hawai'i at Mānoa, Honolulu
| | - Maria V Petukhova
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Nancy A Sampson
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Jordan W Smoller
- Psychiatric and Neurodevelopmental Genetics Unit, Center for Genomic Medicine, Massachusetts General Hospital, Boston
| | - Charles J Wolock
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia
| | - Nur Hani Zainal
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Murray B Stein
- Department of Psychiatry, University of California San Diego, La Jolla
- School of Public Health, University of California San Diego, La Jolla
- VA San Diego Healthcare System, La Jolla, California
| | - Robert J Ursano
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - James R Wagner
- Institute for Social Research, University of Michigan, Ann Arbor
| | - Ronald C Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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2
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Edwards E, Osterberg T, Coolidge B, Greene AL, Epshteyn G, Gorman D, Ruiz D, El-Meouchy P. Military experiences, connection to military identity, and time since military discharge as predictors of United States veteran suicide risk. MILITARY PSYCHOLOGY 2024; 36:465-478. [PMID: 37204335 PMCID: PMC11407380 DOI: 10.1080/08995605.2023.2209006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 04/12/2023] [Indexed: 05/20/2023]
Abstract
Veterans navigating the military-to-civilian transition appear at elevated risk for suicide. However, research on the transition-suicide association often fails to consider co-occurring risk factors. The independent association of time since military discharge and suicide among veterans therefore remains unclear. Data from 1,495 post-Vietnam community veterans provided estimates of suicide risk, military-based stressful experiences, connection to military identity, and recency of military discharge. Hierarchical regression analyses examined independent, incremental utility of factors associated with suicide risk after controlling for quality of life, age, and duration of military service among the total veteran sample and a subsample discharged from military service within five years prior. The resulting model explained 41% of variance in suicide risk in the total veteran sample and 51% of variance in suicide risk in the recently discharged subsample. Recency of discharge, combat exposure, moral injury, poor quality of life, and poor psychological wellness showed statistically significant, independent associations with suicide risk, whereas connection to military identity did not show significant, independent associations. Results highlight the salience of the military-to-civilian transition as an independent risk factor for veteran suicide even after controlling for military-based stressful experiences, military identity, quality of life, age, and service duration.
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Affiliation(s)
- Emily Edwards
- Department of Veterans Affairs, VISN 2 MIRECC, Bronx, New York
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Terra Osterberg
- Department of Veterans Affairs, VISN 2 MIRECC, Bronx, New York
| | - Brettland Coolidge
- Department of Veterans Affairs, VISN 2 MIRECC, Bronx, New York
- Department of Psychology, University of Central Florida, Orlando, Florida
| | - Ashley L Greene
- Department of Veterans Affairs, VISN 2 MIRECC, Bronx, New York
- Department of Psychiatry, Icahn School of Medicine, New York, New York
| | - Gabriella Epshteyn
- Department of Veterans Affairs, VISN 2 MIRECC, Bronx, New York
- Department of Psychology, University of Rhode Island, Kingston, Rhode Island
| | - Daniel Gorman
- Department of Veterans Affairs, VISN 2 MIRECC, Bronx, New York
| | - Danny Ruiz
- Department of Veterans Affairs, VISN 2 MIRECC, Bronx, New York
| | - Paul El-Meouchy
- Department of Veterans Affairs, VISN 2 MIRECC, Bronx, New York
- Department of Psychology, Fielding Graduate University, Santa Barbara, California
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Levin C, Nenninger S, Freundlich D, Glatt S, Sokol Y. How future self-continuity mediates the impact of job loss on negative mental health outcomes among transitioning veterans. MILITARY PSYCHOLOGY 2024; 36:491-503. [PMID: 37252891 PMCID: PMC11407375 DOI: 10.1080/08995605.2023.2215697] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 05/10/2023] [Indexed: 06/01/2023]
Abstract
Veterans in the transition stage out of the military have an increased risk for negative mental health outcomes and suicide. Previous research has found that finding and retaining employment is the most challenging post-service adjustment for veterans. Job loss may have a greater impact on mental health for veterans than for civilians due to the myriad challenges often faced when transitioning to the civilian workplace, as well as preexisting vulnerabilities that are common among veterans such as trauma exposure or service-related injuries. Previous studies have demonstrated that low Future Self-Continuity (FSC), which refers to the sense of "psychological connectedness" that a person has between their present and future selves, has also been associated with the abovementioned mental health outcomes. 167 U.S. military veterans who exited the military 10 or fewer years prior to their participation in the study, of which 87 experienced subsequent job loss, completed a series of questionnaires to assess future self-continuity (FSC) and mental health outcomes. Results confirmed previous findings in that job loss, as well as low FSC, were individually associated with an increased risk for negative mental health outcomes. Findings suggest that FSC may act as a mediator, where levels of FSC mediate the effects of job loss on negative mental outcomes (depression, anxiety, stress, and suicidality) among veterans during their first 10 years out of the military. These findings may have implications for enhancing current clinical interventions for veterans experiencing job loss and mental health difficulties during the transition period.
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Affiliation(s)
- Chynna Levin
- VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York
| | | | - Devora Freundlich
- VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York
| | - Sofie Glatt
- VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York
| | - Yosef Sokol
- VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York
- Department of Psychology, School of Health Sciences, Touro University, New York, New York
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4
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Sher L, Bierer LM, Flory J, Makotkine I, Yehuda R. Interplay of combat deployment harassment, testosterone concentrations and post-deployment suicide risk in male veterans. Acta Neuropsychiatr 2024; 36:167-171. [PMID: 38528804 DOI: 10.1017/neu.2024.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
OBJECTIVE Many combat veterans exhibit suicidal ideation and behaviour, but the relationships among experiences occurring during combat deployment and suicidality are still not fully understood. In this study, we tested the hypothesis that harassment during a combat deployment is associated with post-deployment suicidality and testosterone function. METHODS Male combat veterans who made post-deployment suicide attempts and demographically matched veterans without a history of suicide attempts were enrolled in the study. Demographic and clinical parameters of study participants were assessed and recorded. Study participants were interviewed by a trained clinician using the Mini-International Neuropsychiatric Interview (MINI), the Deployment Risk and Resilience Inventory (DRRI) – Relationships within unit scale, the Scale for Suicidal Ideation (SSI), and the Brown–Goodwin Aggression Scale. Free testosterone levels were assessed in morning blood samples. RESULTS DRRI harassment scores were higher and free testosterone levels were lower among suicide attempters in comparison with non-attempters. In the whole sample, DRRI harassment scores positively correlated with SSI scores and negatively correlated with free testosterone levels. Free testosterone levels negatively correlated with SSI scores. Aggression scale scores positively correlated with DRRI harassment scores among non-attempters but not among attempters. CONCLUSION Our observations that harassment scores are associated with suicidality and testosterone levels, and suicidality is associated with testosterone levels may indicate that there is a link between deployment harassment, testosterone function and suicidality.
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Affiliation(s)
- Leo Sher
- James J. Peters VA Medical Center, New York, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Linda M Bierer
- James J. Peters VA Medical Center, New York, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Janine Flory
- James J. Peters VA Medical Center, New York, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Iouri Makotkine
- James J. Peters VA Medical Center, New York, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Rachel Yehuda
- James J. Peters VA Medical Center, New York, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, USA
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5
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Jamieson SK, Cerel J, Maple M. Impacts of exposure to suicide of a military colleague from the lived experience of veterans: Informing postvention responses from a military cultural perspective. DEATH STUDIES 2024; 48:688-697. [PMID: 38212987 DOI: 10.1080/07481187.2023.2261408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
Although exposure to the suicide death of a military colleague has been shown quantitatively to increase suicide risk factors among veterans, there are very few studies where veterans have been asked about this experience. This article presents a qualitative analysis of 38 interviews with U.S. veterans with exposure to the suicide death of a military colleague in past war operations. Participants described the impact of exposure in relation to the military context and official response to the death, which had long-term ramifications. Our findings suggest suicide prevention and postvention responses for veterans should be informed by the lived experience of veterans, including those for whom this experience occurred significantly in the past, as the impacts of different military policies and practices in response to suicide deaths over time are relevant to the impact of exposure to death of a military colleague in the short and long term.
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Affiliation(s)
- Sacha Kendall Jamieson
- Sydney School of Education and Social Work, The University of Sydney, Sydney, Australia
- School of Health, University of New England, Armidale, Australia
| | - Julie Cerel
- Suicide Prevention & Exposure Lab (SPEL), College of Social Work, University of Kentucky, Lexington, KY, USA
| | - Myfanwy Maple
- School of Health, University of New England, Armidale, Australia
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6
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Kearns JC, Edwards ER, Finley EP, Geraci JC, Gildea SM, Goodman M, Hwang I, Kennedy CJ, King AJ, Luedtke A, Marx BP, Petukhova MV, Sampson NA, Seim RW, Stanley IH, Stein MB, Ursano RJ, Kessler RC. A practical risk calculator for suicidal behavior among transitioning U.S. Army soldiers: results from the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS). Psychol Med 2023; 53:7096-7105. [PMID: 37815485 PMCID: PMC10575670 DOI: 10.1017/s0033291723000491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
BACKGROUND Risk of suicide-related behaviors is elevated among military personnel transitioning to civilian life. An earlier report showed that high-risk U.S. Army soldiers could be identified shortly before this transition with a machine learning model that included predictors from administrative systems, self-report surveys, and geospatial data. Based on this result, a Veterans Affairs and Army initiative was launched to evaluate a suicide-prevention intervention for high-risk transitioning soldiers. To make targeting practical, though, a streamlined model and risk calculator were needed that used only a short series of self-report survey questions. METHODS We revised the original model in a sample of n = 8335 observations from the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS) who participated in one of three Army STARRS 2011-2014 baseline surveys while in service and in one or more subsequent panel surveys (LS1: 2016-2018, LS2: 2018-2019) after leaving service. We trained ensemble machine learning models with constrained numbers of item-level survey predictors in a 70% training sample. The outcome was self-reported post-transition suicide attempts (SA). The models were validated in the 30% test sample. RESULTS Twelve-month post-transition SA prevalence was 1.0% (s.e. = 0.1). The best constrained model, with only 17 predictors, had a test sample ROC-AUC of 0.85 (s.e. = 0.03). The 10-30% of respondents with the highest predicted risk included 44.9-92.5% of 12-month SAs. CONCLUSIONS An accurate SA risk calculator based on a short self-report survey can target transitioning soldiers shortly before leaving service for intervention to prevent post-transition SA.
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Affiliation(s)
- Jaclyn C. Kearns
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | - Emily R. Edwards
- Transitioning Servicemember/Veteran And Suicide Prevention Center (TASC), VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Erin P. Finley
- Center of Excellence for Research on Returning War Veterans, VISN 17, Doris Miller VA Medical Center, Waco, TX, USA
- Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Joseph C. Geraci
- Transitioning Servicemember/Veteran And Suicide Prevention Center (TASC), VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Center of Excellence for Research on Returning War Veterans, VISN 17, Doris Miller VA Medical Center, Waco, TX, USA
- Resilience Center for Veterans & Families, Teachers College, Columbia University, New York, NY, USA
| | - Sarah M. Gildea
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Marianne Goodman
- Transitioning Servicemember/Veteran And Suicide Prevention Center (TASC), VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA
- Center of Excellence for Research on Returning War Veterans, VISN 17, Doris Miller VA Medical Center, Waco, TX, USA
| | - Irving Hwang
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Chris J. Kennedy
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew J. King
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Alex Luedtke
- Department of Statistics, University of Washington, Seattle, WA, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Brian P. Marx
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | - Maria V. Petukhova
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Nancy A. Sampson
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Richard W. Seim
- Center of Excellence for Research on Returning War Veterans, VISN 17, Doris Miller VA Medical Center, Waco, TX, USA
| | - Ian H. Stanley
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO USA
- Center for COMBAT Research, Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Murray B. Stein
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
- School of Public Health, University of California San Diego, La Jolla, CA, USA
- VA San Diego Healthcare System, La Jolla, CA, USA
| | - Robert J. Ursano
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
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Sokol Y, Andrusier S, Glatt S, Dixon L, Ridley J, Brown CH, Landa Y, Glynn S, Goodman M. Feasibility and acceptability of continuous identity cognitive therapy as a recovery-oriented suicide treatment for Veterans: A study protocol. Contemp Clin Trials Commun 2023; 35:101193. [PMID: 37546228 PMCID: PMC10400862 DOI: 10.1016/j.conctc.2023.101193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/29/2023] [Accepted: 07/15/2023] [Indexed: 08/08/2023] Open
Abstract
Background Suicide is a leading cause of death among Veterans, with rates significantly higher than the general population. To address this issue, it is crucial to develop and implement more effective treatments for Veterans with suicidal thoughts and/or behaviors, particularly those in the post-acute suicidal episode (PASE) stage. The present study aims to establish the feasibility and acceptability of a novel, recovery-oriented treatment called Continuous Identity Cognitive Therapy (CI-CT) for PASE Veterans. Methods This 3-year open-label pilot study will include three one-arm trials and a pilot randomized controlled trial (RCT). A total of 57 Veterans with a history of an acute suicidal episode within the previous year will be recruited. Primary outcome measures will include changes in personal recovery, suicidal thoughts, and behaviors. Secondary outcomes will include changes in self-identity, life satisfaction, and hopefulness. Feasibility and acceptability will be assessed through attendance and retention rates, drop-out rates, and client satisfaction. Conclusion This study aims to develop and evaluate the feasibility and acceptability of a novel recovery-oriented intervention for Veterans experiencing PASE. If the intervention is found to be feasible and acceptable, a manualized version will be finalized and a large-scale multi-site RCT will be designed to assess its clinical efficacy on a broader Veteran population. The results of this trial will aid in the development of effective treatment and provide valuable insights into the preliminary feasibility, acceptability, and effectiveness of this approach in reducing suicidal thoughts and behaviors and promoting recovery and rehabilitation in this population.
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Affiliation(s)
- Yosef Sokol
- VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA
- Department of Psychology, Touro University, School of Health Sciences, New York, NY, USA
| | - Sarah Andrusier
- VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA
| | - Sofie Glatt
- VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA
| | - Lisa Dixon
- New York State Psychiatric Institute, New York, NY, USA
- Vagelos College of Physicians and Surgeons, Columbia University/New York-Presbyterian, New York, NY, USA
| | - Josephine Ridley
- Department of Psychological Sciences, Case Western Reserve University, Cleveland, OH, USA
- Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH, USA
| | - Clayton H. Brown
- Department of Epidemiology and Public Health, School of Medicine, University of Maryland, Baltimore, MD, USA
- Veterans Affairs Capitol Healthcare Network, Mental Illness Research, Education and Clinical Center, Baltimore, MD, USA
| | - Yulia Landa
- VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shirley Glynn
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, USA
- VISN 22 Mental Illness Research, Education and Clinical Center, Los Angeles, CA, USA
| | - Marianne Goodman
- VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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8
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Sayer NA, Nelson DB, Gradus JL, Sripada RK, Murdoch M, Teo AR, Orazem RJ, Cerel J. The Effects of Suicide Exposure on Mental Health Outcomes Among Post-9/11 Veterans: Protocol for an Explanatory, Sequential, Mixed Methods Study. JMIR Res Protoc 2023; 12:e51324. [PMID: 37751271 PMCID: PMC10565621 DOI: 10.2196/51324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 08/11/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND The toll associated with suicide goes well beyond the individual who died. This study focuses on a risk factor for veteran suicide that has received little previous empirical attention-exposure to the suicide death of another person. OBJECTIVE The study's primary objective is to describe the mental health outcomes associated with suicide exposure among veterans who served on active duty after September 2001 ("post-9/11"). The secondary objective is to elucidate why some veterans develop persistent problems following suicide exposure, whereas others do not. METHODS This is an explanatory, sequential, mixed methods study of a nationally representative sample of post-9/11 veterans enrolled in Department of Veterans Affairs (VA) health care. Our sampling strategy was designed for adequate representation of female and American Indian and Alaska Native veterans to allow for examination of associations between suicide exposure and outcomes within these groups. Primary outcomes comprise mental health problems associated with trauma and loss (posttraumatic stress disorder and prolonged grief disorder) and suicide precursors (suicidal ideation, attempts, and planning). Data collection will be implemented in 3 waves. During wave 1, we will field a brief survey to a national probability sample to assess exposure history (suicide, other sudden death, or neither) and exposure characteristics (eg, closeness with the decedent) among 11,400 respondents. In wave 2, we will include 39.47% (4500/11,400) of the wave-1 respondents, stratified by exposure history (suicide, other sudden death, or neither), to assess health outcomes and other variables of interest. During wave 3, we will conduct interviews with a purposive subsample of 32 respondents exposed to suicide who differ in mental health outcomes. We will supplement the survey and interview data with VA administrative data identifying diagnoses, reported suicide attempts, and health care use. RESULTS The study began on July 1, 2022, and will end on June 30, 2026. This is the only national, population-based study of suicide exposure in veterans and the first one designed to study differences based on sex and race. Comparing those exposed to suicide with those exposed to sudden death for reasons other than suicide (eg, combat) and those unexposed to any sudden death may allow for the identification of the common and unique contribution of suicide exposure to outcomes and help seeking. CONCLUSIONS Integrating survey, qualitative, and VA administrative data to address significant knowledge gaps regarding the effects of suicide exposure in a national sample will lay the foundation for interventions to address the needs of individuals affected by a suicide death, including female and American Indian and Alaska Native veterans. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/51324.
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Affiliation(s)
- Nina A Sayer
- Center for Care Delivery and Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, United States
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, United States
- Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - David B Nelson
- Center for Care Delivery and Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, United States
- Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Jaimie L Gradus
- Department of Epidemiology, School of Public Health, Boston University, Boston, MA, United States
| | - Rebecca K Sripada
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Maureen Murdoch
- Center for Care Delivery and Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, United States
- Department of Medicine, University of Minnesota, Minneapolis, MN, United States
- Section of General Internal Medicine, Minneapolis VA Health Care System, Minneapolis, MN, United States
| | - Alan R Teo
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, United States
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, United States
| | - Robert J Orazem
- Center for Care Delivery and Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, United States
| | - Julie Cerel
- College of Social Work, University of Kentucky, Lexington, KY, United States
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9
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Rodway C, Ibrahim S, Westhead J, Bojanić L, Turnbull P, Appleby L, Bacon A, Dale H, Harrison K, Kapur N. Suicide after leaving the UK Armed Forces 1996-2018: A cohort study. PLoS Med 2023; 20:e1004273. [PMID: 37552686 PMCID: PMC10409259 DOI: 10.1371/journal.pmed.1004273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 07/06/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND There are comparatively few international studies investigating suicide in military veterans and no recent UK-wide studies. This is important because the wider context of being a UK Armed Forces (UKAF) veteran has changed in recent years following a period of intensive operations. We aimed to investigate the rate, timing, and risk factors for suicide in personnel who left the UKAF over a 23-year period. METHODS AND FINDINGS We carried out a retrospective cohort study of suicide in personnel who left the regular UKAF between 1996 and 2018 linking national databases of discharged personnel and suicide deaths, using survival analysis to examine the risk of suicide in veterans compared to the general population and conditional logistic regression to investigate factors most strongly associated with suicide after discharge. The 458,058 individuals who left the UKAF accumulated over 5,852,100 person years at risk, with a median length of follow-up of 13 years, were mostly male (91%), and had a median age of 26 years at discharge. 1,086 (0.2%) died by suicide. The overall rate of suicide in veterans was slightly lower than the general population (standardised mortality ratio, SMR [95% confidence interval, CI] 94 [88 to 99]). However, suicide risk was 2 to 3 times higher in male and female veterans aged under 25 years than in the same age groups in the general population (age-specific mortality ratios ranging from 160 to 409). Male veterans aged 35 years and older were at reduced risk of suicide (age-specific mortality ratios 47 to 80). Male sex, Army service, discharge between the ages of 16 and 34 years, being untrained on discharge, and length of service under 10 years were associated with higher suicide risk. Factors associated with reduced risk included being married, a higher rank, and deployment on combat operations. The rate of contact with specialist NHS mental health services (273/1,086, 25%) was lowest in the youngest age groups (10% for 16- to 19-year-olds; 23% for 20- to 24-year-olds). Study limitations include the fact that information on veterans was obtained from administrative databases and the role of pre-service vulnerabilities and other factors that may have influenced later suicide risk could not be explored. In addition, information on contact with support services was only available for veterans in contact with specialist NHS mental health services and not for those in contact with other health and social care services. CONCLUSIONS In this study, we found suicide risk in personnel leaving the UKAF was not high but there are important differences according to age, with higher risk in young men and women. We found a number of factors which elevated the risk of suicide but deployment was associated with lower risk. The focus should be on improving and maintaining access to mental health care and social support for young service leavers, as well as implementing general suicide prevention measures for all veterans regardless of age.
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Affiliation(s)
- Cathryn Rodway
- National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH), Centre for Mental Health and Safety, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Saied Ibrahim
- National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH), Centre for Mental Health and Safety, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Jodie Westhead
- National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH), Centre for Mental Health and Safety, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Lana Bojanić
- National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH), Centre for Mental Health and Safety, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Pauline Turnbull
- National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH), Centre for Mental Health and Safety, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Louis Appleby
- National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH), Centre for Mental Health and Safety, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Andy Bacon
- Armed Forces Team, NHS England, London, United Kingdom
- Westminster Centre for Research in Veterans, University of Chester, Chester, United Kingdom
| | - Harriet Dale
- Ministry of Defence, Defence Statistics Health, Bristol, United Kingdom
| | - Kate Harrison
- Ministry of Defence, Defence Statistics Health, Bristol, United Kingdom
| | - Nav Kapur
- National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH), Centre for Mental Health and Safety, School of Health Sciences, University of Manchester, Manchester, United Kingdom
- NIHR Greater Manchester Patient Safety Research Centre, University of Manchester, Manchester, United Kingdom
- Mersey Care NHS Foundation Trust, Liverpool, United Kingdom
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Naifeh JA, Capaldi VF, Chu C, King AJ, Koh KA, Marx BP, Montgomery AE, O'Brien RW, Sampson NA, Stanley IH, Tsai J, Vogt D, Ursano RJ, Stein MB, Kessler RC. Prospective Associations of Military Discharge Characterization with Post-active Duty Suicide Attempts and Homelessness: Results from the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS). Mil Med 2023; 188:e2197-e2207. [PMID: 35943145 PMCID: PMC10363011 DOI: 10.1093/milmed/usac232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/07/2022] [Accepted: 08/02/2022] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Active duty service members transitioning to civilian life can experience significant readjustment stressors. Over the past two decades of the United States' longest sustained conflict, reducing transitioning veterans' suicidal behavior and homelessness became national priorities. However, it remains a significant challenge to identify which service members are at greatest risk of these post-active duty outcomes. Discharge characterization, which indicates the quality of an individual's military service and affects eligibility for benefits and services at the Department of Veterans Affairs, is a potentially important indicator of risk. MATERIALS AND METHODS This study used data from two self-report panel surveys of the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS) (LS1: 2016-2018, n = 14,508; and LS2: 2018-2019, n = 12,156), which were administered to respondents who previously participated while on active duty in one of the three Army STARRS baseline self-report surveys (2011-2014): the New Soldier Study (NSS), a survey of soldiers entering basic training; All Army Study, a survey of active duty soldiers around the world; and the Pre-Post Deployment Study, a survey of soldiers before and after combat deployment. Human Subjects Committees of the participating institutions approved all recruitment, informed consent, and data collection protocols. We used modified Poisson regression models to prospectively examine the association of discharge characterization (honorable, general, "bad paper" [other than honorable, bad conduct, dishonorable], and uncharacterized [due to separation within the first 180 days of service]) with suicide attempt (subsample of n = 4334 observations) and homelessness (subsample of n = 6837 observations) among those no longer on active duty (i.e., separated or deactivated). Analyses controlled for other suicide attempt and homelessness risk factors using standardized risk indices that were previously developed using the LS survey data. RESULTS Twelve-month prevalence rates of self-reported suicide attempts and homelessness in the total pooled LS sample were 1.0% and 2.9%, respectively. While not associated with suicide attempt risk, discharge characterization was associated with homelessness after controlling for other risk factors. Compared to soldiers with an honorable discharge, those with a bad paper discharge had an increased risk of homelessness in the total sample (relative risk [RR] = 4.4 [95% CI = 2.3-8.4]), as well as within subsamples defined by which baseline survey respondents completed (NSS vs. All Army Study/Pre-Post Deployment Study), whether respondents had been separated (vs. deactivated), and how much time had elapsed since respondents were last on active duty. CONCLUSIONS There is a robust association between receiving a bad paper discharge and post-separation/deactivation homelessness. Policies that enhance transition assistance and access to mental healthcare for high-risk soldiers may aid in reducing post-separation/deactivation homelessness among those who do not receive an honorable discharge.
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Affiliation(s)
- James A Naifeh
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Vincent F Capaldi
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Carol Chu
- Minneapolis VA Health Care System, Minneapolis, MN 55417, USA
- Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN 55454, USA
| | - Andrew J King
- Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, USA
| | - Katherine A Koh
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Boston Health Care for the Homeless Program, Boston, MA 02118, USA
| | - Brian P Marx
- National Center for PTSD, VA Boston Healthcare System, Boston, MA 02130, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA 02118, USA
| | - Ann Elizabeth Montgomery
- Department of Health Behavior, School of Public Health, The University of Alabama at Birmingham, Birmingham, AL 35233, USA
- Birmingham VA Health Care System, Birmingham, AL 35233, USA
| | - Robert W O'Brien
- VA Health Services Research and Development Service, Washington, DC 20571, USA
| | - Nancy A Sampson
- Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, USA
| | - Ian H Stanley
- National Center for PTSD, VA Boston Healthcare System, Boston, MA 02130, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA 02118, USA
| | - Jack Tsai
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06511, USA
- U.S. Department of Veterans Affairs, National Center on Homelessness Among Veterans, Tampa, FL 33637, USA
- University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Dawne Vogt
- National Center for PTSD, VA Boston Healthcare System, Boston, MA 02130, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA 02118, USA
| | - Robert J Ursano
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Murray B Stein
- Department of Psychiatry and School of Public Health, University of California San Diego, La Jolla, CA 92093-0855, USA
- VA San Diego Healthcare System, San Diego, CA 92161, USA
| | - Ronald C Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, USA
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11
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Chu C, Stanley IH, Marx BP, King AJ, Vogt D, Gildea SM, Hwang IH, Sampson NA, O’Brien R, Stein MB, Ursano RJ, Kessler RC. Associations of vulnerability to stressful life events with suicide attempts after active duty among high-risk soldiers: results from the Study to Assess Risk and Resilience in Servicemembers-longitudinal study (STARRS-LS). Psychol Med 2023; 53:4181-4191. [PMID: 35621161 PMCID: PMC9701247 DOI: 10.1017/s0033291722000915] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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 transition from military service to civilian life is a high-risk period for suicide attempts (SAs). Although stressful life events (SLEs) faced by transitioning soldiers are thought to be implicated, systematic prospective evidence is lacking. METHODS Participants in the Army Study to Assess Risk and Resilience in Servicemembers (STARRS) completed baseline self-report surveys while on active duty in 2011-2014. Two self-report follow-up Longitudinal Surveys (LS1: 2016-2018; LS2: 2018-2019) were subsequently administered to probability subsamples of these baseline respondents. As detailed in a previous report, a SA risk index based on survey, administrative, and geospatial data collected before separation/deactivation identified 15% of the LS respondents who had separated/deactivated as being high-risk for self-reported post-separation/deactivation SAs. The current report presents an investigation of the extent to which self-reported SLEs occurring in the 12 months before each LS survey might have mediated/modified the association between this SA risk index and post-separation/deactivation SAs. RESULTS The 15% of respondents identified as high-risk had a significantly elevated prevalence of some post-separation/deactivation SLEs. In addition, the associations of some SLEs with SAs were significantly stronger among predicted high-risk than lower-risk respondents. Demographic rate decomposition showed that 59.5% (s.e. = 10.2) of the overall association between the predicted high-risk index and subsequent SAs was linked to these SLEs. CONCLUSIONS It might be possible to prevent a substantial proportion of post-separation/deactivation SAs by providing high-risk soldiers with targeted preventive interventions for exposure/vulnerability to commonly occurring SLEs.
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Affiliation(s)
- Carol Chu
- Minneapolis VA Health Care System, Minneapolis, MN, USA
- Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Ian H. Stanley
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | - Brian P. Marx
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | - Andrew J. King
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Dawne Vogt
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | - Sarah M. Gildea
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Irving H. Hwang
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Nancy A. Sampson
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Robert O’Brien
- VA Health Services Research and Development Service, Washington, DC, USA
| | - Murray B. Stein
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
- School of Public Health, University of California San Diego, La Jolla, CA, USA
- VA San Diego Healthcare System, La Jolla, CA, USA
| | - Robert J. Ursano
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
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12
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Kumar SR, Augustine MR, Sherman RL, Thysen JA, Zaidi M, Gorman DT, Geraci JC. Facilitating Veterans Health Administration Primary Care for Transitioning Servicemembers: a Novel Virtual Care Clinic. J Gen Intern Med 2023:10.1007/s11606-023-08192-6. [PMID: 37340263 DOI: 10.1007/s11606-023-08192-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 03/24/2023] [Indexed: 06/22/2023]
Affiliation(s)
- Sumit R Kumar
- James J. Peters VA Medical Center, Bronx, NY, USA.
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA.
| | - Matthew R Augustine
- James J. Peters VA Medical Center, Bronx, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rachel L Sherman
- James J. Peters VA Medical Center, Bronx, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Julie A Thysen
- James J. Peters VA Medical Center, Bronx, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Meenakshi Zaidi
- James J. Peters VA Medical Center, Bronx, NY, USA
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | | | - Joseph C Geraci
- James J. Peters VA Medical Center, Bronx, NY, USA
- Teachers College, Columbia University, New York, NY, USA
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13
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Brandenburg JE, Schultz BA, Prideaux CC, Driscoll SW. Physician distress: Where are we and what can be done. J Pediatr Rehabil Med 2023; 16:435-442. [PMID: 37718875 DOI: 10.3233/prm-230032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
Depression, suicidal ideation, burnout, and moral injury are on the rise among physicians. Depression and suicidal ideation are mental health disorders that result from multiple interacting factors including biological vulnerabilities and acute stressors. Medical treatment for depression and suicidal ideation is critical to interrupt the potentially deadly progression to suicide that occurs when one's ability to find hope and other solutions is clouded by despair. Yet, stigma and perceived stigma of seeking treatment for mental health disorders still plagues medical providers. Transitions during medical training and practice can be particularly vulnerable time periods, though newer evidence suggests that overall, physicians are not at an increased risk of suicide compared to the general population. While burnout and moral injury are common among rehabilitation physicians, unlike depression, they are not directly associated with suicidal ideation. Opportunities for continued improvement in mental health resources and institutional support exist across the spectrum from medical student to staff physician. With wellness now increasingly supported and promoted by various medical organizations and recognition of the importance of access to effective mental health treatment, regaining hope and positivity while restoring resiliency in physicians, trainees, and medical students is possible.
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Affiliation(s)
- Joline E Brandenburg
- Department of Physical Medicine & Rehabilitation, Mayo Clinic, Rochester, MN, USA
- Department of Pediatric & Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Billie A Schultz
- Department of Physical Medicine & Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - Cara C Prideaux
- Department of Physical Medicine & Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - Sherilyn W Driscoll
- Department of Physical Medicine & Rehabilitation, Mayo Clinic, Rochester, MN, USA
- Department of Pediatric & Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
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14
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Adams RS, Forster JE, Gradus JL, Hoffmire CA, Hostetter TA, Larson MJ, Walsh CG, Brenner LA, Adams RS, Forster JE, Gradus JL, Hoffmire CA, Hostetter TA, Larson MJ, Walsh CG, Brenner LA. Time-dependent suicide rates among Army soldiers returning from an Afghanistan/Iraq deployment, by military rank and component. Inj Epidemiol 2022; 9:46. [PMID: 36564780 PMCID: PMC9783392 DOI: 10.1186/s40621-022-00410-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND To date, knowledge is limited regarding time-dependent suicide risk in the years following return from deployment and whether such rates vary by military rank (i.e., enlisted, officer) or component (i.e., active duty, National Guard, reserve). To address these gaps in knowledge, the objectives of this study were to determine and compare postdeployment suicide rates and trends (percent change over time), and hazard rates for Army soldiers, by rank and component (measured at the end of the deployment). METHODS Longitudinal cohort study of 860,930 Army soldiers returning from Afghanistan/Iraq deployment in fiscal years 2008-2014 from the Substance Use and Psychological Injury Combat study. Death by suicide was observed from the end of the first deployment in the study period through 2018 (i.e., the most recently available mortality data) for up to 11 years of follow-up. Analyses were conducted in 2021-2022. RESULTS Adjusting for age, lowest-ranking Junior Enlisted (E1-E4) soldiers had a suicide rate 1.58 times higher than Senior Enlisted (E5-E9)/Warrant Officers (95% CI [1.24, 2.01]) and 2.41 times higher than Officers (95% CI [1.78, 3.29]). Suicide rates among lower-ranking enlisted soldiers remained elevated for 11 years postdeployment. Overall and annual postdeployment suicide rates did not differ significantly across components. Comparisons across rank and component for females were generally consistent with the full cohort results. CONCLUSIONS Lower-ranking enlisted soldiers had the highest rate of suicide, underscoring the importance of understanding rank as it relates to social determinants of health. For over a decade following Afghanistan/Iraq deployment, lower-enlisted rank during deployment was associated with an elevated rate of suicide; thereby suggesting that postdeployment prevention interventions targeting lower-ranking military members are warranted.
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Affiliation(s)
- Rachel Sayko Adams
- grid.189504.10000 0004 1936 7558Department of Health Law, Policy and Management, Boston University School of Public Health, 715 Albany Street, Boston, MA 02118 USA ,grid.253264.40000 0004 1936 9473Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA USA ,VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, CO USA
| | - Jeri E. Forster
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, CO USA ,grid.430503.10000 0001 0703 675XUniversity of Colorado, Anschutz Medical Campus, Aurora, CO USA
| | - Jaimie L. Gradus
- grid.189504.10000 0004 1936 7558Department of Epidemiology, Boston University School of Public Health, Boston University, Boston, MA USA
| | - Claire A. Hoffmire
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, CO USA ,grid.430503.10000 0001 0703 675XUniversity of Colorado, Anschutz Medical Campus, Aurora, CO USA
| | - Trisha A. Hostetter
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, CO USA
| | - Mary Jo Larson
- grid.253264.40000 0004 1936 9473Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA USA
| | - Colin G. Walsh
- grid.412807.80000 0004 1936 9916Departments of Biomedical Informatics, Medicine, and Psychiatry, Vanderbilt University Medical Center, Nashville, TN USA
| | - Lisa A. Brenner
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, CO USA ,grid.430503.10000 0001 0703 675XUniversity of Colorado, Anschutz Medical Campus, Aurora, CO USA
| | - Rachel Sayko Adams
- grid.189504.10000 0004 1936 7558Department of Health Law, Policy and Management, Boston University School of Public Health, 715 Albany Street, Boston, MA 02118 USA ,grid.253264.40000 0004 1936 9473Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA USA ,VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, CO USA
| | - Jeri E. Forster
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, CO USA ,grid.430503.10000 0001 0703 675XUniversity of Colorado, Anschutz Medical Campus, Aurora, CO USA
| | - Jaimie L. Gradus
- grid.189504.10000 0004 1936 7558Department of Epidemiology, Boston University School of Public Health, Boston University, Boston, MA USA
| | - Claire A. Hoffmire
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, CO USA ,grid.430503.10000 0001 0703 675XUniversity of Colorado, Anschutz Medical Campus, Aurora, CO USA
| | - Trisha A. Hostetter
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, CO USA
| | - Mary Jo Larson
- grid.253264.40000 0004 1936 9473Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA USA
| | - Colin G. Walsh
- grid.412807.80000 0004 1936 9916Departments of Biomedical Informatics, Medicine, and Psychiatry, Vanderbilt University Medical Center, Nashville, TN USA
| | - Lisa A. Brenner
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, CO USA ,grid.430503.10000 0001 0703 675XUniversity of Colorado, Anschutz Medical Campus, Aurora, CO USA
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15
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Frazee KM, Shepler DK. Interpersonal Needs and Suicidality of Discharged Army Veterans. JOURNAL OF VETERANS STUDIES 2022. [DOI: 10.21061/jvs.v8i3.337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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16
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Geraci JC, Finley EP, Edwards ER, Frankfurt S, Kurz AS, Kamdar N, Vanneman ME, Lopoo LM, Patnaik H, Yoon J, Armstrong N, Greene AL, Cantor G, Wrobleski J, Young E, Goldsmith M, Seim RW, Goodman M. Partnered implementation of the veteran sponsorship initiative: protocol for a randomized hybrid type 2 effectiveness-implementation trial. Implement Sci 2022; 17:43. [PMID: 35804354 PMCID: PMC9264302 DOI: 10.1186/s13012-022-01212-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/15/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The USA is undergoing a suicide epidemic for its youngest Veterans (18-to-34-years-old) as their suicide rate has almost doubled since 2001. Veterans are at the highest risk during their first-year post-discharge, thus creating a "deadly gap." In response, the nation has developed strategies that emphasize a preventive, universal, and public health approach and embrace the value of community interventions. The three-step theory of suicide suggests that community interventions that reduce reintegration difficulties and promote connectedness for Veterans as they transition to civilian life have the greatest likelihood of reducing suicide. Recent research shows that the effectiveness of community interventions can be enhanced when augmented by volunteer and certified sponsors (1-on-1) who actively engage with Veterans, as part of the Veteran Sponsorship Initiative (VSI). METHOD/DESIGN The purpose of this randomized hybrid type 2 effectiveness-implementation trial is to evaluate the implementation of the VSI in six cities in Texas in collaboration with the US Departments of Defense, Labor and Veterans Affairs, Texas government, and local stakeholders. Texas is an optimal location for this large-scale implementation as it has the second largest population of these young Veterans and is home to the largest US military installation, Fort Hood. The first aim is to determine the effectiveness of the VSI, as evidenced by measures of reintegration difficulties, health/psychological distress, VA healthcare utilization, connectedness, and suicidal risk. The second aim is to determine the feasibility and potential utility of a stakeholder-engaged plan for implementing the VSI in Texas with the intent of future expansion in more states. The evaluators will use a stepped wedge design with a sequential roll-out to participating cities over time. Participants (n=630) will be enrolled on military installations six months prior to discharge. Implementation efforts will draw upon a bundled implementation strategy that includes strategies such as ongoing training, implementation facilitation, and audit and feedback. Formative and summative evaluations will be guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework and will include interviews with participants and periodic reflections with key stakeholders to longitudinally identify barriers and facilitators to implementation. DISCUSSION This evaluation will have important implications for the national implementation of community interventions that address the epidemic of Veteran suicide. Aligned with the Evidence Act, it is the first large-scale implementation of an evidence-based practice that conducts a thorough assessment of TSMVs during the "deadly gap." TRIAL REGISTRATION ClinicalTrials.gov ID number: NCT05224440 . Registered on 04 February 2022.
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Affiliation(s)
- Joseph C Geraci
- Transitioning Servicemember/Veteran And Suicide Prevention Center (TASC), VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA. .,Center of Excellence for Research on Returning War Veterans, VISN 17, Doris Miller VA Medical Center, Waco, TX, USA. .,Resilience Center for Veterans & Families, Teachers College, Columbia University, New York, NY, USA. .,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Erin P Finley
- Center of Excellence for Research on Returning War Veterans, VISN 17, Doris Miller VA Medical Center, Waco, TX, USA.,Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, New York, USA
| | - Emily R Edwards
- Transitioning Servicemember/Veteran And Suicide Prevention Center (TASC), VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sheila Frankfurt
- Center of Excellence for Research on Returning War Veterans, VISN 17, Doris Miller VA Medical Center, Waco, TX, USA.,Central Texas Veterans Healthcare System, Temple, TX, USA
| | - A Solomon Kurz
- Center of Excellence for Research on Returning War Veterans, VISN 17, Doris Miller VA Medical Center, Waco, TX, USA
| | - Nipa Kamdar
- Center for Innovations in Quality, Effectiveness and Safety, VA, VA, Houston, USA
| | - Megan E Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.,Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Leonard M Lopoo
- Department of Public Administration and International Affairs, Syracuse University, Syracuse, NY, USA
| | - Hannah Patnaik
- Department of Public Administration and International Affairs, Syracuse University, Syracuse, NY, USA
| | - Jean Yoon
- VA Health Economics Resource Center, VA Palo Alto Healthcare System, Livermore, CA, USA.,Center for Primary Care and Outcomes Research, Stanford University, Palo Alto, CA, USA
| | - Nicholas Armstrong
- Institute for Veterans and Military Families, Syracuse University, Syracuse, NY, USA
| | - Ashley L Greene
- Transitioning Servicemember/Veteran And Suicide Prevention Center (TASC), VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gilly Cantor
- Institute for Veterans and Military Families, Syracuse University, Syracuse, NY, USA
| | - Joseph Wrobleski
- Transitioning Servicemember/Veteran And Suicide Prevention Center (TASC), VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA.,Resilience Center for Veterans & Families, Teachers College, Columbia University, New York, NY, USA
| | - Erin Young
- Transitioning Servicemember/Veteran And Suicide Prevention Center (TASC), VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA.,Resilience Center for Veterans & Families, Teachers College, Columbia University, New York, NY, USA.,Global Mental Health Lab, Teachers College, Columbia University, New York, NY, USA
| | - Matthew Goldsmith
- Transitioning Servicemember/Veteran And Suicide Prevention Center (TASC), VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA.,Resilience Center for Veterans & Families, Teachers College, Columbia University, New York, NY, USA
| | - Richard W Seim
- Center of Excellence for Research on Returning War Veterans, VISN 17, Doris Miller VA Medical Center, Waco, TX, USA
| | - Marianne Goodman
- Transitioning Servicemember/Veteran And Suicide Prevention Center (TASC), VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA.,Center of Excellence for Research on Returning War Veterans, VISN 17, Doris Miller VA Medical Center, Waco, TX, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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17
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Stanley IH, Chu C, Gildea SM, Hwang IH, King AJ, Kennedy CJ, Luedtke A, Marx BP, O’Brien R, Petukhova MV, Sampson NA, Vogt D, Stein MB, Ursano RJ, Kessler RC. Predicting suicide attempts among U.S. Army soldiers after leaving active duty using information available before leaving active duty: results from the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS). Mol Psychiatry 2022; 27:1631-1639. [PMID: 35058567 PMCID: PMC9106812 DOI: 10.1038/s41380-021-01423-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 12/03/2021] [Accepted: 12/09/2021] [Indexed: 01/28/2023]
Abstract
Suicide risk is elevated among military service members who recently transitioned to civilian life. Identifying high-risk service members before this transition could facilitate provision of targeted preventive interventions. We investigated the feasibility of doing this by attempting to develop a prediction model for self-reported suicide attempts (SAs) after leaving or being released from active duty in the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS). This study included two self-report panel surveys (LS1: 2016-2018, LS2: 2018-2019) administered to respondents who previously participated while on active duty in one of three Army STARRS 2011-2014 baseline self-report surveys. We focus on respondents who left active duty >12 months before their LS survey (n = 8899). An ensemble machine learning model using predictors available prior to leaving active duty was developed in a 70% training sample and validated in a 30% test sample. The 12-month self-reported SA prevalence (SE) was 1.0% (0.1). Test sample AUC (SE) was 0.74 (0.06). The 15% of respondents with highest predicted risk included nearly two-thirds of 12-month SAs and over 80% of medically serious 12-month SAs. These results show that it is possible to identify soldiers at high post-transition self-report SA risk before the transition. Future model development is needed to examine prediction of SAs assessed by administrative data and using surveys administered closer to the time of leaving active duty.
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Affiliation(s)
- Ian H. Stanley
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA,Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | - Carol Chu
- Minneapolis VA Health Care System, Minneapolis, MN, USA,Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Sarah M. Gildea
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Irving H. Hwang
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Andrew J. King
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Chris J. Kennedy
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
| | - Alex Luedtke
- Department of Statistics, University of Washington, Seattle, WA, USA,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Brian P. Marx
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA,Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | - Robert O’Brien
- VA Health Services Research and Development Service, Washington, DC, USA
| | - Maria V. Petukhova
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Nancy A. Sampson
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Dawne Vogt
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA,Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | - Murray B. Stein
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA,School of Public Health, University of California San Diego, La Jolla, CA, USA,VA San Diego Healthcare System, La Jolla, CA, USA
| | - Robert J. Ursano
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
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18
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Street AE, Jiang T, Horváth-Puhó E, Rosellini AJ, Lash TL, Sørensen HT, Gradus JL. Stress Disorders and the Risk of Nonfatal Suicide Attempts in the Danish Population. J Trauma Stress 2021; 34:1108-1117. [PMID: 34048069 PMCID: PMC8627519 DOI: 10.1002/jts.22695] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 03/10/2021] [Accepted: 04/17/2021] [Indexed: 11/12/2022]
Abstract
Accurate documentation of the associations between stress disorders and suicide attempts provides important information about a high-risk population and target group for preventative interventions. In this case-cohort study, cases were all individuals born or residing in Denmark who made a nonfatal suicide attempt during 1995-2015 (n = 22,974). The comparison subcohort included a 5% random sample of the Danish population on January 1, 1995 (n = 265,183). Stress disorder diagnoses and suicide attempts were identified using ICD-10 codes from national medical registries. The presence of any stress disorder substantially increased the rate of suicide attempts versus the comparison subcohort, rate per 100,000 person-years (PYs) = 604 vs. 13. We observed associations between each type of stress disorder and suicide attempts, hazard ratios (HRs) = 10.1-37.6, even after adjustment for potential confounders, adjusted HRs = 1.8-8.3, with the strongest associations for adjustment disorder relative to other diagnoses. After adjusting for demographic and health variables, the rate of suicide attempts among individuals with any stress disorder diagnosis was nearly 13 times the suicide attempt rate in the comparison cohort. A bias analysis demonstrated that associations remained robust despite potential differential misclassification of suicide attempts. Study strengths included the use of individual-level data linked across administrative and medical registries in the setting of universal health care and the use of longitudinal analyses capturing data over 20 years. The study demonstrated associations between the full range of stress disorders and suicide attempts, extending research specific to posttraumatic stress disorder.
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Affiliation(s)
- Amy E. Street
- National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Tammy Jiang
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | | | - Anthony J. Rosellini
- Center for Anxiety and Related Disorders, Department of Psychological and Brain Sciences, Boston University, Boston, Massachusetts, USA
| | - Timothy L. Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Henrik T. Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jaimie L. Gradus
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA,Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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19
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Peterson AL. General Perspective on the U.S. Military Conflicts in Iraq and Afghanistan After 20 Years. Mil Med 2021; 187:248-251. [PMID: 34850070 DOI: 10.1093/milmed/usab496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 10/26/2021] [Accepted: 11/16/2021] [Indexed: 11/13/2022] Open
Abstract
It has been 20 years since the September 11, 2001 terrorist attacks on America. The ongoing military conflicts in this region are the longest sustained conflicts in U.S. history. Almost 3 million military personnel have deployed, with over 7,000 fatalities and more than 53,000 wounded in action. The most common psychological health condition associated with combat deployments is PTSD. No data exist to compare the prevalence of PTSD across war eras. Therefore, a potential proxy for PTSD risk is the number of combat-related deaths, because this figure has been consistently tracked across U.S. military conflicts. This commentary includes a table of death statistics from major military conflicts, which shows that fewer military personnel have deployed, been killed, sustained wounds, and, one might conclude, suffered from PTSD than any other major U.S. military conflict in history. Advances in the military equipment, tactics, and healthcare programs perhaps mitigated casualties and suffering among Iraq/Afghanistan veterans compared to previous wars. The estimated causality differences across various military conflicts are not meant to minimize the significant contributions and sacrifices made by this new generation of military warriors but to help us gain perspective on military conflicts over the past century as we recognize the 20th anniversary of 9/11.
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Affiliation(s)
- Alan L Peterson
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA.,Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX 78229, USA
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20
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Jiang T, Smith ML, Street AE, Seegulam VL, Sampson L, Murray EJ, Fox MP, Gradus JL. A comorbid mental disorder paradox: Using causal diagrams to understand associations between posttraumatic stress disorder and suicide. PSYCHOLOGICAL TRAUMA : THEORY, RESEARCH, PRACTICE AND POLICY 2021; 13:725-729. [PMID: 34723565 DOI: 10.1037/tra0001033] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Although some studies document that posttraumatic stress disorder (PTSD) increases suicide risk, other studies have produced the paradoxical finding that PTSD decreases suicide risk. We sought to understand methodologic biases that may explain these paradoxical findings through the use of directed acyclic graphs (DAGs). METHOD DAGs are causal diagrams that visually encode a researcher's assumptions about data generating mechanisms and assumed causal relations among variables. DAGs can connect theories to data and guide statistical choices made in study design and analysis. In this article, we describe DAGs and explain how they can be used to identify biases that may arise from inappropriate analytic decisions and data limitations. RESULTS We define a particular form of bias, collider bias, that is a likely explanation for why studies have found a supposedly protective association of PTSD with suicide. This protective association is interpreted by some researchers as evidence that PTSD reduces the risk of suicide. Collider bias may occur through inappropriate adjustment for a psychiatric comorbidity, such as adjustment for variables that are affected by PTSD and share common causes with suicide. CONCLUSIONS We recommend that researchers collect longitudinal measurements of psychiatric comorbidities, which would help establish the temporal ordering of variables and avoid the biases discussed in this article. Furthermore, researchers could use DAGs to explore how results may be impacted by design and analytic decisions prior to execution. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Tammy Jiang
- Department of Epidemiology, Boston University School of Public Health
| | - Meghan L Smith
- Department of Epidemiology, Boston University School of Public Health
| | - Amy E Street
- National Center for PTSD, VA Boston Healthcare System
| | - Vijaya L Seegulam
- Department of Epidemiology, Boston University School of Public Health
| | - Laura Sampson
- Department of Epidemiology, Harvard T.H. Chan School of Public Health
| | - Eleanor J Murray
- Department of Epidemiology, Boston University School of Public Health
| | - Matthew P Fox
- Department of Epidemiology, Boston University School of Public Health
| | - Jaimie L Gradus
- Department of Epidemiology, Boston University School of Public Health
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21
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Abdur-Rahman IT, Watkins EY, Jarvis BP, Beymer MR, Schoenbaum M, Bossarte RM, Pecko JA, Cox KL. Mortality Among Male U.S. Army Soldiers Within 18 Months of Separation. Mil Med 2021; 186:e988-e995. [PMID: 33230545 DOI: 10.1093/milmed/usaa511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/30/2020] [Accepted: 11/10/2020] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Understanding how soldiers die after separation from military service, particularly those who die shortly after separating from service, may help to identify opportunities to ease transitions to civilian life. MATERIALS AND METHODS Mortality data were analyzed for male U.S. Army soldiers who died within 18 months of their separation from service (from 1999 to 2011). Descriptive statistics were calculated for natural, accidental, suicidal, homicidal, undetermined, and legal/operation of war deaths and were stratified by age, component, time in service, and type of discharge. Crude and age-adjusted mortality rates, standardized for all years using the 2004 Regular Army population, were also calculated. The Public Health Review Board of the U.S. Army Public Health Center approved this study as Public Health Practice. RESULTS Of the 1,884,653 male soldiers who separated from service during the study period, 3,819 died within 18 months of separation. A majority of all separations were Reserve or National Guard (58%), and 62% of decedents were in the Reserve or National Guard. Deaths from natural causes (38%) were the most common, followed by accident deaths (34%), suicides (20%), homicides (6%), undetermined deaths (2%), and legal/operation of war deaths (<1%). For overall mortality, age-adjusted rates were higher among the male U.S. population when compared to male soldiers who had separated from the Army. CONCLUSIONS The time period immediately following separation from the Army presents a unique challenge for many soldiers. Developing more effective pre-separation prevention programs that target specific risks requires knowing the causes of death for natural deaths, suicides, and accidents. Over half of all deaths occurring shortly after separation from service are preventable. Continued surveillance of specific causes of preventable deaths following separation can improve pre-separation prevention programs and transitions to post-service care.
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Affiliation(s)
- Ihsan T Abdur-Rahman
- U.S. Army Public Health Center, Clinical Public Health and Epidemiology Directorate, Behavioral and Social Health Outcomes Program, Aberdeen Proving Ground, MD 21010, USA
| | - Eren Y Watkins
- U.S. Army Public Health Center, Clinical Public Health and Epidemiology Directorate, Behavioral and Social Health Outcomes Program, Aberdeen Proving Ground, MD 21010, USA
| | | | - Matthew R Beymer
- U.S. Army Public Health Center, Clinical Public Health and Epidemiology Directorate, Behavioral and Social Health Outcomes Program, Aberdeen Proving Ground, MD 21010, USA
| | | | - Robert M Bossarte
- Department of Behavioral Medicine and Psychiatry, West Virginia University, Morgantown, WV 26505, USA.,VISN 2 Center of Excellence for Suicide Prevention, Canandaigua, NY 14424, USA
| | - Joseph A Pecko
- U.S. Army Public Health Center, Clinical Public Health and Epidemiology Directorate, Behavioral and Social Health Outcomes Program, Aberdeen Proving Ground, MD 21010, USA
| | - Kenneth L Cox
- U.S. Army Public Health Center, Clinical Public Health and Epidemiology Directorate, Behavioral and Social Health Outcomes Program, Aberdeen Proving Ground, MD 21010, USA
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22
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Kilbourne AM, Evans E, Atkins D. Learning health systems: Driving real-world impact in mental health and substance use disorder research. FASEB Bioadv 2021; 3:626-638. [PMID: 34377958 PMCID: PMC8332471 DOI: 10.1096/fba.2020-00124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 03/01/2021] [Accepted: 03/17/2021] [Indexed: 11/11/2022] Open
Abstract
The Veterans Health Administration (VHA), under the U.S. Department of Veterans Affairs (VA), is one of the largest single providers of health care in the U.S. VA supports an embedded research program that addresses VA clinical priorities in close partnership with operations leaders, which is a hallmark of a Learning Health System (LHS). Using the LHS framework, we describe current VA research initiatives in mental health and substance use disorders that rigorously evaluate national programs and policies designed to reduce the risk of suicide and opioid use disorder (data to knowledge); test implementation strategies to improve the spread of effective programs for Veterans at risk of suicide or opioid use disorder (knowledge to performance); and identify novel research directions in suicide prevention and opioid/pain treatments emanating from implementation and quality improvement research (performance to data). Lessons learned are encapsulated into best practices for building and sustaining an LHS within health systems, including the need for early engagement with clinical leaders; pragmatic research questions that focus on continuous improvement; multi-level, ongoing input from regional and local stakeholders, and business case analyses to inform ongoing investment in sustainable infrastructure to maintain the research-health system partnership. Essential ingredients for supporting VA as an LHS include data and information sharing capacity, protected time for researchers and leaders, and governance structures to enhance health system ownership of research findings. For researchers, incentives to work with health systems operations (e.g., retainer funding) are vital for LHS research to be recognized and valued by academic promotion committees.
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Affiliation(s)
- Amy M. Kilbourne
- Health Services Research and DevelopmentOffice of Research and DevelopmentVeterans Health AdministrationU.S. Department of Veterans AffairsWashingtonDCUSA
- Department of Learning Health SciencesUniversity of MichiganAnn ArborMIUSA
| | - Emily Evans
- Health Services Research and DevelopmentOffice of Research and DevelopmentVeterans Health AdministrationU.S. Department of Veterans AffairsWashingtonDCUSA
| | - David Atkins
- Health Services Research and DevelopmentOffice of Research and DevelopmentVeterans Health AdministrationU.S. Department of Veterans AffairsWashingtonDCUSA
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23
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Gibert L, El Hage W, Verdonk C, Levy B, Falissard B, Trousselard M. The negative association between trait mindfulness and post-traumatic stress disorder: A 4.5-year prospective cohort study. Brain Behav 2021; 11:e02163. [PMID: 34363334 PMCID: PMC8413811 DOI: 10.1002/brb3.2163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 04/05/2021] [Accepted: 04/07/2021] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE Post-traumatic stress disorder (PTSD) is a chronic, disabling condition. Our main objective is to investigate the association between trait mindfulness and PTSD over a period of 54 months. The secondary objective is to provide an exhaustive description of PTSD trajectories after the Bataclan attack. METHODS We designed a prospective cohort study of 133 subjects present in the Bataclan concert hall during the November 2015 terrorist attack in Paris, France. Data were recorded 6, 18, 30, and 54 months after the attack. The primary endpoint was evaluated using the PTSD Check List Scale. Trait mindfulness was measured by the 14-item Freiburg Mindfulness Inventory. RESULTS FMI scores were consistently, significantly, and negatively associated with PCL-5 scores. Adjusted odds ratios were at 0.81 (6 months), 0.88 (18 months) 0.82 (30 months), and 0.81 (54 months). PTSD prevalence 6 months after the event was 77%; it remained at 41% after 54 months. PTSD status of subjects is fluctuating. Latent class analysis divided the cohort into 3 groups: 21% of subject who remained below PTSD threshold throughout, 30% who remained above throughout, and 49% who steadily reduced their PTSD scores over time. CONCLUSION In our cohort, mindfulness is negatively associated with PTSD. Mindfulness programs are designed to improve global resilience and treat anxiety and mood disorders. Further research is needed to investigate if improving trait mindfulness is possible and beneficial for patients suffering from PTSD.
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Affiliation(s)
- Lionel Gibert
- IRBA: Institut de Recherche Biomédicale des Armées, Brétigny sur Orge, France.,INSERM: Institut National de la Santé et de la Recherche Médicale, Paris, France.,Centre Hospitalier Universitaire Paul Brousse, Unité de Recherche Psychiatrie-Comorbidités-Addictions, PSYCOMADD, Villejuif, France
| | - Wissam El Hage
- INSERM: Institut National de la Santé et de la Recherche Médicale, Paris, France.,Centre Hospitalier Universitaire de Tours, Tours, France
| | - Charles Verdonk
- IRBA: Institut de Recherche Biomédicale des Armées, Brétigny sur Orge, France
| | - Bernard Levy
- INSERM: Institut National de la Santé et de la Recherche Médicale, Paris, France
| | - Bruno Falissard
- INSERM: Institut National de la Santé et de la Recherche Médicale, Paris, France
| | - Marion Trousselard
- IRBA: Institut de Recherche Biomédicale des Armées, Brétigny sur Orge, France
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24
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Campbell-Sills L, Stein MB, Liu H, Agtarap S, Heeringa SG, Nock MK, Ursano RJ, Kessler RC. Associations of Lifetime Traumatic Brain Injury Characteristics With Prospective Suicide Attempt Among Deployed US Army Soldiers. J Head Trauma Rehabil 2021; 35:14-26. [PMID: 31306300 PMCID: PMC6940544 DOI: 10.1097/htr.0000000000000516] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To estimate associations of lifetime traumatic brain injury (TBI) characteristics with prospective suicide attempt among US Army soldiers. METHOD The Army STARRS (Study to Assess Risk and Resilience in Servicemembers) Pre/Post Deployment Study surveyed 3 Brigade Combat Teams that were deployed to Afghanistan in 2012. Lifetime TBI and past-month postconcussive/post-TBI symptoms were evaluated at predeployment baseline. Recency and number of TBIs were quantified, and TBI severity was classified on the basis of reports of alteration/loss of consciousness and memory lapse. Suicide attempt data came from administrative records and surveys administered after return from deployment. Logistic regression models estimated associations of TBI characteristics with prospective suicide attempt among baseline respondents who were deployed (n = 7677), adjusting for other risk factors including lifetime mental disorder. RESULTS One hundred three soldiers made a suicide attempt over a median follow-up period of 30 months (weighted prevalence = 1.31% [0.14%]). In the final model estimating joint associations of TBI severity/recency and past-month postconcussive/post-TBI symptoms, only postconcussive/post-TBI symptoms were associated with a higher risk of suicide attempt (per standard score increase: AOR [adjusted odds ratio] = 1.31; 95% CI, 1.05-1.63; P = .012). CONCLUSIONS Among the lifetime TBI characteristics evaluated at predeployment baseline, only past-month postconcussive/post-TBI symptoms were prospectively associated with an increased risk of suicide attempt following deployment. Detection of postconcussive/post-TBI symptoms could facilitate targeting of Army suicide prevention programs.
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Affiliation(s)
| | - Murray B. Stein
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
- Department of Family Medicine and Public Health, University of California San Diego, La Jolla, CA, USA
- VA San Diego Healthcare System, San Diego, CA, USA
| | - Howard Liu
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Stephanie Agtarap
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Steven G. Heeringa
- University of Michigan, Institute for Social Research, Ann Arbor, MI, USA
| | - Matthew K. Nock
- Department of Psychology, Harvard University, Cambridge, MA, USA
| | - Robert J. Ursano
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
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25
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Sokol Y, Gromatsky M, Edwards ER, Greene AL, Geraci JC, Harris RE, Goodman M. The deadly gap: Understanding suicide among veterans transitioning out of the military. Psychiatry Res 2021; 300:113875. [PMID: 33901974 DOI: 10.1016/j.psychres.2021.113875] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 03/13/2021] [Indexed: 11/26/2022]
Abstract
In the period following separation from the military, service members face the challenge of transitioning to a post-military civilian life. Some evidence suggests these transitioning Veterans are at higher risk for suicide compared with both the broader Veteran population and the United States public, yet they often do not receive adequate support and resources. In this review, we use the Three-Step Theory of suicide to outline characteristics of transitioning Veterans and the transition process that may affect suicide risk. We then highlight relevant services available to this specific subgroup of Veterans and make recommendations that address barriers to care. Cumulatively, this literature suggests transitioning Veterans fall within a "deadly gap" between the end of their military service and transition into civilian life. This "deadly gap" consists of limited psychiatric services and increased suicide risk factors which together may explain the increase in suicide during this transition period.
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Affiliation(s)
- Yosef Sokol
- Transitioning Servicemember/Veteran and Suicide Prevention Center (TASC), United States; VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, United States; Icahn School of Medicine at Mt. Sinai Hospital, United States.
| | - Molly Gromatsky
- Transitioning Servicemember/Veteran and Suicide Prevention Center (TASC), United States; VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, United States; Icahn School of Medicine at Mt. Sinai Hospital, United States
| | - Emily R Edwards
- Transitioning Servicemember/Veteran and Suicide Prevention Center (TASC), United States; VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, United States; Icahn School of Medicine at Mt. Sinai Hospital, United States
| | - Ashley L Greene
- Transitioning Servicemember/Veteran and Suicide Prevention Center (TASC), United States; VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, United States; Icahn School of Medicine at Mt. Sinai Hospital, United States
| | - Joseph C Geraci
- Transitioning Servicemember/Veteran and Suicide Prevention Center (TASC), United States; VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, United States; Resilience Center for Veterans & Families, Teachers College, Columbia University, United States; Icahn School of Medicine at Mt. Sinai Hospital, United States; Columbia University, United States; Syracuse University, Institute for Veterans and Military Families, United States
| | - Rachel E Harris
- VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, United States; William Paterson University, United States
| | - Marianne Goodman
- Transitioning Servicemember/Veteran and Suicide Prevention Center (TASC), United States; VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, United States; Icahn School of Medicine at Mt. Sinai Hospital, United States
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26
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Fruhbauerova M, DeCou CR, Crow BE, Comtois KA. Borderline personality disorder and self-directed violence in a sample of suicidal army soldiers. Psychol Serv 2021; 18:104-115. [PMID: 31180691 PMCID: PMC6901805 DOI: 10.1037/ser0000369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
There has been a sharp increase in the military suicide rates in 2004. While, borderline personality disorder (BPD) has a stronger association with suicide attempts than any other mental health disorder, there is limited evidence concerning the prevalence and scope of BPD symptoms among military personnel. This secondary data analysis compared active duty suicidal soldiers to characterize the presence-absence of BPD diagnostic criteria and lifetime history of self-directed violence in a suicidal military sample. The current study examined data of 137 active Service Members with significant suicidal ideation. Approximately one-quarter of the soldiers in this sample met full diagnostic criteria for BPD. The presence of BPD criteria was generally consistent among participants with BPD who reported past self-directed violence relative to those who did not. The number of BPD criteria was a significant predictor of the odds of reporting any nonsuicidal self-injury (NSSI) as well as the amount of NSSI, but was not associated with suicide attempt. This study demonstrated that a nontrivial proportion of suicidal soldiers meet criteria for this condition, which is strongly associated with self-directed violence. It is important to rigorously assess for the presence-absence of BPD criteria among suicidal military personnel and cultivate prevention strategies and treatment options for BPD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
| | | | - Bruce E Crow
- Department of Psychiatry and Behavioral Sciences
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27
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Lawrence KA, Vogt D, Nigam S, Dugan AJ, Slade E, Smith BN. Temporal Sequencing of Mental Health Symptom Severity and Suicidal Ideation in Post-9/11 Men and Women Veterans Who Recently Separated from the Military. CHRONIC STRESS (THOUSAND OAKS, CALIF.) 2021; 5:24705470211061347. [PMID: 34870056 PMCID: PMC8637689 DOI: 10.1177/24705470211061347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 11/03/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Despite some evidence for gender differences in associations between military veterans' mental health and suicidal ideation (SI), gender-specific prospective studies are lacking. The aims of this prospective study were to: (1) examine gender differences in veterans' initial status and trajectories of mental health severity and SI status and (2) identify temporal sequencing of mental health predictors of SI. METHODS Surveys of 1035 US veterans were administered at 3 time-points (T1, T2, T3) over a 7-year period following military separation, with an initial assessment within 2 years of military separation. RESULTS Men reported higher baseline PTSD and alcohol misuse severity than women. No baseline gender difference in SI prevalence was detected. Baseline gender differences in mental health severity were maintained over time. For both men and women, remittance of SI was more likely from T1 to T2 than from T2 to T3 while chronic SI was more likely from T2 to T3. The strongest predictors of T3 SI were prior SI followed by alcohol misuse, depression, and PTSD severity with stronger effects for T2 predictors than T1. CONCLUSION The maintenance of baseline gender differences throughout trajectories of mental health predictors of SI supports the need for ongoing gender-specific mental health services. Current governmental interorganizational efforts are focused on suicide prevention during the first year after military service completion. Our findings indicate a need to extend mental health screening and treatment beyond the early post-military period to reduce risk and recurrence of SI for both men and women.
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Affiliation(s)
| | - Dawne Vogt
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA
- Boston University School of
Medicine, Boston, MA, USA
| | | | | | | | - Brian N. Smith
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA
- Boston University School of
Medicine, Boston, MA, USA
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Ravindran C, Morley SW, Stephens BM, Stanley IH, Reger MA. Association of Suicide Risk With Transition to Civilian Life Among US Military Service Members. JAMA Netw Open 2020; 3:e2016261. [PMID: 32915235 PMCID: PMC7489860 DOI: 10.1001/jamanetworkopen.2020.16261] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
IMPORTANCE Although interest is high in addressing suicide mortality after the transition from military to civilian life, little is known about the risk factors associated with this transition. To support the ongoing suicide surveillance work of the US Department of Veterans Affairs (VA) Office of Mental Health and Suicide Prevention, examining these factors is important for targeting suicide prevention efforts. OBJECTIVE To examine the prevalence, patterns, and associated characteristics of suicide mortality among US service members after separation from military active status. DESIGN, SETTING, AND PARTICIPANTS This retrospective population-based cohort study obtained demographic and military service data from the VA/Department of Defense Identity Repository. Individuals who served on active duty in the US Army, Navy, Air Force, Marine Corps, or Coast Guard after September 11, 2001, and who separated from active status between January 1, 2010, and December 31, 2017, were included in the cohort. Data analyses were conducted from September 9, 2019, to April 1, 2020. MAIN OUTCOMES AND MEASURES Suicide mortality within 6 years after separation from military service. RESULTS A total of 1 868 970 service members (1 572 523 men [84.1%]; mean [SD] age at separation, 30.9 [9.9] years) separated from the military during the study period. Through the end of the study period (December 31, 2017), 3030 suicides (2860 men and 170 women) were identified as having occurred within 6 years of separation from the military. Statistically significant differences in suicide risk were found by demographic and military service characteristics. Suicide rates after separation were time dependent, generally peaking 6 to 12 months after separation and declining only modestly over the study period. Male service members had a statistically significantly higher hazard of suicide than their female counterparts (hazard ratio [HR], 3.13; 95% CI, 2.68-3.69). Younger individuals (aged 17-19 years; HR, 4.46 [95% CI, 3.71-5.36]) had suicide hazard rates that were approximately 4.5 times higher than those who transitioned at an older age (≥40 years). Service branch remained a risk factor for suicide even 6 years after separation; those who separated from the Marine Corps (HR, 1.55; 95% CI, 1.36-1.78) and the Army (HR, 1.48; 95% CI, 1.31-1.67) had a higher hazard than those who transitioned from the Air Force. The hazard for those who separated from the active component was higher than for those who separated from the reserve component (HR, 1.29; 95% CI, 1.18-1.42). Service members with a shorter length of service had a higher hazard (HR, 1.26; 95% CI, 1.11-1.42) than those with a longer service history. CONCLUSIONS AND RELEVANCE Results of this study show that not all service members who recently transitioned from military life had the same risk of suicide. The data suggest that awareness of military service and demographic characteristics can help identify those most at risk for suicide to target prevention efforts.
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Affiliation(s)
- Chandru Ravindran
- Veterans Integrated Service Network (VISN) 2, Center of Excellence for Suicide Prevention, Canandaigua, New York
| | - Sybil W. Morley
- Veterans Integrated Service Network (VISN) 2, Center of Excellence for Suicide Prevention, Canandaigua, New York
| | - Brady M. Stephens
- Veterans Integrated Service Network (VISN) 2, Center of Excellence for Suicide Prevention, Canandaigua, New York
| | - Ian H. Stanley
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Mark A. Reger
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
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Holliday R, Borges LM, Stearns-Yoder KA, Hoffberg AS, Brenner LA, Monteith LL. Posttraumatic Stress Disorder, Suicidal Ideation, and Suicidal Self-Directed Violence Among U.S. Military Personnel and Veterans: A Systematic Review of the Literature From 2010 to 2018. Front Psychol 2020; 11:1998. [PMID: 32982838 PMCID: PMC7479813 DOI: 10.3389/fpsyg.2020.01998] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 07/20/2020] [Indexed: 01/02/2023] Open
Abstract
Rates of suicide and posttraumatic stress disorder remain high among United States military personnel and veterans. Building upon prior work, we conducted a systematic review of research published from 2010 to 2018 regarding: (1) the prevalence of suicidal ideation, suicide attempt, and suicide among United States military personnel and veterans diagnosed with posttraumatic stress disorder; (2) whether posttraumatic stress disorder was associated with suicidal ideation, suicide attempt, and suicide among United States military personnel and veterans. 2,106 titles and abstracts were screened, with 48 articles included. Overall risk of bias was generally high for studies on suicidal ideation or suicide attempt and low for studies on suicide. Across studies, rates of suicidal ideation, suicide attempt, and suicide widely varied based on study methodology and assessment approaches. Findings regarding the association between posttraumatic stress disorder diagnosis with suicidal ideation and suicide were generally mixed, and some studies reported that posttraumatic stress disorder was associated with lower risk for suicide. In contrast, most studies reported significant associations between posttraumatic stress disorder and suicide attempt. These findings suggest complex associations between posttraumatic stress disorder and suicidal ideation, suicide attempt, and suicide, which are likely influenced by other factors (e.g., psychiatric comorbidity). In addition, most samples were comprised of veterans, rather than military personnel. Further research is warranted to elucidate associations between posttraumatic stress disorder and suicidal ideation, suicide attempt, and suicide, including identification of moderators and mediators of this relationship. Addressing this among United States military personnel, by gender, and in relation to different trauma types is also necessary.
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Affiliation(s)
- Ryan Holliday
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, CO, United States
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Lauren M. Borges
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, CO, United States
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Kelly A. Stearns-Yoder
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, CO, United States
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Adam S. Hoffberg
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, CO, United States
| | - Lisa A. Brenner
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, CO, United States
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Lindsey L. Monteith
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, CO, United States
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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30
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Fisher LB, Bomyea J, Thomas G, Cheung JC, He F, Jain S, Flashman LA, Andaluz N, Coimbra R, George MS, Grant GA, Marx CE, McAllister TW, Shutter L, Lang AJ, Stein MB, Zafonte RD. Contributions of posttraumatic stress disorder (PTSD) and mild TBI (mTBI) history to suicidality in the INTRuST consortium. Brain Inj 2020; 34:1339-1349. [PMID: 32811203 DOI: 10.1080/02699052.2020.1807054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Mild TBI (mTBI) and posttraumatic stress disorder (PTSD) are independent risk factors for suicidal behaviour (SB). Further, co-occurring mTBI and PTSD increase one's risk for negative health and psychiatric outcomes. However, little research has examined the role of comorbid mTBI and PTSD on suicide risk. METHODS The present study utilized data from the Injury and TRaUmatic STress (INTRuST) Consortium to examine the prevalence of suicidal ideation (SI) and behaviours among four groups: 1) comorbid mTBI+PTSD, 2) PTSD only, 3) mTBI only, and 4) healthy controls. RESULTS Prevalence of lifetime SI, current SI, and lifetime SB for individuals with mTBI+PTSD was 40%, 25%, and 19%, respectively. Prevalence of lifetime SI, current SI, and lifetime SB for individuals with PTSD only was 29%, 11%, and 11%, respectively. Prevalence of lifetime SI, current SI, and lifetime SB for individuals with mTBI only was 14%, 1%, and 2%, respectively. Group comparisons showed that individuals with mTBI alone experienced elevated rates of lifetime SI compared to healthy controls. History of mTBI did not add significantly to risk for suicidal ideation and behaviour beyond what is accounted for by PTSD. CONCLUSION Findings suggest that PTSD seems to be driving risk for suicidal behaviour.
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Affiliation(s)
- Lauren B Fisher
- Department of Psychiatry, Harvard Medical School , Boston, Massachusetts, USA.,Department of Psychiatry, Massachusetts General Hospital , Boston, Massachusetts, USA
| | - Jessica Bomyea
- VA San Diego Center of Excellence for Stress and Mental Health , San Diego, California, USA.,Department of Psychiatry, University of California San Diego , La Jolla, California, USA
| | - Garrett Thomas
- Department of Psychiatry, Massachusetts General Hospital , Boston, Massachusetts, USA
| | - Joey C Cheung
- Department of Psychiatry, Massachusetts General Hospital , Boston, Massachusetts, USA
| | - Feng He
- Biostatistics Research Center, Department of Family Medicine and Public Health, University of California San Diego , La Jolla, California, USA
| | - Sonia Jain
- Biostatistics Research Center, Department of Family Medicine and Public Health, University of California San Diego , La Jolla, California, USA
| | - Laura A Flashman
- Dartmouth-Hitchcock Medical Center, Department of Psychiatry, Dartmouth Geisel School of Medicine at Dartmouth , Hanover, New Hampshire, USA
| | - Norberto Andaluz
- Department of Neurological Surgery, University of Louisville , Louisville, Kentucky, USA
| | - Raul Coimbra
- Department of Surgery, Riverside University Health System , Moreno Valley, California, USA
| | - Mark S George
- Psychiatry Division, Ralph H. Johnson VA Medical Center , Charleston, South Carolina, USA.,Department of Psychiatry and Behavioral Sciences, The Medical University of South Carolina , Charleston, South Carolina, USA
| | - Gerald A Grant
- Department of Neurology and Neurosciences, Stanford University Medical Center , Stanford, California, USA
| | - Christine E Marx
- Durham VA Medical Center , Durham, North Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Duke University , Durham, North Carolina, USA
| | - Thomas W McAllister
- Dartmouth-Hitchcock Medical Center, Department of Psychiatry, Dartmouth Geisel School of Medicine at Dartmouth , Hanover, New Hampshire, USA.,Department of Psychiatry, Indiana University School of Medicine , Indianapolis, Indiana, USA
| | - Lori Shutter
- Department of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh , Pittsburgh, Pennsylvania, USA
| | - Ariel J Lang
- VA San Diego Center of Excellence for Stress and Mental Health , San Diego, California, USA.,Department of Psychiatry, University of California San Diego , La Jolla, California, USA.,Department of Family Medicine and Public Health, University of California San Diego , La Jolla, California, USA
| | - Murray B Stein
- Department of Psychiatry, University of California San Diego , La Jolla, California, USA.,Department of Family Medicine and Public Health, University of California San Diego , La Jolla, California, USA
| | - Ross D Zafonte
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Brigham and Women's Hospital, Massachusetts General Hospital, and Harvard Medical School , Boston, Massachusetts, USA.,Massachusetts General Hospital for Children Sports Concussion Program , Boston, Massachusetts, USA.,MGH Red Sox Foundation Home Base Program , Boston, Massachusetts, USA
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Abstract
PURPOSE OF REVIEW We review military doctrine, military public health data, medical literature, and educational literature with the intent of condensing key precepts into a succinct, pragmatic description of the essential steps for leaders looking to build a resilience program to provide secondary prevention services. RECENT FINDINGS Although there continues to be a shortage of high-level evidence in support of specific preventive programs, there are numerous large-scale reviews of prevention and health promotion efforts. When combined with population-specific analyses, several essential concepts emerge as most relevant for smaller-scale prevention programs. The key tenets that program leaders should embrace to optimize program effectiveness include utilization of an instructional design approach, focus on evidence-based practices, and teaching resilience skills in order to decrease risk factors and increase protective factors for improved mental health outcomes.
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32
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Weber FC, Norra C, Wetter TC. Sleep Disturbances and Suicidality in Posttraumatic Stress Disorder: An Overview of the Literature. Front Psychiatry 2020; 11:167. [PMID: 32210854 PMCID: PMC7076084 DOI: 10.3389/fpsyt.2020.00167] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 02/21/2020] [Indexed: 12/11/2022] Open
Abstract
A causal relationship between sleep disturbances and suicidal behavior has been previously reported. Insomnia and nightmares are considered as hallmarks of posttraumatic stress disorder (PTSD). In addition, patients with PTSD have an increased risk for suicidality. The present article gives an overview about the existing literature on the relationship between sleep disturbances and suicidality in the context of PTSD. It aims to demonstrate that diagnosing and treating sleep problems as still underestimated target symptoms may provide preventive strategies with respect to suicidality. However, heterogeneous study designs, different samples and diverse outcome parameters hinder a direct comparison of studies and a causal relationship cannot be shown. More research is necessary to clarify this complex relationship and to tackle the value of treatment of sleep disturbances for suicide prevention in PTSD.
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Affiliation(s)
- Franziska C. Weber
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - Christine Norra
- LWL Hospital Paderborn, Psychiatry-Psychotherapy-Psychosomatics, Ruhr University of Bochum, Bochum, Germany
| | - Thomas C. Wetter
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
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Zuromski KL, Bernecker SL, Chu C, Wilks CR, Gutierrez PM, Joiner TE, Liu H, Naifeh JA, Nock MK, Sampson NA, Zaslavsky AM, Stein MB, Ursano RJ, Kessler RC. Pre-deployment predictors of suicide attempt during and after combat deployment: Results from the Army Study to Assess Risk and Resilience in Servicemembers. J Psychiatr Res 2020; 121:214-221. [PMID: 31865211 PMCID: PMC6953717 DOI: 10.1016/j.jpsychires.2019.12.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/04/2019] [Accepted: 12/05/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Deployment-related experiences might be risk factors for soldier suicides, in which case identification of vulnerable soldiers before deployment could inform preventive efforts. We investigated this possibility by using pre-deployment survey and administrative data in a sample of US Army soldiers to develop a risk model for suicide attempt (SA) during and shortly after deployment. METHODS Data came from the Army Study to Assess Risk and Resilience in Servicemembers Pre-Post Deployment Survey (PPDS). Soldiers completed a baseline survey shortly before deploying to Afghanistan in 2011-2012. Survey measures were used to predict SAs, defined using administrative and subsequent survey data, through 30 months after deployment. Models were built using penalized regression and ensemble machine learning methods. RESULTS Significant pre-deployment risk factors were history of traumatic brain injury, 9 + mental health treatment visits in the 12 months before deployment, young age, female, previously married, and low relationship quality. Cross-validated AUC of the best penalized and ensemble models were .75-.77. 21.3-40.4% of SAs occurred among the 5-10% of soldiers with highest predicted risk and positive predictive value (PPV) among these high-risk soldiers was 4.4-5.7%. CONCLUSIONS SA can be predicted significantly from pre-deployment data, but intervention planning needs to take PPV into consideration.
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Affiliation(s)
- Kelly L. Zuromski
- Department of Psychology, Harvard University, Cambridge, MA, USA,Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Samantha L. Bernecker
- Department of Psychology, Harvard University, Cambridge, MA, USA,Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Carol Chu
- Department of Psychology, Harvard University, Cambridge, MA, USA,Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Chelsey R. Wilks
- Department of Psychology, Harvard University, Cambridge, MA, USA,Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Peter M. Gutierrez
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, USA,Rocky Mountain Mental Illness Research, Education, and Clinical Center, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
| | - Thomas E. Joiner
- Department of Psychology, Florida State University, Tallahassee, FL, USA
| | - Howard Liu
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - James A. Naifeh
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University School of Medicine, Bethesda, MD, USA
| | - Matthew K. Nock
- Department of Psychology, Harvard University, Cambridge, MA, USA
| | - Nancy A. Sampson
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Alan M. Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Murray B. Stein
- Departments of Psychiatry and Family Medicine and Public Health, University of California San Diego, La Jolla, CA, USA
| | - Robert J. Ursano
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University School of Medicine, Bethesda, MD, USA
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
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Mahar AL, Aiken AB, Whitehead M, Tien H, Cramm H, Fear NT, Kurdyak P. Suicide in Canadian veterans living in Ontario: a retrospective cohort study linking routinely collected data. BMJ Open 2019; 9:e027343. [PMID: 31160275 PMCID: PMC6549618 DOI: 10.1136/bmjopen-2018-027343] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES To compare the risk of death by suicide in male veterans with age-matched civilians. DESIGN Retrospective cohort study linking provincial administrative databases between 1990 and 2013 with follow-up complete until death or December 31, 2015. SETTING Population-based study in Ontario, Canada. PARTICIPANTS Ex-serving Canadian Armed Forces and Royal Canadian Mounted Police veterans living in Ontario who registered for provincial health insurance were included. A civilian comparator group was matched 4:1 on age and sex. MAIN OUTCOME Death by suicide was classified using standard cause of death diagnosis codes from a provincial registry of mandatory data collected from death certificates. Fine and Gray sub-distribution hazards regression compared the risk of death by suicide between veterans and civilians. Analyses were adjusted for age, residential region, income, rurality and major physical comorbidities. RESULTS 20 397 male veterans released to Ontario between 1990 and 2013 and 81 559 age-sex matched civilians were included. 4.2% of veterans died during the study time frame, compared with 6.5% of the civilian cohort. Death by suicide was rare in both cohorts, accounting for 4.6% and 3.6% of veteran and civilian deaths, respectively. After adjustment for confounders, veterans had an 18% lower risk of dying from causes other than suicide (HR 0.82, 95% CI 0.76 to 0.89) and a similar risk of dying by suicide (HR 1.01, 95% CI 0.71 to 1.43), compared with civilians. CONCLUSIONS Deaths by suicide were rare in male veterans residing in Ontario. Our findings demonstrate that veterans had a similar risk of suicide-related mortality as an age-matched civilian population. A better understanding of effective suicide prevention as well as clarifying pathways to seeking and receiving mental health supports and services are important areas for future consideration.
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Affiliation(s)
- Alyson L Mahar
- Community Health Sciences, University of Manitoba College of Medicine, Winnipeg, Manitoba, Canada
| | - Alice B Aiken
- Office of Research and Innovation, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Homer Tien
- 1 Canadian Field Hospital, Canadian Armed Forces, Toronto, Ontario, Canada
| | - Heidi Cramm
- School of Rehabilitation Therapy, Queens University, Kingston, Ontario, Canada
| | | | - Paul Kurdyak
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
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Gutierrez PM, Joiner T, Hanson J, Stanley IH, Silva C, Rogers ML. Psychometric Properties of Four Commonly Used Suicide Risk Assessment Measures: Applicability to Military Treatment Settings. ACTA ACUST UNITED AC 2019. [DOI: 10.1080/21635781.2018.1562390] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Peter M. Gutierrez
- Military Suicide Research Consortium
- Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora, Colorado
- University of Colorado School of Medicine, Aurora, Colorado
| | - Thomas Joiner
- Military Suicide Research Consortium
- Florida State University, Tallahassee, Florida
| | - Jetta Hanson
- Military Suicide Research Consortium
- Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora, Colorado
| | - Ian H. Stanley
- Military Suicide Research Consortium
- Florida State University, Tallahassee, Florida
| | - Caroline Silva
- University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Megan L. Rogers
- Military Suicide Research Consortium
- Florida State University, Tallahassee, Florida
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36
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Reger MA, Tucker RP, Carter SP, Ammerman BA. Military Deployments and Suicide: A Critical Examination. PERSPECTIVES ON PSYCHOLOGICAL SCIENCE 2018; 13:688-699. [PMID: 30286298 DOI: 10.1177/1745691618785366] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Deployment to a combat zone is a fundamental mission for most military forces, but prior research suggests that there is a complex and nuanced association between deployment and related risk factors for suicide. Deployment and combat experiences vary greatly among military personnel and can affect a variety of protective and risk factors for suicide. This article offers a critical examination of the association among modern U.S. military deployments, suicide attempts, and death while considering the context of a prominent theory of suicide. Although previous work has demonstrated that deployment is not associated with suicide overall in this population, there is growing evidence that risk may be elevated shortly after deployment, and for some subgroups. Specific aspects of combat exposure, including the experience of killing or witnessing death in combat, may be important contributing factors. An analysis of the literature illustrates that deployment-related risk factors for suicide are complex. The limitations of the literature are discussed, and future directions are suggested.
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Affiliation(s)
- Mark A Reger
- 1 VA Puget Sound Health Care System, Seattle, Washington.,2 Department of Psychiatry & Behavioral Sciences, University of Washington
| | | | - Sarah P Carter
- 1 VA Puget Sound Health Care System, Seattle, Washington
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37
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Ursano RJ, Kessler RC, Naifeh JA, Herberman Mash HB, Nock MK, Aliaga PA, Fullerton CS, Wynn GH, Ng THH, Dinh HM, Sampson NA, Kao TC, Heeringa SG, Stein MB. Risk Factors Associated With Attempted Suicide Among US Army Soldiers Without a History of Mental Health Diagnosis. JAMA Psychiatry 2018; 75:1022-1032. [PMID: 30167650 PMCID: PMC6233801 DOI: 10.1001/jamapsychiatry.2018.2069] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE The US Army suicide attempt rate increased sharply during the wars in Afghanistan and Iraq. Although soldiers with a prior mental health diagnosis (MH-Dx) are known to be at risk, little is known about risk among those with no history of diagnosis. OBJECTIVE To examine risk factors for suicide attempt among soldiers without a previous MH-Dx. DESIGN, SETTING, AND PARTICIPANTS In this retrospective longitudinal cohort study using administrative data from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), person-month records were identified for all active-duty Regular Army enlisted soldiers who had a medically documented suicide attempt from January 1, 2004, through December 31, 2009 (n = 9650), and an equal-probability sample of control person-months (n = 153 528). Data analysis in our study was from September 16, 2017, to June 6, 2018. In a stratified sample, it was examined whether risk factors for suicide attempt varied by history of MH-Dx. MAIN OUTCOMES AND MEASURES Suicide attempts were identified using Department of Defense Suicide Event Report records and International Classification of Diseases, Ninth Revision, Clinical Modification E95 × diagnostic codes. Mental health diagnoses and related codes, as well as sociodemographic, service-related, physical health care, injury, subjection to crime, crime perpetration, and family violence variables, were constructed from Army personnel, medical, legal, and family services records. RESULTS Among 9650 enlisted soldiers with a documented suicide attempt (74.8% male), 3507 (36.3%) did not have a previous MH-Dx. Among soldiers with no previous diagnosis, the highest adjusted odds of suicide attempt were for the following: female sex (odds ratio [OR], 2.6; 95% CI, 2.4-2.8), less than high school education (OR, 1.9; 95% CI, 1.8-2.0), first year of service (OR, 6.0; 95% CI, 4.7-7.7), previously deployed (OR, 2.4; 95% CI, 2.1-2.8), promotion delayed 2 months or less (OR, 2.1; 95% CI, 1.7-2.6), past-year demotion (OR, 1.6; 95% CI, 1.3-1.8), 8 or more outpatient physical health care visits in the past 2 months (OR, 3.3; 95% CI, 2.9-3.8), past-month injury-related outpatient (OR, 3.0; 95% CI, 2.8-3.3) and inpatient (OR, 3.8; 95% CI, 2.3-6.3) health care visits, previous combat injury (OR, 1.6; 95% CI, 1.0-2.4), subjection to minor violent crime (OR, 1.6; 95% CI, 1.1-2.4), major violent crime perpetration (OR, 2.0; 95% CI, 1.3-3.0), and family violence (OR, 2.9; 95% CI, 1.9-4.4). Most of these variables were also associated with suicide attempts among soldiers with a previous MH-Dx, although the strength of associations differed. CONCLUSIONS AND RELEVANCE Suicide attempt risk among soldiers with unrecognized mental health problems is a significant and important challenge. Administrative records from personnel, medical, legal, and family services systems can assist in identifying soldiers at risk.
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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
| | - Ronald C. Kessler
- 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
| | - Holly B. Herberman Mash
- 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
| | - Pablo A. Aliaga
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Carol S. Fullerton
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Gary H. Wynn
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Tsz Hin H. Ng
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Hieu M. Dinh
- 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, Massachusetts
| | - Tzu-Cheg Kao
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | | | - Murray B. Stein
- Department of Psychiatry, University of California San Diego, La Jolla,Department of Family Medicine and Public Health, University of California San Diego, La Jolla,Veterans Affairs San Diego Healthcare System, San Diego, California
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Abstract
PURPOSE OF REVIEW This review summarizes the increasing public health concern about PTSD and suicide, and the population-based studies that have examined this association. Further, we discuss methodological issues that provide important context for the examination of this association. RECENT FINDINGS The majority of epidemiologic studies have shown that PTSD is associated with an increased risk of suicide; however, a notable minority of studies have documented a decreased risk of suicide among persons with PTSD. Methodological (e.g., sample size and misclassification) and etiologic issues (e.g., complicated psychiatric comorbidity) may explain the conflicting evidence. PTSD may be associated with an increased risk of suicide, but further research is needed. Increasing the use of appropriate methods (e.g., marginal structural models that can evaluate both confounding and effect modification, machine learning methods, quantification of systematic error) will strengthen the evidence base and advance our understanding.
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Affiliation(s)
- Jaimie L Gradus
- Department of Epidemiology, Boston University School of Public Health, 715 Albany St., T318E, Boston, MA, 02118, USA. .,Department of Psychiatry, Boston University School of Medicine, Boston, USA.
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Levin-Rector A, Hourani LL, Van Dorn RA, Bray RM, Stander VA, Cartwright JK, Morgan JK, Trudeau J, Lattimore PK. Predictors of Posttraumatic Stress Disorder, Anxiety Disorders, Depressive Disorders, and Any Mental Health Condition Among U.S. Soldiers and Marines, 2001-2011. J Trauma Stress 2018; 31:568-578. [PMID: 30025180 DOI: 10.1002/jts.22316] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 04/27/2018] [Accepted: 04/28/2018] [Indexed: 11/10/2022]
Abstract
Understanding mental health disorder diagnosis and treatment seeking among active-duty military personnel is a topic with both clinical and policy implications. It has been well documented in military populations that individual-level military experience, including deployment history and combat exposure, influences mental health outcomes, but the impact of unit-level factors is less well understood. In the current study, we used administrative longitudinal data to examine a comprehensive set of unit- and individual-level predictors of posttraumatic stress disorder (PTSD), non-PTSD anxiety disorders, depressive disorders, and overall mental health diagnoses among Army and Marines Corps personnel. Using Cox survival models for time-dependent variables, we analyzed time from military accession (between January 1, 2001 and December 31, 2011) until first mental health diagnosis for 773,359 soldiers and 332,093 Marines. Prior diagnosis of a substance abuse disorder during one's military career, hazard ratios (HRs) = 1.68-3.10, and cumulative time spent deployed, HRs = 1.11-2.04, were the most predictive risk factors for all outcomes. Male sex, HRs = 0.35-0.57, and officer rank, HRs = 0.13-0.23, were the most protective factors. Unit-level rate of high deployment stress was a small but significant predictor of all outcomes after controlling for individual-level deployment history and other predictors, HRs = 1.01-1.05. Findings suggest both unit- and individual-level risk and protective factors of mental health diagnoses associated with treatment seeking. Clinical, including mental health assessment and management, and policy implications related to the military environment and the individual as it relates to mental health disorders are discussed.
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Affiliation(s)
| | | | | | - Robert M Bray
- RTI International, Research Triangle Park, North Carolina, USA
| | | | | | | | - James Trudeau
- RTI International, Research Triangle Park, North Carolina, USA
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40
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Lento RM, Carson-Wong A, Green JD, AhnAllen CG, Kleespies PM. Is Suicidal Behavior in Mood Disorders Altered by Comorbid PTSD? CRISIS 2018; 40:62-66. [PMID: 30052078 DOI: 10.1027/0227-5910/a000532] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Suicide is a leading cause of death among US veterans. Associations between depression, posttraumatic stress disorder (PTSD), and suicidal behaviors have been found in this population, yet minimal research has explored how manifestations of self-injurious behavior (SIB) may vary among different diagnostic presentations. AIMS This study aimed to identify clinically useful differences in SIB among veterans who experience comorbid mood disorder and PTSD (CMP) compared with those who experience a mood disorder alone (MDA). METHOD Participants were 57 US military veterans who reported an incident of intentional SIB. The semistructured Post Self-Injury/Attempted Self-Injury Debriefing Interview was used to examine characteristics of the SIB. RESULTS Veterans diagnosed with CMP were more likely than those with MDA to (a) report that the SIB was impulsive and (b) to be under the influence of substances at the time of self-injury. LIMITATIONS Generalizability may be limited by small sample size and predominantly European American, male demographics. While highly relevant to routine clinical practice, caution is recommended, as study diagnoses were attained from medical records rather than structured interviews. CONCLUSION Safety planning that emphasizes protection against impulsive suicide attempts (e.g., means restriction) may be especially important among veterans with comorbid mood disorder and PTSD.
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Affiliation(s)
- René M Lento
- 1 VA Boston Healthcare System, Boston, MA, USA.,2 Harvard Medical School, Boston, MA, USA.,3 Massachusetts General Hospital, Boston, MA, USA
| | - Amanda Carson-Wong
- 1 VA Boston Healthcare System, Boston, MA, USA.,2 Harvard Medical School, Boston, MA, USA
| | - Jonathan D Green
- 1 VA Boston Healthcare System, Boston, MA, USA.,4 Boston University School of Medicine, Boston, MA, USA
| | - Christopher G AhnAllen
- 1 VA Boston Healthcare System, Boston, MA, USA.,2 Harvard Medical School, Boston, MA, USA.,5 Brigham and Women's Faulkner Hospital, Boston, MA USA
| | - Phillip M Kleespies
- 1 VA Boston Healthcare System, Boston, MA, USA.,4 Boston University School of Medicine, Boston, MA, USA
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42
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Ursano RJ, Kessler RC, Naifeh JA, Herberman Mash H, Fullerton CS, Aliaga PA, Wynn GH, Ng THH, Dinh HM, Sampson NA, Kao TC, Bliese PD, Stein MB. Associations of Time-Related Deployment Variables With Risk of Suicide Attempt Among Soldiers: Results From the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry 2018; 75:596-604. [PMID: 29710270 PMCID: PMC6137524 DOI: 10.1001/jamapsychiatry.2018.0296] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 01/24/2018] [Indexed: 11/14/2022]
Abstract
Importance There has been limited systematic examination of whether risk of suicide attempt (SA) among US Army soldiers is associated with time-related deployment variables, such as time in service before first deployment, duration of first deployment, and dwell time (DT) (ie, length of time between deployments). Objective To examine the associations of time-related deployment variables with subsequent SA among soldiers who had deployed twice. Design, Setting, and Participants Using administrative data from January 1, 2004, through December 31, 2009, this longitudinal, retrospective cohort study identified person-month records of active-duty Regular Army enlisted soldiers who had served continuously in the US Army for at least 2 years and deployed exactly twice. The dates of analysis were March 1 to December 1, 2017. There were 593 soldiers with a medically documented SA during or after their second deployment. An equal-probability sample of control person-months was selected from other soldiers with exactly 2 deployments (n = 19 034). Logistic regression analyses examined the associations of time in service before first deployment, duration of first deployment, and DT with subsequent SA. Main Outcomes and Measures Suicide attempts during or after second deployment were identified using US Department of Defense Suicide Event Report records and International Classification of Diseases, Ninth Revision, Clinical Modification E950 to E958 diagnostic codes. Independent variables were constructed from US Army personnel records. Results Among 593 SA cases, most were male (513 [86.5%]), white non-Hispanic (392 [66.1%]), at least high school educated (477 [80.4%]), currently married (398 [67.1%]), and younger than 21 years when they entered the US Army (384 [64.8%]). In multivariable models adjusting for sociodemographics, service-related characteristics, and previous mental health diagnosis, odds of SA during or after second deployment were higher among soldiers whose first deployment occurred within the first 12 months of service vs after 12 months (odds ratio, 2.0; 95% CI, 1.6-2.4) and among those with a DT of 6 months or less vs longer than 6 months (odds ratio, 1.6; 95% CI, 1.2-2.0). Duration of first deployment was not associated with subsequent SA. Analysis of 2-way interactions indicated that the associations of early deployment and DT with SA risk were not modified by other characteristics. Multivariable population-attributable risk proportions were 14.2% for deployment within the first 12 months of service and 4.0% for DT of 6 months or less. Conclusions and Relevance Time in service before first deployment and DT are modifiable risk factors for SA risk among soldiers.
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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
| | - Ronald C. Kessler
- 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
| | - Holly Herberman Mash
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Carol S. Fullerton
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Pablo A. Aliaga
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Gary H. Wynn
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Tsz Hin H. Ng
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Hieu M. Dinh
- 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, Massachusetts
| | - Tzu-Cheg Kao
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Paul D. Bliese
- Darla Moore School of Business, University of South Carolina, Columbia
| | - Murray B. Stein
- Department of Psychiatry, University of California San Diego, La Jolla
- Veterans Affairs San Diego Healthcare System, La Jolla, California
- Department of Family Medicine and Public Health, University of California San Diego, La Jolla
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43
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Reger MA, Smolenski DJ, Skopp NA, Metzger-Abamukang MJ, Kang HK, Bullman TA, Gahm GA. Suicides, homicides, accidents, and undetermined deaths in the U.S. military: comparisons to the U.S. population and by military separation status. Ann Epidemiol 2018; 28:139-146.e1. [DOI: 10.1016/j.annepidem.2017.12.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 11/02/2017] [Accepted: 12/18/2017] [Indexed: 10/18/2022]
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Sareen J, Afifi TO, Taillieu T, Cheung K, Turner S, Stein MB, Zamorski MA. Deployment-Related Traumatic Events and Suicidal Behaviours in a Nationally Representative Sample of Canadian Armed Forces Personnel. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2017; 62:795-804. [PMID: 28490190 PMCID: PMC5697623 DOI: 10.1177/0706743717699174] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Worldwide, there has been substantial controversy with respect to whether military deployment is a risk factor for suicidal behaviour. The present study examined the relationship between lifetime exposure to deployment and deployment-related traumatic events (DRTEs) and past-year suicidal ideation (SI), suicidal plans (SP), and suicidal attempts (SA). METHOD Data were analysed from the 2013 Canadian Forces Mental Health Survey (8161 respondents; response rate, 79.8%; aged 18-60 years). A total of 12 individual items assessed exposure to DRTEs (e.g., combat, witnessing human atrocities, feeling responsible for the death of Canadian or ally personnel, knowing someone who was injured or killed). We examined each individual DRTE type as well as the number of types of DRTEs in relation to suicidal behaviour. RESULTS Lifetime deployment was not significantly associated with suicidal behaviour. In models adjusted for sociodemographic variables, most of the individual DRTE items and the DRTE count variable were significantly associated with suicidal behaviours (adjusted odds ratio ranged between 1.10 and 5.32). When further adjusting for child abuse exposure, these associations were minimally attenuated, and some became nonsignificant. In models adjusting for mental disorders and child abuse, most DRTEs and number of types of DRTEs became nonsignificant in relation to SI, SP, and SA. CONCLUSIONS Active military personnel exposed to increasing number of DRTEs are at increased risk for SI, SP, and SA. However, most of the association between DRTEs and suicidal behaviour is accounted for by child abuse exposure and mental disorders.
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Affiliation(s)
- Jitender Sareen
- Departments of Psychiatry, Psychology, and Community Health Sciences, University of Manitoba, Winnipeg, Manitoba
| | - Tracie O. Afifi
- Departments of Community Health Sciences and Psychiatry, University of Manitoba, Winnipeg, Manitoba
| | - Tamara Taillieu
- Applied Health Sciences Program, University of Manitoba, Winnipeg, Manitoba
| | - Kristene Cheung
- Department of Psychology, University of Manitoba, Winnipeg, Manitoba
| | - Sarah Turner
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba
| | - Murray B. Stein
- University of California San Diego, San Diego, California, USA
- VA San Diego Healthcare System, San Diego, California, USA
| | - Mark A. Zamorski
- Research and Analysis Section, Directorate of Mental Health, Canadian Forces Health Services Group HQ, Ottawa, Ontario
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario
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45
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Bandoli G, Campbell-Sills L, Kessler RC, Heeringa SG, Nock MK, Rosellini AJ, Sampson NA, Schoenbaum M, Ursano RJ, Stein MB. Childhood adversity, adult stress, and the risk of major depression or generalized anxiety disorder in US soldiers: a test of the stress sensitization hypothesis. Psychol Med 2017; 47:2379-2392. [PMID: 28443533 PMCID: PMC5595661 DOI: 10.1017/s0033291717001064] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The stress sensitization theory hypothesizes that individuals exposed to childhood adversity will be more vulnerable to mental disorders from proximal stressors. We aimed to test this theory with respect to risk of 30-day major depressive episode (MDE) and generalized anxiety disorder (GAD) among new US Army soldiers. METHODS The sample consisted of 30 436 new soldier recruits in the Army Study to Assess Risk and Resilience (Army STARRS). Generalized linear models were constructed, and additive interactions between childhood maltreatment profiles and level of 12-month stressful experiences on the risk of 30-day MDE and GAD were analyzed. RESULTS Stress sensitization was observed in models of past 30-day MDE (χ2 8 = 17.6, p = 0.025) and GAD (χ2 8 = 26.8, p = 0.001). This sensitization only occurred at high (3+) levels of reported 12-month stressful experiences. In pairwise comparisons for the risk of 30-day MDE, the risk difference between 3+ stressful experiences and no stressful experiences was significantly greater for all maltreatment profiles relative to No Maltreatment. Similar results were found with the risk for 30-day GAD with the exception of the risk difference for Episodic Emotional and Sexual Abuse, which did not differ statistically from No Maltreatment. CONCLUSIONS New soldiers are at an increased risk of 30-day MDE or GAD following recent stressful experiences if they were exposed to childhood maltreatment. Particularly in the military with an abundance of unique stressors, attempts to identify this population and improve stress management may be useful in the effort to reduce the risk of mental disorders.
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Affiliation(s)
- Gretchen Bandoli
- Department of Pediatrics, University of California San Diego, La Jolla, CA, USA
| | | | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Steven G. Heeringa
- University of Michigan, Institute for Social Research, Ann Arbor, MI, USA
| | - Matthew K. Nock
- Department of Psychology, Harvard College, Cambridge, MA, USA
| | | | - Nancy A. Sampson
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | | | - Robert J. Ursano
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Murray B. Stein
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
- Department of Family Medicine and Public Health, University of California San Diego, La Jolla, CA, USA
- VA San Diego Healthcare System, San Diego, CA, USA
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46
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Kleiman EM, Nock MK. Real-time assessment of suicidal thoughts and behaviors. Curr Opin Psychol 2017; 22:33-37. [PMID: 30122275 DOI: 10.1016/j.copsyc.2017.07.026] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 07/17/2017] [Accepted: 07/20/2017] [Indexed: 11/28/2022]
Abstract
One of the greatest challenges to understanding, predicting, and preventing suicide is that we have never had the ability to observe and intervene upon them as they unfold in real-time. Recently developed real-time monitoring methods are creating new opportunities for scientific and clinical advances. For instance, recent real-time monitoring studies of suicidal thoughts show that they typically are episodic, with quick onset and short duration. Many known risk factors that predict changes in suicidal thoughts over months/years (e.g. hopelessness) do not predict changes over hours/days-highlighting the gap in our abilities for short-term prediction. Current and future studies using newer streams of data from smartphone sensors (e.g. GPS) and wearables (e.g. heart rate) are further expanding knowledge and clinical possibilities.
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Affiliation(s)
- Evan M Kleiman
- Department of Psychology, Harvard University, 33 Kirkland Street, 1280, Cambridge, MA 02138, USA.
| | - Matthew K Nock
- Department of Psychology, Harvard University, 33 Kirkland Street, 1280, Cambridge, MA 02138, USA
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47
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Ursano RJ, Kessler RC, Naifeh JA, Mash HH, Fullerton CS, Ng THH, Aliaga PA, Wynn GH, Dinh HM, McCarroll JE, Sampson NA, Kao TC, Schoenbaum M, Heeringa SG, Stein MB. Suicide attempts in U.S. Army combat arms, special forces and combat medics. BMC Psychiatry 2017; 17:194. [PMID: 28545424 PMCID: PMC5445296 DOI: 10.1186/s12888-017-1350-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 05/05/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The U.S. Army suicide attempt rate increased sharply during the wars in Iraq and Afghanistan. Risk may vary according to occupation, which significantly influences the stressors that soldiers experience. METHODS Using administrative data from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), we identified person-month records for all active duty Regular Army enlisted soldiers who had a medically documented suicide attempt from 2004 through 2009 (n = 9650) and an equal-probability sample of control person-months (n = 153,528). Logistic regression analyses examined the association of combat occupation (combat arms [CA], special forces [SF], combat medic [CM]) with suicide attempt, adjusting for socio-demographics, service-related characteristics, and prior mental health diagnosis. RESULTS In adjusted models, the odds of attempting suicide were higher in CA (OR = 1.2 [95% CI: 1.1-1.2]) and CM (OR = 1.4 [95% CI: 1.3-1.5]), but lower in SF (OR = 0.3 [95% CI: 0.2-0.5]) compared to all other occupations. CA and CM had higher odds of suicide attempt than other occupations if never deployed (ORs = 1.1-1.5) or previously deployed (ORs = 1.2-1.3), but not when currently deployed. Occupation was associated with suicide attempt in the first ten years of service, but not beyond. In the first year of service, primarily a time of training, CM had higher odds of suicide attempt than both CA (OR = 1.4 [95% CI: 1.2-1.6]) and other occupations (OR = 1.5 [95% CI: 1.3-1.7]). Discrete-time hazard functions revealed that these occupations had distinct patterns of monthly risk during the first year of service. CONCLUSIONS Military occupation can inform the understanding suicide attempt risk among soldiers.
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Affiliation(s)
- Robert J. Ursano
- 0000 0001 0421 5525grid.265436.0Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814 USA
| | - Ronald C. Kessler
- 000000041936754Xgrid.38142.3cDepartment of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115 USA
| | - James A. Naifeh
- 0000 0001 0421 5525grid.265436.0Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814 USA
| | - Holly Herberman Mash
- 0000 0001 0421 5525grid.265436.0Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814 USA
| | - Carol S. Fullerton
- 0000 0001 0421 5525grid.265436.0Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814 USA
| | - Tsz Hin Hinz Ng
- 0000 0001 0421 5525grid.265436.0Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814 USA
| | - Pablo A. Aliaga
- 0000 0001 0421 5525grid.265436.0Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814 USA
| | - Gary H. Wynn
- 0000 0001 0421 5525grid.265436.0Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814 USA
| | - Hieu M. Dinh
- 0000 0001 0421 5525grid.265436.0Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814 USA
| | - James E. McCarroll
- 0000 0001 0421 5525grid.265436.0Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814 USA
| | - Nancy A. Sampson
- 000000041936754Xgrid.38142.3cDepartment of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115 USA
| | - Tzu-Cheg Kao
- 0000 0001 0421 5525grid.265436.0Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814 USA
| | - Michael Schoenbaum
- 0000 0004 0464 0574grid.416868.5Office of Clinical and Population Epidemiology Research, Division of Services and Intervention Research, National Institute of Mental Health, 6001 Executive Blvd, Room 7137, MSC 9635, Bethesda, MD 20892 USA
| | - Steven G. Heeringa
- 0000000086837370grid.214458.eInstitute for Social Research, University of Michigan, 426 Thompson Street, Ann Arbor, MI 48106-1248 USA
| | - Murray B. Stein
- 0000 0001 2181 7878grid.47840.3fDepartments of Psychiatry and Family Medicine & Public Health, University of California San Diego, 8939 Villa La Jolla Drive, Suite 200, La Jolla, California, 92037 USA ,0000 0004 0419 2708grid.410371.0VA San Diego Healthcare System, 8810 Rio San Diego Drive, San Diego, CA 92108 USA
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Death by suicide in US military during the Afghanistan and Iraq wars. Lancet Psychiatry 2016; 3:1001-1003. [PMID: 27697515 DOI: 10.1016/s2215-0366(16)30305-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 09/02/2016] [Indexed: 11/20/2022]
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