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Curley LJM, Duffy FF, Kim PY, Clarke-Walper KM, Riviere LA, Wilk JE. Suicide Behavior Results From the U.S. Army's Suicide Prevention Leadership Tool Study: The Behavioral Health Readiness and Suicide Risk Reduction Review (R4). Mil Med 2024; 189:361-369. [PMID: 35726499 PMCID: PMC9384320 DOI: 10.1093/milmed/usac169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/27/2022] [Accepted: 05/26/2022] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION The U.S. Army developed a new tool called the Behavioral Health Readiness and Suicide Risk Reduction Review (R4) for suicide prevention. A 12-month evaluation study with the primary objective of testing the hypothesis (H1) that Army units receiving R4 would demonstrate improved outcomes in suicidal-behavior measures following the intervention, relative to control, was then conducted. The results of analyses to answer H1 are herein presented. MATERIALS AND METHODS The R4 intervention (R4-tools/instructions/orientation) evaluation study, Institutional Review Board approved and conducted in May 2019-June 2020, drew samples from two U.S. Army divisions and employed a repeated measurement in pre-/post-quasi-experimental design, including a nonequivalent, but comparable, business-as-usual control. Intervention effectiveness was evaluated using self-report responses to suicide-related measures (Suicide Behaviors Questionnaire-Revised/total-suicide behaviors/ideations/plans/attempts/non-suicidal self-injuries) at 6-/12-month intervals. Analyses examined baseline to follow-up linked and cross-sectional cohorts, incidence/prevalence, and intervention higher-/lower-use R4 subanalyses. RESULTS Both divisions demonstrated favorable in-study reductions in total-suicide burden, with relatively equivalent trends for total-suicide behaviors, total-suicide risk (Suicide Behaviors Questionnaire-Revised), suicidal ideations, and non-suicidal self-injuries. Although both demonstrated reductions in suicide plans, the control showed a more robust trend. Neither division demonstrated a significant reduction in suicide attempts, but subgroup analyses showed a significant reduction in pre-coronavirus disease 2019-attempt incidence among those with higher-use R4 relative to control. CONCLUSIONS There is no evidence of harm associated with the R4 intervention. R4 effectiveness as a function of R4 itself requires confirmatory study. R4 is judged an improvement (no evidence of harm + weak evidence of effectiveness) over the status quo (no safety data or effectiveness studies) with regard to tool-based decision-making support for suicide prevention in the U.S. Army.
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Affiliation(s)
- Ltc Justin M Curley
- Department of Military Psychiatry, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Farifteh F Duffy
- Department of Military Psychiatry, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Paul Y Kim
- Department of Military Psychiatry, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Kristina M Clarke-Walper
- Department of Military Psychiatry, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Lyndon A Riviere
- Department of Military Psychiatry, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Joshua E Wilk
- Department of Military Psychiatry, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
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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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Taillieu TL, Sareen J, Afifi TO. Associations among child abuse history, deployment-related traumatic events, mental disorders, and suicidal behaviors in Canadian Regular Force personnel. J Trauma Stress 2022; 35:1060-1071. [PMID: 35727709 PMCID: PMC9545891 DOI: 10.1002/jts.22814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 11/17/2021] [Accepted: 12/16/2021] [Indexed: 11/11/2022]
Abstract
Increasing attention has been focused on suicidal behavior among military personnel. Exposure to deployment-related traumatic events (DRTEs) and child abuse (CA) both have been associated with mental disorders and suicidal behaviors among military personnel. Thus, the primary objectives of this study were to examine (a) sex differences in CA history and DRTEs, past-year mental disorders, and past-year suicide-related outcomes and (b) independent, cumulative, and interactive effects of CA history and DRTEs on past-year mental disorders and suicide outcomes among Canadian military personnel. Data were from the representative Canadian Forces Mental Health Survey collected in 2013 (N = 8,161; response rate = 79.8%). The results indicated a high prevalence of trauma exposure, with sex differences noted for specific trauma types. Both CA history and DRTEs were strongly associated with mental disorders, CA history: aORs = 1.60-2.44; DRTEs; aORs = 1.67-3.88. Cumulative, but not interactive, effects were noted for the effects of CA history and DRTEs on most mental disorders. Associations between CA history and DRTEs on suicide outcomes were largely indirect via their impact on mental disorders. Information regarding the role of specific types of predeployment trauma on mental disorders and suicidal behavior can be used to develop more targeted prevention and intervention strategies aimed at improving the mental health of military personnel.
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Affiliation(s)
- Tamara L. Taillieu
- Department of Community Health SciencesUniversity of ManitobaWinnipegManitobaCanada
| | - Jitender Sareen
- Department of PsychiatryUniversity of ManitobaWinnipegManitobaCanada
| | - Tracie O. Afifi
- Departments of Community Health Sciences and PsychiatryUniversity of ManitobaWinnipegManitobaCanada
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Naifeh JA, Ursano RJ, Stein MB, Mash HBH, Aliaga PA, Fullerton CS, Dinh HM, Vance MC, Wynn GH, Kao TC, Sampson NA, Kessler RC. Risk of suicide attempt in reserve versus active component soldiers during deployment to the wars in Iraq and Afghanistan. Suicide Life Threat Behav 2022; 52:24-36. [PMID: 34032314 DOI: 10.1111/sltb.12770] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/12/2021] [Accepted: 02/14/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Little is known about the degree to which U.S. Army soldiers in the Reserve Components (Army National Guard and Army Reserve) and Active Component (Regular Army) differ with respect suicide attempt (SA) risk during high-stress times, such as deployment. METHOD Using administrative person-month records of enlisted soldiers on active duty during 2004-2009, we identified 1170 soldiers with a medically documented SA during deployment and an equal-probability control sample of other deployed soldiers (n = 52,828 person-months). Logistic regression analyses examined the association of Army component (Guard/Reserve vs. Regular) with SA before and after adjusting for socio-demographic and service-related predictors. RESULTS Guard/Reserve comprised 32.1% of enlisted soldiers and 19.7% of suicide attempters in-theater, with a SA rate of 81/100,000 person-years (vs. 157/100,000 person-years among Regular; rate ratio = 0.5 [95% CI = 0.5-0.6]). Risk peaked near mid-deployment for both groups but was consistently lower for Guard/Reserve throughout deployment. Guard/Reserve had lower odds of SA after adjusting for covariates (OR = 0.7 [95%CI = 0.6-0.8]). Predictors of SA were similar between components. CONCLUSIONS Guard/Reserve and Regular soldiers had similar patterns and predictors of SA during deployment, but Guard/Reserve had lower risk even after controlling for important risk factors. Additional research is needed to understand the lower SA risk among Guard/Reserve in-theater.
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Affiliation(s)
- James A Naifeh
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Robert J Ursano
- Department of Psychiatry, Center for the Study of Traumatic Stress, 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 & Public Health, University of California San Diego, La Jolla, CA, USA.,VA San Diego Healthcare System, San Diego, CA, USA
| | - Holly B Herberman Mash
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Pablo A Aliaga
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Carol S Fullerton
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Hieu M Dinh
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Mary C Vance
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Gary H Wynn
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Tzu-Cheg Kao
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Nancy A Sampson
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Ronald C Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
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Lane R, Robles P, Brondolo E, Jansson A, Diduk-Smith RM. Antecedents of Suicide Among Active Military, Veteran, and Nonmilitary Residents of the Commonwealth of Virginia: The Role of Intimate Partner Problems. Arch Suicide Res 2021; 25:790-809. [PMID: 32476621 DOI: 10.1080/13811118.2020.1765927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Intimate partner problems increase suicide risk, particularly among active service members and veterans. Age, marital status and military service status may modify the role of intimate partner problems in suicide. Methods: Participants included 6255 men who died by suicide at 18 years of age and older and who actively, previously, or never served in the military. Reports of intimate partner problems prior to suicide were documented by the Virginia Department of Health. Results: Unmarried active service members, above middle age, were more likely than veterans and individuals without prior military service to have associated reports of intimate partner problems. Conclusion: Life stages and relationship context may influence the role of intimate partner problems as a risk factor for suicide.
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Curley JM, Duffy FF, Kim PY, Clarke-Walper KM, Nugent KL, Penix EA, Elliman TD, Wilk JE, Riviere LA. Methodology of the U.S. Army's Suicide Prevention Leadership Tool Study: The Behavioral Health Readiness and Suicide Risk Reduction Review (R4). Mil Med 2021; 186:336-343. [PMID: 33219666 DOI: 10.1093/milmed/usaa503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 11/04/2020] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION The Secretary of the U.S. Army issued two directives in late 2017 to directly combat the problem of suicide in the U.S. Army. The first was to develop an Army tool to assist commanders and first-line leaders in preventing suicide and improving behavioral health (BH) outcomes, which has been previously published as the BH Readiness and Risk Reduction Review (R4). The second was to conduct an evaluation study of the tool with Army units in the field. This study is the first to empirically examine the Army's tool-based methods for identifying and caring for the health and welfare of soldiers at risk for suicide, and this article outlines the methodology employed to study the effectiveness of the R4 tools and accomplish the Secretary's second directive. METHODS The Walter Reed Army Institute of Research Institutional Review Board approved the R4 study. The study employed a repeated measurements in pre/post quasi-experimental design, including a nonequivalent but comparable business-as-usual control group. The R4 intervention consisted of the R4 tools, accompanying instructions, and an orientation. Samples were drawn from two geographically separated U.S. Army divisions in the continental United States, each composed of four comparable brigades. Study implementation consisted of three phases and three data collections over the course of 12 months. Soldiers completed anonymous survey instruments to assess a range of health factors, behaviors, characteristics, tool-related decision-making processes, and the frequency, type, and quality of interactions between soldiers and leaders. RESULTS The R4 study commenced on May 6, 2019, and concluded on June 4, 2020. Sample size goals were achieved for both the divisions at all three data collection time points. CONCLUSIONS The methodology of the R4 study is critical for the U.S. Army from both a precedential and an outcome-based standpoint. Despite the use of many previous tools and programs for suicide prevention, this is the first time the Army has been able to empirically test the effectiveness of tool-supported decision-making among Army units in a rigorous fashion. The methodology of such a test is a critical marker for future interventional inquiries on the subject of suicide in the Army, and the results will allow for more informed decision-making by leaders when approaching these ongoing challenges.
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Affiliation(s)
- Justin M Curley
- Department of the Army, Office of the Deputy Under Secretary of the Army, Arlington, VA 22202, USA.,Department of Military Psychiatry, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Farifteh F Duffy
- Department of Military Psychiatry, TechWerks, Arlington, VA 22201, USA
| | - Paul Y Kim
- Department of Military Psychiatry, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Kristina M Clarke-Walper
- Department of Military Psychiatry, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Katie L Nugent
- Department of Military Psychiatry, TechWerks, Arlington, VA 22201, USA
| | - Elizabeth A Penix
- Department of Military Psychiatry, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Toby D Elliman
- Department of Military Psychiatry, TechWerks, Arlington, VA 22201, USA
| | - Joshua E Wilk
- Department of Military Psychiatry, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Lyndon A Riviere
- Department of Military Psychiatry, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
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Kok BC, Wilk JE, Wickham RE, Bongar B, Riviere LA, Brown LM. Military occupation as a moderator between combat exposure and posttraumatic stress disorder symptoms in US Army personnel. MILITARY PSYCHOLOGY 2020; 32:410-418. [PMID: 38536367 PMCID: PMC10013536 DOI: 10.1080/08995605.2020.1782625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 06/03/2020] [Indexed: 10/23/2022]
Abstract
Military occupational designations are standardized classifications that help define and convey a service member's expected duties and responsibilities. The present study examined how occupational designation was related to adverse combat-reactions, specifically posttraumatic stress disorder (PTSD). It was hypothesized that at comparable levels of combat, non-combat units would display greater symptomology than combat units. The study sample consisted of 785 combat-deployed, active-duty enlisted US Army personnel. Participants were administered self-report questionnaires, including the Combat Experiences Scale and PTSD Checklist for DSM-5. Occupation was coded using the three-branch system (i.e., Operations, Support, & Force Sustainment). Hierarchical multiple linear regression (MLR) was run to examine the effect of occupation, combat, and unit cohesion on PTSD symptoms. Operations units reported the highest frequency of combat exposure; however, Force Sustainment units displayed the highest PTSD symptoms. In MLR analysis, there was a significant interaction between Force Sustainment units and combat exposure (β = 0.10, p = .019), that was not observed in Operations or Support units. These findings demonstrate that PTSD symptom intensity is not solely a function of combat exposure, and that non-combat units may react differently when exposed to elevated levels of combat.
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Affiliation(s)
| | - Joshua E. Wilk
- Department of Military Psychology, Walter Reed Army Institute of Research, Silver Spring, Maryland
| | | | | | - Lyndon A. Riviere
- Department of Military Psychology, Walter Reed Army Institute of Research, Silver Spring, Maryland
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Ryan AT, Ghahramanlou-Holloway M, Wilcox HC, Umhau JC, Deuster PA. Mental Health Care Utilization and Psychiatric Diagnoses in a Sample of Military Suicide Decedents and Living Matched Controls. J Nerv Ment Dis 2020; 208:646-653. [PMID: 32502074 PMCID: PMC7483990 DOI: 10.1097/nmd.0000000000001192] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This article examines mental health care utilization and psychiatric diagnoses among US military personnel who died by suicide. We employed an existing electronic health record dataset including 800 US military suicide decedents and 800 matched controls. Suicide decedents were more likely to have received outpatient and inpatient mental health care and to have been diagnosed with depression, bipolar, and nonaffective psychotic disorders. Younger decedents and those in the US Marine Corps were less likely to receive MH care before suicide. Given that approximately half of the suicide decedents in our sample had no mental health care visits before their death, our study suggests the need for programs to increase treatment engagement by at-risk individuals. Such programs could address barriers to care such as stigma regarding mental illness and concerns that seeking mental health care would damage a service member's career.
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Affiliation(s)
- Arthur T. Ryan
- Veterans Affairs VISN 5 Mental Illness Research, Education, and Clinical Center (MIRECC), Baltimore, MD, USA
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Holly C. Wilcox
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - John C. Umhau
- Office of New Drugs, Division of Psychiatry Products Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
- Fort Belvoir Community Hospital, Fort Belvoir, VA, USA
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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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Willmund GD, Heß J, Helms C, Wertenauer F, Seiffert A, Nolte A, Wesemann U, Zimmermann PL. Suicides between 2010 and 2014 in the German Armed Forces-Comparison of Suicide Registry Data and a German Armed Forces Survey. Suicide Life Threat Behav 2019; 49:1497-1509. [PMID: 30556592 DOI: 10.1111/sltb.12534] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 10/26/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND The last 10 years have seen an increase in the number of suicides in the US Armed Forces. Accordingly, the topic of suicides in the German military has received a lot of attention in media and science alike. METHODS This study retrospectively examined all suicides (N = 107) committed by active, nonretired German military personnel from 2010 to the end of 2014, analyzing archived medical records. In a second step, these data were compared to a representative German Armed Forces survey conducted in 2012 (N = 1,549). RESULTS The following risk groups for suicide were identified: male (OR = 9.6), single (OR = 7.8), aged over 45 years (OR = 4.0), short period of service (<2 years; OR = 2.7), and low level of education (OR = 2.2). Surprisingly, military personnel with little experience in deployments abroad (<2 missions) showed double the risk (OR = 2.0) compared to those who had been deployed more than once. DISCUSSION Multiple robustness checks show that being single, aged over 45 years, and having obtained a low level of education exhibit the most robust effects on suicide risk. CONCLUSION Efforts should be made to develop and evaluate risk group-focused prevention programs. We conclude, that further studies should be initiated to show differences of risk groups between lethal and nonlethal suicidal behavior.
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Affiliation(s)
- Gerd-Dieter Willmund
- Bundeswehr Centre for Military Mental Health, Bundeswehr Hospital Berlin, Berlin, Germany
| | - Julius Heß
- Bundeswehr Centre for Military History and Social Sciences, Potsdam, Germany
| | - Christian Helms
- Bundeswehr Centre for Military Mental Health, Bundeswehr Hospital Berlin, Berlin, Germany
| | - Florian Wertenauer
- Academic Unit of Psychiatry and Addiction Medicine, Australian National University Medical School, Canberra Hospital, Woden, ACT, Australia.,Psychiatrische Abteilung, Sozialmedizinisches Zentrum Baumgartner Höhe und Otto-Wagner-Spital, Wien, Austria
| | - Anja Seiffert
- Bundeswehr Centre for Military History and Social Sciences, Potsdam, Germany
| | - Almut Nolte
- Bundeswehr, Bundeswehr Central Hospital, Koblenz, Germany
| | - Ulrich Wesemann
- Bundeswehr Centre for Military Mental Health, Bundeswehr Hospital Berlin, Berlin, Germany
| | - Peter L Zimmermann
- Bundeswehr Centre for Military Mental Health, Bundeswehr Hospital Berlin, Berlin, Germany
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11
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Willmund GD, Waechter H, Helms C, Wesemann U, Heß J, Seiffert A, Bambridge D, Lutz Zimmermann P, Himmerich H. German research perspectives on suicidality and the rationale for future multinational suicide prevention projects among military service personnel. Int Rev Psychiatry 2019; 31:60-74. [PMID: 31041871 DOI: 10.1080/09540261.2019.1581146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
As a result of scientific publications indicating that the last two decades have seen an increase in the number of suicides in the US Armed Forces, the topic of suicide in the military of other countries, such as Germany, has also received a lot of attention in media and science alike. Risk factors for suicidal behaviour and suicide were identified in several research projects in the US, Canada, the UK, and Germany. Until now, German suicide research among military service personnel has mainly focused on epidemiological aspects of suicides and suicidality, individual risk factors, sub-groups at risk for suicide, suicides and deployment abroad, and associations of suicide and suicide attempts with acute mental disorders. The key findings are summarized in this review article. Efforts should be made to develop and evaluate risk group-focused and occupation-focused prevention and intervention programs. Future multinational studies should address potential differences between risk groups for fatal and non-fatal suicidal behaviour.
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Affiliation(s)
- Gerd-Dieter Willmund
- a Bundeswehr Centre for Military Mental Health , Bundeswehr Hospital Berlin , Berlin , Germany
| | - Henriette Waechter
- a Bundeswehr Centre for Military Mental Health , Bundeswehr Hospital Berlin , Berlin , Germany
| | - Christian Helms
- a Bundeswehr Centre for Military Mental Health , Bundeswehr Hospital Berlin , Berlin , Germany.,b Department of Psychiatry and Psychotherapy Campus Charité Mitte Berlin , St. Hedwig Hospital , Berlin , Germany
| | - Ulrich Wesemann
- a Bundeswehr Centre for Military Mental Health , Bundeswehr Hospital Berlin , Berlin , Germany
| | - Julius Heß
- c Bundeswehr Centre for Military History and Social Sciences , Potsdam , Germany
| | - Anja Seiffert
- c Bundeswehr Centre for Military History and Social Sciences , Potsdam , Germany
| | - Darren Bambridge
- d Academic Department of Military Mental Health , Weston Education Centre , London , UK.,e Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience (IoPPN) , King's College London , London , UK
| | - Peter Lutz Zimmermann
- a Bundeswehr Centre for Military Mental Health , Bundeswehr Hospital Berlin , Berlin , Germany
| | - Hubertus Himmerich
- a Bundeswehr Centre for Military Mental Health , Bundeswehr Hospital Berlin , Berlin , Germany.,e Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience (IoPPN) , King's College London , London , UK
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12
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Millner AJ, Ursano RJ, Hwang I, King A, Naifeh JA, Sampson NA, Zaslavsky AM, Stein MB, Kessler RC, Nock MK. Prior Mental Disorders and Lifetime Suicidal Behaviors Among US Army Soldiers in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Suicide Life Threat Behav 2019; 49:3-22. [PMID: 28926674 PMCID: PMC6839110 DOI: 10.1111/sltb.12394] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 07/03/2017] [Indexed: 11/27/2022]
Abstract
We report on associations of retrospectively reported temporally prior mental disorders and Army career characteristics with subsequent first onset of suicidal behaviors in a large, representative sample of US Army soldiers who participated in the Consolidated All-Army Survey of the Army Study to Assess Risk and Resilience in Servicemembers (N = 29,982). Results reveal that among men and women, all self-reported lifetime disorders measured (some assessed with screening scales) are associated with subsequent onset of suicide ideation. Among men, three disorders characterized by agitation and impulsiveness (intermittent explosive disorder, panic disorder, and substance disorders) predict the transition from suicide ideation to attempt. For both men and women, being in the Regular Army (vs. National Guard or Army Reserve) predicts suicide attempts in the total sample. For men, a history of deployment and junior rank are predictors of suicide attempts after adjusting for preenlistment disorders but not accounting for pre- and postenlistment disorders, suggesting that postenlistment disorders account for some of the increased suicide risk among these career characteristics. Overall, these results highlight associations between mental disorders and suicidal behaviors, but underscore limitations predicting which people with ideation attempt suicide.
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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
| | - Irving Hwang
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Andrew King
- 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
| | - Nancy A. Sampson
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Alan M. Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Murray B. Stein
- Departments of Psychiatry and Family and Preventive Medicine, University of California San Diego, La Jolla, California and VA San Diego Healthcare System, San Diego, California
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Matthew K. Nock
- Department of Psychology, Harvard University, Cambridge, Massachusetts
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13
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Naifeh JA, Mash HBH, Stein MB, Fullerton CS, Kessler RC, Ursano RJ. The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS): progress toward understanding suicide among soldiers. Mol Psychiatry 2019; 24:34-48. [PMID: 30104726 PMCID: PMC6756108 DOI: 10.1038/s41380-018-0197-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 06/22/2018] [Accepted: 07/02/2018] [Indexed: 01/11/2023]
Abstract
Responding to an unprecedented increase in the suicide rate among soldiers, in 2008 the US Army and US National Institute of Mental Health funded the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), a multicomponent epidemiological and neurobiological study of risk and resilience factors for suicidal thoughts and behaviors, and their psychopathological correlates among Army personnel. Using a combination of administrative records, representative surveys, computerized neurocognitive tests, and blood samples, Army STARRS and its longitudinal follow-up study (STARRS-LS) are designed to identify potentially actionable findings to inform the Army's suicide prevention efforts. The current report presents a broad overview of Army STARRS and its findings to date on suicide deaths, attempts, and ideation, as well as other important outcomes that may increase suicide risk (e.g., mental disorders, sexual assault victimization). The findings highlight the complexity of environmental and genetic risk and protective factors in different settings and contexts, and the importance of life and career history in understanding suicidal thoughts and behaviors.
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Affiliation(s)
- James A. Naifeh
- 0000 0001 0421 5525grid.265436.0Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, MD USA
| | - Holly B. Herberman Mash
- 0000 0001 0421 5525grid.265436.0Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, MD USA
| | - Murray B. Stein
- 0000 0001 2107 4242grid.266100.3Department of Psychiatry and Department of Family Medicine and Public Health, University of California San Diego, La Jolla, CA USA ,0000 0004 0419 2708grid.410371.0VA San Diego Healthcare System, San Diego, CA USA
| | - Carol S. Fullerton
- 0000 0001 0421 5525grid.265436.0Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, MD USA
| | - Ronald C. Kessler
- 000000041936754Xgrid.38142.3cDepartment of Health Care Policy, Harvard Medical School, Boston, MA USA
| | - Robert J. Ursano
- 0000 0001 0421 5525grid.265436.0Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, MD USA
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14
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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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15
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Millner AJ, Ursano RJ, Hwang I, King AJ, Naifeh JA, Sampson NA, Zaslavsky AM, Stein MB, Kessler RC, Nock MK. Lifetime Suicidal Behaviors and Career Characteristics Among U.S. Army Soldiers: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Suicide Life Threat Behav 2018; 48. [PMID: 28631262 PMCID: PMC5738281 DOI: 10.1111/sltb.12363] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The current report presents data on lifetime prevalence of suicide ideation and nonfatal attempts as reported by the large representative sample of U.S. Army soldiers who participated in the Consolidated All-Army Survey of the Army Study to Assess Risk and Resilience in Servicemembers (N = 29,982). We also examine associations of key Army career characteristics with these outcomes. Prevalence estimates for lifetime suicide ideation are 12.7% among men and 20.1% among women, and for lifetime suicide attempts are 2.5% and 5.1%, respectively. Retrospective age-of-onset reports suggest that 53.4%-70% of these outcomes had preenlistment onsets. Results revealed that, for both men and women, being in the Regular Army, compared with being in the National Guard or Army Reserve, and being in an enlisted rank, compared with being an officer, is associated with increased risk of suicidal behaviors and that this elevated risk is present both before and after joining the Army.
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Affiliation(s)
| | - Robert J. Ursano
- Department of Psychiatry; Center for the Study of Traumatic Stress; Uniformed Services University of the Health Sciences; Bethesda MD USA
| | - Irving 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
| | - James A. Naifeh
- Department of Psychiatry; Center for the Study of Traumatic Stress; Uniformed Services University of the Health Sciences; Bethesda MD 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 & Public Health; University of California San Diego; La Jolla CA USA
- VA San Diego Healthcare System; San Diego CA USA
| | - Ronald C. Kessler
- Department of Health Care Policy; Harvard Medical School; Boston MA USA
| | - Matthew K. Nock
- Department of Psychology; Harvard University; Cambridge MA USA
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16
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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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17
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Elliman TD, Shannahoff ME, Metzler JN, Toblin RL. Prevalence of Bystander Intervention Opportunities and Behaviors Among U.S. Army Soldiers. HEALTH EDUCATION & BEHAVIOR 2018; 45:741-747. [PMID: 29353545 DOI: 10.1177/1090198117752788] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The bystander intervention model is one approach utilized to reduce risky behaviors within the U.S. Army; however, it is unclear how frequently soldiers experience opportunities to intervene and whether they already intervene in such situations. The present analysis aims to ascertain frequencies for opportunities to intervene and the rates at which soldiers intervene when presented with such opportunities. Soldiers ( N = 286) were asked whether they had witnessed particular risky behavior scenarios of interest to the Army (i.e., suicide-related behaviors, alcohol misuse, or sexual harassment/assault) during the previous 2 months and whether they had intervened in those scenarios. Prevalence rates within this sample were calculated to determine the frequency of such situations and subsequent interventions. Logistic regression was used to ascertain any differences in witnessing scenarios by demographic groups. Nearly half (46.8%) of the soldiers reported witnessing at least one scenario involving risky behaviors. Most soldiers who witnessed an event relating to suicide or alcohol misuse also reported consistently intervening (87.9% and 74.4%, respectively), whereas just half consistently intervened in response to scenarios relating to sexual harassment/assault (49.2%). Lower ranking soldiers were twice as likely as higher ranks to witness scenarios involving alcohol misuse (odds ratio = 2.18, 95% confidence interval [1.11, 4.26]) and sexual harassment/assault (odds ratio = 2.21, 95% confidence interval [1.05, 4.62]). These data indicate that soldiers regularly encounter opportunities to intervene in risky behaviors, and while a majority intervened in such scenarios, more training is warranted, particularly around sexual assault and harassment. This supports the notion that bystander intervention training is a worthwhile investment for the Army.
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Affiliation(s)
- Toby D Elliman
- 1 Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | | | | | - Robin L Toblin
- 1 Walter Reed Army Institute of Research, Silver Spring, MD, USA
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18
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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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19
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Ursano RJ, Kessler RC, Naifeh JA, Herberman Mash H, Fullerton CS, Bliese PD, Zaslavsky AM, Ng THH, Aliaga PA, Wynn GH, Dinh HM, McCarroll JE, Sampson NA, Kao TC, Schoenbaum M, Heeringa SG, Stein MB. Risk of Suicide Attempt Among Soldiers in Army Units With a History of Suicide Attempts. JAMA Psychiatry 2017; 74:924-931. [PMID: 28746705 PMCID: PMC5674988 DOI: 10.1001/jamapsychiatry.2017.1925] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
IMPORTANCE Mental health of soldiers is adversely affected by the death and injury of other unit members, but whether risk of suicide attempt is influenced by previous suicide attempts in a soldier's unit is unknown. OBJECTIVE To examine whether a soldier's risk of suicide attempt is influenced by previous suicide attempts in that soldier's unit. DESIGN, SETTING, AND PARTICIPANTS Using administrative data from the Army Study to Assess Risk and Resilience in Servicemembers (STARRS), this study identified person-month records for all active-duty, regular US Army, enlisted soldiers who attempted suicide from January 1, 2004, through December 31, 2009 (n = 9650), and an equal-probability sample of control person-months (n = 153 528). Data analysis was performed from August 8, 2016, to April 10, 2017. MAIN OUTCOMES AND MEASURES Logistic regression analyses examined the number of past-year suicide attempts in a soldier's unit as a predictor of subsequent suicide attempt, controlling for sociodemographic features, service-related characteristics, prior mental health diagnosis, and other unit variables, including suicide-, combat-, and unintentional injury-related unit deaths. The study also examined whether the influence of previous unit suicide attempts varied by military occupational specialty (MOS) and unit size. RESULTS Of the final analytic sample of 9512 enlisted soldiers who attempted suicide and 151 526 control person-months, most were male (86.4%), 29 years or younger (68.4%), younger than 21 years when entering the army (62.2%), white (59.8%), high school educated (76.6%), and currently married (54.8%). In adjusted models, soldiers were more likely to attempt suicide if 1 or more suicide attempts occurred in their unit during the past year (odds ratios [ORs], 1.4-2.3; P < .001), with odds increasing as the number of unit attempts increased. The odds of suicide attempt among soldiers in a unit with 5 or more past-year attempts was more than twice that of soldiers in a unit with no previous attempts (OR, 2.3; 95% CI, 2.1-2.6). The association of previous unit suicide attempts with subsequent risk was significant whether soldiers had a combat arms MOS or other MOS (ORs, 1.4-2.3; P < .001) and regardless of unit size, with the highest risk among those in smaller units (1-40 soldiers) (ORs, 2.1-5.9; P < .001). The population-attributable risk proportion for 1 or more unit suicide attempts in the past year indicated that, if this risk could be reduced to no unit attempts, 18.2% of attempts would not occur. CONCLUSIONS AND RELEVANCE Risk of suicide attempt among soldiers increased as the number of past-year suicide attempts within their unit increased for combat arms and other MOSs and for units of any size but particularly for smaller units. Units with a history of suicide attempts may be important targets for preventive interventions.
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Affiliation(s)
- Robert J Ursano
- Department of Psychiatry, Center for the Study of Traumatic Stress, 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
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Holly Herberman Mash
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Carol S Fullerton
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Paul D Bliese
- Darla School of Business, University of South Carolina, Columbia
| | - Alan M Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Tsz Hin Hinz Ng
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Pablo A Aliaga
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Gary H Wynn
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Hieu M Dinh
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - James E McCarroll
- Department of Psychiatry, Center for the Study of Traumatic Stress, 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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20
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Cox KL, Nock MK, Biggs QM, Bornemann J, Colpe CAPTL, Dempsey CL, Heeringa SG, McCarroll JE, Ng TH, Schoenbaum M, Ursano RJ, Zhang BG, Benedek DM. An Examination of Potential Misclassification of Army Suicides: Results from the Army Study to Assess Risk and Resilience in Servicemembers. Suicide Life Threat Behav 2017; 47:257-265. [PMID: 27447096 PMCID: PMC5253335 DOI: 10.1111/sltb.12280] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 04/04/2016] [Indexed: 12/20/2022]
Abstract
Debate continues about the accuracy of military suicide reporting due to concerns that some suicides may be classified as accidents to minimize stigma and ensure survivor benefits. We systematically reviewed records for 998 active duty Army deaths (510 suicides; 488 accident, homicide, and undetermined deaths; 2005-2009) and, using research criteria, reclassified 8.2% of the nonsuicide cases to definite suicide (1), suicide probable (4), or suicide possible (35). The reclassification rate to definite suicide was only 0.2% (1/488). This low rate suggests that flagrant misclassification of Army deaths is uncommon and surveillance reports likely reflect the "true" population of Army suicides.
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Affiliation(s)
- Kenneth L. Cox
- US Army Public Health Center, Aberdeen Proving Ground, Maryland, USA
| | - Matthew K. Nock
- Department of Psychology, Harvard University, Cambridge, Massachusetts, USA
| | - Quinn M. Biggs
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University School of Medicine, Bethesda, Maryland, USA
| | - Jennifer Bornemann
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University School of Medicine, Bethesda, Maryland, USA
| | - CAPT Lisa Colpe
- National Institute of Mental Health, Bethesda, Maryland, USA
| | - Catherine L. Dempsey
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University School of Medicine, Bethesda, Maryland, USA
| | - Steven G. Heeringa
- Institute for Social Research, University of Michigan, Ann Arbor, Michigan, USA
| | - James E. McCarroll
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University School of Medicine, Bethesda, Maryland, USA
| | - Tsz Hin Ng
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University School of Medicine, Bethesda, Maryland, USA
| | | | - Robert J. Ursano
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University School of Medicine, Bethesda, Maryland, USA
| | - Bailey G. Zhang
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University School of Medicine, Bethesda, Maryland, USA
| | - David M. Benedek
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University School of Medicine, Bethesda, Maryland, USA
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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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Risk factors for self-directed violence in US Soldiers: A case-control study. Psychiatry Res 2016; 245:194-199. [PMID: 27544785 DOI: 10.1016/j.psychres.2016.08.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 08/04/2016] [Accepted: 08/08/2016] [Indexed: 11/21/2022]
Abstract
Military suicide has escalated in recent years, however almost no research has used military surveillance data to examine suicide risk factors. The aims of the current study were to compare suicide risk factors among US Soldiers who died by suicide, attempted suicide, and controls using a prospective case-control design. Controls were 247 Soldiers completing standard post-deployment assessment procedures. Cases were 276 suicide decedents (n=85) or suicide attempters (n=191), drawn from the Department of Defense Suicide Event Report. Compared to controls, suicide attempters and decedents had greater odds of failed intimate relationships, legal problems, and substance abuse problems in the past 90 days. Suicide attempters and decedents also had greater odds of a history of a mood disorder and prior suicide attempt compared to controls. Suicide decedents had greater odds of exposure to legal problems in the past 90 days and lower odds of ever having an anxiety disorder, compared to suicide attempters. Vigilance toward early detection of modifiable suicide risk factors such as relationship dissolution, mood disorders, substance abuse, and legal problems may help reduce suicide risk among US Soldiers.
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