Clinical Review & Education

From The JAMA Network

Risk Factors for Suicides Among Army Personnel Matthew J. Friedman, MD, PhD

JAMA PSYCHIATRY

Participants were all members of the US Regular Army serving at any time between 2004 and 2009.

Predictors of Suicide and Accident Death in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS): Results From the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) Michael Schoenbaum, PhD; Ronald C. Kessler, PhD; Stephen E. Gilman, ScD; Lisa J. Colpe, PhD, MPH; Steven G. Heeringa, PhD; Murray B. Stein, MD, MPH; Robert J. Ursano, MD; Kenneth L. Cox, MD, MPH; for the Army STARRS Collaborators IMPORTANCE The Army Study to Assess Risk and Resilience in

Servicemembers (Army STARRS) is a multicomponent study designed to generate actionable recommendations to reduce Army suicides and increase knowledge of risk and resilience factors for suicidality. OBJECTIVES To present data on prevalence, trends, and basic

sociodemographic and Army experience correlates of suicides and accident deaths among active duty Regular Army soldiers between January 1, 2004, and December 31, 2009, and thereby establish a foundation for future Army STARRS investigations. DESIGN, SETTING, AND PARTICIPANTS Analysis of trends and predictors of suicide and accident deaths using Army and Department of Defense administrative data systems.

The US military’s Special Operations Command plans to address the increase in suicides by promoting physical rather than mental health. Command leadership reportedly has “asked Congress for $48 million in 2015 to hire physical therapists, dieticians, sports psychologists, and strength and conditioning specialists to work with troops.”1 Although the armed forces have made substantial investments in mental health, it is discouraging that Special Operations Command is taking such a different approach. This is especially so because rigorous data on risk factors for military suicide are available in 3 publications from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). The first article2 reported that among all regular army personnel (almost 1 million soldiers) who served between 2004 and 2009, the suicide rate increased from approximately 12 to 27 deaths per 100 000. Most surprising was that suicide rates showed similar increases among never-deployed as among deployed soldiers. The second article3 estimated the proportions of 30-day Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) mental disorders among a representative sample of 5428 Army STARRS participants. Approximately 25% of respondents met criteria for any 30-day internalizing disorder (eg, major depressive 1154

MAIN OUTCOMES AND MEASURES Death by suicide or accident

during active Army service. RESULTS The suicide rate rose between 2004 and 2009

among never deployed and currently and previously deployed Regular Army soldiers. Increased suicide risk was associated with being a man (or a woman during deployment), white race/ethnicity, junior enlisted rank, recent demotion, and current or previous deployment. Sociodemographic and Army experience predictors were generally similar for suicides and accident deaths. CONCLUSIONS AND RELEVANCE Predictors of Army suicides were largely similar to those reported elsewhere for civilians, although some predictors distinct to Army service emerged that deserve more in-depth analysis. The existence of a time trend in suicide risk among never-deployed soldiers argues indirectly against the view that exposure to combat-related trauma is the exclusive cause of the increase in Army suicides. JAMA Psychiatry. 2014;71(5):493-503. doi:10.1001/jamapsychiatry.2013.4417.

disorder [MDD], bipolar affective disorder, generalized anxiety disorder, panic disorder, or posttraumatic stress disorder [PTSD]) or externalizing disorder (eg, attention-deficit/hyperactivity disorder, intermittent explosive disorder [IED], or substance use disorder). Of note, 77% of psychiatric cases reported pre-enlistment onset of at least one 30-day disorder (49% internalizing and 82% externalizing), and perhaps most important, soldiers with psychiatric disorders exhibited severely impaired functional capacity. Indeed, 61.5% of soldiers who reported severe role impairment had at least 1 DSM-IV psychiatric disorder. The authors also reported that estimated population attributable risk proportions of severe role impairment due to 30 DSM-IV disorders were 21.7% for pre-enlistment, 24.3% for postenlistment, and 43.3% for all 30-day disorders. The third article,4 using survey data from the same 5428 Army STARRS participants, analyzed the risk of military suicide with regard to pre-enlistment vs postenlistment psychiatric disorder. Nearly half of all soldiers who had attempted suicide (n = 130 attempts) had done so prior to enlistment. One-third of postenlistment attempts were associated with pre-enlistment mental disorders. Although preenlistment MDD and IED were associated with development of suicide ideation, only postenlistment IED predicted attempts among

JAMA March 17, 2015 Volume 313, Number 11 (Reprinted)

Copyright 2015 American Medical Association. All rights reserved.

Downloaded From: http://jama.jamanetwork.com/ by a New York University User on 05/16/2015

jama.com

From The JAMA Network Clinical Review & Education

those with suicidal ideation. Contrary to civilian studies,5 PTSD was associated with lower risk of suicide. The proportion of soldiers who developed suicidal ideation, plans, or attempts were 21.0%, 9.0%, and 4.1%, respectively; 38.5% of those with suicidal ideation developed a plan, and 34% of those with suicidal ideation and a plan made an attempt. Whether a soldier progressed to the suicide plan stage seems to be a tipping point, because 80% of first attempts were planned. However, the transition from suicide ideation to plans was rapid, such that 60% of transitions from ideation to plans and from plans to attempts occurred within 1 year. These Army STARRS findings indicate that a minority of soldiers are responsible for a disproportionate amount of suicidal behavior and have pre-enlistment mental health problems, postenlistment psychiatric problems, or both. Intermittent explosive disorder and externalizing disorders in general are among the most common of these disorders. Although, as expected, deployment was associated with suicide risk, it is noteworthy that suicide rates among never-deployed soldiers also increased between 2004 and 2009. These findings raise doubts about Special Operations Command’s conclusion that the best way to reduce suicide risk is through a widespread emphasis on physical fitness. Instead, a much more focused effort to identify and treat soldiers with pre-enlistment disorders, postenlistment psychiatric disorders, or both is likely to be a more effective approach. Army STARRS data show that soldiers with pre-enlistment mental disorders or suicidal episodes are not disclosing such information at the time they undergo evaluation for military service. Individuals motivated for a military career in the all-volunteer army know that disclosure of such information might prevent enlistment. A pragmatic approach, therefore, would be to acknowledge that individuals with pre-enlistment psychiatric problems will be entering military service and to determine how to ensure that disclosure of pre-enlistment and postenlistment psychiatric problems can be accomplished confidentially and without risk to professional advancement. Service members have realistic concerns about the confidentiality of military medical records, which suppress treatmentseeking behavior despite their recognition that psychiatric symptoms impair both their professional performance and quality of life.6 ARTICLE INFORMATION Author Affiliations: National Center for PTSD, US Department of Veterans Affairs, White River Junction, Vermont; Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Department of Pharmacology and Toxicology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.

This is because Command has the option to review such information if there are questions about fitness for duty of any soldier. Moving the locus of mental health care into the primary care arena7 destigmatizes the public perception of help-seeking behavior for mental health problems but does not eliminate the privacy issue, because details of the visit will still be recorded in the medical record. To increase utilization of mental health services to reduce suicide risk, a middle ground must be found between Command’s need to know about fitness for duty and a soldier’s need for confidentiality of medical care. Consideration should be given to alternatives that might reduce the need for formal mental health treatment such as peer counseling options that would not be reported in the medical record.8 Certain suicide risk factors that could be easily monitored (such as junior rank, recent demotion, poor role performance, etc) might guide the referral to peer counseling programs. In addition, once a soldier requests formal mental health assistance, there is a need to develop engagement strategies that maximize the likelihood that soldiers remain in treatment and receive evidence-based care. A second challenge highlighted by these findings is the identification and remediation of factors that contribute to elevated suicide risk among never-deployed troops. This directs attention to improvement of the stateside military base environment, including the well-being and mental health of spouses and children who constitute a crucial primary support system for soldiers. Given the high risk of suicide attempts among soldiers with IED, aggressive behavior (eg, soldiers who get into frequent fights) should be regarded as more than a disciplinary problem, but also as a red flag for suicide risk. Perhaps it would be worth testing a program in which soldiers with IED are assigned to suicide prevention programs. Future analyses from the massive Army STARRS database will provide more fine-grained analyses of psychological, neurocognitive, social, biological, and genetic risk factors for suicide behavior, especially with regard to treatment and environmental factors that prevent army suicides. The findings from these first 3 articles, however, provide enough information to suggest improvements in current suicide prevention policies and programs. They also clearly indicate that prioritizing physical fitness is not the answer for reducing suicide risk in military personnel.

Department of Veterans Affairs or its National Center for PTSD.

suicidal behavior among soldiers. JAMA Psychiatry. 2014;71(5):514-522.

REFERENCES

5. Nock MK, Hwang I, Sampson NA, Kessler RC. Mental disorders, comorbidity and suicidal behaviors. Mol Psychiatry. 2010;15(8):868-876.

1. Jaffe G. To curb military suicides, does money go for sit-ups or psychologists? Washington Post. http://wapo.st/1qFGLLW. Accessed February 19, 2015.

Corresponding Author: Matthew J. Friedman, MD, PhD, Department of Veterans Affairs, National Center for PTSD, 215 N Main St (116D), White River Junction, VT 05009 ([email protected]).

2. Schoenbaum M, Kessler RC, Gilman SE, et al; Army STARRS Collaborators. Predictors of suicide and accident death in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry. 2014;71(5):493-503.

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

3. Kessler RC, Heeringa SG, Stein MB, et al; Army STARRS Collaborators. Thirty-day prevalence of DSM-IV mental disorders among nondeployed soldiers in the US Army. JAMA Psychiatry. 2014;71 (5):504-513.

Disclaimer: The views expressed are entirely those of the author and do not represent positions of the

4. Nock MK, Stein MB, Heeringa SG, et al; Army STARRS Collaborators. Prevalence and correlates of

jama.com

6. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med. 2004;351(1):13-22. 7. Engel CC, Oxman T, Yamamoto C, et al. RESPECT-Mil: feasibility of a systems-level collaborative care approach to depression and post-traumatic stress disorder in military primary care. Mil Med. 2008;173(10):935-940. 8. Greenberg N, Langston V, Everitt B, et al. A cluster randomized controlled trial to determine the efficacy of Trauma Risk Management (TRiM) in a military population. J Trauma Stress. 2010;23 (4):430-436.

(Reprinted) JAMA March 17, 2015 Volume 313, Number 11

Copyright 2015 American Medical Association. All rights reserved.

Downloaded From: http://jama.jamanetwork.com/ by a New York University User on 05/16/2015

1155

Risk factors for suicides among army personnel.

Risk factors for suicides among army personnel. - PDF Download Free
48KB Sizes 1 Downloads 8 Views