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Kok BC, Dux M, Lee-Wilk T, Clarke-Walper K, Wilk JE. Differential impact of type of killing on posttraumatic stress disorder symptoms in U.S. Army soldiers deployed to Afghanistan. J Trauma Stress 2023; 36:1151-1156. [PMID: 37705140 DOI: 10.1002/jts.22971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/12/2023] [Accepted: 07/16/2023] [Indexed: 09/15/2023]
Abstract
Over the past 20 years, U.S. military conflicts in Iraq and Afghanistan have been marked by high rates of combat and wartime killings. Research on Vietnam-era service members suggests that the type of killing (i.e., killing a combatant vs. noncombatant) is an important predictor of later mental health problems, including posttraumatic stress disorder (PTSD). The present study aimed to update these findings by exploring the impact of type of killing on PTSD symptoms using a sample of postdeployment active duty U.S. Army personnel (N = 875). Using multiple regression analysis, we found that the act of killing a noncombatant was significantly associated with PTSD symptoms, B = 7.50, p < .001, whereas killing a combatant was not, B = -0.85, p = .360. This remained significant after controlling for demographic variables, depressive symptoms, and general combat experiences. These findings support the need for thoughtful postdeployment screenings and targeted clinical interventions.
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Affiliation(s)
- Brian C Kok
- VA Maryland Health Care System, Baltimore, Maryland, USA
| | - Moira Dux
- VA Maryland Health Care System, Baltimore, Maryland, USA
| | - Terry Lee-Wilk
- VA Maryland Health Care System, Baltimore, Maryland, USA
| | - Kristina Clarke-Walper
- Department of Military Psychiatry, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Joshua E Wilk
- Department of Military Psychiatry, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
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2
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Orak U, Yildiz M, Aydogdu R, Koenig HG, Pietrzak RH. The relationship between combat exposure and suicide risk in U.S. military veterans: Exploring the role of posttraumatic stress symptoms and religious coping. J Affect Disord 2023; 341:77-87. [PMID: 37634819 DOI: 10.1016/j.jad.2023.08.115] [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] [Received: 01/04/2023] [Revised: 07/19/2023] [Accepted: 08/23/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Rising suicide rates in the U.S. veteran population are a growing concern. Combat exposure has been identified as a potential predictor of suicide risk, but factors that may mediate the relation between combat exposure and suicide risk, and the role of potential coping mechanisms remain largely understudied. To address this gap, this study examined the association between lifetime combat exposure and current suicide risk; whether this association is mediated by posttraumatic stress disorder (PTSD) symptoms; and whether direct and/or indirect associations with combat exposure are moderated by organizational, non-organizational, and intrinsic religiosity. METHODS Data were analyzed from the National Health and Resilience in Veterans Study (2019-2020; n = 3843). Ordinary least squares and conditional process analyses were conducted to evaluate the conditional direct and indirect predictors of suicide risk. RESULTS PTSD symptoms significantly mediated the association between combat exposure and suicide risk. Intrinsic religiosity showed significant moderation and reduced the coefficient of PTSD symptoms predicting suicide risk but increased the coefficient of combat exposure predicting PTSD symptoms. LIMITATIONS In this cross-sectional, observational study, no conclusions can be made regarding causality. CONCLUSIONS Results of this study suggest a multifaceted relationship between combat exposure, PTSD, religiosity/spirituality, and suicide risk in U.S. veterans, and underscore the importance of PTSD and religious coping as part of ongoing suicide prevention efforts in this population.
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Affiliation(s)
- Ugur Orak
- Department of Sociology and Anthropology, Middle Tennessee State University, Murfreesboro, TN, USA.
| | - Muhammed Yildiz
- Applied Sociology Department, Utah Tech University, St. George, UT, USA
| | - Ramazan Aydogdu
- Division of General Education and Health Studies, Baptist Health Sciences University, Memphis, TN, USA
| | - Harold G Koenig
- Department of Psychiatry and Behavioral Sciences, Department of Medicine, Duke University Medical Center, Durham, NC, USA; Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Robert H Pietrzak
- U.S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, USA; Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA; Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA
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3
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Ahmed AE, Yim MH, Dawood J, Olsen CH, Waters AJ, Singer DE, Mancuso JD. Suicidal Behaviors Among Active-Duty US Service Members: Data from the 2018 Health-Related Behaviors Survey. Psychol Res Behav Manag 2023; 16:4599-4615. [PMID: 37954933 PMCID: PMC10638889 DOI: 10.2147/prbm.s432835] [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: 07/28/2023] [Accepted: 10/31/2023] [Indexed: 11/14/2023] Open
Abstract
Background This study aimed to 1) determine the prevalence of past-year suicidal ideation (SI) and attempts (SA) among active-duty SMs; 2) determine whether differences exist by age, sex, and race; and 3) assess whether prevalence estimates vary by risk profiles of mental health conditions and substance use. Methods Data were from the 2018 Health-Related Behavior Survey (HRBS), a cross-sectional survey of active-duty SMs (n = 17,166). We used the logistic model to identify the factors of SI and SA and latent class analysis (LCA) to identify the risk profiles. Results Among active duty SMs, 8.26% had SI and 1.25% had SA in the past year. Gender and age have been shown to influence how race might contribute to suicidal behaviors. Mental health conditions were associated with higher odds of SI and SA, as were younger ages; LGB identity; being separated, divorced, or widowed; use of e-cigarettes, dual use of e-cigarettes and cigarettes, or drugs; and history of deployment of less than 12 months. Frequencies of cigarette and e-cigarette use were also associated with SI and SA, indicating the odds were increasing by 0.3% for every additional cigarette or e-cigarette used. Five risk profiles were identified: class 1 (illegal drug use), class 2 (mental health needs with tobacco and alcohol use), class 3 (mental health conditions only), class 4 ("low risk" SMs with low levels of illegal drug use, mental health visits, tobacco use, and alcohol use), and class 5 (alcohol use). Compared to class 4 ("low risk"), all other risk profiles were associated with increased odds of suicidal behaviors. Conclusion Despite the resources and increased access provided for mental health support, the prevalence of SI among active-duty SMs is greater than in the general population of the same age, likely due to additional military exposures and stressors.
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Affiliation(s)
- Anwar E Ahmed
- Department of Preventive Medicine & Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
| | - Michael H Yim
- Department of Preventive Medicine & Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
| | - Jimmy Dawood
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
| | - Cara H Olsen
- Department of Preventive Medicine & Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
| | - Andrew J Waters
- Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
| | - Darrell E Singer
- Department of Preventive Medicine & Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
| | - James D Mancuso
- Department of Preventive Medicine & Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
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4
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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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Maguen S, Griffin BJ, Vogt D, Hoffmire CA, Blosnich JR, Bernhard PA, Akhtar FZ, Cypel YS, Schneiderman AI. Moral injury and peri- and post-military suicide attempts among post-9/11 veterans. Psychol Med 2023; 53:3200-3209. [PMID: 35034682 PMCID: PMC10235653 DOI: 10.1017/s0033291721005274] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 11/29/2021] [Accepted: 12/06/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Our goal was to examine the association between moral injury, mental health, and suicide attempts during military service and after separation by gender in post-9/11 veterans. METHODS A nationally representative sample of 14057 veterans completed a cross-sectional survey. To examine associations of exposure to potentially morally injurious events (PMIEs; witnessing, perpetrating, and betrayal) and suicidal self-directed violence, we estimated two series of multivariable logistic regressions stratified by gender, with peri- and post-military suicide attempt as the dependent variables. RESULTS PMIE exposure accounted for additional risk of suicide attempt during and after military service after controlling for demographic and military characteristics, current mental health status, and pre-military history of suicidal ideation and attempt. Men who endorsed PMIE exposure by perpetration were 50% more likely to attempt suicide during service and twice as likely to attempt suicide after separating from service. Men who endorsed betrayal were nearly twice as likely to attempt suicide during service; however, this association attenuated to non-significance after separation in the fully adjusted models. In contrast, women who endorsed betrayal were over 50% more likely to attempt suicide during service and after separation; PMIE exposure by perpetration did not significantly predict suicide attempts before or after service among women in the fully adjusted models. CONCLUSIONS Our findings indicate that suicide assessment and prevention programs should consider the impact of moral injury and attend to gender differences in this risk factor in order to provide the most comprehensive care.
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Affiliation(s)
- Shira Maguen
- San Francisco VA Healthcare System, San Francisco, CA, USA
- University of California – San Francisco, San Francisco, CA, USA
| | - Brandon J. Griffin
- Central Arkansas VA Healthcare System, Little Rock, AR, USA
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Dawne Vogt
- VA Boston Healthcare System, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Claire A. Hoffmire
- VA Eastern Colorado Health Care System, Aurora, Colorado, USA
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - John R. Blosnich
- University of Southern California, Los Angeles, CA, USA
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Paul A. Bernhard
- Health Outcomes of Military Exposures, Epidemiology Program, Office of Patient Care Services, Veterans Health Administration, Washington, DC, USA
| | - Fatema Z. Akhtar
- Health Outcomes of Military Exposures, Epidemiology Program, Office of Patient Care Services, Veterans Health Administration, Washington, DC, USA
| | - Yasmin S. Cypel
- Health Outcomes of Military Exposures, Epidemiology Program, Office of Patient Care Services, Veterans Health Administration, Washington, DC, USA
| | - Aaron I. Schneiderman
- Health Outcomes of Military Exposures, Epidemiology Program, Office of Patient Care Services, Veterans Health Administration, Washington, DC, USA
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6
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Yard E, Brown M, Stone D. Nonfatal suicidal behaviors among former active duty servicemembers-United States, 2013-2019. MILITARY BEHAVIORAL HEALTH 2023; 11:45-53. [PMID: 37969570 PMCID: PMC10641751 DOI: 10.1080/21635781.2022.2151535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
Introduction Examine characteristics associated with increased odds of nonfatal suicidal behaviors among former active-duty servicemembers (F-ADSM) using data from the 2013-2019 National Survey on Drug Use and Health (NSDUH). Methods F-ADSM were respondents who reported being separated/retired from the military and previously serving on active-duty. For each outcome of interest (suicidal ideation, made a suicide plan, made a suicide attempt), we used multivariable logistic regression with backwards elimination to identify characteristics with statistically significant associations. Results In the 12 months preceding the survey, 3.6% of F-ADSM reported suicidal ideation, 1.0% reported making a plan, and 0.3% reported making a suicide attempt. There were increased odds of self-reported suicide attempts among F-ADSM who were female; aged 18-49 years; non-Hispanic black; gay or bisexual; divorced/separated or widowed; not employed; in poverty; binged alcohol in the past month; or ever had a major depressive episode. Conclusions Suicide can be prevented through a comprehensive, upstream approach addressing veteran's holistic needs to prevent them from becoming suicidal in the first place, and support veterans at increased risk.
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Affiliation(s)
- Ellen Yard
- Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Injury Prevention, Suicide Prevention Team, Atlanta, GA 30341
| | - Melissa Brown
- Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Injury Prevention, Suicide Prevention Team, Atlanta, GA 30341
| | - Deborah Stone
- Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Injury Prevention, Suicide Prevention Team, Atlanta, GA 30341
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7
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Trends in suicide rates by race and ethnicity among members of the United States Army. PLoS One 2023; 18:e0280217. [PMID: 36649302 PMCID: PMC9844903 DOI: 10.1371/journal.pone.0280217] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 12/08/2022] [Indexed: 01/18/2023] Open
Abstract
Efforts were focused on identifying differences in suicide rates and time-dependent hazard rate trends, overall and within age groups, by race and ethnicity among United States Army members who returned from an index deployment (October 2007 to September 2014). This retrospective cohort study was conducted using an existing longitudinal database, the Substance Use and Psychological Injury Combat Study (SUPIC). Demographic (e.g., race and ethnicity) and military data from the Department of Defense compiled within SUPIC, as well as Department of Veterans Affairs data were linked with National Death Index records (through 2018) to identify deaths by suicide including those that occurred after military service. The cohort included 860,930 Army Service members (Active Duty, National Guard, and Reserve). Age-adjusted (using the direct standardization method) and age-specific suicide rates per 100,000 person years were calculated and rate ratios (RR) were used for comparisons. Trends were evaluated using hazard rates over time since the end of individuals' index deployments. Among those aged 18-29 at the end of their index deployment, the suicide rate for American Indian/Alaskan Native (AI/AN) individuals was 1.51 times higher (95% confidence interval [CI]: 1.03, 2.14) compared to White non-Hispanic individuals (WNH), and lower for Hispanic and Black non-Hispanic (BNH) than for WNH individuals (RR = 0.65 [95% CI: 0.55, 0.77] and RR = 0.71 [95% CI: 0.61, 0.82], respectively). However, analyses revealed increasing trends in hazard rates post-deployment (≤ 6.5 years) within groups of Hispanic and BNH individuals (Average Annual Percent Change [APC]: 12.1% [95% CI: 1.3%, 24.1%] and 11.4% [95% CI: 6.9%, 16.0%], respectively) with a smaller, increase for WNH individuals (APC: 3.1%; 95% CI: 0.1%, 6.1%). Findings highlight key subgroups at risk for post-deployment suicide (i.e., WNH, AI/AN and younger individuals), as well as heterogeneous trends overtime, with rates and trends varying within race and ethnic groups by age groups. Post-deployment suicide prevention efforts that address culturally relevant factors and social determinants of health associated with health inequities are needed.
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Walker LE, Poltavskiy E, Howard JT, Janak JC, Watrous J, Alcover K, Pettey WBP, Ambardar S, Meyer E, Gundlapalli AV, Stewart IJ. Suicide attempts and mental health diagnoses in combat-injured service members: A retrospective cohort study. Suicide Life Threat Behav 2022; 53:227-240. [PMID: 36576267 DOI: 10.1111/sltb.12938] [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] [Received: 04/15/2022] [Revised: 08/19/2022] [Accepted: 12/05/2022] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Examinations of risk factors for suicide attempt in United States service members at high risk of mental health diagnoses, such as those with combat injuries, are essential to guiding prevention and intervention efforts. METHODS Retrospective cohort study of 8727 combat-injured patients matched to deployed, non-injured patients utilizing Department of Defense and Veterans Affairs administrative records. RESULTS Combat injury was positively associated with suicide attempt in the univariate model (HR = 1.75, 95% CI 1.5-2.1), but lost significance after adjustment for mental health diagnoses. Utilizing Latent Transition Analysis in the combat-injured group, we identified five mental/behavioral health profiles: (1) Few mental health diagnoses, (2) PTSD and depressive disorders, (3) Adjustment disorder, (4) Multiple mental health comorbidities, and (5) Multiple mental health comorbidities with alcohol use disorder (AUD). Multiple mental health comorbidities with AUD had the highest suicide attempt rate throughout the study and more than four times that of Multiple mental health comorbidities in the first study year (23.4 vs. 5.1 per 1000 person years, respectively). CONCLUSION Findings indicate that (1) combat injury's impact on suicide attempt is attenuated by mental health and (2) AUD with multiple mental health comorbidities confers heightened suicide attempt risk in combat-injured service members.
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Affiliation(s)
- Lauren E Walker
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA.,Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Eduard Poltavskiy
- David Grant USAF Medical Center, Travis AFB, Fairfield, California, USA
| | | | | | - Jessica Watrous
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,Leidos Inc., San Diego, California, USA
| | - Karl Alcover
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Warren B P Pettey
- VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Shiva Ambardar
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Eric Meyer
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Adi V Gundlapalli
- VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Ian J Stewart
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,Military Cardiovascular Outcomes Research (MiCOR), Bethesda, Maryland, 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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10
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Rivera AC, LeardMann CA, Rull RP, Cooper A, Warner S, Faix D, Deagle E, Neff R, Caserta R, Adler AB. Combat exposure and behavioral health in U.S. Army Special Forces. PLoS One 2022; 17:e0270515. [PMID: 35763535 PMCID: PMC9239470 DOI: 10.1371/journal.pone.0270515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 06/10/2022] [Indexed: 11/18/2022] Open
Abstract
Although combat has been found to be associated with adverse health outcomes, little is known about the impact of specific combat exposures, particularly among specialized personnel. This study examined the association of different types of combat exposures with behavioral health outcomes, and whether these associations differed by Army occupational specialization: General Purpose Forces infantrymen (n = 5,361), Ranger Qualified infantrymen (n = 308), and Special Forces personnel (n = 593). Multivariable regression models estimated the association of combat severity, type of combat event (fighting, killing, threat to oneself, death/injury of others), and type of killing with mental health disorders, trouble sleeping, and problem drinking. Combat severity, each type of combat event, and killing noncombatants were associated with adverse health outcomes after adjusting for covariates and other combat exposures. Except for trouble sleeping, these associations did not differ by occupational specialization, though the prevalence and odds of outcomes were generally lower for Special Forces personnel.
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Affiliation(s)
- Anna C. Rivera
- Deployment Health Research Department, Naval Health Research Center, San Diego, California, United States of America
- Leidos, San Diego, California, United States of America
- * E-mail:
| | - Cynthia A. LeardMann
- Deployment Health Research Department, Naval Health Research Center, San Diego, California, United States of America
- Leidos, San Diego, California, United States of America
| | - Rudolph P. Rull
- Deployment Health Research Department, Naval Health Research Center, San Diego, California, United States of America
| | - Adam Cooper
- Deployment Health Research Department, Naval Health Research Center, San Diego, California, United States of America
- Innovative Employee Solutions, San Diego, California, United States of America
| | - Steve Warner
- Deployment Health Research Department, Naval Health Research Center, San Diego, California, United States of America
- Leidos, San Diego, California, United States of America
| | - Dennis Faix
- Naval Health Research Center, San Diego, California, United States of America
| | - Edwin Deagle
- Preservation of the Force and Family, United States Special Operation Command Headquarters, MacDill Air Force Base, Tampa, Florida, United States of America
| | - Rob Neff
- Preservation of the Force and Family, United States Special Operation Command Headquarters, MacDill Air Force Base, Tampa, Florida, United States of America
| | - Ryan Caserta
- Preservation of the Force and Family, United States Special Operation Command Headquarters, MacDill Air Force Base, Tampa, Florida, United States of America
| | - Amy B. Adler
- Walter Reed Army Institute of Research, Silver Spring, Maryland, United States of America
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11
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Howard JT, Stewart IJ, Amuan M, Janak JC, Pugh MJ. Association of Traumatic Brain Injury With Mortality Among Military Veterans Serving After September 11, 2001. JAMA Netw Open 2022; 5:e2148150. [PMID: 35147684 PMCID: PMC8837911 DOI: 10.1001/jamanetworkopen.2021.48150] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Emerging evidence suggests that harmful exposures during military service, such as traumatic brain injury (TBI), may contribute to mental health, chronic disease, and mortality risks. OBJECTIVE To assess the mortality rates and estimate the number of all-cause and cause-specific excess deaths among veterans serving after the September 11, 2001, terrorist attacks (9/11) with and without exposure to TBI. DESIGN, SETTING, AND PARTICIPANTS This cohort study analyzed administrative and mortality data from January 1, 2002, through December 31, 2018, for a cohort of US military veterans who served during the Global War on Terrorism after the 9/11 terrorist attacks. Veterans who served active duty after 9/11 with 3 or more years of care in the Military Health System or had 3 or more years of care in the Military Health System and 2 or more years of care in the Veterans Health Administration were included for analysis. The study used data from the Veterans Affairs/Department of Defense Identity Repository database, matching health records data from the Military Health Service Management Analysis and Reporting tool, the Veterans Health Administration Veterans Informatics and Computing Infrastructure, and the National Death Index. For comparison with the total US population, the study used the Centers for Disease Control and Prevention WONDER database. Data analysis was performed from June 16 to September 8, 2021. EXPOSURE Traumatic brain injury. MAIN OUTCOMES AND MEASURES Multivariable, negative binomial regression models were used to estimate adjusted all-cause and cause-specific mortality rates for the post-9/11 military veteran cohort, stratified by TBI severity level, and the total US population. Differences in mortality rates between post-9/11 military veterans and the total US population were used to estimate excess deaths from each cause of death. RESULTS Among 2 516 189 post-9/11 military veterans (2 167 736 [86.2%] male; and 45 324 [1.8%] American Indian/Alaska Native, 160 178 [6.4%], Asian/Pacific Islander, 259 737 [10.3%] Hispanic, 387 926 [15.4%] non-Hispanic Black, 1 619 834 [64.4%] non-Hispanic White, and 43 190 [1.7%] unknown), 17.5% had mild TBI and 3.0% had moderate to severe TBI; there were 30 564 deaths. Adjusted, age-specific mortality rates were higher for post-9/11 military veterans than for the total US population and increased with TBI severity. There were an estimated 3858 (95% CI, 1225-6490) excess deaths among all post-9/11 military veterans. Of these, an estimated 275 (95% CI, -1435 to 1985) were not exposed to TBI, 2285 (95% CI, 1637 to 2933) had mild TBI, and 1298 (95% CI, 1023 to 1572) had moderate to severe TBI. Estimated excess deaths were predominantly from suicides (4218; 95% CI, 3621 to 4816) and accidents (2631; 95% CI, 1929 to 3333). Veterans with moderate to severe TBI accounted for 33.6% of total excess deaths, 11-fold higher than would otherwise be expected. CONCLUSIONS AND RELEVANCE This military veteran cohort experienced more excess mortality compared with the total US population than all combat deaths from 9/11/01 through 9/11/21, concentrated among individuals exposed to TBI. These results suggest that a focus on what puts veterans at risk for accelerated aging and increased mortality is warranted.
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Affiliation(s)
| | - Ian J. Stewart
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Megan Amuan
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
- Division of Epidemiology, US Department of Veterans Affairs, Salt Lake City, Utah
| | | | - Mary Jo Pugh
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
- Division of Epidemiology, US Department of Veterans Affairs, Salt Lake City, Utah
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12
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Belding JN, Castañeda SF, Jacobson IG, LeardMann CA, Porter B, Powell TM, Kolaja CA, Seelig AD, Matsuno RK, Carey FR, Rivera AC, Trone DW, Sheppard B, Walstrom J, Boyko EJ, Rull RP, For The Millennium Cohort Study Team. The Millennium Cohort Study: The First 20 Years of Research Dedicated to Understanding the Long-Term Health of US Service Members and Veterans. Ann Epidemiol 2021; 67:61-72. [PMID: 34906635 DOI: 10.1016/j.annepidem.2021.12.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/29/2021] [Accepted: 12/01/2021] [Indexed: 01/22/2023]
Abstract
The Millennium Cohort Study, the US Department of Defense's largest and longest running study, was conceived in 1999 to investigate the effects of military service on service member health and well-being by prospectively following active duty, Reserve, and National Guard personnel from all branches during and following military service. In commemoration of the Study's 20th anniversary, this paper provides a summary of its methods, key findings, and future directions. Recruitment and enrollment of the first 5 panels occurred between 2001 and 2021. After completing a baseline survey, participants are requested to complete follow-up surveys every 3 to 5 years. Study research projects are categorized into 3 core portfolio areas (psychological health, physical health, and health-related behaviors) and several cross-cutting areas and have culminated in more than 120 publications to date. For example, some key Study findings include that specific military service-related factors (e.g., experiencing combat, serving in certain occupational subgroups) were associated with adverse health-related outcomes and that unhealthy behaviors and mental health issues may increase following the transition from military service to veteran status. The Study will continue to foster stakeholder relationships such that research findings inform and guide policy initiatives and health promotion efforts.
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Key Words
- Abbreviations
- Army STARRS, Army Study to Assess Risk and Resilience in Servicemembers
- DoD, Department of Defense
- Millennium Cohort Study, military, veterans, deployment, risk factors, protective factors, physical health, mental health, health-related behaviors, longitudinal cohort
- OEF, Operation Enduring Freedom
- OIF, Operation Iraqi Freedom
- OND, Operation New Dawn
- PTSD, posttraumatic stress disorder
- VA, Department of Veterans Affairs
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Affiliation(s)
- Jennifer N Belding
- Leidos, San Diego, California, USA; Naval Health Research Center, San Diego, California, USA
| | - Sheila F Castañeda
- Leidos, San Diego, California, USA; Naval Health Research Center, San Diego, California, USA
| | - Isabel G Jacobson
- Leidos, San Diego, California, USA; Naval Health Research Center, San Diego, California, USA
| | - Cynthia A LeardMann
- Leidos, San Diego, California, USA; Naval Health Research Center, San Diego, California, USA
| | - Ben Porter
- Leidos, San Diego, California, USA; Naval Health Research Center, San Diego, California, USA; Mississippi State University, Mississippi State, Mississippi, USA
| | - Teresa M Powell
- Leidos, San Diego, California, USA; Naval Health Research Center, San Diego, California, USA
| | - Claire A Kolaja
- Leidos, San Diego, California, USA; Naval Health Research Center, San Diego, California, USA
| | - Amber D Seelig
- VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Rayna K Matsuno
- Leidos, San Diego, California, USA; Naval Health Research Center, San Diego, California, USA
| | - Felicia R Carey
- Leidos, San Diego, California, USA; Naval Health Research Center, San Diego, California, USA
| | - Anna C Rivera
- Leidos, San Diego, California, USA; Naval Health Research Center, San Diego, California, USA
| | - Daniel W Trone
- Naval Health Research Center, San Diego, California, USA
| | - Beverly Sheppard
- Leidos, San Diego, California, USA; Naval Health Research Center, San Diego, California, USA
| | - Jennifer Walstrom
- Leidos, San Diego, California, USA; Naval Health Research Center, San Diego, California, USA
| | - Edward J Boyko
- VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Rudolph P Rull
- Naval Health Research Center, San Diego, California, USA.
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13
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Georgoulas-Sherry V, Hernandez HG. The effects of grit and resilience on moral competence following simulated combat exposure. MILITARY PSYCHOLOGY 2021. [DOI: 10.1080/08995605.2021.1982631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
| | - Hanna G. Hernandez
- Department of Psychology, California State University, Fresno, California, USA
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