Exploring heterogeneity in PTSD symptoms and associated predictors and outcomes in Afghanistan veterans: A latent profile analysis

Research on posttraumatic stress symptoms (PTSS) typically focuses on diagnosis or symptom severity, however, this overlooks the variety of symptom patterns that exist. Latent profile analysis was used to explore PTSS profiles in a sample of Norwegian Afghanistan veterans (n = 4052, 91.7% males). Multinomial logistic regression analyses were conducted to examine predictors and outcomes associated with PTSS profile membership. Three profiles emerged: Low Symptoms profile (85%); High Numbing and Arousal profile (13%); and High Symptoms profile (2%). Being female, lower number of deployments, barriers to disclose war-related experiences, and higher number of potentially morally injurious events (PMIEs) were associated with belonging to the High Symptoms profile compared to the High Numbing and Arousal (Male gender: OR = 0.37, p < .05; Number of deployments: OR = 0.68, p < .05; Barriers to disclose: OR = 1.39, p < .001; PMIEs: OR = 1.15. p < .05), or Low Symptoms profile (Male gender: OR = 0.36, p < .05; Number of deployments: OR = 0.67, p < .01; Barriers to disclose: OR = 1.80, p < .001; PMIEs: OR = 1.32. p < .001). Participants in the High Symptoms profile had the highest probability of mental health service use (0.37) and endorsing suicidal ideation (0.38), compared to the two other profiles (p < .01). Participants in the High Numbing and Arousal profile had a higher probability of seeking professional mental health care (0.17), endorsing suicidal ideation (0.16), and reporting more suicide attempts compared to the Low Symptom profile (0.02 vs. 0.00, p < .001). These findings highlight the importance of considering the heterogeneity of PTSS profiles and understanding the predictors and responses of individuals who exhibit elevated PTSS symptoms.

PTSD, Comorbidities, Gender, and Increased Risk of Cardiovascular Disease in a Large Military Cohort

Importance

Posttraumatic stress disorder (PTSD) is a prevalent mental health problem that increases risk of cardiovascular disease (CVD). It is not known whether gender or comorbidities modify associations between PTSD and CVD.

Objective

To assess risk of hypertension and atherosclerotic CVD (ASCVD) associated with PTSD in a predominantly young military population, and determine if gender or PTSD comorbidities modify these associations.

Design setting and participants

Using administrative medical records, this longitudinal, retrospective cohort study assessed relationships of PTSD, gender, comorbidities (metabolic risk factors [MRF], behavioral risk factors [BRF], depression, and sleep disorders) to subsequent hypertension and ASCVD among 863,993 active-duty U.S. Army enlisted soldiers (86.2% male; 93.7%

Main outcomes and measures

ICD-9-CM diagnoses of hypertension, ASCVD (coronary artery disease, myocardial infarction, stroke, heart failure), PTSD, MRF (Type 2 diabetes, obesity), BRF (tobacco/alcohol use disorders), depression, and sleep disorders.

Results

PTSD was associated with subsequent hypertension (OR=3.0 [95% CI=2.9-3.1]), and ASCVD (OR=2.7 [95% CI=2.2-3.3]). These associations remained significant but were attenuated after adjusting for comorbidities and sociodemographic/service-related variables (Hypertension: OR=1.9 [95% CI=1.8-2.0]; ASCVD: OR=1.4 [95% CI=1.2-1.8]). For hypertension, gender and each comorbidity were significant explanatory variables in multivariable models, and there were significant PTSD interactions with gender, MRF, depression, and sleep disorders. Stratifying separately by gender and presence of each comorbidity, PTSD-hypertension associations were stronger among men, those without MRF, without depression, and without sleep disorders. Standardized risk estimates indicated that predicted hypertension rates for those with vs. without PTSD were higher for men, and for those with vs. without MRF, depression, and sleep disorders. For ASCVD, comorbidities, but not gender, were independent predictors, and associations between PTSD and ASCVD were not modified by gender or comorbidities.

Conclusions and relevance

PTSD and comorbidities are independent risk factors for hypertension and ASVD in younger individuals, and gender and comorbid conditions modify PTSD relationships with hypertension. These findings suggest that CVD preventive interventions address PTSD and medical and behavioral comorbidities.

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Polygenic risk for suicide attempt is associated with lifetime suicide attempt in US soldiers independent of parental risk

BACKGROUND

Suicide is a leading cause of death worldwide. Whereas some studies have suggested that a direct measure of common genetic liability for suicide attempts (SA), captured by a polygenic risk score for SA (SA-PRS), explains risk independent of parental history, further confirmation would be useful. Even more unsettled is the extent to which SA-PRS is associated with lifetime non-suicidal self-injury (NSSI).

METHODS

We used summary statistics from the largest available GWAS study of SA to generate SA-PRS for two non-overlapping cohorts of soldiers of European ancestry. These were tested in multivariable models that included parental major depressive disorder (MDD) and parental SA.

RESULTS

In the first cohort, 417 (6.3 %) of 6573 soldiers reported lifetime SA and 1195 (18.2 %) reported lifetime NSSI. In a multivariable model that included parental history of MDD and parental history of SA, SA-PRS remained significantly associated with lifetime SA [aOR = 1.26, 95%CI:1.13-1.39, p < 0.001] per standardized unit SA-PRS]. In the second cohort, 204 (4.2 %) of 4900 soldiers reported lifetime SA, and 299 (6.1 %) reported lifetime NSSI. In a multivariable model that included parental history of MDD and parental history of SA, SA-PRS remained significantly associated with lifetime SA [aOR = 1.20, 95%CI:1.04-1.38, p = 0.014]. A combined analysis of both cohorts yielded similar results. In neither cohort or in the combined analysis was SA-PRS significantly associated with NSSI.

CONCLUSIONS

PRS for SA conveys information about likelihood of lifetime SA (but not NSSI, demonstrating specificity), independent of self-reported parental history of MDD and parental history of SA.

LIMITATIONS

At present, the magnitude of effects is small and would not be immediately useful for clinical decision-making or risk-stratified prevention initiatives, but this may be expected to improve with further iterations. Also critical will be the extension of these findings to more diverse populations.

Prospective association of attachment style with suicide attempts among US Army soldiers

BACKGROUND

Insecure attachment styles are associated with retrospectively reported suicide attempts (SAs). It is not known if attachment styles are prospectively associated with medically documented SAs.

METHODS

A representative sample of US Army soldiers entering service (n = 21 772) was surveyed and followed via administrative records for their first 48 months of service. Attachment style (secure, preoccupied, fearful, dismissing) was assessed at baseline. Administrative medical records identified SAs. Discrete-time survival analysis examined associations of attachment style with future SA during service, adjusting for time in service, socio-demographics, service-related variables, and mental health diagnosis (MH-Dx). We examined whether associations of attachment style with SA differed based on sex and MH-Dx.

RESULTS

In total, 253 respondents attempted suicide. Endorsed attachment styles included secure (46.8%), preoccupied (9.1%), fearful (15.7%), and dismissing (19.2%). Examined separately, insecure attachment styles were associated with increased odds of SA: preoccupied [OR 2.5 (95% CI 1.7-3.4)], fearful [OR 1.6 (95% CI 1.1-2.3)], dismissing [OR 1.8 (95% CI 1.3-2.6)]. Examining attachment styles simultaneously along with other covariates, preoccupied [OR 1.9 (95% CI 1.4-2.7)] and dismissing [OR 1.7 (95% CI 1.2-2.4)] remained significant. The dismissing attachment and MH-Dx interaction was significant. In stratified analyses, dismissing attachment was associated with SA only among soldiers without MH-Dx. Other interactions were non-significant. Soldiers endorsing any insecure attachment style had elevated SA risk across the first 48 months in service, particularly during the first 12 months.

CONCLUSIONS

Insecure attachment styles, particularly preoccupied and dismissing, are associated with increased future SA risk among soldiers. Elevated risk is most substantial during first year of service but persists through the first 48 months. Dismissing attachment may indicate risk specifically among soldiers not identified by the mental healthcare system.

Overview and Design of the Child Maltreatment in Military Families Life Course Study

OBJECTIVE

This report presents an overview of the objectives, design, and analytic strategy of the Child Maltreatment in Military Families Life Course Study, an investigation of factors associated with child maltreatment in active duty military families.

METHOD

The study uses a case-control retrospective research design and discrete-time survival methodology to examine service member demographic characteristics, family characteristics, military-related characteristics, and military family life events associated with child maltreatment incidents that meet the Department of Defense definition of child abuse or neglect. The sample includes all active duty families with a first occurrence of child maltreatment anytime between Fiscal Year (FY) 2009 and FY 2018 (n  = 28,684), and a representative sample of control families with children under age of 18 during the same period (n  = 589,417). Analyses include child maltreatment and domestic abuse data from the Family Advocacy Program Central Registry; sponsor socio-demographic, military-related, and family data from the Active Duty Military Personnel Master and Defense Enrollment Eligibility Reporting System data files; deployment data from the Contingency Tracking System; and mental health data from the Medical Data Repository.

RESULTS AND CONCLUSIONS

Study results identify risk and protective factors associated with child maltreatment in military families, subgroups at elevated risk of child maltreatment, and periods of heightened risk during the military family life course. These results are expected to improve the ability to identify families most at-risk for particular types of child maltreatment and inform prevention strategies that promote the health and safety of military families.

Uncommon protein-coding variants associated with suicide attempt in a diverse sample of US Army soldiers

BACKGROUND

Suicide is a societal and public health concern of global scale. Identifying genetic risk factors for suicide attempt can characterize underlying biology and enable early interventions to prevent deaths. Recent studies have described common genetic variants for suicide-related behaviors. Here, we advance this search for genetic risk by analyzing the association between suicide attempt and uncommon variation, exome-wide in a large, ancestrally diverse sample.

METHODS

We sequenced whole genomes of 13,584 soldiers from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), including 979 with a history of suicide attempt. Uncommon, non-silent protein coding variants were analyzed exome-wide for association with suicide attempt by gene-collapsed and single variant analyses.

RESULTS

We identified 19 genes with variants enriched in individuals with suicide attempt, either through gene-collapsed or single variant analysis (Bonferroni PAdjusted< 0.05). These genes were CIB2, MLF1, HERC1, YWHAE, RCN2, VWA5B1, ATAD3A, NACA, EP400, ZNF585A, LYST, RC3H2, PSD3, STARD9, SGMS1, ACTR6, RGS7BP, DIRAS and KRTAP10-1. Most genes had variants across multiple genomic ancestry groups. Seventeen of these genes were expressed in healthy brain tissue, with seven genes expressed at highest levels in brain vs. other tissues. Brains from individuals deceased from suicide aberrantly expressed RGS7BP (PAdjusted=0.035) in addition to nominally significant genes including YWHAE, DIRAS2 and ACTR6, all of which have reported associations with other mental disorders.

CONCLUSIONS

These results advance the molecular characterization of suicide attempt behavior and support the utility of whole genome sequencing for complementing the findings of GWAS in suicide research.

Optimism, Sociability, and the Risk of Future Suicide Attempt among U.S. Army Soldiers

INTRODUCTION

Most research on suicide attempts among U.S. service members has been focused on risk factors that occur during service. There is an important gap in our understanding of premilitary factors, such as personality characteristics, that may be associated with future suicide attempt risk during service. Of particular importance is identifying risk factors for the 1/3 of suicide attempters who never receive a mental health diagnosis (MH-Dx)-and therefore are not identified as having a mental health problem in the military healthcare system-prior to their suicide attempt.

MATERIALS AND METHODS

Using two components of the Army Study to Assess Risk and Resilience in Servicemembers, we examined the association of personality facets from the Tailored Adaptive Personality Assessment System, a computerized instrument administered prior to entering service, with medically documented suicide attempts during service. A 2010-2016 sample of historical administrative records from U.S. Regular Army enlisted soldiers with complete data on 11 commonly administered Tailored Adaptive Personality Assessment System facets was examined using a series of logistic regression analyses to identify the facets associated with future suicide attempt. Significant facets were then applied to data from a longitudinal cohort study of 11,288 soldiers surveyed upon entering basic combat training and followed via administrative records for their first 48 months of service. This research was approved by the Institutional Review Boards at the collaborating institutions.

RESULTS

Analysis of the historical administrative data (87.0% male, 61.6% White non-Hispanic), found that low Optimism (odds ratio (OR) = 1.2 [95% CI = 1.0-1.4]) and high/low (vs. moderate) Sociability (OR = 1.3 [95%CI = 1.1-1.6]) were associated with suicide attempt after adjusting for other univariable-significant facets and socio-demographic and service-related variables. When examined in the longitudinal survey cohort, low Optimism (OR = 1.7 [95% CI = 1.1-2.4]) and high/low (vs. moderate) Sociability (OR = 1.7 [95% CI = 1.1-2.5]) were still associated with increased odds of documented suicide attempt during service, even after adjusting for each other, socio-demographic and service-related variables, and medically documented MH-Dx. Mental health diagnosis had a significant two-way interaction with Optimism (F = 5.27, p = 0.0236) but not Sociability. Stratified analyses indicated that low Optimism was associated with suicide attempt among soldiers without, but not among those with, a MH-Dx. Interactions of Optimism and Sociability with gender were nonsignificant. In the full model, population attributable risk proportions for Optimism and Sociability were 15.0% and 18.9%, respectively. Optimism and Sociability were differentially associated with suicide attempt risk across time in service.

CONCLUSIONS

Optimism and Sociability, assessed prior to entering U.S. Army service, are consistently associated with future suicide attempt during service, even after adjusting for other important risk factors. While Sociability is equally associated with suicide attempt among those with and without a MH-Dx, Optimism is specifically associated with suicide attempt among soldiers not identified in the mental healthcare system. Risk differences across time in service suggest that Optimism and Sociability interact with stressors and contextual factors in particular developmental and Army career phases.

Associations of active-duty mental health trajectories with post-military adjustment: Results from the STARRS Longitudinal Study

BACKGROUND

Many servicemembers experience difficulties transitioning from military to civilian life. We examined whether changes in mental health observed during active duty were associated with indices of post-military adjustment.

METHODS

Survey data from the multi-wave Army STARRS Pre/Post Deployment Study (PPDS; conducted 2012-2014) were linked to follow-up data from wave 1 of the STARRS Longitudinal Study (STARRS-LS1; conducted 2016-2018). Empirical Bayes estimates of intercepts and slopes of posttraumatic stress, problematic anger, and depressive symptoms during the PPDS were extracted from mixed-effects growth models and evaluated as predictors of life stress among 1080 participants who had separated or retired from the Army at STARRS-LS1; and of job satisfaction among 586 veterans who were employed at STARRS-LS1.

RESULTS

Higher average levels and larger increases in posttraumatic stress, anger, and depression over the deployment period were each associated with increased stress and (in the case of anger and depression) reduced job satisfaction. Posttraumatic stress and anger slopes were associated with overall stress (b = 5.60, p < 0.01 and b = 15.64, p = 0.04, respectively) and relationship stress (b = 5.50, p = 0.01 and b = 22.86, p = 0.01, respectively) beyond the average levels of those symptoms.

LIMITATIONS

Some transition-related difficulties may have resolved before outcome assessment; some measures were not previously validated.

CONCLUSIONS

Larger increases in posttraumatic stress and anger over a deployment period were associated with increased stress after leaving the Army, even after controlling for average symptom levels during the same period. Monitoring changes in mental health during active duty may help identify personnel who need additional support to facilitate the military-to-civilian transition.

Prospective associations of emotion reactivity and risk behaviors with suicide attempts in US Army soldiers

BACKGROUND

Emotion reactivity and risk behaviors (ERRB) are transdiagnostic dimensions associated with suicide attempt (SA). ERRB patterns may identify individuals at increased risk of future SAs.

METHODS

A representative sample of US Army soldiers entering basic combat training (n = 21 772) was surveyed and followed via administrative records for their first 48 months of service. Latent profile analysis of baseline survey items assessing ERRB dimensions, including emotion reactivity, impulsivity, and risk-taking behaviors, identified distinct response patterns (classes). SAs were identified using administrative medical records. A discrete-time survival framework was used to examine associations of ERRB classes with subsequent SA during the first 48 months of service, adjusting for time in service, socio-demographic and service-related variables, and mental health diagnosis (MH-Dx). We examined whether associations of ERRB classes with SA differed by year of service and for soldiers with and without a MH-Dx.

RESULTS

Of 21 772 respondents (86.2% male, 61.8% White non-Hispanic), 253 made a SA. Four ERRB classes were identified: 'Indirect Harming' (8.9% of soldiers), 'Impulsive' (19.3%), 'Risk-Taking' (16.3%), and 'Low ERRB' (55.6%). Compared to Low ERRB, Impulsive [OR 1.8 (95% CI 1.3-2.4)] and Risk-Taking [OR 1.6 (95% CI 1.1-2.2)] had higher odds of SA after adjusting for covariates. The ERRB class and MH-Dx interaction was non-significant. Within each class, SA risk varied across service time.

CONCLUSIONS

SA risk within the four identified ERRB classes varied across service time. Impulsive and Risk-Taking soldiers had increased risk of future SA. MH-Dx did not modify these associations, which may therefore help identify risk in those not yet receiving mental healthcare.

Predictors of suicide attempt within 30 days of first medically documented major depression diagnosis in U.S. army soldiers with no prior suicidal ideation

BACKGROUND

Understanding mental health predictors of imminent suicide attempt (SA; within 30 days) among soldiers with depression and no prior suicide ideation (SI) can inform prevention and treatment. The current study aimed to identify sociodemographic and service-related characteristics and mental disorder predictors associated with imminent SA among U.S. Army soldiers following first documented major depression diagnosis (MDD) with no history of SI.

METHODS

In this case-control study using Army Study to Assess Risk and Resilience in Servicemembers (STARRS) administrative data, we identified 101,046 active-duty Regular Army enlisted soldiers (2010-2016) with medically-documented MDD and no prior SI (MDD/No-SI). We examined risk factors for SA within 30 days of first MDD/No-SI using logistic regression analyses, including socio-demographic/service-related characteristics and psychiatric diagnoses.

RESULTS

The 101,046 soldiers with documented MDD/No-SI were primarily male (78.0%), < 29 years old (63.9%), White (58.1%), high school-educated (74.5%), currently married (62.0%) and < 21 when first entering the Army (56.9%). Among soldiers with MDD/No-SI, 2,600 (2.6%) subsequently attempted suicide, 16.2% (n = 421) within 30 days (rate: 416.6/100,000). Our final multivariable model identified: Soldiers with less than high school education (χ²₃ = 11.21, OR = 1.5[95%CI = 1.2-1.9]); combat medics (χ²₂ = 8.95, OR = 1.5[95%CI = 1.1-2.2]); bipolar disorder (OR = 3.1[95%CI = 1.5-6.3]), traumatic stress (i.e., acute reaction to stress/not PTSD; OR = 2.6[95%CI = 1.4-4.8]), and "other" diagnosis (e.g., unspecified mental disorder: OR = 5.5[95%CI = 3.8-8.0]) diagnosed same day as MDD; and those with alcohol use disorder (OR = 1.4[95%CI = 1.0-1.8]) and somatoform/dissociative disorders (OR = 1.7[95%CI = 1.0-2.8]) diagnosed before MDD were more likely to attempt suicide within 30 days. Currently married soldiers (χ²₂ = 6.68, OR = 0.7[95%CI = 0.6-0.9]), those in service 10 + years (χ²₃ = 10.06, OR = 0.4[95%CI = 0.2-0.7]), and a sleep disorder diagnosed same day as MDD (OR = 0.3[95%CI = 0.1-0.9]) were less likely.

CONCLUSIONS

SA risk within 30 days following first MDD is more likely among soldiers with less education, combat medics, and bipolar disorder, traumatic stress, and "other" disorder the same day as MDD, and alcohol use disorder and somatoform/dissociative disorders before MDD. These factors identify imminent SA risk and can be indicators for early intervention.

Effects of prior deployments and perceived resilience on anger trajectories of combat-deployed soldiers

BACKGROUND

Problematic anger is frequently reported by soldiers who have deployed to combat zones. However, evidence is lacking with respect to how anger changes over a deployment cycle, and which factors prospectively influence change in anger among combat-deployed soldiers.

METHODS

Reports of problematic anger were obtained from 7298 US Army soldiers who deployed to Afghanistan in 2012. A series of mixed-effects growth models estimated linear trajectories of anger over a period of 1-2 months before deployment to 9 months post-deployment, and evaluated the effects of pre-deployment factors (prior deployments and perceived resilience) on average levels and growth of problematic anger.

RESULTS

A model with random intercepts and slopes provided the best fit, indicating heterogeneity in soldiers' levels and trajectories of anger. First-time deployers reported the lowest anger overall, but the most growth in anger over time. Soldiers with multiple prior deployments displayed the highest anger overall, which remained relatively stable over time. Higher pre-deployment resilience was associated with lower reports of anger, but its protective effect diminished over time. First- and second-time deployers reporting low resilience displayed different anger trajectories (stable v. decreasing, respectively).

CONCLUSIONS

Change in anger from pre- to post-deployment varies based on pre-deployment factors. The observed differences in anger trajectories suggest that efforts to detect and reduce problematic anger should be tailored for first-time v. repeat deployers. Ongoing screening is needed even for soldiers reporting high resilience before deployment, as the protective effect of pre-deployment resilience on anger erodes over time.

Prospective Associations of Military Discharge Characterization with Post-active Duty Suicide Attempts and Homelessness: Results from the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS)

INTRODUCTION

Active duty service members transitioning to civilian life can experience significant readjustment stressors. Over the past two decades of the United States' longest sustained conflict, reducing transitioning veterans' suicidal behavior and homelessness became national priorities. However, it remains a significant challenge to identify which service members are at greatest risk of these post-active duty outcomes. Discharge characterization, which indicates the quality of an individual's military service and affects eligibility for benefits and services at the Department of Veterans Affairs, is a potentially important indicator of risk.

MATERIALS AND METHODS

This study used data from two self-report panel surveys of the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS) (LS1: 2016-2018, n = 14,508; and LS2: 2018-2019, n = 12,156), which were administered to respondents who previously participated while on active duty in one of the three Army STARRS baseline self-report surveys (2011-2014): the New Soldier Study (NSS), a survey of soldiers entering basic training; All Army Study, a survey of active duty soldiers around the world; and the Pre-Post Deployment Study, a survey of soldiers before and after combat deployment. Human Subjects Committees of the participating institutions approved all recruitment, informed consent, and data collection protocols. We used modified Poisson regression models to prospectively examine the association of discharge characterization (honorable, general, "bad paper" [other than honorable, bad conduct, dishonorable], and uncharacterized [due to separation within the first 180 days of service]) with suicide attempt (subsample of n = 4334 observations) and homelessness (subsample of n = 6837 observations) among those no longer on active duty (i.e., separated or deactivated). Analyses controlled for other suicide attempt and homelessness risk factors using standardized risk indices that were previously developed using the LS survey data.

RESULTS

Twelve-month prevalence rates of self-reported suicide attempts and homelessness in the total pooled LS sample were 1.0% and 2.9%, respectively. While not associated with suicide attempt risk, discharge characterization was associated with homelessness after controlling for other risk factors. Compared to soldiers with an honorable discharge, those with a bad paper discharge had an increased risk of homelessness in the total sample (relative risk [RR] = 4.4 [95% CI = 2.3-8.4]), as well as within subsamples defined by which baseline survey respondents completed (NSS vs. All Army Study/Pre-Post Deployment Study), whether respondents had been separated (vs. deactivated), and how much time had elapsed since respondents were last on active duty.

CONCLUSIONS

There is a robust association between receiving a bad paper discharge and post-separation/deactivation homelessness. Policies that enhance transition assistance and access to mental healthcare for high-risk soldiers may aid in reducing post-separation/deactivation homelessness among those who do not receive an honorable discharge.

Association of Premilitary Mental Health With Suicide Attempts During US Army Service

IMPORTANCE

Approximately one-third of US soldiers who attempt suicide have not received a mental health diagnosis (MH-Dx) before their suicide attempt (SA), yet little is known about risk factors for SA in those with no MH-Dx.

OBJECTIVE

To examine whether premilitary mental health is associated with medically documented SA among US Army soldiers who do not receive an MH-Dx before their SA.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from a representative survey of soldiers in the US Army entering basic combat training from April 1, 2011, to November 30, 2012, who were followed up via administrative records for the first 48 months of service. Analyses were conducted from April 5, 2021, to January 21, 2022. Regular Army enlisted soldiers (n = 21 772) recruited from 3 US Army installations during the first week of service who agreed to have their administrative records linked to their survey responses were included.

EXPOSURES

Preenlistment lifetime history of mental disorder, suicide ideation, SA, and nonsuicidal self-injury (NSSI) as reported during the baseline survey. Service-acquired MH-Dx and sociodemographic and service-related variables were identified using administrative records.

MAIN OUTCOMES AND MEASURES

Documented SAs were identified using administrative medical records. Using a discrete-time survival framework, linear splines examined the pattern of SA risk over the first 48 months of service. Logistic regression analysis examined associations of lifetime baseline survey variables with subsequent, medically documented SA among soldiers who did vs did not receive an MH-Dx during service. Models were adjusted for time in service and sociodemographic and service-related variables.

RESULTS

Of the 21 722 respondents (86.2% male, 20.4% Black, 61.8% White non-Hispanic), 253 made an SA in the first 48 months of service (male [75.4%]; Black [22.7%], White non-Hispanic [59.9%], or other race or ethnicity [17.4%]). Risk of SA peaked toward the end of the first year of service for both those who did and did not receive an MH-Dx during service. Of the 42.3% of individuals reporting at least 1 of the 4 baseline risk factors, 50.2% received an administrative MH-Dx during service vs 41.5% of those with none, and 1.6% had a documented SA vs 1.0% of those with none. Among individuals with no MH-Dx, medically documented SAs were associated with suicide ideation (odds ratio [OR], 2.2; 95% CI, 1.1-4.4), SA (OR, 11.3; 95% CI, 4.3-29.2), and NSSI (OR, 3.0; 95% CI, 1.3-6.8). For those who received an MH-Dx, medically documented SAs were associated with mental disorder (OR, 1.4; 95% CI, 1.0-1.9), SA (OR, 3.4; 95% CI, 2.1-5.6), and NSSI (OR, 1.8; 95% CI, 1.1-2.8). Interactions indicated the only explanatory variable that differed based on history of MH-Dx was preenlistment SA (χ21 = 4.7; P = .03), which had a larger OR among soldiers with no MH-Dx than among those with an MH-Dx.

CONCLUSIONS AND RELEVANCE

In this study, the period of greatest SA risk and baseline risk factors for SA were similar in soldiers with and without an MH-Dx. This finding suggests that knowledge of the time course and preenlistment mental health factors can equally aid in identifying SA risk in soldiers who do and do not receive an MH-Dx.

Association of emotion reactivity and distress intolerance with suicide attempts in U.S. Army soldiers

INTRODUCTION

Emotion reactivity (ER) and distress intolerance (DI) may be associated with increased suicide attempt (SA) risk among U.S. Army soldiers.

METHOD

In this case-control study, 74 soldiers recently hospitalized for SA (cases) were compared with 133 control soldiers from the same Army installations selected based on either propensity score matching (n = 103) or reported 12-month suicide ideation (SI) (n = 30). Controls were weighted to represent the total Army population at the study sites and the subpopulation of 12-month ideators. Participants completed questionnaires assessing ER, DI, and other psychosocial variables. Logistic regression analyses examined whether ER and DI differentiated SA cases from the general population and from 12-month ideators before and after controlling for additional important risk factors (sociodemographic characteristics, stressors, mental disorders).

RESULTS

In univariate analyses, ER differentiated SA cases from both the general population (OR = 2.5[95%CI = 1.7-3.6]) and soldiers with 12-month SI (OR = 2.5[95%CI = 1.3-4.6]). DI also differentiated cases from the general population (OR = 2.9[95%CI = 2.0-4.1]) and 12-month ideators (OR = 1.9[95%CI = 1.1-3.5]). These associations persisted after controlling for sociodemographic variables, stressors, and mental disorders.

CONCLUSION

Findings provide evidence that higher ER and DI are associated with increased risk of SA among soldiers, even after adjusting for known risk factors. Prospective research with larger samples is needed.

Parental suicide attempt and subsequent risk of pre-enlistment suicide attempt among male and female new soldiers in the U.S. Army

OBJECTIVE

Suicide and suicide attempts among U.S. Army soldiers are a significant concern for public health. This study examined the association of parental suicide attempt prior to age 13 of the soldier with subsequent risk of pre-enlistment suicide attempt.

METHOD

We conducted secondary analyses of survey data from new soldiers who participated in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) (N = 38,396). A series of logistic regression analyses were conducted.

RESULTS

Of all new soldiers, 1.4% reported that they attempted suicide between age 13 and entering the Army, and 2.3% reported a parental suicide attempt prior to age 13. Parental suicide attempt was associated with increased odds of subsequent suicide attempt; however, this association was moderated by gender and was significant only among male soldiers. The association between parental suicide attempt and pre-enlistment suicide attempt among male soldiers was still significant after controlling for socio-demographic characteristics, soldier/parental psychopathology, and childhood adversities.

CONCLUSIONS

These results highlight parental suicide attempt as a unique pre-enlistment risk factor for suicide attempt, especially among male new soldiers. Further studies are needed to separate the genetic and environmental contributions to intra-familial risk for suicidal behavior.

Risk of suicide attempt in reserve versus active component soldiers during deployment to the wars in Iraq and Afghanistan

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.

Attachment Style and Risk of Suicide Attempt Among New Soldiers in the U.S. Army

OBJECTIVE

Among U.S. Army soldiers suicide attempts (SAs) are a significant public health concern, particularly early in service. We examined the association of attachment style with SA and suicide ideation (SI) among U.S. Army soldiers.

METHODS

We analyzed survey data from new soldiers who participated in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). The sample consists of 38,507 soldiers entering Basic Combat Training (BCT) between April 2011 and November 2012. Attachment style (secure, preoccupied, fearful, and dismissing) was assessed using items from the Relationship Questionnaire. Lifetime (pre-enlistment) SA and SI were assessed with a modified Columbia Suicide Severity Rating Scale. Logistic regression analyses examined associations of attachment style with lifetime SA, SI, and attempts among ideators, after adjusting for socio-demographic characteristics.

RESULTS

The secure attachment style was associated with lower odds of SA (OR = 0.76, 95% CI = 0.63-0.92), whereas preoccupied (OR = 4.63, 95% CI = 3.83-5.61), fearful (OR = 4.08, 95% CI = 3.38-4.94), or dismissing (OR = 1.56, 95% CI = 1.24-1.96) attachment styles were associated with higher odds of SA. Similar results were found for SI. Importantly, both preoccupied (OR = 1.67, 95% CI = 1.37-2.04) and fearful (OR = 1.70, 95% CI = 1.38-2.08) attachment were associated with attempts among ideators.

CONCLUSION

These findings highlight the clinical importance of attachment style in predicting suicidal behavior and as possible targets for intervention. A critical next step is for prospective research to examine whether attachment style predicts future suicidal behavior.

Association between neurocognitive functioning and suicide attempts in U.S. Army Soldiers

BACKGROUND

Suicide is a serious public health problem, including among U.S. Army personnel. There is great interest in discovering objective predictors of suicide and non-fatal suicidal behaviors. The current study examined the association between neurocognitive functioning and pre-military history of suicide attempts (SA) and post-enlistment onset of SA.

METHODS

New Soldiers reporting for Basic Combat Training (N = 38,507) completed a comprehensive computerized neurocognitive assessment battery and self-report questionnaires. A subset of Soldiers (n = 6216) completed a follow-up survey, including assessment of lifetime SA, 3-7 years later.

RESULTS

Six hundred eighty-nine Soldiers indicated lifetime SA at baseline and 210 Soldiers indicated new-onset SA at follow-up. Regression analyses, adjusted for demographic variables, revealed significant bivariate associations between neurocognitive performance on measures of sustained attention, impulsivity, working memory, and emotion recognition and lifetime SA at baseline. In a multivariable model including each of these measures as predictors, poorer impulse control and quicker response times on an emotion recognition measure were significantly and independently associated with increased odds of lifetime SA. A second model predicted new-onset SA at follow-up for Soldiers who did not indicate a history of SA at baseline. Poorer impulse control on a measure of sustained attention was predictive of new-onset SA.

LIMITATIONS

Effect sizes are small and of unlikely clinical predictive utility.

CONCLUSIONS

We simultaneously examined multiple neurocognitive domains as predictors of SA in a large, representative sample of new Army Soldiers. Impulsivity most strongly predicted past and future SA over and beyond other implicated cognitive-emotional domains.

Predictors of Suicide Attempt Within 30 Days After First Medically Documented Suicidal Ideation in U.S. Army Soldiers

OBJECTIVE

The authors sought to identify predictors of imminent suicide attempt (within 30 days) among U.S. Army soldiers following their first documented suicidal ideation.

METHODS

Using administrative data from the Army Study to Assess Risk and Resilience in Servicemembers, the authors identified 11,178 active-duty Regular Army enlisted soldiers (2006-2009) with medically documented suicidal ideation and no prior medically documented suicide attempts. The authors examined risk factors for suicide attempt within 30 days of first suicidal ideation using logistic regression analyses, including sociodemographic and service-related characteristics, psychiatric diagnoses, physical health care visits, injuries, and history of family violence or crime perpetration or victimization.

RESULTS

Among soldiers with first documented suicidal ideation, 830 (7.4%) attempted suicide, 46.3% of whom (N=387) attempted suicide within 30 days (rate, 35.4 per 1,000 soldiers). Following a series of multivariate analyses, the final model identified females (odds ratio=1.3, 95% CI=1.0, 1.8), combat medics (odds ratio=1.6, 95% CI=1.1, 2.2), individuals with an anxiety disorder diagnosis prior to suicidal ideation (odds ratio=1.3, 95% CI=1.0, 1.6), and those who received a sleep disorder diagnosis on the same day as the recorded suicidal ideation (odds ratio=2.3, 95% CI=1.1, 4.6) as being more likely to attempt suicide within 30 days. Black soldiers (odds ratio=0.6, 95% CI=0.4, 0.9) and those who received an anxiety disorder diagnosis on the same day as suicidal ideation (odds ratio=0.7, 95% CI=0.5, 0.9) were less likely.

CONCLUSIONS

Suicide attempt risk is highest in the first 30 days following ideation diagnosis and is more likely among women, combat medics, and soldiers with an anxiety disorder diagnosis before suicidal ideation and a same-day sleep disorder diagnosis. Black soldiers and those with a same-day anxiety disorder diagnosis were at decreased risk. These factors may help identify soldiers at imminent risk of suicide attempt.

Sex Differences in US Army Suicide Attempts During the Wars in Iraq and Afghanistan

OBJECTIVE

To examine sex differences in risk for administratively documented suicide attempt (SA) among US Army soldiers during the Iraq/Afghanistan wars.

METHOD

Using administrative person-month records of Regular Army enlisted soldiers from 2004 to 2009, we identified 9650 person-months with a first documented SA and an equal-probability control sample (n=153,528 person-months). Person-months were weighted to the population and pooled over time. After examining the association of sex with SA in a logistic regression analysis, predictors were examined separately among women and men.

RESULTS

Women (an estimated 13.7% of the population) accounted for 25.2% of SAs and were more likely than men to attempt suicide after adjusting for sociodemographic, service-related, and mental health diagnosis (MHDx) variables (odds ratio=1.6; 95% confidence interval, 1.5-1.7). Women with increased odds of SA in a given person-month were younger, non-Hispanic White, less educated, in their first term of enlistment, never or previously deployed (vs. currently deployed), and previously received a MHDx. The same variables predicted SA among men. Interactions indicated significant but generally small differences between women and men on 6 of the 8 predictors, the most pronounced being time in service, deployment status, and MHDx. Discrete-time survival models examining risk by time in service demonstrated that patterns for women and men were similar, and that women's initially higher risk diminished as time in service increased.

CONCLUSIONS

Predictors of documented SAs are similar for US Army women and men. Differences associated with time in service, deployment status, and MHDx require additional research. Future research should consider stressors that disproportionately affect women.

A test of the interpersonal theory of suicide in a large, representative, retrospective and prospective study: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

The interpersonal theory of suicide hypothesizes that perceived burdensomeness, thwarted belongingness, and hopelessness lead to active suicidal thoughts and individuals with active suicidal thoughts and elevated capability for suicide are most likely to attempt suicide. We retrospectively and prospectively tested this theory in a large sample of 7677 U.S. Army soldiers followed post-deployment for up to nine months. The interaction of perceived burdensomeness and hopelessness (OR = 2.59) was significantly associated with lifetime suicidal thoughts; however, the interactions of thwarted belongingness and perceived burdensomeness and of thwarted belongingness and hopelessness were not. Consistent with the theory, capability for suicide prospectively predicted suicide attempts during and following deployment (OR = 1.22); however, among soldiers reporting lifetime suicidal thoughts, capability did not predict attempts, only perceived burdensomeness did (OR = 1.36). Results supported some, but not all, theory hypotheses, suggesting that additional constructs may be needed to better identify the psychological factors that lead soldiers to attempt suicide.

Self-injurious thoughts and behaviors that differentiate soldiers who attempt suicide from those with recent suicide ideation

BACKGROUND

Risk for suicide attempt (SA) versus suicide ideation (SI) is clinically important and difficult to differentiate. We examined whether a history of self-injurious thoughts and behaviors (SITBs) differentiates soldiers with a recent SA from nonattempting soldiers with current/recent SI.

METHODS

Using a unique case-control design, we administered the same questionnaire (assessing the history of SITBs and psychosocial variables) to representative U.S. Army soldiers recently hospitalized for SA (n = 132) and soldiers from the same Army installations who reported 30-day SI but did not make an attempt (n = 125). Logistic regression analyses examined whether SITBs differentiated attempters and ideators after controlling for previously identified covariates.

RESULTS

In separate models that weighted for systematic nonresponse and controlled for gender, education, posttraumatic stress disorder, and intermittent explosive disorder, SA was positively and significantly associated with the history of suicide plan and/or intention to act (odds ratio [OR] = 12.1 [95% confidence interval {CI} = 3.6-40.4]), difficulty controlling suicidal thoughts during the worst week of ideation (OR = 3.5 [95% CI = 1.1-11.3]), and nonsuicidal self-injury (NSSI) (OR = 4.9 [95% CI = 1.3-18.0]). Area under the curve was 0.87 in a full model that combined these SITBs and covariates. The top ventile based on predicted risk had a sensitivity of 24.7%, specificity of 99.8%, and positive predictive value of 97.5%.

CONCLUSIONS

History of suicide plan/intention, difficult to control ideation, and NSSI differentiate soldiers with recent SA from those with current/recent SI independent of sociodemographic characteristics and mental disorders. Longitudinal research is needed to determine whether these factors are prospectively associated with the short-term transition from SI to SA.

Early First Deployment and Risk of Suicide Attempt Among First-term Enlisted Soldiers in the U.S. Army

OBJECTIVE

We examined early first deployment and subsequent suicide attempt among U.S. Army soldiers.

METHOD

Using 2004-2009 administrative data and person-month records of first-term, Regular Army, enlisted soldiers with one deployment (89.2% male), we identified 1,704 soldiers with a documented suicide attempt during or after first deployment and an equal-probability control sample (n = 25,861 person-months).

RESULTS

Logistic regression analyses indicated soldiers deployed within the first 12 months of service were more likely than later deployers to attempt suicide (OR = 1.7 [95% CI = 1.5-1.8]). Adjusting for sociodemographic characteristics, service-related characteristics, and previous mental health diagnosis slightly attenuated this association (OR = 1.6 [95% CI = 1.5-1.8]). Results were not modified by gender, deployment status, military occupation, or mental health diagnosis. The population-attributable risk proportion for deploying within the first 12 months of service was 17.8%. Linear spline models indicated similar risk patterns over time for early and later deployers, peaking at month 9 during deployment and month 5 postdeployment; however, monthly suicide attempt rates were consistently higher for early deployers.

CONCLUSIONS

Enlisted soldiers deployed within the first 12 months of service have elevated risk of suicide attempt during and after first deployment. Improved understanding of why early deployment increases risk can inform the development of policies and intervention programs.

Pre-deployment predictors of suicide attempt during and after combat deployment: Results from the Army Study to Assess Risk and Resilience in Servicemembers

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.

Factors Associated With Suicide Ideation in US Army Soldiers During Deployment in Afghanistan

IMPORTANCE

Understanding suicide ideation (SI) during combat deployment can inform prevention and treatment during and after deployment.

OBJECTIVE

To examine associations of sociodemographic characteristics, lifetime and past-year stressors, and mental disorders with 30-day SI among a representative sample of US Army soldiers deployed in Afghanistan.

DESIGN, SETTING, AND PARTICIPANTS

In this survey study, soldiers deployed to Afghanistan completed self-administered questionnaires in July 2012. The sample was weighted to represent all 87 032 soldiers serving in Afghanistan. Prevalence of lifetime, past-year, and 30-day SI and mental disorders was determined. Logistic regression analyses examined risk factors associated with SI. Data analyses for this study were conducted between August 2018 and August 2019.

MAIN OUTCOMES AND MEASURES

Suicide ideation, lifetime and 12-month stressors, and mental disorders were assessed with questionnaires. Administrative records identified sociodemographic characteristics and suicide attempts.

RESULTS

A total of 3957 soldiers (3473 [weighted 87.5%] male; 2135 [weighted 52.6%] aged ≤29 years) completed self-administered questionnaires during their deployment in Afghanistan. Lifetime, past-year, and 30-day SI prevalence estimates were 11.7%, 3.0%, and 1.9%, respectively. Among soldiers with SI, 44.2% had major depressive disorder (MDD) and 19.3% had posttraumatic stress disorder in the past 30-day period. A series of analyses of the 23 grouped variables potentially associated with SI resulted in a final model of sex; race/ethnicity; lifetime noncombat trauma; past 12-month relationship problems, legal problems, and death or illness of a friend or family member; and MDD. In this final multivariable model, white race/ethnicity (odds ratio [OR], 3.1 [95% CI, 1.8-5.1]), lifetime noncombat trauma (OR, 2.1 [95% CI, 1.1-4.0]), and MDD (past 30 days: OR, 31.8 [95% CI, 15.0-67.7]; before past 30 days: OR, 4.9 [95% CI, 2.5-9.6]) were associated with SI. Among the 85 soldiers with past 30-day SI, from survey administration through 12 months after returning from deployment, 6% (5 participants) had a documented suicide attempt vs 0.14% (6 participants) of the 3872 soldiers without SI.

CONCLUSIONS AND RELEVANCE

This study suggests that major depressive disorder and noncombat trauma are important factors in identifying SI risk during combat deployment.

Cross-sectional evaluation of perceived health care provider engagement, self-efficacy, and ART adherence in people living with HIV/AIDS

Despite advancements in the treatment and prevention of HIV/AIDS, adherence to antiretroviral therapy (ART) remains suboptimal. Research indicates that health care provider (HCP) engagement is related to adherence, yet little is known about the specific pathways that underlie this relation. This cross-sectional study examined the relation between perceived HCP engagement and ART adherence in people living with HIV/AIDS (PLWHA), as well as the role of adherence self-efficacy in this relation. Participants (N = 207) completed self-report measures assessing monthly ART adherence, perceived ability to take ART as prescribed, and perceptions of HCP engagement. Results of a path analysis revealed a direct positive relation between perceived HCP engagement and ART adherence, and a significant indirect relation of perceived HCP engagement to ART adherence through adherence self-efficacy. Higher perceived HCP engagement was related to greater adherence self-efficacy, which, in turn was related to higher ART adherence. Findings are consistent with research demonstrating that HCP support leads to increased motivation to engage in treatment and extends past work on the importance of positive patient-provider relationships. Notably, results suggest that increasing patient perceptions of HCP engagement may be one way to boost adherence self-efficacy and improve ART adherence in PLWHA.

Genetic predictor of current suicidal ideation in US service members deployed to Iraq and Afghanistan

OBJECTIVE

Suicide is one of the ten leading causes of death in United States and the suicide rate in the military population has increased since the start of the Iraq and Afghanistan wars. However, few biomarkers for current suicidal ideation (CSI) have been identified. The current study examined the association of four candidate genes with CSI in active duty US Army Special Operations Command and National Guard units (n = 3,889) who served in Iraq and Afghanistan between November 2009 and July 2014.

METHODS

Current PTSD symptoms and CSI were assessed using the PTSD Checklist (PCL) and PHQ-9, respectively. Traumatic events were assessed using items from the Life Events Checklist (LEC) that met the DSM-IV PTSD criteria of a traumatic stressor. All genotypes of saliva DNA were discriminated using the TaqMan 5'-exonuclease assay.

RESULTS

The associations between CSI and brain-derived neurotrophic factor (BDNF), FK506 binding protein (FKBP5), catechol-O-methyltransferase (COMT), or S100A10 (p11) were examined. We found CSI was associated with BDNF (OR = 1.5, 95% CI = 1.5-1.8, P = 0.0002), but not FKBP5, COMT and p11. Female soldiers reported CSI more often than males (χ2 = 7.403, p = 0.0065), although gender did not affect CSI severity. In addition, associations were found between CSI and depression, PTSD, and BDNF, but not traumatic events. The BDNF Val66Met contributed to the severity of CSI even after adjusting to PTSD, depression and LEC.

CONCLUSIONS

The associations of BDNF with CSI and its severity suggest that BDNF may be a predictor of suicidal risk and present an opportunity to develop laboratory tools with clinical implications in suicide prevention and treatment.

Transition to suicide attempt from recent suicide ideation in U.S. Army soldiers: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

BACKGROUND

Most people with suicide ideation (SI) do not attempt suicide (SA). Understanding the transition from current/recent SI to SA is important for mental health care. Our objective was to identify characteristics that differentiate SA from 30-day SI among representative U.S. Army soldiers.

METHODS

Using a unique case-control design, soldiers recently hospitalized for SA (n = 132) and representative soldiers from the same four communities (n = 10,193) were administered the same questionnaire. We systematically identified variables that differentiated suicide attempters from the total population, then examined whether those same variables differentiated all 30-day ideators (n = 257) from the total population and attempters from nonattempting 30-day ideators.

RESULTS

In univariable analyses, 20 of 23 predictors were associated with SA in the total population (0.05 level). The best multivariable model included eight significant predictors: interpersonal violence, relationship problems, major depressive disorder, posttraumatic stress disorder (PTSD), and substance use disorder (all having positive associations), as well as past 12-month combat trauma, intermittent explosive disorder (IED), and any college education (all having negative associations). Six of these differentiated 30-day ideators from the population. Three differentiated attempters from ideators: past 30-day PTSD (OR = 6.7 [95% CI = 1.1-39.4]), past 30-day IED (OR = 0.2 [95% CI = 0.1-0.5]), and any college education (OR = 0.1 [95% CI = 0.0-0.6]). The 5% of ideators with highest predicted risk in this final model included 20.9% of attempters, a four-fold concentration of risk.

CONCLUSIONS

Prospective army research examining transition from SI to SA should consider PTSD, IED, and education. Combat exposure did not differentiate attempters from ideators. Many SA risk factors in the Army population are actually risk factors for SI.

Association between leukocyte telomere length and hostility in US army service members

Hostility is a common form of emotionally charged anger which can lead to maladaptive and unhealthy behaviors. Significant association between shortened telomeres and greater levels of hostility has been observed in civilian populations, but has not yet been comprehensively studied in military populations. Our study investigates the relationship between hostility, post-traumatic stress disorder (PTSD), and leukocyte telomere length (LTL) in a sample of United States Army Special Operations personnel (n = 474) who deployed to Iraq and/or Afghanistan as part of combat operations. Hostility was measured with five items from the Brief Symptom Inventory (BSI). PTSD was determined using the PTSD Checklist (PCL) total score. The LTL was assessed using quantitative polymerase chain reaction methods and regression analyses were conducted to determine the association of hostility and telomere length. PTSD subjects reported higher hostility scores compared with those without PTSD. Among the participants with PTSD, those with medium or high level of hostility had shorter LTL than those with low level hostility (P < 0.01). Stepwise regression indicated that hostility level and age, but not gender and PTSD, were negatively correlated with LTL. Univariate regression showed that total hostility score was negatively associated with LTL (CI= -0.06 to -0.002, Beta= -0.095, p < 0.039) as well as a significant correlation between LTL and hostility impulses (HI) (CI= -0.108 to -0.009, Beta= -0.106, p < 0.021) and hostility controlling (HC) (CI= -0.071 to -0.002, Beta= -0.095, p < 0.004). Multiple regression analyses revealed that, while HC has no significant association with LTL, HI was still negatively correlated with LTL (p = 0.021). Our data indicates that LTL is associated with HI levels. Prevention and treatment efforts designed to reduce hostility may help mitigate risk for LTL shortening, a process of cellular aging, and thus slow accelerated aged-related health outcomes.

Internal consistency and factor structure of a brief scale assessing sensitivity to blood, injury, and mutilation

OBJECTIVE

US Army soldiers and military veterans experience high rates of post-traumatic stress disorder (PTSD). However, PTSD risk factors are not fully understood. Sensitivity to blood, injury, and mutilation (SBIM), which includes fear of being injured, seeing another person injured, and exposure to mutilation-relevant stimuli (e.g., blood, wounds) may be a PTSD risk factor that is identifiable prior to trauma exposure. Building on previous research that used a subset of items from the Mutilation Questionnaire (MQ), the aim of this study was to examine the reliability and validity of two brief scales assessing SBIM.

RESULTS

Data from two independent samples of male, US Army soldiers, was utilized to examine a brief 10-item SBIM measure (MQ-SBIM-10) and a shorter version 5-item SBIM measure (MQ-SBIM-5). Internal consistency was indexed by the Kuder-Richardson 20 formula. Construct validity was assessed using confirmatory factor analysis and results obtained from each sample, and from a combined sample. The MQ-SBIM-10 demonstrated acceptable internal consistency and the hypothesized one-factor structure. Although the MQ-SBIM-5 explained a substantial amount of the variance in the 10-item measure and had a one-factor structure, internal consistency of the 5-item measure was poor. Analyses supported the MQ-SBIM-10 as a reliable and cohesive measure of sensitivity to blood, injury, and mutilation.

Assessment of a Risk Index for Suicide Attempts Among US Army Soldiers With Suicide Ideation: Analysis of Data From the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

IMPORTANCE

The Department of Veterans Affairs recently began requiring annual suicide ideation (SI) screening of all patients and additional structured questions for patients reporting SI. Related changes are under consideration at the Department of Defense. These changes will presumably lead to higher SI detection, which will require hiring additional clinical staff and/or developing a clinical decision support system to focus in-depth suicide risk assessments on patients considered high risk.

OBJECTIVE

To carry out a proof-of-concept study for whether a brief structured question battery from a survey of US Army soldiers can help target in-depth suicide risk assessments by identifying soldiers with self-reported lifetime SI who are at highest risk of subsequent administratively recorded nonfatal suicide attempts (SAs).

DESIGN, SETTING, AND PARTICIPANTS

Cohort study with prospective observational design. Data were collected from May 2011 to February 2013. Participants were followed up through December 2014. Analyses were conducted from March to November 2018. A logistic regression model was used to assess risk for subsequent administratively recorded nonfatal SAs. A total of 3649 Regular Army soldiers in 3 Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) surveys who reported lifetime SI were followed up for 18 to 45 months from baseline to assess administratively reported nonfatal SAs.

MAIN OUTCOMES AND MEASURES

Outcome was administratively recorded nonfatal SAs between survey response and December 2014. Predictors were survey variables.

RESULTS

The 3649 survey respondents were 80.5% male and had a median (interquartile range) age of 29 (25-36) years (range, 18-55 years); 69.4% were white non-Hispanic, 14.6% were black, 9.0% were Hispanic, 7.0% were another racial/ethnic group. Sixty-five respondents had administratively recorded nonfatal SAs between survey response and December 2014. One additional respondent died by suicide without making a nonfatal SA but was excluded from analysis based on previous evidence that predictors are different for suicide death and nonfatal SAs. Significant risk factors were SI recency (odds ratio [OR], 7.2; 95% CI, 2.9-18.0) and persistence (OR, 2.6; 95% CI, 1.0-6.8), positive screens for mental disorders (OR, 26.2; 95% CI, 6.1-112.0), and Army career characteristics (OR for junior enlisted rank, 30.0; 95% CI, 3.3-272.5 and OR for senior enlisted rank, 6.7; 95% CI, 0.8-54.9). Cross-validated area under the curve was 0.78. The 10% of respondents with highest estimated risk accounted for 39.2% of subsequent SAs.

CONCLUSIONS AND RELEVANCE

Results suggest the feasibility of developing a clinically useful risk index for SA among soldiers with SI using a small number of self-report questions. If implemented, a continuous quality improvement approach should be taken to refine the structured question series.

Prior Mental Disorders and Lifetime Suicidal Behaviors Among US Army Soldiers in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

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.

Suicide attempts among activated soldiers in the U.S. Army reserve components

BACKGROUND

Although the majority of active duty U.S. Army soldiers are full-time personnel in the Active Component (AC), a substantial minority of soldiers on active duty are in the Reserve Components (RCs). These "citizen-soldiers" (Army National Guard and Army Reserve) represent a force available for rapid activation in times of national need. RC soldiers experience many of the same stressors as AC soldiers as well as stressors that are unique to their intermittent service. Despite the important role of RC soldiers, the vast majority of military mental health research focuses on AC soldiers. One important goal of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is to address this gap. Here we examine predictors of suicide attempts among activated RC soldiers.

METHODS

This longitudinal, retrospective cohort study used individual-level person-month records from Army and Department of Defense administrative data systems to examine socio-demographic, service-related, and mental health predictors of medically documented suicide attempts among activated RC soldiers during 2004-2009. Data from all 1103 activated RC suicide attempters and an equal-probability sample of 69,867 control person-months were analyzed using a discrete-time survival framework.

RESULTS

Enlisted soldiers comprised 84.3% of activated RC soldiers and accounted for 95.7% of all activated RC suicide attempts (overall rate = 108/100,000 person-years, more than four times the rate among officers). Multivariable predictors of enlisted RC suicide attempts included being female, entering Army service at age ≥ 25, current age < 30, non-Hispanic white, less than high school education, currently married, having 1-2 years of service, being previously deployed (vs. currently deployed), and history of mental health diagnosis (particularly when documented in the previous month). Predictors among RC officers (overall rate = 26/100,000 person-years) included being female and receiving a mental health diagnosis in the previous month. Discrete-time hazard models showed suicide attempt risk among enlisted soldiers was inversely associated with time in service.

CONCLUSIONS

Risk factors for suicide attempt in the RCs were similar to those previously observed in the AC, highlighting the importance of research and prevention focused on RC enlisted soldiers in the early phases of Army service and those with a recent mental health diagnosis.

Risk factors and timing of suicide attempts among US Army Reserve Component soldiers during deployment to the Afghanistan and Iraq wars: Results from the Army Study to Assess Risk and Resilience in Servicemembers

Objective: During the wars in Afghanistan and Iraq, suicidal behaviors increased among U.S. Army soldiers. Although Reserve Component (RC) soldiers (National Guard and Army Reserve) comprise approximately one third of those deployed in support of the wars, few studies have examined suicidal behaviors among these "citizen-soldiers". The objective of this study is to examine suicide attempt risk factors and timing among RC enlisted soldiers. Methods: This longitudinal, retrospective cohort study used individual-level person-month records from Army and Department of Defense administrative data systems to examine socio-demographic, service-related, and mental health predictors of medically documented suicide attempts among enlisted RC soldiers during deployment from 2004-2009. Data were analyzed using discrete-time survival models. Results: A total of 230 enlisted RC soldiers attempted suicide. Overall, the in-theater suicide attempt rate among RC soldiers was 81/100,000 person-years. Risk was highest in the fifth month of deployment (13.8 per 100,000 person-months). Suicide attempts were more likely among soldiers who were women (adjusted odds ratio, aOR = 2.5 [95% CI: 1.8-3.5]), less than high school educated (aOR = 1.8 [95% CI: 1.3-2.5]), in their first 2 years of service (aOR = 2.0 [95% CI: 1.2-3.4]), were currently married (aOR = 2.0 [95% CI: 1.5-2.7]), and had received a mental health diagnosis in the previous month (aOR = 24.7 [95% CI: 17.4-35.0]). Conclusions: Being female, early in service and currently married are associated with increased odds of suicide attempt in RC soldiers. Risk of suicide attempt was greatest at mid deployment. These predictors and the timing of suicide attempt for RC soldiers in-theater are largely consistent with those of deployed Active Component (Regular) soldiers. Results also reinforce and replicate the findings among Active Component soldiers related to the importance of a recent mental health diagnosis and the mid-deployment as a period of enhanced risk.

The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS): progress toward understanding suicide among soldiers

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.

Patterns and predictors of persistence of suicide ideation: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

Persistent suicide ideation (SI) is known to be a risk factor for subsequent suicidal behaviors. Reducing SI persistence among people with a history of SI consequently might be a useful target for preventive intervention; however, basic information is lacking about patterns and predictors of SI persistence. We report preliminary retrospective data on annual SI persistence in a representative sample of 3,501 U.S. Army soldiers with lifetime SI from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Reports about age-of-onset and number of years with SI were used to estimate two definitions of persistence: persistence beyond year-of-onset and proportional annual persistence (i.e., percentage of years with SI since year-of-onset). Results revealed that for 47.8% of respondents with lifetime SI, their SI did not persist beyond the year-of-onset. For the 52.2% whose SI did persist beyond the year-of-onset, the median (interquartile range) proportional annual persistence was 33% (17-67%). Significant predictors of increased persistence were different for respondents with preenlistment SI onset (prior histories of attention-deficit/hyperactivity disorder [ADHD], bipolar disorder, and panic disorder) and postenlistment SI onset (male, combat support military occupation specialty, prior histories of ADHD, panic disorder, and posttraumatic stress disorder). These predictors of persistence are different from the predictors of SI onset, suggesting that secondary preventive interventions to reduce SI persistence may need to focus on different factors than primary preventive interventions to reduce SI onset. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Risk factors for the transition from suicide ideation to suicide attempt: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

Prior research has shown that most known risk factors for suicide attempts in the general population actually predict suicide ideation rather than attempts among ideators. Yet clinical interest in predicting suicide attempts often involves the evaluation of risk among patients with ideation. We examined a number of characteristics of suicidal thoughts hypothesized to predict incident attempts in a retrospective analysis of lifetime ideators (N = 3,916) drawn from a large (N = 29,982), representative sample of United States Army soldiers. The most powerful predictors of first nonfatal lifetime suicide attempt in a multivariate model controlling for previously known predictors (e.g., demographics, mental disorders) were: recent onset of ideation, presence and recent onset of a suicide plan, low controllability of suicidal thoughts, extreme risk-taking or "tempting fate," and failure to answer questions about the characteristics of one's suicidal thoughts. A predictive model using these risk factors had strong accuracy (area under the curve [AUC] = .93), with 66.2% of all incident suicide attempts occurring among the 5% of soldiers with highest composite predicted risk. This high concentration of risk in this retrospective study suggests that a useful clinical decision support model could be constructed from prospective data to identify those with highest risk of subsequent suicide attempt. (PsycINFO Database Record

Risk Factors Associated With Attempted Suicide Among US Army Soldiers Without a History of Mental Health Diagnosis

IMPORTANCE

The US Army suicide attempt rate increased sharply during the wars in Afghanistan and Iraq. Although soldiers with a prior mental health diagnosis (MH-Dx) are known to be at risk, little is known about risk among those with no history of diagnosis.

OBJECTIVE

To examine risk factors for suicide attempt among soldiers without a previous MH-Dx.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective longitudinal cohort study using administrative data from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), person-month records were identified for all active-duty Regular Army enlisted soldiers who had a medically documented suicide attempt from January 1, 2004, through December 31, 2009 (n = 9650), and an equal-probability sample of control person-months (n = 153 528). Data analysis in our study was from September 16, 2017, to June 6, 2018. In a stratified sample, it was examined whether risk factors for suicide attempt varied by history of MH-Dx.

MAIN OUTCOMES AND MEASURES

Suicide attempts were identified using Department of Defense Suicide Event Report records and International Classification of Diseases, Ninth Revision, Clinical Modification E95 × diagnostic codes. Mental health diagnoses and related codes, as well as sociodemographic, service-related, physical health care, injury, subjection to crime, crime perpetration, and family violence variables, were constructed from Army personnel, medical, legal, and family services records.

RESULTS

Among 9650 enlisted soldiers with a documented suicide attempt (74.8% male), 3507 (36.3%) did not have a previous MH-Dx. Among soldiers with no previous diagnosis, the highest adjusted odds of suicide attempt were for the following: female sex (odds ratio [OR], 2.6; 95% CI, 2.4-2.8), less than high school education (OR, 1.9; 95% CI, 1.8-2.0), first year of service (OR, 6.0; 95% CI, 4.7-7.7), previously deployed (OR, 2.4; 95% CI, 2.1-2.8), promotion delayed 2 months or less (OR, 2.1; 95% CI, 1.7-2.6), past-year demotion (OR, 1.6; 95% CI, 1.3-1.8), 8 or more outpatient physical health care visits in the past 2 months (OR, 3.3; 95% CI, 2.9-3.8), past-month injury-related outpatient (OR, 3.0; 95% CI, 2.8-3.3) and inpatient (OR, 3.8; 95% CI, 2.3-6.3) health care visits, previous combat injury (OR, 1.6; 95% CI, 1.0-2.4), subjection to minor violent crime (OR, 1.6; 95% CI, 1.1-2.4), major violent crime perpetration (OR, 2.0; 95% CI, 1.3-3.0), and family violence (OR, 2.9; 95% CI, 1.9-4.4). Most of these variables were also associated with suicide attempts among soldiers with a previous MH-Dx, although the strength of associations differed.

CONCLUSIONS AND RELEVANCE

Suicide attempt risk among soldiers with unrecognized mental health problems is a significant and important challenge. Administrative records from personnel, medical, legal, and family services systems can assist in identifying soldiers at risk.

Associations of Time-Related Deployment Variables With Risk of Suicide Attempt Among Soldiers: Results From the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

Importance

There has been limited systematic examination of whether risk of suicide attempt (SA) among US Army soldiers is associated with time-related deployment variables, such as time in service before first deployment, duration of first deployment, and dwell time (DT) (ie, length of time between deployments).

Objective

To examine the associations of time-related deployment variables with subsequent SA among soldiers who had deployed twice.

Design, Setting, and Participants

Using administrative data from January 1, 2004, through December 31, 2009, this longitudinal, retrospective cohort study identified person-month records of active-duty Regular Army enlisted soldiers who had served continuously in the US Army for at least 2 years and deployed exactly twice. The dates of analysis were March 1 to December 1, 2017. There were 593 soldiers with a medically documented SA during or after their second deployment. An equal-probability sample of control person-months was selected from other soldiers with exactly 2 deployments (n = 19 034). Logistic regression analyses examined the associations of time in service before first deployment, duration of first deployment, and DT with subsequent SA.

Main Outcomes and Measures

Suicide attempts during or after second deployment were identified using US Department of Defense Suicide Event Report records and International Classification of Diseases, Ninth Revision, Clinical Modification E950 to E958 diagnostic codes. Independent variables were constructed from US Army personnel records.

Results

Among 593 SA cases, most were male (513 [86.5%]), white non-Hispanic (392 [66.1%]), at least high school educated (477 [80.4%]), currently married (398 [67.1%]), and younger than 21 years when they entered the US Army (384 [64.8%]). In multivariable models adjusting for sociodemographics, service-related characteristics, and previous mental health diagnosis, odds of SA during or after second deployment were higher among soldiers whose first deployment occurred within the first 12 months of service vs after 12 months (odds ratio, 2.0; 95% CI, 1.6-2.4) and among those with a DT of 6 months or less vs longer than 6 months (odds ratio, 1.6; 95% CI, 1.2-2.0). Duration of first deployment was not associated with subsequent SA. Analysis of 2-way interactions indicated that the associations of early deployment and DT with SA risk were not modified by other characteristics. Multivariable population-attributable risk proportions were 14.2% for deployment within the first 12 months of service and 4.0% for DT of 6 months or less.

Conclusions and Relevance

Time in service before first deployment and DT are modifiable risk factors for SA risk among soldiers.

Improving risk prediction accuracy for new soldiers in the U.S. Army by adding self-report survey data to administrative data

BACKGROUND

High rates of mental disorders, suicidality, and interpersonal violence early in the military career have raised interest in implementing preventive interventions with high-risk new enlistees. The Army Study to Assess Risk and Resilience in Servicemembers (STARRS) developed risk-targeting systems for these outcomes based on machine learning methods using administrative data predictors. However, administrative data omit many risk factors, raising the question whether risk targeting could be improved by adding self-report survey data to prediction models. If so, the Army may gain from routinely administering surveys that assess additional risk factors.

METHODS

The STARRS New Soldier Survey was administered to 21,790 Regular Army soldiers who agreed to have survey data linked to administrative records. As reported previously, machine learning models using administrative data as predictors found that small proportions of high-risk soldiers accounted for high proportions of negative outcomes. Other machine learning models using self-report survey data as predictors were developed previously for three of these outcomes: major physical violence and sexual violence perpetration among men and sexual violence victimization among women. Here we examined the extent to which this survey information increases prediction accuracy, over models based solely on administrative data, for those three outcomes. We used discrete-time survival analysis to estimate a series of models predicting first occurrence, assessing how model fit improved and concentration of risk increased when adding the predicted risk score based on survey data to the predicted risk score based on administrative data.

RESULTS

The addition of survey data improved prediction significantly for all outcomes. In the most extreme case, the percentage of reported sexual violence victimization among the 5% of female soldiers with highest predicted risk increased from 17.5% using only administrative predictors to 29.4% adding survey predictors, a 67.9% proportional increase in prediction accuracy. Other proportional increases in concentration of risk ranged from 4.8% to 49.5% (median = 26.0%).

CONCLUSIONS

Data from an ongoing New Soldier Survey could substantially improve accuracy of risk models compared to models based exclusively on administrative predictors. Depending upon the characteristics of interventions used, the increase in targeting accuracy from survey data might offset survey administration costs.

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)

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.

Documented family violence and risk of suicide attempt among U.S. Army soldiers

Suicide attempt (SA) rates in the U.S. Army increased substantially during the wars in Afghanistan and Iraq. This study examined associations of family violence (FV) history with SA risk among soldiers. Using administrative data from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), we identified person-month records of active duty, Regular Army, enlisted soldiers with medically documented SAs from 2004 to 2009 (n = 9650) and a sample of control person-months (n = 153,528). Logistic regression analyses examined associations of FV with SA, adjusting for socio-demographics, service-related characteristics, and prior mental health diagnosis. Odds of SA were higher in soldiers with a FV history and increased as the number of FV events increased. Soldiers experiencing past-month FV were almost five times as likely to attempt suicide as those with no FV history. Odds of SA were elevated for both perpetrators and those who were exclusively victims. Male perpetrators had higher odds of SA than male victims, whereas female perpetrators and female victims did not differ in SA risk. A discrete-time hazard function indicated that SA risk was highest in the initial months following the first FV event. FV is an important consideration in understanding risk of SA among soldiers.

Frequency of Improvised Explosive Devices and Suicide Attempts in the U.S. Army

BACKGROUND

Improvised explosive devices (IEDs) were a prominent and initially new threat in the Iraq and Afghanistan war which raised concerns and anticipatory fear in and out of theater. This study examined the association of monthly IED rates with risk of soldier suicide attempt among those deployed and nondeployed.

METHODS

Person-month records for all active duty Regular Army suicide attempters from 2004 through 2009 (n = 9,791) and an equal-probability sample of control person-months (n = 183,826) were identified. Logistic regression analyses examined soldiers' risk of attempting suicide as a function of monthly IED frequency, controlling for sociodemographics, service-related characteristics, rate of deployment/redeployment, and combat deaths and injuries. The association of IED frequency with suicide attempt was examined overall and by time in service and deployment status.

FINDINGS

Soldiers' risk of suicide attempt increased with increasing numbers of IEDs. Suicide attempt was 26% more likely for each 1,000 IED increase in monthly frequency (odds ratio [OR] = 1.26, 95% confidence interval [CI] = 1.22-1.30). The association of IED frequency with suicide attempt was greater for soldiers in their first 2 years of service (OR = 1.30, 95% CI = 1.25-1.36) than for those with 3 or more years of service (OR = 1.18, 95% CI = 1.12-1.24). Among soldiers in their first 2 years of service, the association was constant, regardless of deployment status (χ₂² = 3.89, p = 0.14). Among soldiers with 3 or more years of service, the association was higher for those never deployed (OR = 1.12, 95% CI = 1.01-1.24) and currently deployed (OR = 1.14, 95% CI = 1.05-1.23) than for those previously deployed.

DISCUSSION

To our knowledge, this is the first study to examine and demonstrate an association between the aggregate frequency of IEDs and risk of suicide attempts among U.S. Army soldiers. This association was observed across deployment status and time in service, and for early-career soldiers in particular. The findings suggest that the threat of new weapons may increase stress burden among soldiers. Targeting risk perception and perceived preparedness, particularly early in a soldier's career, may improve psychological resilience and reduce suicide risk.

Trauma exposure interacts with the genetic risk of bipolar disorder in alcohol misuse of US soldiers

OBJECTIVE

To investigate whether trauma exposure moderates the genetic correlation between substance use disorders and psychiatric disorders, we tested whether trauma exposure modifies the association of genetic risks for mental disorders with alcohol misuse and nicotine dependence (ND) symptoms.

METHODS

High-resolution polygenic risk scores (PRSs) were calculated for 10 732 US Army soldiers (8346 trauma-exposed and 2386 trauma-unexposed) based on genome-wide association studies of bipolar disorder (BD), major depressive disorder, and schizophrenia.

RESULTS

The main finding was a significant BD PRS-by-trauma interaction with respect to alcohol misuse (P = 6.07 × 10^-3 ). We observed a positive correlation between BD PRS and alcohol misuse in trauma-exposed soldiers (r = 0.029, P = 7.5 × 10^-3 ) and a negative correlation in trauma-unexposed soldiers (r = -0.071, P = 5.61 × 10^-4 ). Consistent (nominally significant) result with concordant effect, directions were observed in the schizophrenia PRS-by-trauma interaction analysis. The variants included in the BD PRS-by-trauma interaction showed significant enrichments for gene ontologies related to high voltage-gated calcium channel activity (GO:0008331, P = 1.51 × 10^-5 ; GO:1990454, P = 4.49 × 10^-6 ; GO:0030315, P = 2.07 × 10^-6 ) and for Beta1/Beta2 adrenergic receptor signaling pathways (P = 2.61 × 10^-4 ).

CONCLUSIONS

These results indicate that the genetic overlap between alcohol misuse and BD is significantly moderated by trauma exposure. This provides molecular insight into the complex mechanisms that link substance abuse, psychiatric disorders, and trauma exposure.

Barriers to Initiating and Continuing Mental Health Treatment Among Soldiers in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

U.S. Army soldiers with mental disorders report a variety of barriers to initiating and continuing treatment. Improved understanding of these barriers can help direct mental health services to soldiers in need. A representative sample of 5,428 nondeployed Regular Army soldiers participating in the Army Study to Assess Risk and Resilience in Servicemembers completed a self-administered questionnaire and consented to linking self-administered questionnaire data with administrative records. We examined reported treatment barriers (perceived need, structural reasons, attitudinal reasons) among respondents with current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, mental disorders who either did not seek treatment in the past year (n = 744) or discontinued treatment (n = 145). About 82.4% of soldiers who did not initiate treatment and 69.5% of those who discontinued treatment endorsed at least two barriers; 69.8% of never-treated soldiers reported no perceived need. Attitudinal reasons were cited more frequently than structural reasons among never-treated soldiers with perceived need (80.7% vs. 62.7%) and those who discontinued treatment (71.0% vs. 37.8%). Multivariate associations with sociodemographic, Army career, and mental health predictors varied across barrier categories. These findings suggest most soldiers with mental disorders do not believe they need treatment and those who do typically face multiple attitudinal and, to a lesser extent, structural barriers.

Non-Fatal Suicidal Behaviors in the Administrative Records of Activated U.S. Army National Guard and Army Reserve Soldiers, 2004–2009

OBJECTIVE

The U.S. Army suicide rate increased sharply during the wars in Iraq and Afghanistan. There is limited information about medically documented, nonfatal suicidal behaviors among soldiers in the Army's Reserve Component (RC), which is composed of the Army National Guard and Army Reserve. Here we examine trends and sociodemographic correlates of suicide attempts, suspicious injuries, and suicide ideation among activated RC soldiers.

METHODS

Data come from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) Historical Administrative Data Study (HADS), which integrates administrative records for all soldiers on active duty for the years 2004 through 2009 (n = 1.66 million).

RESULTS

We identified 2,937 unique RC soldiers on active duty with a nonfatal suicidal event documented at some point during the HADS study period. There were increases in the annual incidence rates of suicide attempts (71 to 204/100,000 person-years) and suicide ideation (326 to 425/100,000 person-years). Incidence rates for suspicious injuries also generally increased but were more variable. Using hierarchical classification rules, we identified the first instance of each soldier's most severe behavior (suicide attempt versus suspicious injury versus suicide ideation). For each of those suicide- or injury-related outcomes, we found increased risk among those who were female, younger, non-Hispanic White, less educated, never married, and lower-ranking enlisted. These sociodemographic associations significantly differed across outcomes, although the patterns were similar.

CONCLUSION

Results provide a broad overview of nonfatal suicidal trends in the RC during the period 2004 through 2009. They also demonstrate that integration of multiple administrative data systems enriches analysis of the predictors of such events.

Genomewide association studies of suicide attempts in US soldiers

Suicide is a global public health problem with particular resonance for the US military. Genetic risk factors for suicidality are of interest as indicators of susceptibility and potential targets for intervention. We utilized population-based nonclinical cohorts of US military personnel (discovery: N = 473 cases and N = 9778 control subjects; replication: N = 135 cases and N = 6879 control subjects) and a clinical case-control sample of recent suicide attempters (N = 51 cases and N = 112 control subjects) to conduct GWAS of suicide attempts (SA). Genomewide association was evaluated within each ancestral group (European-, African-, Latino-American) and study using logistic regression models. Meta-analysis of the European ancestry discovery samples revealed a genomewide significant locus in association with SA near MRAP2 (melanocortin 2 receptor accessory protein 2) and CEP162 (centrosomal protein 162); 12 genomewide significant SNPs in the region; peak SNP rs12524136-T, OR = 2.88, p = 5.24E-10. These findings were not replicated in the European ancestry subsamples of the replication or suicide attempters samples. However, the association of the peak SNP remained significant in a meta-analysis of all studies and ancestral subgroups (OR = 2.18, 95%CI 1.70, 2.80). Polygenic risk score (PRS) analyses showed some association of SA with bipolar disorder. The association with SNPs encompassing MRAP2, a gene expressed in brain and adrenal cortex and involved in neural control of energy homeostasis, points to this locus as a plausible susceptibility gene for suicidality that should be further studied. Larger sample sizes will be needed to confirm and extend these findings.