Personality disorders and cause-specific mortality: a nationwide study of 2 million adolescents

BACKGROUND

Personality disorders are prevalent in 6-10% of the population, but their risk for cause-specific mortality is unclear. The aim of the study was to assess the association between personality disorders diagnosed in late adolescence and all-cause as well as cause-specific (cardiovascular-related, external-related) mortality.

METHODS

We performed a longitudinal study on a historical prospective cohort based on nationwide screening prior to recruitment to the Israeli army. The study participants were 16-19-year-old persons who attended the army screening (medical and cognitive, including screening for psychiatric disorders) between 1967 and 2006. Participants were followed from 1967 till 2011.

RESULTS

The study included 2 051 606 subjects, of whom 1 229 252 (59.9%) were men and 822 354 (40.1%) were women, mean age 17.36 years. There were 55 508 (4.5%) men and 8237 (1.0%) women diagnosed with personality disorders. The adjusted hazard ratio (HRs) for coronary, stroke, cardiovascular, external-related causes and all-cause mortality among men with personality disorders were 1.34 (1.03-1.74), 1.82 (1.20-2.76), 1.45 (1.23-1.71), 1.41 (1.30-1.53) and 1.44 (1.36-1.51), respectively. The absolute rate difference for all-cause mortality was 56.07 and 13.19 per 10⁵ person-years among men and women, respectively. Among women with personality disorders, the adjusted HRs for external-related causes and all-cause mortality were 2.74 (1.87-4.00) and 2.01 (1.56-2.58). Associations were already evident within 10 years of follow-up.

CONCLUSIONS

Personality disorder in late adolescence is associated with increased risk of cardiovascular, external- and all-cause mortality. Increased cardiovascular mortality is evident before the age of 40 years and may point to the importance of lifestyle education already in youth.

A military suicide prevention program in the Israeli Defense Force: a review of an important military medical procedure

The phenomenon of suicide during military service is not unique to the Israeli military and other armies. Soldiers’ age––adolescence––is a known factor contributing to suicide, in light of psychological processes of identity formation and self-definition, the stresses of military service, and above all, the availability of weapons. The stigma of seeking help deters some soldiers from getting the assistance they need when they need it most, thus contributing to the higher suicide rate. In the previous decade the IDF initiated intensive and structured preventive procedures aimed at reducing suicide rate among soldiers. The IDF’s Suicide Prevention Program (SPP) was grounded in professional knowledge and backed by military policy changes, both critical to the implementation and change processes. The SPP includes thorough psycho-education and guidance, supervision, greater accessibility of mental health officers, and lower accessibility of nonessential weapons. The SPP has succeeded in reducing the suicide rate by almost 50 %.

The aim of this article is to review the background of the design of the IDF’s SPP and its major components, leading to the current success.

Characteristics of the suicidal soldier in the Israeli Defense Force-a review of literature

Suicide is the third leading cause of death among adolescents in most Western world countries. Similar findings have been reported among adolescents in Israel (including the Israeli army) in times of peace; nonetheless, suicide rate has decreased significantly in recent years.

In Israel, IDF service is mandatory and adolescents are obligated to serve by law. Therefore, the IDF is responsible under state and moral law to care for the physical and mental health of its soldiers. Additionally, there is an understanding that the Israeli soldiers represent a mentally healthy population as prior to their enlistment they undergo a series of tests and evaluations to determine their suitability for service. The IDF is one of the few organizations in the world that is comprised of the majority of a country’s healthy adolescent population. International literature defines this population (i.e., the adolescent population) as having the highest risk of suicidality. Moreover, the risk of suicide increases in the face of two additional circumstances within the context of military service: the army service as a stressor and the availability of weapons.

The IDF invests significant resources in delineating the characteristics of suicidal soldiers, realizing its importance for suicide prevention during military service. This article reviews studies regarding complete suicide cases of Israeli soldiers in the aim of characterising a ‘suicidal soldier’s profile’ to inform better screening and prevention policies.