Public Release:  Suicidal ideation among US soldiers begins before enlistment

Early interventions might hold the key to reducing the high Army suicide rate

Harvard Medical School

Nearly 60% of soldier suicide attempts can be traced to pre-enlistment mental disorders, which are much more common among nondeployed U.S. Army soldiers than demographically similar populations of civilians (25.1% vs. 11.6%), according to a major new study. The vast majority (76.6%) of soldiers with mental disorders say their conditions started before enlistment, researchers found.

These are among the initial results published online today in JAMA Psychiatry based on a survey carried out as part of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), the largest study of mental health risk and resilience ever conducted among U.S. Army personnel.

Althoughthe suicide death rate in the U.S. Army has historically been below the civilian rate, the Army rate began climbing at the beginning of the Iraq and Afghanistan conflicts, and by 2008, it exceeded the demographically matched civilian rate (20.2 suicide deaths per 100,000 vs. 19.2). Concerns about this increase led to Army STARRS, a partnership between the Army and the NIMH designed to help understand and address this issue. The initial findings published today include three papers that use different strategies to evaluate suicide risk and protective factors among service people, including an analysis comparing the prevalence of mental disorders among Army and civilian populations.

"Some of the differences in disorder rates are truly remarkable," said Ronald Kessler, McNeil Family Professor of Health Care Policy at Harvard Medical School and senior author of the paper on mental disorder prevalence. "The rate of major depression is 5 times as high among soldiers as civilians, intermittent explosive disorder 6 times as high, and PTSD nearly 15 times as high."

The most common disorders in the Army STARRS survey were attention deficit hyperactivity disorder (ADHD) and intermittent explosive disorder (IED), or recurrent and uncontrollable anger attacks, Kessler said.

The findings suggest that soldiers did not have higher rates of most "internalizing disorders" (anxiety disorders and depression) than civilians before enlistment, but rather developed high rates of these disorders only after they enlisted in the Army. The situation was different, though, for "behavioral disorders" (ADHD, IED and substance abuse), which were much more common among young people who subsequently enlisted in the Army than those who did not. Rates for these disorders increased even more after enlistment. Nearly half of current soldier internalizing disorders and 80% of behavioral disorders started before enlistment

"These results are a wake-up call highlighting the importance of outreach and intervention for new soldiers who enter the Army with pre-existing mental disorders," said Robert Ursano, Chair of the Department of Psychiatry at the Uniformed Services University of the Health Sciences and co-principal investigator of Army STARRS.

A second Army STARRS paper appearing today in JAMA Psychiatry revealed that 13.9% of soldiers considered suicide at some point in their lifetime, 5.3% had made a suicide plan, and 2.4% had attempted suicide, with between 47% to 60% of these outcomes first occurring prior to enlistment. Pre-existing mental disorders were found to be by far the strongest predictors of these suicidal behaviors.

"It is striking that nearly 50% of the soldiers who attempted suicide made their first attempt before joining the Army, as applicants are asked about any history of suicide attempts in recruitment interviews and those who report such a history typically are excluded from service," said Matthew Nock, professor of psychology at Harvard University and lead author of this report on soldier suicidality.

Nock noted that the most practical implication of this finding might be that the Army should develop outreach and intervention programs for new soldiers based on the realization that a nontrivial proportion of new soldiers come into the Army with a history of mental disorder and suicidality, and that applicants are not always forthcoming about these concerns during the recruitment process.

The researchers added that intermittent explosive disorder is of special importance because it was the only disorder found to predict suicide attempts after developing suicidal thoughts, which has important implications for screening and prevention. This important finding shows that it is not only depression and PTSD that predict suicide attempts.

A third JAMA Psychiatry article by lead author Michael Schoenbaum of NIMH examined the suicide and accident death rates in relation to basic sociodemographic and Army experience factors in the 975,057 regular Army soldiers who served between Jan. 1, 2004, and Dec. 31, 2009, charting variations in the rates based on a variety of factors including sex, race, education level and rank.

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Written by Jake Miller

The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is funded by the U.S. Army and the National Institute of Mental Health. The study is led by co-principal investigators Robert J. Ursano (Uniformed Services University of the HealthSciences) and Murray B. Stein (University of California, San Diego), with site investigators Steven G. Heeringa (University of Michigan) and Ronald C. Kessler (Harvard Medical School), and with collaborating scientists Lisa J. Colpe (NIMH), and Michael Schoenbaum (NIMH). More information at: http://www.armystarrs.org/media_room

ADDITIONAL CONTACT INFORMATION

Army STARRS Co-Principal Investigator

Robert J. Ursano, MD, Uniformed Services University of the Health Sciences:

Contact: Sharon Willis, 301-295-3578, sharon.willis@usuhs.edu

Army STARRS Co-Principal Investigator

Murray B. Stein. MD, MPH, University of California, San Diego:

Contact: Debra Kain, 619-543-6202, DDKain@ucsd.edu

Lead author and Army STARRS Site Principal Investigator

Ronald C. Kessler, PhD, Harvard Medical School:

Contact: David Cameron, (617) 432-0441, david_cameron@hms.harvard.edu

Lead author and Army STARRS Site Co-Principal Investigator

Matthew Nock, PhD, Harvard University:

Contact: Peter Reuell, (617) 495-1585, preuell@harvard.edu

For commentary on the significance of the Army STARRS reports:

Lieutenant General (Retired) Eric Schoomaker, MD, former Surgeon General of the United States Army and Commanding General, United States Army Medical Command

Contact: Sharon Holland (301) 295-3578, sharon.holland@usuhs.edu

REFERENCES

Thirty-day prevalence of DSM-IV mental disorders among non-deployed soldiers in the U.S. Army: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Kessler RC, Heeringa SG, Stein MB, Colpe LJ, Fullerton CS, Hwang I, Naifeh JA, Nock MK, Petukhova M, Sampson NA, Schoenbaum M, Zaslavsky AM, Ursano RJ. JAMA Psychiatry.

Prevalence and correlates of suicidal behavior among soldiers: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Nock MK, Stein MB, Heeringa SG, Ursano RJ, Colpe LJ, Fullerton CS, Hwang I, Naifeh JA, Sampson NA, Schoenbaum M, Zaslavsky AM, Kessler RC. JAMA Psychiatry.

Predictors of suicide and accident death in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Schoenbaum M, Kessler RC, Gilman SE, Colpe LJ, Heeringa SG, Stein MB, Ursano RJ, Cox KL. JAMA Psychiatry.

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