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Psychological autopsy study comparing suicide decedents, suicide ideators, and propensity score matched controls: results from the study to assess risk and resilience in service members (Army STARRS).

ABSTRACT: The suicide rate has increased significantly among US Army soldiers over the past decade. Here we report the first results from a large psychological autopsy study using two control groups designed to reveal risk factors for suicide death among soldiers beyond known sociodemographic factors and the presence of suicide ideation.Informants were next-of-kin and Army supervisors for: 135 suicide cases, 137 control soldiers propensity-score-matched on known sociodemographic risk factors for suicide and Army history variables, and 118 control soldiers who reported suicide ideation in the past year.Results revealed that most (79.3%) soldiers who died by suicide have a prior mental disorder; mental disorders in the prior 30-days were especially strong risk factors for suicide death. Approximately half of suicide decedents tell someone that they are considering suicide. Virtually all of the risk factors identified in this study differed between suicide cases and propensity-score-matched controls, but did not significantly differ between suicide cases and suicide ideators. The most striking difference between suicides and ideators was the presence in the former of an internalizing disorder (especially depression) and multi-morbidity (i.e. 3+ disorders) in the past 30 days.Most soldiers who die by suicide have identifiable mental disorders shortly before their death and tell others about their suicidal thinking, suggesting that there are opportunities for prevention and intervention. However, few risk factors distinguish between suicide ideators and decedents, pointing to an important direction for future research.

SUBMITTER: Nock MK

PROVIDER: S-EPMC5674992 | biostudies-literature | 2017 Nov

REPOSITORIES: biostudies-literature

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Psychological autopsy study comparing suicide decedents, suicide ideators, and propensity score matched controls: results from the study to assess risk and resilience in service members (Army STARRS).

Nock M K MK Dempsey C L CL Aliaga P A PA Brent D A DA Heeringa S G SG Kessler R C RC Stein M B MB Ursano R J RJ Benedek D D

Psychological medicine 20170515 15

<h4>Background</h4>The suicide rate has increased significantly among US Army soldiers over the past decade. Here we report the first results from a large psychological autopsy study using two control groups designed to reveal risk factors for suicide death among soldiers beyond known sociodemographic factors and the presence of suicide ideation.<h4>Methods</h4>Informants were next-of-kin and Army supervisors for: 135 suicide cases, 137 control soldiers propensity-score-matched on known sociodem ...[more]

PMID: 28502265

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Project description:ImportanceThe 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.ObjectiveTo 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 participantsCohort 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 measuresOutcome was administratively recorded nonfatal SAs between survey response and December 2014. Predictors were survey variables.ResultsThe 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 relevanceResults 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.

Project description: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.

Project description:The US Army experienced a sharp increase in soldier suicides beginning in 2004. Administrative data reveal that among those at highest risk are soldiers in the 12 months after inpatient treatment of a psychiatric disorder.To develop an actuarial risk algorithm predicting suicide in the 12 months after US Army soldier inpatient treatment of a psychiatric disorder to target expanded posthospitalization care.There were 53,769 hospitalizations of active duty soldiers from January 1, 2004, through December 31, 2009, with International Classification of Diseases, Ninth Revision, Clinical Modification psychiatric admission diagnoses. Administrative data available before hospital discharge abstracted from a wide range of data systems (sociodemographic, US Army career, criminal justice, and medical or pharmacy) were used to predict suicides in the subsequent 12 months using machine learning methods (regression trees and penalized regressions) designed to evaluate cross-validated linear, nonlinear, and interactive predictive associations.Suicides of soldiers hospitalized with psychiatric disorders in the 12 months after hospital discharge.Sixty-eight soldiers died by suicide within 12 months of hospital discharge (12.0% of all US Army suicides), equivalent to 263.9 suicides per 100,000 person-years compared with 18.5 suicides per 100,000 person-years in the total US Army. The strongest predictors included sociodemographics (male sex [odds ratio (OR), 7.9; 95% CI, 1.9-32.6] and late age of enlistment [OR, 1.9; 95% CI, 1.0-3.5]), criminal offenses (verbal violence [OR, 2.2; 95% CI, 1.2-4.0] and weapons possession [OR, 5.6; 95% CI, 1.7-18.3]), prior suicidality [OR, 2.9; 95% CI, 1.7-4.9], aspects of prior psychiatric inpatient and outpatient treatment (eg, number of antidepressant prescriptions filled in the past 12 months [OR, 1.3; 95% CI, 1.1-1.7]), and disorders diagnosed during the focal hospitalizations (eg, nonaffective psychosis [OR, 2.9; 95% CI, 1.2-7.0]). A total of 52.9% of posthospitalization suicides occurred after the 5% of hospitalizations with highest predicted suicide risk (3824.1 suicides per 100,000 person-years). These highest-risk hospitalizations also accounted for significantly elevated proportions of several other adverse posthospitalization outcomes (unintentional injury deaths, suicide attempts, and subsequent hospitalizations).The high concentration of risk of suicide and other adverse outcomes might justify targeting expanded posthospitalization interventions to soldiers classified as having highest posthospitalization suicide risk, although final determination requires careful consideration of intervention costs, comparative effectiveness, and possible adverse effects.

Dataset Information

Psychological autopsy study comparing suicide decedents, suicide ideators, and propensity score matched controls: results from the study to assess risk and resilience in service members (Army STARRS).

Publications

Psychological autopsy study comparing suicide decedents, suicide ideators, and propensity score matched controls: results from the study to assess risk and resilience in service members (Army STARRS).

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