Dataset Information

Risk Factors and Timing of Suicide Attempts among US Army Reserve Component Soldiers during Deployment to the Afghanistan and Iraq Wars: Results from Army Study to Assess Risk and Resilience in Servicemembers.

ABSTRACT: 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.

SUBMITTER: Stokes CM

PROVIDER: S-EPMC7446572 | biostudies-literature | 2019

REPOSITORIES: biostudies-literature

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Risk Factors and Timing of Suicide Attempts among US Army Reserve Component Soldiers during Deployment to the Afghanistan and Iraq Wars: Results from Army Study to Assess Risk and Resilience in Servicemembers.

Stokes Cara M CM Naifeh James A JA Kessler Ronald C RC Stein Murray B MB Fullerton Carol S CS Mash Holly B Herberman HBH Riggs-Donovan Charlotte A CA Ng Tsz Hin Hinz THH Aliaga Pablo A PA Wynn Gary H GH Dinh Hieu M HM Kao Tzu-Cheg TC Gonzalez Oscar I OI Sampson Nancy A NA Ursano Robert J RJ

Psychiatry 20190101 3

<i>Objective</i>: 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. <i>Methods</i>: This longitudinal, retrospective ...[more]

PMID: 31566520

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Project description:ImportanceThe rate of suicide attempts in the US Army increased sharply during the wars in Afghanistan and Iraq. Research on this important health outcome has been hampered by the lack of integration among Army administrative data systems.ObjectiveTo identify risk factors for suicide attempts among active-duty members of the regular Army from January 1, 2004, through December 31, 2009.Design, setting, and participantsThis longitudinal, retrospective cohort study, as part of the Army Study to Assess Risk and Resilience in Servicemembers (STARRS), used individual-level person-month records from Army and Department of Defense administrative data systems to examine sociodemographic, service-related, and mental health predictors of medically documented suicide attempts among active-duty regular Army soldiers from January 1, 2004, through December 31, 2009. We analyzed data from 9791 suicide attempters and an equal-probability sample of 183,826 control person-months using a discrete-time survival framework. Data analysis was performed from February 3 through November 12, 2014.Main outcomes and measuresSuicide attempts identified using Department of Defense Suicide Event Report records and diagnostic codes E950 through E958 from the International Classification of Diseases, Ninth Revision, Clinical Modification. Standardized estimates of suicide attempt risk for sociodemographic, service-related, and mental health predictor variables were constructed from Army personnel and medical records.ResultsEnlisted soldiers accounted for 98.6% of all suicide attempts (9650 attempters; overall rate, 377.0 [95% CI, 369.7-384.7] per 100,000 person-years). In multivariate models, suicide attempts among enlisted soldiers were predicted (data reported as odds ratio [95% CI]) by female sex (2.4 [2.3-2.5]), entering Army service at 25 years or older (1.6 [1.5-1.8]), current age of 29 years or younger (<21 years, 5.6 [5.1-6.2]; 21-24 years, 2.9 [2.6-3.2]; 25-29 years, 1.6 [1.5-1.8]), white race (black, 0.7 [0.6-0.7]; Hispanic, 0.7 [0.7-0.8]; Asian, 0.7 [0.6-0.8]), an educational level of less than high school (2.0 [2.0-2.1]), being in the first 4 years of service (1-2 years, 2.4 [2.2-2.6]; 3-4 years, 1.5 [1.4-1.6]), having never (2.8 [2.6-3.0]) or previously (2.6 [2.4-2.8]) been deployed, and a mental health diagnosis during the previous month (18.2 [17.4-19.1]). Attempts among officers (overall rate, 27.9 per 100,000 person-years) were predicted by female sex (2.8 [2.0-4.1]), entering Army service at 25 years or older (2.0 [1.3-3.1]), current age of 40 years or older (0.5 [0.3-0.8]), and a mental health diagnosis during the previous month (90.2 [59.5-136.7]). Discrete-time hazard models indicated risk among enlisted soldiers was highest in the second month of service (102.7 per 100,000 person-months) and declined substantially as length of service increased (mean during the second year of service, 56.0 per 100,000 person-years; after 4 years of service, 29.4 per 100,000 person-months), whereas risk among officers remained stable (overall mean, 6.1 per 100,000 person-months).Conclusions and relevanceOur results represent, to our knowledge, the most comprehensive accounting to date of suicide attempts in the Army. The findings reveal unique risk profiles for enlisted soldiers and officers and highlight the importance of research and prevention focused on enlisted soldiers in their first Army tour.

Project description:BackgroundAlthough 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.MethodsThis 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.ResultsEnlisted 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.ConclusionsRisk 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.

Project description:ImportanceUnderstanding suicide ideation (SI) during combat deployment can inform prevention and treatment during and after deployment.ObjectiveTo 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 participantsIn 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 measuresSuicide ideation, lifetime and 12-month stressors, and mental disorders were assessed with questionnaires. Administrative records identified sociodemographic characteristics and suicide attempts.ResultsA 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 relevanceThis study suggests that major depressive disorder and noncombat trauma are important factors in identifying SI risk during combat deployment.

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: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: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.

Project description:IMPORTANCE:Suicide attempts in the US Army have risen in the past decade. Understanding the association between suicide attempts and deployment, as well as method and timing of suicide attempts, can assist in developing interventions. OBJECTIVE:To examine suicide attempt risk factors, methods, and timing among soldiers currently deployed, previously deployed, and never deployed at the time this study was conducted. DESIGN, SETTING, AND PARTICIPANTS:This longitudinal, retrospective cohort study of Regular Army-enlisted soldiers on active duty from 2004 through 2009 used individual-level person-month records to examine risk factors (sociodemographic, service related, and mental health), method, and time of suicide attempt by deployment status (never, currently, and previously deployed). Administrative data for the month before each of 9650 incident suicide attempts and an equal-probability sample of 153?528 control person-months for other soldiers were analyzed using a discrete-time survival framework. MAIN OUTCOMES AND MEASURES:Suicide attempts and career, mental health, and demographic predictors were obtained from administrative and medical records. RESULTS:Of the 9650 enlisted soldiers who attempted suicide, 86.3% were male, 68.4% were younger than 30 years, 59.8% were non-Hispanic white, 76.5% were high school educated, and 54.7% were currently married. The 40.4% of enlisted soldiers who had never been deployed (n?=?12?421?294 person-months) accounted for 61.1% of enlisted soldiers who attempted suicide (n?=?5894 cases). Risk among those never deployed was highest in the second month of service (103 per 100?000 person-months). Risk among soldiers on their first deployment was highest in the sixth month of deployment (25 per 100?000 person-months). For those previously deployed, risk was highest at 5 months after return (40 per 100?000 person-months). Currently and previously deployed soldiers were more likely to attempt suicide with a firearm than those never deployed (currently deployed: OR, 4.0; 95% CI, 2.9-5.6; previously deployed: OR, 2.7; 95% CI, 1.8-3.9). Across deployment status, suicide attempts were more likely among soldiers who were women (currently deployed: OR, 3.4; 95% CI, 3.0-4.0; previously deployed: OR, 1.5; 95% CI, 1.4-1.7; and never deployed: OR, 2.4; 95% CI, 2.3-2.6), in their first 2 years of service (currently deployed: OR, 1.9; 95% CI, 1.5-2.3; previously deployed: OR, 2.2; 95% CI, 1.9-2.7; and never deployed: OR, 3.1; 95% CI, 2.7-3.6), and had a recently received a mental health diagnosis in the previous month (currently deployed: OR, 29.8; 95% CI, 25.0-35.5; previously deployed: OR, 22.2; 95% CI, 20.1-24.4; and never deployed: OR, 15.0; 95% CI, 14.2-16.0). Among soldiers with 1 previous deployment, odds of a suicide attempt were higher for those who screened positive for depression or posttraumatic stress disorder after return from deployment and particularly at follow-up screening, about 4 to 6 months after deployment (depression: OR, 1.4; 95% CI, 1.1-1.9; posttraumatic stress disorder: OR, 2.4; 95% CI, 2.1-2.8). CONCLUSIONS AND RELEVANCE:Identifying the timing and risk factors for suicide attempt in soldiers requires consideration of environmental context, individual characteristics, and mental health. These factors can inform prevention efforts.

Dataset Information

Risk Factors and Timing of Suicide Attempts among US Army Reserve Component Soldiers during Deployment to the Afghanistan and Iraq Wars: Results from Army Study to Assess Risk and Resilience in Servicemembers.

Publications

Risk Factors and Timing of Suicide Attempts among US Army Reserve Component Soldiers during Deployment to the Afghanistan and Iraq Wars: Results from Army Study to Assess Risk and Resilience in Servicemembers.

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