Military Matters: Understanding and Preventing Military Suicides
James A. Naifeh, PhD, Holly B. Herberman Mash, PhD, and Gary H. Wynn, MD
October 27, 2015
The suicide rate in the U.S. Army began a sharp rise in 2004 following the invasion of Iraq and surpassing that of civilians in 2008 for the first time in decades (Nock et al., 2013). In response to this public health crisis, the Army partnered with the National Institute of Mental Health (NIMH) to fund the Army Study to Assess Risk and Resilience in Service members (Army STARRS)(Ursano et al., 2014), a multi-institutional epidemiological and neurobiological study that seeks to understand the determinants of suicidality and provide the Army with actionable recommendations to mitigate suicide and suicidal behaviors.
The largest study of mental health risk and resilience ever conducted among Army personnel, the study surveys more than 100,000 soldiers (with blood samples from 52,000) and integrating 40 Army and Department of Defense (DoD) data systems containing administrative records for all 1.6 million soldiers on active duty from 2004 through 2009 (more than 1.1 billion records). Army STARRS has thus far generated a number of important findings regarding the influence of trauma, deployment, time in service, and mental health history.
The association between deployment and suicidal behaviors appears to be complex. From 2004 through 2009, risk of suicide death was particularly elevated among enlisted Regular Army soldiers deployed during their first year of service (Gilman et al., 2014) and among deployed females (Street et al., 2015). Although suicide rates increased most substantially in currently and previously deployed soldiers, rates also increased in soldiers who had never deployed (Schoenbaum et al., 2014).
Among infantrymen and combat engineers, two occupations with significantly elevated suicide rates, risk was highest in those who had never deployed, less so in those previously deployed, and not at all in those currently deployed (Kessler et al., in press).
Furthermore, suicide risk was not associated with time in current deployment, length of time since returning from deployment, total number of deployments, or the time interval between most recent deployments (i.e., dwell time) (Gilman et al., 2014).
The rate of nonfatal suicide attempts also rose sharply from 2004 through 2009 (Ursano, Kessler, Heeringa, et al., 2015). Nearly 99 percent of attempts were made by enlisted soldiers, with higher risk in those never and previously deployed than in those currently deployed. The differential effects of deployment on fatal versus nonfatal suicidal behaviors may indicate that exposure to deployed environments influences the lethality of self-injurious behaviors, although additional research is needed to address this possibility.
It is noteworthy that other large-scale studies, which included additional U.S. military branches, found no association between deployment history and suicide death (LeardMann et al., 2013; Reger et al., 2015), highlighting the importance of methodological factors. A recent meta-analysis suggests that suicide risk may be influenced more by specific traumatic experiences in combat (e.g., killing) than deployment, per se (Bryan et al., 2015).
In addition to the elevated risk of suicide death in soldiers deployed during their first year of service, risk of nonfatal suicide attempts was also highest during the first year of service (Ursano, Kessler, Stein, et al., 2015). Relevant to this observed risk among soldiers in the early stages of their careers, an Army STARRS survey of 38,507 soldiers in their first week of service found that the lifetime prevalence of pre-enlistment suicide ideation, plans, and attempts were 14.1 percent, 2.3 percent, and 1.9 percent, respectively (Ursano, Heeringa, et al., 2015), and most new soldiers with a pre-enlistment history of a suicide attempt reported a prior mental disorder (59.0 percent) (Nock et al., in press).
These findings are consistent with Army STARRS data from a representative survey of the Regular Army, in which approximately half of the lifetime suicidal outcomes reported by soldiers first occurred prior to enlistment, and pre-enlistment mental disorders were associated with one-third of post-enlistment suicide attempts (Nock et al., 2014).
Taken together, these findings support prevention efforts focused on enlisted soldiers who are in the early phases of their first tour of duty and those with a history of mental disorders. Army STARRS is guided by this concentration of risk approach, which aims to produce actionable findings regarding when, where, and for whom risk of suicidal behaviors is greatest within the Army population.
The benefits of a concentration of risk framework are evident in a recent Army STARRS study that used machine learning to predict suicides in the 12 months following discharge from psychiatric hospitalization, a particularly high-risk period accounting for 12 percent of all U.S. Army suicides. Nearly 53 percent of post-hospitalization suicides occurred among the 5 percent of discharged soldiers with highest predicted risk. Those same soldiers also accounted for significantly elevated proportions of subsequent hospitalizations, unintentional injury deaths, and suicide attempts (Kessler et al., 2015).
Army STARRS provides a model for studying rare events of concern for public health and national security. The DoD recently funded a five-year continuation of study that will include analysis of administrative records from 2010 to the present, and longitudinal follow-up of the initial survey respondents as they progress through their Army careers and transition back into civilian life. The extensive Army STARRS databases, including those available for secondary analysis at the Inter-university Consortium for Political and Social Research (http://www.icpsr.umich.edu/icpsrweb/ICPSR/studies/35197), will continue to provide the Army, DoD, and broader scientific community with valuable information for years to come.
About the Authors
James A. Naifeh, PhD, is a research assistant professor in the Department of Psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Maryland, and a scientist at the Center for the Study of Traumatic Stress. His primary research interests include the psychological, environmental, and biological factors that influence risk for PTSD, suicide, and other health-risk behaviors in military service members and veterans.
Holly B. Herberman Mash, PhD, is a research assistant professor in the Department of Psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Maryland, and a scientist at the Center for the Study of Traumatic Stress. Her primary research interests include the risk and protective factors for complicated grief following traumatic events, suicidal behavior, and alcohol use disorders.
Gary H. Wynn, MD, is a Lieutenant Colonel in the United States Army. He is also an associate professor of psychiatry and neuroscience and assistant chair for the Department of Psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Maryland, and a scientist at the Center for the Study of Traumatic Stress. His primary research interests include suicide, complementary and alternative medicine for PTSD, and psychopharmacologic treatments for PTSD.
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