By Brenda L. Mooney
CAMBRIDGE, MA — About half of all soldiers reporting that they had tried to kill themselves said that their initial suicide attempt occurred before enlistment, according to a new study.
In fact, pre-enlistment mental disorders are significant contributors to suicide risk in the Army, the authors pointed out.
That was just one area of research results, drawn from the largest study of mental health and resilience ever conducted among U.S. military personnel and reported in a series of three articles published recently in JAMA Psychiatry. Other articles in the series, based on data from The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), found that the rise in suicide deaths from 2004 to 2009 occurred not only in currently and previously deployed soldiers but also among soldiers never deployed and that, in general, soldiers reported higher rates of certain mental disorders than civilians, including attention deficit hyperactivity disorder (ADHD), intermittent explosive disorder and substance use disorder.
Historically, suicide death rates in the U.S. Army have remained below the civilian rate but began climbing early this century. By 2008, those rates exceeded the demographically matched civilian rate, rising to 20.2 suicide deaths per 100,000 vs. 19.2 in those not in the military. Concerned about the steady increase, the Army and the National Institutes for Mental Health partnered in the Army STARRS study to identify risks.
The report on pre-enlistment suicide ideation and attempts, led by Matthew Nock, PhD, of Harvard University, detailed the findings from a survey of more than 5,000 nondeployed soldiers. The survey was designed to elicit information on suicidal thoughts, plans and attempts before and after entering the Army, and results revealed that 13.9% of soldiers considered suicide at some point in their lifetimes, 5.3% made a suicide plan and 2.4% attempted suicide. Between 47% to 60% of the outcomes were found to have occurred prior to joining the Army.1
Soldiers attempting suicide tended to be lower-ranking, enlisted, female and to have been previously deployed, according to the study, which pointed out that about one-third of post-enlistment suicide attempts tied back to pre-enlistment mental disorders, such as panic disorder and post-traumatic stress disorder.
The research indicated that pre- and post-enlistment mental disorders accounted for 60% of first suicide attempts in the Army. Associations were found between five mental disorders and a post-enlistment first suicide attempt: pre-enlistment panic disorder, pre-enlistment posttraumatic stress disorder, post-enlistment depression and both pre- and post-enlistment intermittent explosive disorder.
Interestingly, the soldiers’ pre-enlistment patterns of suicidal thoughts and behaviors remained lower than suicidal thoughts and behaviors reported by a demographically matched civilian group, but, once in the Army, the onset of suicidal thoughts and planning became more common in the servicemembers than among comparable civilians, according to the study. Both of those groups had similar rates of suicide attempts.
“The possibility of higher fatality rates among Army suicide attempts than among civilian suicide attempts highlights the potential importance of means control (i.e., restricting access to lethal means [such as firearms]) as a suicide prevention strategy,” the study authors wrote.
Common Mental Health Issues
Other research, led by Ronald C. Kessler, PhD, also of Harvard, discussed the comparison of mental disorder rates in the Army to a demographically matched civilian population from the National Comorbidity Survey Replication, a national household study that assesses mental disorders. The study found that ADHD and intermittent explosive disorder were the most common mental health issues among solders and that those conditions had an earlier onset in soldiers than in civilians.2
Among the active duty, nondeployed Army soldiers who participated in the mental health assessment, one-quarter met criteria for at least one psychiatric disorder, and 11% met criteria for multiple disorders. Background in the article pointed out that mental health disorders are a leading cause of illness in the U.S. military, with healthcare visits and days out of work due to mental health issues second only to injuries.
Of the servicemembers who met criteria for psychiatric disorders, researchers noted that 76.6% had pre-enlistment onsets — 49.6% were internalizing disorders (major depressive, bipolar, generalized anxiety, panic and posttraumatic stress disorders) and 81.7% were externalizing disorders (ADHD, intermittent explosive [anger] disorder and alcohol/drug problems). All together, the study reported that nearly 13% of soldiers reported severe impairment of their ability to carry out their Army roles.
“Implications of these findings for recruitment are unclear because the Army already screens for emotional problems in pre-enlistment health examinations,” the authors said. “However, knowledge that new recruits have high externalizing disorder rates (even if denied in recruitment interviews) might be useful to the Army in developing targeted outreach intervention programs for new soldiers such as interventions for ADHD and for problems with anger management.”
An article by lead author Michael Schoenbaum, PhD, of NIMH, meanwhile, found that suicide rates increased between Jan. 1, 2004, and Dec. 31, 2009, even among those who had never been deployed. That study looked at the 569 deaths classified as suicides and another 1,331 deaths classified as accidents in relation to basic socio-demographic and Army experience factors in the 975,057 soldiers who served during the six-year period.3
For example, that report noted a correlation between demotion and suicide risk: Soldiers who had been demoted in the past two years experienced increased suicide risk compared with those without such demotions. The suicide risk also was elevated in soldiers without at least a high school diploma or a GED certificate, compared to soldiers with similar or higher degrees.
In terms of gender, being deployed increased suicide risk more for women than men, according to the study, but the overall risk still remained lower for deployed women than for deployed men. In fact, the data suggested that being male, white or a junior enlisted rank made soldiers more likely to attempt to take their own lives.
Some of the findings were hard to explain, according to the authors: Married soldiers and parents have a lower suicide risk than unmarried soldiers without dependents during deployment but not among either the never deployed or previously deployed. Authors also found no consistent associations between suicide risk and accession waivers or stop loss orders, which require soldiers to serve past their original obligation.
“These results set the stage for more in-depth analyses aimed at helping the Army target both high-risk soldiers and high-risk situations, as well as at developing, implementing and evaluating preventive interventions to reverse the rising Army suicide rate,” the authors wrote.
An accompanying editorial suggested the first results from the Army STARRS initiative provide data to improve prevention and treatment of mental health issues leading to suicide.
“To me, the most striking findings concern suicides among nondeployed soldiers and the effect of a pre-enlistment psychiatric disorder on suicidal behavior, psychiatric morbidity, and functional impairment. These findings have major implications for screening, assessment, recruitment, and retention of volunteers seeking military enlistment,” wrote Matthew J. Friedman, MD, PhD, of Dartmouth University in Hanover, NH.4
“These are the only the first articles to come from the groundbreaking Army STARRS initiative. Future articles will hopefully provide finer-grained measurements and more in-depth analyses of the variables already mentioned, as well as new information on psychological, neurocognitive, social, biological and genetic factors. They will also investigate the impact of intervention,” Friedman emphasized, adding, “The current articles have already provided a very rich context and raise some important issues that were less apparent previously. Even without further data, we know enough to begin to consider better assessment, monitoring and intervention strategies.”
1Nock MK, Stein MB, Heeringa SG, Ursano RJ, Colpe LJ, Fullerton CS, Hwang I, Naifeh JA, Sampson NA, Schoenbaum M, Zaslavsky AM, Kessler RC; for the Army STARRS Collaborators. Prevalence and Correlates of Suicidal Behavior Among Soldiers: Results From the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry. 2014 Mar 5. doi: 10.1001/jamapsychiatry.2014.30. [Epub ahead of print] PubMed PMID: 24590178.
2Kessler 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; for the Army STARRS Collaborators. Thirty-Day Prevalence of DSM-IV Mental Disorders Among Nondeployed Soldiers in the US Army: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry. 2014 Mar 5. doi: 10.1001/jamapsychiatry.2014.28. [Epub ahead of print] PubMed PMID: 24590120.
3Schoenbaum M, Kessler RC, Gilman SE, Colpe LJ, Heeringa SG, Stein MB, Ursano RJ, Cox KL; for the Army STARRS Collaborators. Predictors of Suicide and Accident Death in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS): Results From the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry. 2014 Mar 5. doi: 10.1001/jamapsychiatry.2013.4417. [Epub ahead of print] PubMed PMID: 24590048.
4Friedman MJ. Suicide Risk Among Soldiers: Early Findings From Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry. 2014 Mar 5. doi: 10.1001/jamapsychiatry.2014.24. [Epub ahead of print] PubMed PMID: 24590002.