The National Institute of Mental Health (NIMH) has tapped a consortium of
four research universities to investigate risk and protective factors
influencing a troubling increase in suicides in the U.S. Army.
The number of suicides by U.S. soldiers has risen steadily in recent years
until levels have equaled those among comparable civilians, who historically
have had higher rates. Responding to concern from Congress, the public, and
Pentagon officials, the Army allotted $50 million to NIMH for the new study,
whose goal is to "provide a science base for effective and practical
interventions to reduce suicide rates and address associated mental health
problems," according to an NIMH statement.
Such large, longitudinal studies that look at risk and protective factors
are unusual in military populations, said Robert Heinssen, Ph.D., acting
director of the Division of Services and Intervention Research at NIMH. But
the study is unlikely to come up with a single cause for military suicides, he
told Psychiatric News.
"[The researchers] are really searching for likely, but weakly
linked, risk factors that in combination might create different risk states
over time," he said.
The new study will draw on soldiers' personnel and health records and will
survey several hundred thousand current soldiers and incoming recruits over
the next five years.
The Army now investigates every suicide within the service. It began
issuing public reports in 2007 and stated that failed marital or other
relationships were most strongly associated with suicide (Psychiatric
News, September 21, 2007).
Robert Ursano, M.D., director of the Center for Traumatic Stress Studies at
the Uniformed Services University of the Health Sciences (USUHS) in Bethesda,
Md., where he also chairs the Department of Psychiatry, will direct the
project, the largest ever military study of suicide and mental health.
"This is a unique joining of the Department of Defense and the NIMH
to address an issue of national security that will also build tools with
peacetime implications," Ursano told Psychiatric News.
His principal collaborators will each add a different area of expertise to
USUHS's familiarity with military epidemiology. Stephen Heeringa, Ph.D., of
the University of Michigan's Institute for Social Research has experience in
securely handling large datasets. Ronald Kessler, Ph.D., of Harvard Medical
School is a leading psychiatric epidemiologist, while Columbia University's J.
John Mann, M.D., has extensively studied the neurobiology of suicide and the
use of the psychological autopsy to examine factors leading up to the
The study is a collaborative research project grant, NIMH's term for
projects in which the government takes a direct interest beyond routine
management, said Heinssen in an interview.
"Two NIMH scientific officers—a psychiatric epidemiologist and
a mental health services researcher—will participate as investigators,
working on ways to integrate data from surveys with the data the Army
routinely collects," said Heinssen.
Several researchers with military backgrounds are also involved in the
project, including psychiatric epidemiologist Col. Charles Hoge, director of
the Division of Psychiatry and Behavioral Sciences at Walter Reed Army
Institute of Research in Silver Spring, Md., and Col. Charles Engel, assistant
chair of the Department of Psychiatry at USUHS.
Former APA President Paul Appelbaum, M.D., the Elizabeth K. Dollard
Professor of Psychiatry, Medicine, and Law and director of the Division of
Psychiatry, Law, and Ethics at the Department of Psychiatry at Columbia
University College of Physicians and Surgeons, will chair the project's ethics
committee, which faces two primary challenges in a study of military
populations: confidentiality of information and voluntariness of consent to
protect soldiers from coercion and undue influence.
Study data will come from four main sources, beginning with the Army's
massive existing records on service personnel. Researchers will also survey
90,000 current service members, including those from the National Guard and
Reserves, asking about risk and protective factors, as well as about suicidal
ideation and attempts. The 80,000 to 120,000 recruits who join the Army in
each of the study's first three years will be asked to complete a similar
Study investigators will also set up a case-control study matching soldiers
who attempted or completed suicide in recent years with demographically
The project may be analogous to another long-term study of
"The Framingham heart study looked at the roles of lifestyle,
behavioral characteristics, and biological functions and came up with a good
algorithm for stroke and heart attack," said Heinssen. "With that
information, the risk factors in cardiovascular disease became targets for
The new study will look for and evaluate several personal and community
factors that might influence the risk for suicide, including combat exposure,
overseas deployments, and unit cohesion. It will also consider intermediate
outcomes such as posttraumatic stress disorder, depression, anxiety, divorce,
family violence, and substance abuse. An "adaptive survey design"
will permit investigators to alter survey questions if necessary to provide
The investigators will not wait to complete the study before passing along
any useful results.
"Real-time information can allow the leadership to respond quickly
and allocate resources for prevention," said Ursano.
The study will provide unpublished interim reports to the Army every six
months over the five-year life of the project. However, researchers may
present results through normal peer-reviewed channels in print or at
scientific conferences as results reach meaningful levels, said Heinssen.
At least one long-time student of suicide hopes the researchers will look
beyond proximate causes.
"I applaud the effort, but they may have to go back earlier in life
to find vulnerabilities to suicidal behavior," said Mark Kaplan,
Dr.P.H., a professor of community health at Portland State University in
Suicide is a rare and complex phenomenon, said Kaplan in an interview. The
inevitable access of soldiers to weapons and the desensitization to killing of
military training and combat make it simpler for an unhappy soldier to
impulsively take his own life, but stoicism and difficulty articulating
emotions that are part of American masculine culture are contributing factors
too, he said.
Nevertheless, the knowledge gained by the study may be generalizable to
broader populations, said another civilian expert.
"I believe it is exciting and a very comprehensive approach to
understanding the problems that lead to suicide in the adult
population," said psychiatrist Paula Clayton, M.D., medical director of
the American Foundation for Suicide Prevention. "I'm grateful to the
service for recognizing a problem that needs investigating and for funding