Army May Be Missing Risk Factors Beyond MH for Attempted Suicide Among Soldiers

Mental illness and suicidality are frequently associated, but not all individuals who attempt suicide have a history of psychiatric disorders. A new report concludes that risk factors for attempted suicide among U.S. Army soldiers are often the same for both groups and are at least partly visible in advance, wrote Robert Ursano, M.D., and colleagues in a study published August 29 in JAMA Psychiatry.

Many soldiers who attempted suicide had encounters with the military medical system in the year before the event, suggesting “the importance of strengthening mental health care embedded within primary care,” wrote Ursano and his team. Ursano is a professor of psychiatry and neuroscience and director of the Center for the Study of Traumatic Stress at the Uniformed Services University of the Health Sciences (USUHS) in Bethesda, Md.

“This is an important article about some of the practical challenges in preventing suicidal behavior in military populations,” said Charles Engel, M.D., M.P.H., a former Army psychiatrist and now a senior scientist at the RAND Corporation in Boston. Engel was not involved with the current study. “It can be a starting point for military policymakers for addressing the problem.”

The report is another in a series from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) collaboration, a multimillion-dollar federal effort that ran from 2009 to 2015 designed “to improve understanding of suicide and PTSD and related mental health risk and resilience in the U.S. Army.” It was followed by the ongoing STARRS–Longitudinal Study.

Ursano and colleagues combed through 38 Army and Department of Defense administrative databases seeking relevant information on the 9,650 enlisted soldiers with a documented suicide attempt between January 1, 2004, and December 31, 2009. The cases were compared with an equal-probability sample of 153,528 control person-months.

Overall, the likelihood of an attempt was greater for those with a prior mental health diagnosis, but 3,507 (36.3 percent) of the soldiers had no such diagnosis.

“Odds of suicide attempt were higher among soldiers who were female, younger, non-Hispanic white, less educated, in their first four years of service, never or previously deployed, and those with a delayed promotion, demotion, and combat arms or combat medic occupation,” said the authors. Those who did not have a prior mental health diagnosis and were younger than age 21 when they entered the Army had higher odds of a suicide attempt.

The researchers suggested that women without a prior diagnosis may have had some undetected mental health problems or undisclosed exposure to violence or discrimination. Women soldiers may also face additional stressors in their first months in the Army.

Marriage has been considered protective against suicide, but soldiers married four to 12 months had higher odds of an attempt compared with those married for shorter or longer times, possibly suggesting a difficult transition time.

Time in the service also influenced risk. Undiagnosed soldiers in their first year in the Army were six times more likely to attempt suicide than those who had served for five years or more. Individuals subjected to crime or family violence or who had perpetrated crimes also had higher odds ratio for suicide attempts.

Perhaps the most significant factor was the proportion of visits to military health services in the weeks leading up to the attempt, wrote the researchers. More than 72 percent of soldiers without a history of a mental health diagnosis and almost 87 percent of those with such a history had at least one outpatient physical health visit in the two months prior to the attempt. The odds of a suicide attempt were also linked to both previous injury and the recency of an injury.

“The Army has implemented mental screening and collaborative care programs in primary care settings to improve recognition and clinical management of mental disorders,” said the researchers. “Ensuring routine assessment of psychological distress and suicide risk during all encounters can help identify at-risk soldiers who are unknown to the mental health care system.”

“High utilization rates in general medical care could be a way that people with treatable mental disorders are recognized and treated,” said Engel, who helped develop the program that integrated mental health care into primary care in the Army health system.

Using Army records to research suicide attempts was useful in the ArmySTARRS study but may have its pitfalls for predicting risk in real time.

“Administrative records can help identify service members at risk for suicide attempts but there are challenges, like privacy issues, for the use of those records,” Engel said. “If soldiers know that their superiors are mining the records, they may not seek medical, psychological, or legal services because they fear career repercussion.”

Ursano has previously cautioned that people who attempt suicide and those who complete it are largely different populations. Engel agreed: “It’s important to remember that suicide attempts are not completed suicides and predictors of suicide attempts are not always predictors for suicide completion.” ■