Brief Test May Help Pinpoint Soldiers Likely to Attempt Suicide

A short, self-report test given to soldiers with suicidal ideation (SI) may help identify those at highest risk of a suicide attempt, according to the latest findings from the Army STARRS (Army Study to Assess Risk and Resilience in Servicemembers), published March 15 in JAMA Network Open.

iStock/Steve Debenport

“We were surprised to find that information on so few risk factors allowed us to predict future suicide attempts with such a high degree of accuracy,” said lead author Kelly L. Zuromski, Ph.D., a postdoctoral research fellow at Army STARRS and Military Suicide Research Consortium at Harvard University. “This paper demonstrates the high level of predictive accuracy that may be possible using a suicide-risk index containing only a few pieces of information about high-risk individuals.”

In fact, zeroing in on the 10% of respondents with the highest estimated risk accounted for 39% of the subsequent suicide attempts, reported Zuromski and colleagues.

The most significant risk factors among the 3,700 soldiers were SI “recency” (thinking about suicide in the past 30 days), SI “persistence” (thinking about suicide every day or more than nine hours a day during their worst week), screening positive for two or more lifetime mental disorders, and being of enlisted rank (as opposed to officer).

Earlier this year, the Department of Veterans Affairs began requiring annual SI screening for all patients, along with additional structured questions for patients reporting SI.

The results represent “a step toward precision medicine for suicide-attempt risk,” said study co-author Robert Ursano, M.D., 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 in Bethesda, Md. “The goal was to develop a sophisticated support tool for clinical use—an algorithm that would work similarly to a lab test for cholesterol screening. After the patient completes a brief questionnaire and demographic information is entered, the physician would receive a flag or a comment to indicate whether that patient is at particular risk of suicide attempt. We haven’t reached that type of algorithm yet in mental health, but we are moving toward it. The next level is to not only predict risks but [also] better identify which treatments are most effective for which patients.”

SI Recency, Persistence Raise Risk

The Army STARRS sample for this study included 28,000 soldiers; this analysis focused on the 3,700 (14%) who, at baseline, reported lifetime thoughts of wanting to kill themselves or wishing they were dead. About half of these patients had no lifetime plan of suicide or prior suicide attempt at baseline.

Researchers also asked soldiers questions to determine the presence of any mental disorders, history and severity of self-injurious thoughts and behaviors, and demographic characteristics. Soldiers were followed for 18 to 45 months. During this time, 65 soldiers attempted suicide, and one participant died by suicide. The 14% of the original sample with lifetime SI accounted for 26% of the suicide attempts.

Among patients with SI, the following risk factors were found to be highly significant for suicide attempts:

• SI in the past 30 days (seven times more likely to attempt suicide)

• Lifetime SI persistence, defined as thinking about suicide seven days out of the week or more than nine hours a day during their worst week (nearly three times more likely)

• Positive screen for two or more lifetime mental disorders (26 times more likely)

• Junior enlisted rank as opposed to officer rank (30 times more likely)

Importantly, nearly three-quarters of the subsequent suicide attempts involved participants who had not reported SI during their lifetime at baseline. Researchers are calling for the development of a separate suicide-attempt risk assessment for soldiers who do not report suicidal ideation.

This study was funded under a cooperative agreement with the Department of Health and Human Services, National Institutes of Health, National Institute of Mental Health, and the Department of Defense. The study also was supported in part by the Military Suicide Research Consortium. ■