The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS): progress toward understanding suicide among soldiers

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Abstract

Responding to an unprecedented increase in the suicide rate among soldiers, in 2008 the US Army and US National Institute of Mental Health funded the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), a multicomponent epidemiological and neurobiological study of risk and resilience factors for suicidal thoughts and behaviors, and their psychopathological correlates among Army personnel. Using a combination of administrative records, representative surveys, computerized neurocognitive tests, and blood samples, Army STARRS and its longitudinal follow-up study (STARRS-LS) are designed to identify potentially actionable findings to inform the Army’s suicide prevention efforts. The current report presents a broad overview of Army STARRS and its findings to date on suicide deaths, attempts, and ideation, as well as other important outcomes that may increase suicide risk (e.g., mental disorders, sexual assault victimization). The findings highlight the complexity of environmental and genetic risk and protective factors in different settings and contexts, and the importance of life and career history in understanding suicidal thoughts and behaviors.

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Most cited references 83

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Suicidal behavior is a leading cause of injury and death worldwide. Information about the epidemiology of such behavior is important for policy-making and prevention. The authors reviewed government data on suicide and suicidal behavior and conducted a systematic review of studies on the epidemiology of suicide published from 1997 to 2007. The authors' aims were to examine the prevalence of, trends in, and risk and protective factors for suicidal behavior in the United States and cross-nationally. The data revealed significant cross-national variability in the prevalence of suicidal behavior but consistency in age of onset, transition probabilities, and key risk factors. Suicide is more prevalent among men, whereas nonfatal suicidal behaviors are more prevalent among women and persons who are young, are unmarried, or have a psychiatric disorder. Despite an increase in the treatment of suicidal persons over the past decade, incidence rates of suicidal behavior have remained largely unchanged. Most epidemiologic research on suicidal behavior has focused on patterns and correlates of prevalence. The next generation of studies must examine synergistic effects among modifiable risk and protective factors. New studies must incorporate recent advances in survey methods and clinical assessment. Results should be used in ongoing efforts to decrease the significant loss of life caused by suicidal behavior.

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Toward a clinical model of suicidal behavior in psychiatric patients.

J Mann, C Waternaux, G L Haas … (1999)

Risk factors for suicide attempts have rarely been studied comprehensively in more than one psychiatric disorder, preventing estimation of the relative importance and the generalizability of different putative risk factors across psychiatric diagnoses. The authors conducted a study of suicide attempts in patients with mood disorders, psychoses, and other diagnoses. Their goal was to determine the generalizability and relative importance of risk factors for suicidal acts across diagnostic boundaries and to develop a hypothetical, explanatory, and predictive model of suicidal behavior that can subsequently be tested in a prospective study. Following admission to a university psychiatric hospital, 347 consecutive patients who were 14-72 years old (51% were male and 68% were Caucasian) were recruited for study. Structured clinical interviews generated axis I and axis II diagnoses. Lifetime suicidal acts, traits of aggression and impulsivity, objective and subjective severity of acute psychopathology, developmental and family history, and past substance abuse or alcoholism were assessed. Objective severity of current depression or psychosis did not distinguish the 184 patients who had attempted suicide from those who had never attempted suicide. However, higher scores on subjective depression, higher scores on suicidal ideation, and fewer reasons for living were reported by suicide attempters. Rates of lifetime aggression and impulsivity were also greater in attempters. Comorbid borderline personality disorder, smoking, past substance use disorder or alcoholism, family history of suicidal acts, head injury, and childhood abuse history were more frequent in suicide attempters. The authors propose a stress-diathesis model in which the risk for suicidal acts is determined not merely by a psychiatric illness (the stressor) but also by a diathesis. This diathesis may be reflected in tendencies to experience more suicidal ideation and to be more impulsive and, therefore, more likely to act on suicidal feelings. Prospective studies are proposed to test this model.

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Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial.

S M T H ten Have, William T Beck, David K Brown … (2005)

Suicide attempts constitute a major risk factor for completed suicide, yet few interventions specifically designed to prevent suicide attempts have been evaluated. To determine the effectiveness of a 10-session cognitive therapy intervention designed to prevent repeat suicide attempts in adults who recently attempted suicide. Randomized controlled trial of adults (N = 120) who attempted suicide and were evaluated at a hospital emergency department within 48 hours of the attempt. Potential participants (N = 350) were consecutively recruited from October 1999 to September 2002; 66 refused to participate and 164 were ineligible. Participants were followed up for 18 months. Cognitive therapy or enhanced usual care with tracking and referral services. Incidence of repeat suicide attempts and number of days until a repeat suicide attempt. Suicide ideation (dichotomized), hopelessness, and depression severity at 1, 3, 6, 12, and 18 months. From baseline to the 18-month assessment, 13 participants (24.1%) in the cognitive therapy group and 23 participants (41.6%) in the usual care group made at least 1 subsequent suicide attempt (asymptotic z score, 1.97; P = .049). Using the Kaplan-Meier method, the estimated 18-month reattempt-free probability in the cognitive therapy group was 0.76 (95% confidence interval [CI], 0.62-0.85) and in the usual care group was 0.58 (95% CI, 0.44-0.70). Participants in the cognitive therapy group had a significantly lower reattempt rate (Wald chi2(1) = 3.9; P = .049) and were 50% less likely to reattempt suicide than participants in the usual care group (hazard ratio, 0.51; 95% CI, 0.26-0.997). The severity of self-reported depression was significantly lower for the cognitive therapy group than for the usual care group at 6 months (P= .02), 12 months (P = .009), and 18 months (P = .046). The cognitive therapy group reported significantly less hopelessness than the usual care group at 6 months (P = .045). There were no significant differences between groups based on rates of suicide ideation at any assessment point. Cognitive therapy was effective in preventing suicide attempts for adults who recently attempted suicide.

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Author and article information

Contributors

Robert J. Ursano: 301-295-9797 , robert.ursano@usuhs.edu

Journal

Journal ID (nlm-ta): Mol Psychiatry

Journal ID (iso-abbrev): Mol. Psychiatry

Title: Molecular Psychiatry

Publisher: Nature Publishing Group UK (London )

ISSN (Print): 1359-4184

ISSN (Electronic): 1476-5578

Publication date (Electronic): 13 August 2018

Publication date PMC-release: 13 August 2018

Publication date (Print): 2019

Volume: 24

Issue: 1

Pages: 34-48

Affiliations

[1 ]ISNI 0000 0001 0421 5525, GRID grid.265436.0, Department of Psychiatry, Center for the Study of Traumatic Stress, , Uniformed Services University of the Health Sciences, ; Bethesda, MD USA

[2 ]ISNI 0000 0001 2107 4242, GRID grid.266100.3, Department of Psychiatry and Department of Family Medicine and Public Health, , University of California San Diego, ; La Jolla, CA USA

[3 ]ISNI 0000 0004 0419 2708, GRID grid.410371.0, VA San Diego Healthcare System, ; San Diego, CA USA

[4 ]ISNI 000000041936754X, GRID grid.38142.3c, Department of Health Care Policy, , Harvard Medical School, ; Boston, MA USA

Author information

Murray B. Stein http://orcid.org/0000-0001-9564-2871

Article

Publisher ID: 197

DOI: 10.1038/s41380-018-0197-z

PMC ID: 6756108

PubMed ID: 30104726

SO-VID: adf55a91-1e45-42e9-9818-2daa81a65915

License:

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/.

History

Date received : 1 November 2017

Date revision received : 22 June 2018

Date accepted : 2 July 2018

Funding

Funded by: FundRef https://doi.org/10.13039/100000005, U.S. Department of Defense (DOD);

Award ID: HU0001-15-2-0004

Award Recipient : James A. Naifeh Holly B. Herberman Mash Murray B. Stein Carol S. Fullerton Ronald C. Kessler Robert J. Ursano

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ScienceOpen disciplines: Molecular medicine

Keywords: diseases,psychology,genetics

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ScienceOpen disciplines: Molecular medicine

Keywords: diseases, psychology, genetics

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The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS): progress toward understanding suicide among soldiers

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Most cited references 83

Suicide and suicidal behavior.

Toward a clinical model of suicidal behavior in psychiatric patients.

Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial.

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