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Figure.
Risk for Suicide Attempt by Month Since Entering Army Service Among Enlisted Soldiers and Officers
Risk for Suicide Attempt by Month Since Entering Army Service Among Enlisted Soldiers and Officers

Data are from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) Historical Administrative Data Study (HADS) Sample, 2004 to 2009. The sample of 193 617 person-months includes all regular Army soldiers (ie, excluding those in the US Army National Guard and Army Reserve) with a suicide attempt in the administrative records from 2004 to 2009 (n = 9791), plus a 1:200 stratified probability sample of all other active-duty regular Army person-months in the population exclusive of soldiers with a suicide attempt or other nonfatal suicidal event (eg, suicidal ideation) and person-months associated with death (ie, suicides, combat deaths, homicides, and deaths due to other injuries or illnesses). All records in the 1:200 sample were assigned a weight of 200 to adjust for the undersampling of months not associated with suicide attempt.

Table 1.  
Multivariate Associations of Sociodemographic Characteristics With Suicide Attempts by Enlisted Soldiers in the Army STARRSa
Multivariate Associations of Sociodemographic Characteristics With Suicide Attempts by Enlisted Soldiers in the Army STARRSa
Table 2.  
Multivariate Associations of Sociodemographic Characteristics With Suicide Attempts by Officers in the Army STARRSa
Multivariate Associations of Sociodemographic Characteristics With Suicide Attempts by Officers in the Army STARRSa
Table 3.  
Multivariate Associations of Length of Service, Deployment Status, and Time Since Most Recent Mental Health Diagnosis With Suicide Attempts by Enlisted Soldiers in the Army STARRSa,b
Multivariate Associations of Length of Service, Deployment Status, and Time Since Most Recent Mental Health Diagnosis With Suicide Attempts by Enlisted Soldiers in the Army STARRSa,b
Table 4.  
Multivariate Associations of Length of Service, Deployment Status, and Time Since Most Recent Mental Health Diagnosis With Suicide Attempts by Officers in the Army STARRSa,b
Multivariate Associations of Length of Service, Deployment Status, and Time Since Most Recent Mental Health Diagnosis With Suicide Attempts by Officers in the Army STARRSa,b
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Original Investigation
September 2015

Suicide Attempts in the US Army During the Wars in Afghanistan and Iraq, 2004 to 2009

Author Affiliations
  • 1Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland
  • 2Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
  • 3Department of Psychiatry, University of California, San Diego, La Jolla
  • 4Department of Family and Preventive Medicine, University of California. San Diego, La Jolla
  • 5Psychiatry Service, Veterans Affairs San Diego Healthcare System, San Diego, California
  • 6Department of Preventive Medicine and Biometrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
  • 7National Institute of Mental Health (NIMH), Bethesda, Maryland
  • 8US Army Public Health Command, Aberdeen Proving Ground, Maryland
  • 9Institute for Social Research, University of Michigan, Ann Arbor
JAMA Psychiatry. 2015;72(9):917-926. doi:10.1001/jamapsychiatry.2015.0987
Abstract

Importance  The rate of suicide attempts in the US Army increased sharply during the wars in Afghanistan and Iraq. Research on this important health outcome has been hampered by the lack of integration among Army administrative data systems.

Objective  To identify risk factors for suicide attempts among active-duty members of the regular Army from January 1, 2004, through December 31, 2009.

Design, Setting, and Participants  This longitudinal, retrospective cohort study, as part of the Army Study to Assess Risk and Resilience in Servicemembers (STARRS), used individual-level person-month records from Army and Department of Defense administrative data systems to examine sociodemographic, service-related, and mental health predictors of medically documented suicide attempts among active-duty regular Army soldiers from January 1, 2004, through December 31, 2009. We analyzed data from 9791 suicide attempters and an equal-probability sample of 183 826 control person-months using a discrete-time survival framework. Data analysis was performed from February 3 through November 12, 2014.

Main Outcomes and Measures  Suicide attempts identified using Department of Defense Suicide Event Report records and diagnostic codes E950 through E958 from the International Classification of Diseases, Ninth Revision, Clinical Modification. Standardized estimates of suicide attempt risk for sociodemographic, service-related, and mental health predictor variables were constructed from Army personnel and medical records.

Results  Enlisted soldiers accounted for 98.6% of all suicide attempts (9650 attempters; overall rate, 377.0 [95% CI, 369.7-384.7] per 100 000 person-years). In multivariate models, suicide attempts among enlisted soldiers were predicted (data reported as odds ratio [95% CI]) by female sex (2.4 [2.3-2.5]), entering Army service at 25 years or older (1.6 [1.5-1.8]), current age of 29 years or younger (<21 years, 5.6 [5.1-6.2]; 21-24 years, 2.9 [2.6-3.2]; 25-29 years, 1.6 [1.5-1.8]), white race (black, 0.7 [0.6-0.7]; Hispanic, 0.7 [0.7-0.8]; Asian, 0.7 [0.6-0.8]), an educational level of less than high school (2.0 [2.0-2.1]), being in the first 4 years of service (1-2 years, 2.4 [2.2-2.6]; 3-4 years, 1.5 [1.4-1.6]), having never (2.8 [2.6-3.0]) or previously (2.6 [2.4-2.8]) been deployed, and a mental health diagnosis during the previous month (18.2 [17.4-19.1]). Attempts among officers (overall rate, 27.9 per 100 000 person-years) were predicted by female sex (2.8 [2.0-4.1]), entering Army service at 25 years or older (2.0 [1.3-3.1]), current age of 40 years or older (0.5 [0.3-0.8]), and a mental health diagnosis during the previous month (90.2 [59.5-136.7]). Discrete-time hazard models indicated risk among enlisted soldiers was highest in the second month of service (102.7 per 100 000 person-months) and declined substantially as length of service increased (mean during the second year of service, 56.0 per 100 000 person-years; after 4 years of service, 29.4 per 100 000 person-months), whereas risk among officers remained stable (overall mean, 6.1 per 100 000 person-months).

Conclusions and Relevance  Our results represent, to our knowledge, the most comprehensive accounting to date of suicide attempts in the Army. The findings reveal unique risk profiles for enlisted soldiers and officers and highlight the importance of research and prevention focused on enlisted soldiers in their first Army tour.

Introduction

Preventing military suicides is a national health concern and research priority.1 From January 1, 2004, through December 31, 2009, the Army experienced the longest sustained increase in suicide rates relative to other US military branches (ie, Navy, Marines, and Air Force).2 Rates of nonfatal suicide attempts among soldiers also rose sharply during this time,3 in parallel with the trend in suicide deaths.4,5 Individuals with a previous suicide attempt are approximately 40 times more likely to die by suicide than those with no previous attempt,6 yet our understanding of Army suicide attempts remains limited. Recent survey findings are informative,79 with approximately 1.3% of soldiers reporting the onset of a first suicide attempt after enlistment.10 These data may not correspond with actual medical encounters, which are particularly important owing to their effect on the Army health care system. Although prior studies of medically documented attempts relied on a single Army or Department of Defense (DOD) database to identify cases,11,12 recent evidence suggests that a comprehensive examination of Army suicide attempts requires integration of multiple administrative data systems.3

Our aim is to provide the first comprehensive analysis of documented suicide attempts in the active-duty US Army during the wars in Afghanistan and Iraq. Using data from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS; http://www.armystarrs.org),13,14 we examined sociodemographic, service-related, and mental health predictors of suicide attempts from 2004 through 2009 to identify segments of the regular Army population at greatest risk. This analysis of administrative records is an important addition to retrospective self-report data on suicide attempts from recent Army STARRS survey research, which did not include soldiers in basic combat training or soldiers currently deployed.10

Methods
Sample

The Historical Administrative Data Study (HADS) is a component of the Army STARRS that integrates 38 Army and DOD administrative data systems, including every system in which suicidal events are medically documented. Creation and analysis of the consolidated and deidentified data system were approved by the institutional review boards of the Uniformed Services University of the Health Sciences for the Henry M. Jackson Foundation (the primary grantee), the University of Michigan Institute for Social Research (site of the Army STARRS Data Enclave), University of California, San Diego, and Harvard Medical School. The HADS includes individual-level person-month records for all 1.66 million soldiers on active duty from January 1, 2004, through December 31, 2009.14 In this longitudinal, retrospective cohort study, we focused on records for the 975 057 regular Army soldiers on active duty during this time (excluding activated Army National Guard and Army Reserve soldiers), 9791 of whom had a documented suicide attempt. Data were analyzed using a discrete-time survival framework with person-month as the unit of analysis,15 such that each month in the career of a soldier was treated as a separate observational record. Given that discrete-time survival coefficients can be estimated without bias when control person-months are subsampled randomly and weighted using the logic of case-control analysis,16 we reduced computational intensity by selecting from the population an equal-probability 1:200 sample of control person-months stratified by sex, rank, time in the Army, deployment status (never, currently, or previously), and historical time (n = 183 826). Control person-months excluded all soldiers with a documented suicide attempt or other nonfatal suicidal event (eg, suicidal ideation)3 and person-months in which a soldier died of suicide, combat, homicide, injury, or illness. The full case-control analytic sample contained 193 617 person-months, with each control person-month assigned a weight of 200 to adjust for the undersampling of months without a suicide attempt.

Measures

Cases of attempted suicide were identified using records from the DOD Suicide Event Report,17 a DOD-wide surveillance mechanism that aggregates information on suicidal behaviors via a standardized form completed by health care professionals at DOD treatment facilities (3594 cases), and diagnostic codes E950 through E958 from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) (indicating self-inflicted poisoning or injury with suicidal intent) from the Military Health System Data Repository, Theater Medical Data Store, and TRANSCOM (Transportation Command) Regulating and Command and Control Evacuation System, which together provide health care encounter information from military and civilian treatment facilities, combat operations, and aeromedical evacuations (6197 cases). We excluded suicide deaths and DOD Suicide Event Report records indicating only suicidal ideation. The ICD-9-CM code E959 (late effects of a self-inflicted injury) was excluded because it confounded the temporal relationships between the predictor variables and the suicide attempt.18 Records from different data systems were cross-referenced to ensure all cases represent unique soldiers. For soldiers with multiple suicide attempts, we selected the first attempt by using a hierarchical classification scheme that prioritized DOD Suicide Event Report records owing to that system’s more extensive reporting requirements.3 Sociodemographic, length of service, deployment status, and mental health diagnosis variables were constructed from administrative records (eTable 1 in the Supplement; http://www.armystarrs.org/publications). An indicator variable for a previous mental health diagnosis was created from ICD-9-CM codes for mental disorder (eg, major depression, posttraumatic stress disorder, personality disorders), excluding postconcussion syndrome, tobacco use disorder, and supplemental V-codes that are not disorders (eg, stressors/adversities, marital problems) (eTable 2 in the Supplement). Recency of diagnosis was determined based on the number of months elapsed from the most recent diagnostic record to the suicide attempt (cases) or control person-month.

Statistical Analysis

Analyses were conducted separately among enlisted soldiers (163 178 person-months) and officers (30 439 person-months [including warrant officers]) owing to their different sociodemographic profiles, training, Army career experiences,19 and risks for mental health problems7,20,21 and suicide.22,23 Logistic regression analyses examined multivariate associations of sociodemographic characteristics (sex, age at entry into Army service, current age, race, educational level, and marital status) with suicide attempts, followed by separate models evaluating incremental predictive effects of the length of service (1-2, 3-4, 5-10, and ≥11 years), deployment status (never, currently, and previously), and the presence or recency of a mental health diagnosis (no diagnosis vs 1, 2-3, 4-12, and ≥13 months since the most recent diagnosis). Logistic regression coefficients were exponentiated to obtain odds ratios (ORs) and 95% CIs. Final model coefficients were used to generate standardized estimates of risk24 (number of suicide attempters per 100 000 person-years) for each category of each predictor under the model, assuming other predictors were at their samplewide means. Based on evidence that the Army suicide attempt rate increased from 2004 through 2009,3 a separate dummy predictor was included in each logistic regression equation to control for the calendar month and year. Coefficients of other predictors can consequently be interpreted as mean within-month associations based on the assumption that the effects of other predictors do not vary over time.

To further examine associations between length of service and the risk for suicide attempts, we generated separate discrete-time hazard functions for enlisted soldiers and officers. These hazard functions were used to estimate the risk for suicide attempts in each month since entering Army service (number of suicide attempters per 100 000 person-months). Data analysis was performed from February 3 through November 12, 2014.

Results

Enlisted soldiers constituted 83.5% of active-duty regular Army soldiers and accounted for 98.6% of all cases of suicide attempt (n = 9650), with an overall rate of 377.0 (95% CI, 369.7-384.7) per 100 000 person-years during the 2004-2009 study period. Officers (commissioned and warrant officers) constituted 16.5% of the regular Army and accounted for 1.4% of cases (n = 141), with an overall rate of 27.9 (95% CI, 23.7-32.9) per 100 000 person-years (Table 1 and Table 2).

Sociodemographic Characteristics

Enlisted soldiers with higher odds of a suicide attempt (OR [95% CI]) were female (2.4 [2.3-2.5]), entered Army service at 25 years or older (1.6 [1.5-1.8]), were currently 29 years or younger (<21 years, 5.6 [5.1-6.2]; 21-24 years, 2.9 [2.6-3.2]; 25-29 years, 1.6 [1.5-1.8]), and did not complete high school (2.0 [2.0-2.1]). Lower odds (OR [95% CI]) were associated with entering Army service before age 21 years (0.7 [0.7-0.8]), being 35 years or older (35-39 years, 0.7 [0.6-0.8]; ≥40 years, 0.5 [0.4-0.6]), completing at least some college (some college, 0.7 [0.6-0.8]; completed college, 0.6 [0.5-0.7]), and being of black (0.7 [0.6-0.7]), Hispanic (0.7 [0.7-0.8]), or Asian (0.7 [0.6-0.8]) race or ethnicity (Table 1). Officers with increased odds of suicide attempt were female (OR, 2.8 [95% CI, 2.0-4.1]) and entered Army service at 25 years or older (OR, 2.0 [95% CI, 1.3-3.1]). Officers currently 40 years or older had decreased odds (OR, 0.5 [95% CI, 0.3-0.8]) (Table 2).

Examination of the standardized risk estimates reveals that enlisted women had nearly 13 times the risk of female officers (rate ratio [RR], 12.6 [95% CI, 9.4-16.8]). Similarly, enlisted soldiers who entered Army service at 25 years or older had more than 16 times the standardized risk of officers in the same group (RR, 16.3 [95% CI, 12.2-21.6]). Although currently being 40 years or older was protective for enlisted soldiers and officers, the risk among enlisted personnel in this age group was 5.6 times higher than that of officers in the same age group (RR, 5.6 [95% CI, 3.5-9.0]).

Length of Service

After we adjusted for sociodemographic characteristics, enlisted soldiers in their first 4 years of service had higher odds of suicide attempts (OR for 1-2 years, 2.4 [95% CI, 2.2-2.6]; OR for 3-4 years, 1.5 [95% CI, 1.4-1.6]) than those with 5 to 10 years of service, whereas those serving for more than 10 years had lower odds (OR, 0.5 [95% CI, 0.4-0.5]) (Table 3). Additional pairwise analyses revealed that the rates of attempted suicide differed significantly by time in service (χ21 values, 226.9-390.2; P < .001 for all comparisons). Length of service was not associated with suicide attempt among officers (χ23 = 6.3; P = .10), although the ORs had a similar decrease beyond the second year of service (Table 4). Enlisted soldiers in their first 2 years of service had the greatest standardized risk, which was more than 10 times that of officers in the same category (RR, 10.6 [95% CI, 7.4-15.1]).

A discrete-time hazard model examining time to suicide attempt demonstrated greatly elevated risk among enlisted soldiers during their first year in Army service, with the risk peaking in the second month of service (102.5 per 100 000 person-months). Risk decreased substantially to a mean of 56.0 per 100 000 person-years during the second year of service, followed by a more gradual decline to a mean of 29.4 per 100 000 person-months after 4 years of service. Risk among officers remained relatively stable across time, with an overall mean of 6.1 per 100 000 person-months (Figure).

Deployment Status

We found higher odds of suicide among never deployed (OR, 2.8 [95% CI, 2.6-3.0]) and previously deployed (OR, 2.6 [95% CI, 2.4-2.8]) enlisted soldiers than among those currently deployed when we controlled for sociodemographic variables (Table 3). The pairwise difference between never and previously deployed was also significant (χ21 = 6.3; P = .01). Deployment status was not associated with suicide attempt among officers (χ22 = 1.2; P = .54), although the ORs changed in the same direction as for enlisted soldiers (Table 4). Never-deployed enlisted soldiers, the group at greatest risk based on deployment status, accounted for a similar proportion of their respective population as never-deployed officers (40.4% vs 37.9%) but had a standardized risk nearly 16 times higher (RR, 15.9 [95% CI, 12.2-20.9]). Although a smaller proportion of enlisted soldiers were previously deployed compared with officers (36.2% vs 42.8%), their standardized risk for suicide attempt was approximately 14 times higher (RR, 14.0 [95% CI, 11.0-17.9]).

Mental Health Diagnosis

Among those who attempted suicide, 5774 enlisted soldiers (59.8%) and 99 officers (70.2%) had a previous mental health diagnosis. Among attempters with a history of diagnosis, 3516 enlisted soldiers (60.9%) and 65 officers (65.7%) were most recently diagnosed in the month before their attempt. When we controlled for sociodemographic characteristics, enlisted soldiers with a diagnosis in the previous month had the highest odds of suicide attempt (OR, 18.2 [95% CI, 17.4-19.1]) compared with those without a diagnosis, with odds decreasing as the time since the most recent diagnosis increased from 2 to 3 months (OR, 5.8 [95% CI, 5.4-6.3]) to 13 months or more (OR, 1.4 [95% CI, 1.3-1.6]) (Table 3). All additional pairwise comparisons between time intervals were also significant (χ21 values, 153.2-2910.4; P < .001 for all comparisons). Officers with a mental health diagnosis in the previous month similarly had the greatest likelihood of attempt (OR, 90.2 [95% CI, 59.5-136.7]), and longer intervals resulted in increasingly smaller ORs, ranging from 14.8 (95% CI, 7.3-29.8) for 2 to 3 months to 2.3 (95% CI, 1.0-4.9) for 13 months or more (Table 4). Most pairwise analyses of these intervals were significant (χ21 values, 12.0-96.0; P < .001 for all comparisons), except for 2 to 3 months vs 4 to 12 months (χ21 = 0.9; P = .35). The elevated risk in the month after the diagnosis was more than 4 times higher for enlisted soldiers than officers (RR, 4.2 [95% CI, 3.3-5.3]). The population-attributable risk proportions for previous mental health diagnosis (ie, the proportion of observed suicide attempts associated with the predictor)25 based on these models were 54.0% for enlisted soldiers and 66.5% for officers. The presence of a mental health diagnosis did not change the significant sociodemographic findings noted above.

Discussion

Using comprehensive data on administratively documented US Army suicide attempts, this study identified segments of the active-duty regular Army population at greatest risk for suicide attempts, highlighting pathways for further inquiry and intervention. The findings suggest that enlisted soldiers and officers require unique considerations in research and prevention. Beyond potentially important differences in sociodemographic characteristics (eg, higher educational levels among officers), training, and occupational responsibilities, these groups also have distinct risk distributions. Enlisted soldiers constituted approximately 84% of the Army and nearly 99% of suicide attempters, with an overall rate of 377.0 per 100 000 person-years from 2004 through 2009. Comparisons with US general population rates are challenging because demographic differences and less comprehensive ascertainment of civilian suicide attempts can result in substantial bias.26 Based on data from the Centers for Disease Control and Prevention, the rate of nonfatal self-injury among men aged 18 to 34 years was 213.8 per 100 000 persons from 2004 through 2009 (273.6 per 100 000 persons for women).27 However, the data from the Centers for Disease Control and Prevention only capture self-injury treated in US hospital emergency departments, suggesting that they underestimate the true general population rate.

For clinicians assessing individual risk, distinguishing between who they are likely to see in practice vs who is at highest risk in the population is important. Similarly, program planners seeking to have the greatest effect on population health must consider where risk is concentrated within the population when developing interventions. For example, female enlisted soldiers are more than twice as likely as male enlisted soldiers to attempt suicide but constitute only 13.7% of the active-duty regular Army. The consistency of sex as a predictor suggests that examination of risk in men and women separately may be beneficial.9 Identification of sex-specific risk profiles would assist in the development and targeting of interventions, particularly for women because they may require prevention programs that differ from those designed for a male-dominated Army population. In contrast, race was only associated with suicide attempts among enlisted soldiers, with non-Hispanic white soldiers at greater risk than black, Hispanic, or Asian soldiers. Enlisted soldiers and officers were at increased risk if they entered Army service at 25 years or older, suggesting the importance of early intervention (eg, additional training, education, and/or mental health resources) for new soldiers in this age group.

Length of Army service was also important among enlisted soldiers. Risk was elevated during the first tour of duty, particularly the initial months after entering Army service. Prior Army STARRS survey findings indicate that nearly 39% of new soldiers report a preenlistment history of common internalizing or externalizing mental health disorders,28 and preenlistment suicidal ideation, plans, and attempts are reported by 14.1%, 2.3%, and 1.9%, respectively.29 The combination of high population prevalence and high risk for suicide attempts among early-career enlisted soldiers suggests that enhanced surveillance and evidence-based prevention targeting this segment of the Army population could have the greatest effect on rates of suicide attempts.

Currently deployed enlisted soldiers were less likely than other enlisted soldiers to attempt suicide. Numerous studies have documented adverse mental health outcomes after deployment,3034 although our finding of higher risk among previously vs currently deployed enlisted soldiers differs from a recent Army STARRS study of suicide deaths that found risk was comparable between these groups.22 That prior study of suicide fatalities also contrasts with our finding that the risk for suicide attempts was greatest in soldiers who were never deployed. Additional research is needed to examine the role of deployment status in fatal vs nonfatal suicidal behaviors and whether predeployment mental health screening may have contributed to decreased risk for suicide attempts in those currently deployed (ie, a healthy deployed-soldier effect).35 To better understand the relationship between deployment and suicide attempts, studies should examine variables such as time to (anticipated) future deployment among those never deployed, time since deployment among those currently deployed, and time since redeployment among those previously deployed.

Mental health diagnoses, which are among the most consistent risk factors for suicidal behaviors,4 increased dramatically in the US military during the past decade of war.36 In the present study, suicide attempts among enlisted soldiers and officers were associated with a history of receiving a mental health diagnosis, particularly in the previous month. We found that 59.8% of enlisted soldiers (5774 of 9650 suicide attempts) and 70.2% of officers (99 of 141 suicide attempts) received a diagnosis before their suicide attempt, suggesting that many at-risk soldiers have already been identified by the Army health care system as needing mental health services and providing opportunities for further risk assessment and intervention. Future research should examine which mental health disorders carry the greatest risk among soldiers and the trajectories of diagnoses over time, as well as systems-level factors, such as quantity, quality, and continuity of care.

Many of the significant sociodemographic predictors among enlisted soldiers are consistent with the literature on civilian suicide attempts,37 including female sex, being younger, non-Hispanic white race, and lower educational attainment. The findings regarding sex, rank, and history of mental health disorder are also generally supported by Army STARRS survey results10 but not the associations with age, race, and deployment history. However, caution is warranted in making these comparisons owing to important methodologic differences between studies. In addition to the use of self-report survey data, the prior Army STARRS study did not stratify by rank or include soldiers who were in basic combat training or currently deployed. The prior study also examined predictors of suicide attempts with first onset after enlistment whereas we could not account for preenlistment history. Finally, survey participation is affected by the high probability that soldiers with a psychiatric hospitalization will be involuntarily separated from the Army.38

A limitation of the present study is that we focused only on suicide attempts documented by the Army health care system. Undocumented suicide attempts, including self-pay treatment at civilian health care facilities, may have different risk and protective factors. We were also unable to examine suicide attempts among those who recently left the Army, an important period of transition and readjustment.39 In addition, we focused on a circumscribed set of sociodemographic and military predictors. Future studies should examine suicide attempt risk in the context of other military characteristics (eg, military occupational specialty, number of previous deployments, history of promotion and demotion) and mental health indicators (eg, number and types of psychiatric diagnoses, treatment history).4

Conclusions

Enlisted soldiers in their first tour of duty account for most medically documented suicide attempts. Risk is particularly high among soldiers with a recent mental health diagnosis. A concentration of risk strategy40 that incorporates factors such as sex, rank, age, length of service, deployment status, and mental health diagnosis into targeted prevention programs may have the greatest effect on population health within the US Army.

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Article Information

Submitted for Publication: January 30, 2015; final revision received April 7, 2015; accepted May 7, 2015.

Corresponding Author: Robert J. Ursano, MD, Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814 (robert.ursano@usuhs.edu).

Published Online: July 8, 2015. doi:10.1001/jamapsychiatry.2015.0987.

Author Contributions: Dr Ursano had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Ursano, Kessler, Fullerton, Kao, Schoenbaum, Heeringa.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Ursano, Kessler, Naifeh, Fullerton.

Critical revision of the manuscript for important intellectual content: Ursano, Kessler, Stein, Aliaga, Fullerton, Sampson, Kao, Colpe, Schoenbaum, Cox, Heeringa.

Statistical analysis: Ursano, Kessler, Aliaga, Fullerton, Sampson, Kao, Schoenbaum.

Obtained funding: Ursano, Kessler, Fullerton, Colpe, Heeringa.

Administrative, technical, or material support: Ursano, Kessler, Naifeh, Fullerton, Colpe, Schoenbaum, Heeringa.

Study supervision: Ursano, Kessler.

Conflict of Interest Disclosures: Dr Kessler has been a consultant during the past 3 years for J & J Wellness & Prevention, Inc, Lake Nona Institute, Ortho-McNeil Janssen Scientific Affairs, Sanofi, Shire US Inc, and Transcept Pharmaceuticals Inc; has received research support for his epidemiologic studies during this period from EPI-Q, Sanofi, and Walgreens Co; and owns a 25% share in DataStat, Inc. Dr Stein has been a consultant for Healthcare Management Technologies, Janssen Pharmaceuticals, Pfizer, and Tonix Pharmaceuticals. No other disclosures were reported.

Funding/Support: Army STARRS was sponsored by the US Department of the Army and funded by cooperative agreement U01MH087981 with the US Department of Health and Human Services, National Institutes of Health, NIMH.

Role of the Funder/Sponsor: As part of the cooperative agreement, scientists employed by the NIMH (Drs Colpe and Schoenbaum) and Army liaisons and consultants (Steven Cersovsky, MD, MPH, USAPHC, and Dr Cox) collaborated to develop the study protocol and data collection instruments, supervise data collection, interpret results, and prepare reports. Although a draft of this manuscript was submitted to the Army and NIMH for review and comment before submission, this was with the understanding that comments would be advisory.

Group Information: The Army Study to Assess Risk and Resilience in Servicemembers (STARRS) Team consists of coprincipal investigators Robert J. Ursano, MD (Uniformed Services University of the Health Sciences, Bethesda, Maryland) and Murray B. Stein, MD, MPH (University of California, San Diego, and Veterans Affairs San Diego Healthcare System); site principal investigators Steven Heeringa, PhD (University of Michigan) and Ronald C. Kessler, PhD (Harvard Medical School, Boston, Massachusetts); NIMH collaborating scientists Lisa J. Colpe, PhD, MPH and Michael Schoenbaum, PhD; and Army liaisons/consultants Steven Cersovsky, MD, MPH, US Army Public Health Command, and Kenneth Cox, MD, MPH, US Army Public Health Command. Other members of the Army STARRS team included the following: Pablo A. Aliaga, MA (Uniformed Services University of the Health Sciences); David M. Benedek, MD (Uniformed Services University of the Health Sciences); K. Nikki Benevides, MA (Uniformed Services University of the Health Sciences); Paul D. Bliese, PhD (University of South Carolina, Columbia); Susan Borja, PhD (NIMH); Evelyn J. Bromet, PhD (Stony Brook University School of Medicine, Stony Brook, NY); Gregory G. Brown, PhD (University of California, San Diego); Christina L. Wryter, BA (Uniformed Services University of the Health Sciences); Laura Campbell-Sills, PhD (University of California, San Diego); Catherine L. Dempsey, PhD, MPH (Uniformed Services University of the Health Sciences); Carol S. Fullerton, PhD (Uniformed Services University of the Health Sciences); Nancy Gebler, MA (University of Michigan, Ann Arbor); Robert K. Gifford, PhD (Uniformed Services University of the Health Sciences); Stephen E. Gilman, ScD (Harvard School of Public Health); Marjan G. Holloway, PhD (Uniformed Services University of the Health Sciences); Paul E. Hurwitz, MPH (Uniformed Services University of the Health Sciences); Sonia Jain, PhD (University of California, San Diego); Tzu-Cheg Kao, PhD (Uniformed Services University of the Health Sciences); Karestan C. Koenen, PhD (Columbia University, New York, NY); Lisa Lewandowski-Romps, PhD (University of Michigan); Holly Herberman Mash, PhD (Uniformed Services University of the Health Sciences); James E. McCarroll, PhD, MPH (Uniformed Services University of the Health Sciences); James A. Naifeh, PhD (Uniformed Services University of the Health Sciences); Tsz Hin Hinz Ng, MPH (Uniformed Services University of the Health Sciences); Matthew K. Nock, PhD (Harvard University); Rema Raman, PhD (University of California, San Diego); Holly J. Ramsawh, PhD (Uniformed Services University of the Health Sciences); Anthony Joseph Rosellini, PhD (Harvard Medical School); Nancy A. Sampson, BA (Harvard Medical School); Patcho Santiago, MD, MPH (Uniformed Services University of the Health Sciences); Michaelle Scanlon, MBA (NIMH); Jordan W. Smoller, MD, ScD (Harvard Medical School); Amy Street, PhD (Boston University School of Medicine); Michael L. Thomas, PhD (University of California, San Diego); Patti L. Vegella, MS, MA (Uniformed Services University of the Health Sciences); Leming Wang, MS (Uniformed Services University of the Health Sciences); Christina L. Wassel, PhD (University of Pittsburgh, Pittsburgh, Pennsylvania); Simon Wessely, FMedSci (King’s College London, London, England); Hongyan Wu, MPH (Uniformed Services University of the Health Sciences); Gary H. Wynn, MD (Uniformed Services University of the Health Sciences); Alan M. Zaslavsky, PhD (Harvard Medical School); and Bailey G. Zhang, MS (Uniformed Services University of the Health Sciences).

Disclaimer: The contents of this report are solely the responsibility of the authors and do not necessarily represent the views of the Department of Health and Human Services, NIMH, the Department of the Army, or the Department of Defense.

Additional Contributions: John Mann, MD, Maria Oquedo, MD, Barbara Stanley, PhD, Kelly Posner, PhD, and John Keilp, PhD, Department of Psychiatry, Columbia University, College of Physicians and Surgeons, and New York State Psychiatric Institute contributed to the early stages of the US Army STARRS development. No financial compensation was given for their services.

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