Association of Combat Experiences With Suicide Attempts Among Active-Duty US Service Members | Psychiatry and Behavioral Health | JAMA Network Open | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 18.207.129.82. Please contact the publisher to request reinstatement.
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    1 Comment for this article
    EXPAND ALL
    Combat experiences and risk of suicide attempts
    Tomoyuki Kawada, MD | Nippon Medical School
    LeardMann et al. reported that combat exposures had significantly contributed to subsequent risk of suicide attempts among active-duty US service members (1). The adjusted hazard ratios of being attacked, seeing dead bodies, and being directly responsible for the death of a noncombatant on suicide attempts were 1.55, 1.34, and 1.81, respectively, and I present information regarding risk factors of suicide attempts.

    Ursano et al. reported that the adjusted odds ratio (95% confidence intervals [CIs]) of having mental disorder for suicide attempts was 90.2 (59.5-136.7) (2). Suicide attempts were also related to sex, age, ethnicity, contents of combat exposure and
    exposure periods, and mental disorders largely contributed to subsequent suicide attempts. The same authors subsequently reported that simultaneous consideration of environmental and individual factors was indispensable for the risk assessment of suicide attempts in solders (3), and mental health diagnosis was closely related to subsequent suicide attempts in activated solders (4). To verify the causal association, more prospective studies regarding the effect of combat exposures on suicide attempts should be continued.

    References
    1. LeardMann CA, Matsuno RK, Boyko EJ, et al. Association of combat experiences with suicide attempts among active-duty US Service members. JAMA Netw Open 2021;4(2):e2036065.
    2. Ursano RJ, Kessler RC, Stein MB, et al. Suicide attempts in the US Army during the wars in Afghanistan and Iraq, 2004 to 2009. JAMA Psychiatry 2015;72(9):917-26.
    3. Ursano RJ, Kessler RC, Stein MB, et al. Risk factors, methods, and timing of suicide attempts among US Army soldiers. JAMA Psychiatry 2016;73(7):741-9.
    4. Naifeh JA, Ursano RJ, Kessler RC, et al. Suicide attempts among activated soldiers in the U.S. Army reserve components. BMC Psychiatry 2019;19(1):31.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Views 2,689
    Citations 0
    Original Investigation
    Public Health
    February 2, 2021

    Association of Combat Experiences With Suicide Attempts Among Active-Duty US Service Members

    Author Affiliations
    • 1Deployment Health Research Department, Naval Health Research Center, San Diego, California
    • 2Leidos, San Diego, California
    • 3Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Health Care System, Seattle, Washington
    • 4Department of Epidemiology, University of Washington School of Public Health, Seattle
    • 5Department of Medicine, University of Washington School of Medicine, Seattle
    • 6Veterans Affairs Puget Sound Healthcare System, Seattle, Washington
    • 7Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
    • 8Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland
    • 9Psychiatry Division, Office of the Army Surgeon General, Falls Church, Virginia
    JAMA Netw Open. 2021;4(2):e2036065. doi:10.1001/jamanetworkopen.2020.36065
    Key Points

    Question  What is the association of combat exposure with suicide attempts among active-duty US service members who were deployed in support of the wars in Iraq and Afghanistan?

    Findings  In this cohort study of 57 841 active-duty service members, high combat severity and certain combat experiences (ie, being attacked or ambushed, seeing dead bodies or human remains, and being directly responsible for the death of a noncombatant) were associated with suicide attempts. However, these associations were mostly accounted for by mental disorders, especially posttraumatic stress disorder.

    Meaning  Results of this study suggest that certain types of combat experiences may have different implications for service members than other experiences, increasing these individuals’ risk of attempting suicide, either directly or indirectly through a mental disorder.

    Abstract

    Importance  There is uncertainty about the role that military deployment experiences play in suicide-related outcomes. Most previous research has defined combat experiences broadly, and a limited number of cross-sectional studies have examined the association between specific combat exposure (eg, killing) and suicide-related outcomes.

    Objective  To prospectively examine combat exposures associated with suicide attempts among active-duty US service members while accounting for demographic, military-specific, and mental health factors.

    Design, Setting, and Participants  This cohort study analyzed data from the Millennium Cohort Study, an ongoing prospective longitudinal study of US service members from all military branches. Participants were enrolled in 4 phases from July 1, 2001, to April 4, 2013, and completed a self-administered survey at enrollment and every 3 to 5 years thereafter. The population for the present study was restricted to active-duty service members from the first 4 enrollment phases who deployed in support of the wars in Iraq and Afghanistan. Questionnaire data were linked with medical encounter data through September 30, 2015. Data analyses were conducted from January 10, 2017, to December 14, 2020.

    Exposures  Combat exposure was examined in 3 ways (any combat experience, overall combat severity, and 13 individual combat experiences) using a 13-item self-reported combat measure.

    Main Outcomes and Measures  Suicide attempts were identified from military electronic hospitalization and ambulatory medical encounter data using the International Classification of Diseases, Ninth Revision codes.

    Results  Among 57 841 participants, 44 062 were men (76.2%) and 42 095 were non-Hispanic White individuals (72.8%), and the mean (SD) age was 26.9 (5.3) years. During a mean (SD) follow-up period of 5.6 (4.0) years, 235 participants had a suicide attempt (0.4%). Combat exposure, defined broadly, was not associated with suicide attempts in Cox proportional hazards time-to-event regression models after adjustments for demographic and military-specific factors; high combat severity and certain individual combat experiences were associated with an increased risk for suicide attempts. However, these associations were mostly accounted for by mental disorders, especially posttraumatic stress disorder. After adjustment for mental disorders, combat experiences with significant association with suicide attempts included being attacked or ambushed (hazard ratio [HR], 1.55; 95% CI, 1.16-2.06), seeing dead bodies or human remains (HR, 1.34; 95% CI, 1.01-1.78), and being directly responsible for the death of a noncombatant (HR, 1.81; 95% CI, 1.04-3.16).

    Conclusions and Relevance  This study suggests that deployed service members who experience high levels of combat or are exposed to certain types of combat experiences (involving unexpected events or those that challenge moral or ethical norms) may be at an increased risk of a suicide attempt, either directly or mediated through a mental disorder.

    ×