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Original Investigation
October 2018

Risk Factors Associated With Attempted Suicide Among US Army Soldiers Without a History of Mental Health Diagnosis

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 Psychology, Harvard University, Cambridge, Massachusetts
  • 4Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
  • 5University of Michigan Institute for Social Research, Ann Arbor
  • 6Department of Psychiatry, University of California San Diego, La Jolla
  • 7Department of Family Medicine and Public Health, University of California San Diego, La Jolla
  • 8Veterans Affairs San Diego Healthcare System, San Diego, California
JAMA Psychiatry. 2018;75(10):1022-1032. doi:10.1001/jamapsychiatry.2018.2069
Key Points

Question  What are risk factors for suicide attempt among US Army soldiers with no history of mental health diagnosis?

Findings  This longitudinal cohort study of 9650 enlisted soldiers with a documented suicide attempt and 153 528 control person-months found no history of mental health diagnosis in more than one-third of those who attempted suicide. Risk factors for attempt (sociodemographic, service related, physical health care, injury, subjection to crime, crime perpetration, and family violence) were similar regardless of previous diagnosis, although the strength of associations differed.

Meaning  This study suggests that personnel, medical, legal, and family services records may assist in identifying suicide attempt risk among soldiers with unrecognized mental health problems.

Abstract

Importance  The US Army suicide attempt rate increased sharply during the wars in Afghanistan and Iraq. Although soldiers with a prior mental health diagnosis (MH-Dx) are known to be at risk, little is known about risk among those with no history of diagnosis.

Objective  To examine risk factors for suicide attempt among soldiers without a previous MH-Dx.

Design, Setting, and Participants  In this retrospective longitudinal cohort study using administrative data from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), person-month records were identified for all active-duty Regular Army enlisted soldiers who had a medically documented suicide attempt from January 1, 2004, through December 31, 2009 (n = 9650), and an equal-probability sample of control person-months (n = 153 528). Data analysis in our study was from September 16, 2017, to June 6, 2018. In a stratified sample, it was examined whether risk factors for suicide attempt varied by history of MH-Dx.

Main Outcomes and Measures  Suicide attempts were identified using Department of Defense Suicide Event Report records and International Classification of Diseases, Ninth Revision, Clinical Modification E95 × diagnostic codes. Mental health diagnoses and related codes, as well as sociodemographic, service-related, physical health care, injury, subjection to crime, crime perpetration, and family violence variables, were constructed from Army personnel, medical, legal, and family services records.

Results  Among 9650 enlisted soldiers with a documented suicide attempt (74.8% male), 3507 (36.3%) did not have a previous MH-Dx. Among soldiers with no previous diagnosis, the highest adjusted odds of suicide attempt were for the following: female sex (odds ratio [OR], 2.6; 95% CI, 2.4-2.8), less than high school education (OR, 1.9; 95% CI, 1.8-2.0), first year of service (OR, 6.0; 95% CI, 4.7-7.7), previously deployed (OR, 2.4; 95% CI, 2.1-2.8), promotion delayed 2 months or less (OR, 2.1; 95% CI, 1.7-2.6), past-year demotion (OR, 1.6; 95% CI, 1.3-1.8), 8 or more outpatient physical health care visits in the past 2 months (OR, 3.3; 95% CI, 2.9-3.8), past-month injury-related outpatient (OR, 3.0; 95% CI, 2.8-3.3) and inpatient (OR, 3.8; 95% CI, 2.3-6.3) health care visits, previous combat injury (OR, 1.6; 95% CI, 1.0-2.4), subjection to minor violent crime (OR, 1.6; 95% CI, 1.1-2.4), major violent crime perpetration (OR, 2.0; 95% CI, 1.3-3.0), and family violence (OR, 2.9; 95% CI, 1.9-4.4). Most of these variables were also associated with suicide attempts among soldiers with a previous MH-Dx, although the strength of associations differed.

Conclusions and Relevance  Suicide attempt risk among soldiers with unrecognized mental health problems is a significant and important challenge. Administrative records from personnel, medical, legal, and family services systems can assist in identifying soldiers at risk.

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