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Original Investigation
January 2015

Predicting Suicides After Psychiatric Hospitalization in US Army Soldiers: The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

Author Affiliations
  • 1Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
  • 2Department of Behavioral Medicine, Blanchfield Army Community Hospital, Fort Campbell, Kentucky
  • 3US Army Office of the Surgeon General, Falls Church, Virginia
  • 4Department of Psychiatry, Stony Brook University School of Medicine, Stony Brook, New York
  • 5Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
  • 6National Institute of Mental Health, Bethesda, Maryland
  • 7US Army Public Health Command, Aberdeen Proving Ground, Maryland
  • 8Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland
  • 9Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, Massachusetts
  • 10Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
  • 11Institute for Social Research, University of Michigan, Ann Arbor
  • 12Department of Psychology, Harvard University, Cambridge, Massachusetts
  • 13Department of Psychiatry, University of California, San Diego, La Jolla
  • 14Deapartment of Family and Preventive Medicine, University of California, San Diego, La Jolla
  • 15Veterans Affairs San Diego Healthcare System, San Diego, California
  • 16King’s Centre for Military Health Research, King’s College London, London, United Kingdom
JAMA Psychiatry. 2015;72(1):49-57. doi:10.1001/jamapsychiatry.2014.1754
Abstract

Importance  The US Army experienced a sharp increase in soldier suicides beginning in 2004. Administrative data reveal that among those at highest risk are soldiers in the 12 months after inpatient treatment of a psychiatric disorder.

Objective  To develop an actuarial risk algorithm predicting suicide in the 12 months after US Army soldier inpatient treatment of a psychiatric disorder to target expanded posthospitalization care.

Design, Setting, and Participants  There were 53 769 hospitalizations of active duty soldiers from January 1, 2004, through December 31, 2009, with International Classification of Diseases, Ninth Revision, Clinical Modification psychiatric admission diagnoses. Administrative data available before hospital discharge abstracted from a wide range of data systems (sociodemographic, US Army career, criminal justice, and medical or pharmacy) were used to predict suicides in the subsequent 12 months using machine learning methods (regression trees and penalized regressions) designed to evaluate cross-validated linear, nonlinear, and interactive predictive associations.

Main Outcomes and Measures  Suicides of soldiers hospitalized with psychiatric disorders in the 12 months after hospital discharge.

Results  Sixty-eight soldiers died by suicide within 12 months of hospital discharge (12.0% of all US Army suicides), equivalent to 263.9 suicides per 100 000 person-years compared with 18.5 suicides per 100 000 person-years in the total US Army. The strongest predictors included sociodemographics (male sex [odds ratio (OR), 7.9; 95% CI, 1.9-32.6] and late age of enlistment [OR, 1.9; 95% CI, 1.0-3.5]), criminal offenses (verbal violence [OR, 2.2; 95% CI, 1.2-4.0] and weapons possession [OR, 5.6; 95% CI, 1.7-18.3]), prior suicidality [OR, 2.9; 95% CI, 1.7-4.9], aspects of prior psychiatric inpatient and outpatient treatment (eg, number of antidepressant prescriptions filled in the past 12 months [OR, 1.3; 95% CI, 1.1-1.7]), and disorders diagnosed during the focal hospitalizations (eg, nonaffective psychosis [OR, 2.9; 95% CI, 1.2-7.0]). A total of 52.9% of posthospitalization suicides occurred after the 5% of hospitalizations with highest predicted suicide risk (3824.1 suicides per 100 000 person-years). These highest-risk hospitalizations also accounted for significantly elevated proportions of several other adverse posthospitalization outcomes (unintentional injury deaths, suicide attempts, and subsequent hospitalizations).

Conclusions and Relevance  The high concentration of risk of suicide and other adverse outcomes might justify targeting expanded posthospitalization interventions to soldiers classified as having highest posthospitalization suicide risk, although final determination requires careful consideration of intervention costs, comparative effectiveness, and possible adverse effects.

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