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Original Investigation |

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

Robert J. Ursano, MD1; Ronald C. Kessler, PhD2; Murray B. Stein, MD, MPH3,4,5; James A. Naifeh, PhD1; Pablo A. Aliaga, MA1; Carol S. Fullerton, PhD1; Nancy A. Sampson, BA2; Tzu-Cheg Kao, PhD6; Lisa J. Colpe, PhD, MPH7; Michael Schoenbaum, PhD7; Kenneth L. Cox, MD, MPH8; Steven G. Heeringa, PhD9 ; for the Army Study to Assess Risk and Resilience in Servicemembers (STARRS) collaborators
[+] 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.
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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.

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Figure.
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.

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