From the Journals

36% of soldiers who attempt suicide have no mental health diagnosis

 

Key clinical point: Many U.S. Army soldiers who attempt suicide and have no mental health diagnosis probably have undetected mental health disorders.

Major finding: More than one-third of soldiers who have attempted suicide do not have a history of mental health diagnosis.

Study details: Retrospective cohort study in 9,650 enlisted soldiers who had a documented suicide attempt.

Disclosures: The Army STARRS was supported by the Department of the Army, the U.S. Department of Health & Human Services, the National Institutes of Health, the National Institute of Mental Health, and the Department of Defense. Two authors were employed by the NIMH, and two were Army liaisons or consultants.

Source: Ursano RJ et al. JAMA Psychiatry. 2018 Aug 29. doi: 10.1001/jamapsychiatry.2018.2069.

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Army moves to improve suicide prevention

An increase in suicide rates in the Army during the 2000s led to an increased focus on suicide prevention. However, at the time these study data were being collected, treatment for suicide ideation outside deployment largely occurred in the context of mental health clinics, wrote Mark A. Reger, PhD, Derek J. Smolenski, PhD, and Sarah P. Carter.

Therefore, individuals without mental health symptoms might have been less likely to be identified as being at risk, and therefore, less likely to receive evidence-based treatment. This suggests that greater focus is needed on suicide prevention in other settings, and particularly on combating the stigma associated with a mental health diagnosis – which is often around concerns of career effects from such a diagnosis.

To the Army’s credit, it has shifted toward integrating mental health services into new locations and services – including embedded behavioral health teams – with the aim of increasing access, decreasing stigma, and improving consultation with command.

Dr. Reger and Ms. Carter are affiliated with the Veterans Affairs Puget Sound Health Care System in Seattle, and Dr. Smolenski is with the Psychological Health Center of Excellence at the Defense Health Agency in Tacoma, Wash. These comments are taken from an accompanying editorial (JAMA Psychiatry. 2018 Aug 29. doi: 10.1001/jamapsychiatry.2018.2042). No conflicts of interest were declared.


 

FROM JAMA PSYCHIATRY

About one-third of enlisted soldiers who attempt suicide do not have a history of mental illness, say the authors of a retrospective longitudinal study among U.S. Army personnel.

However, health care use, exposure to violent crime, and first year of service all were significantly associated with suicide attempts.

The study, published online Aug. 29 in JAMA Psychiatry, analyzed administrative data from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) for 9,650 enlisted soldiers (74.8% male) who had a documented suicide attempt.

Overall, 36.3% of the soldiers studied who attempted suicide did not have a previous diagnosis of a mental health disorder. Having a history of mental illness was associated with sixfold higher odds of suicide attempt after adjusting for sociodemographic and service-related variables.

Among those without a history of mental health disorders, the first year of service was associated with sixfold higher odds of a suicide attempt (95% confidence interval, 4.7-7.7), and nearly 60% of those without a previous diagnosis who attempted suicide did so in their first year of service.

“This factor is noteworthy, because, as in the general population, most transitions from ideation to attempt among soldiers occur within 1 year of ideation onset,” wrote Robert J. Ursano, MD, professor of psychiatry and neurosciences at the Center for the Study of Traumatic Stress at the Uniformed Services University of the Health Sciences, Bethesda, Md., and his coauthors.

Among individuals without a history of mental health disorders, women had 2.6-fold higher odds (95% CI, 2.4-2.8) of a suicide attempt. The authors suggested that these women might be more likely to have undetected mental health problems, or have unreported experience of violence and discrimination.

“Given the large proportion of first-year soldiers in the group without previous [mental health diagnosis], it is possible that women face additional stressors and challenges in the initial months of service,” they wrote.

Previous deployment was associated with 2.4-fold higher odds of suicide attempt; a 2-month delay in promotion was associated with 2.1-fold higher odds. In addition, a demotion in the past year was associated with 60% higher odds of a suicide attempt.

Health care use also showed associations with suicide attempts. Individuals who had visited outpatient services eight or more times in the past 2 months had more than threefold higher odds of suicide attempt. Those with an injury-related visit to outpatient services in the previous month had threefold higher odds, and those who had an injury-related visit to inpatient services had a 3.8-fold higher odds.

Exposure to minor violent crime and perpetration of major violent crime or family violence also were associated with higher odds of suicide attempt.

The authors cited several limitations. One is that the study did not capture unreported suicide attempts, mental disorders, or crimes.

The Army STARRS was supported by the Department of the Army, the U.S. Department of Health & Human Services, the National Institutes of Health, the National Institute of Mental Health and the Department of Defense. Two authors were employed by the NIMH, and two were Army liaisons or consultants.

SOURCE: Ursano RJ et al. JAMA Psychiatry. 2018 Aug 29. doi: 10.1001/jamapsychiatry.2018.2069.

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