Derek J. Smolenski

Suicide risk among 1.3 million veterans who were on active duty during the Iraq and Afghanistan wars

PURPOSE We conducted a retrospective cohort mortality study to determine the postservice suicide risk of recent wartime veterans comparing them with the US general population as well as comparing deployed veterans to nondeployed veterans. METHODS Veterans were identified from the Defense Manpower Data Center records, and deployment to Iraq or Afghanistan war zone was determined from the Contingency Tracking System. Vital status of 317,581 deployed and 964,493 nondeployed veterans was followed from the time of discharge to December 31, 2009. Underlying causes of death were obtained from the National Death Index Plus. RESULTS Based on 9353 deaths (deployed, 1650; nondeployed, 7703), of which 1868 were suicide deaths (351; 1517), both veteran cohorts had 24% to 25% lower mortality risk from all causes combined but had 41% to 61% higher risk of suicide relative to the US general population. However, the suicide risk was not associated with a history of deployment to the war zone. After controlling for age, sex, race, marital status, branch of service, and rank, deployed veterans showed a lower risk of suicide compared with nondeployed veterans (hazard ratio, 0.84; 95% confidence interval, 0.75-0.95). Multiple deployments were not associated with the excess suicide risk among deployed veterans (hazard ratio, 1.00; 95% confidence interval, 0.79-1.28). CONCLUSIONS Veterans exhibit significantly higher suicide risk compared with the US general population. However, deployment to the Iraq or Afghanistan war, by itself, was not associated with the excess suicide risk.

Risk of suicide among US Military Service Members following Operation Enduring Freedom or Operation Iraqi Freedom deployment and separation from the US Military

IMPORTANCE A pressing question in military suicide prevention research is whether deployment in support of Operation Enduring Freedom or Operation Iraqi Freedom relates to suicide risk. Prior smaller studies report differing results and often have not included suicides that occurred after separation from military service. OBJECTIVE To examine the association between deployment and suicide among all 3.9 million US military personnel who served during Operation Enduring Freedom or Operation Iraqi Freedom, including suicides that occurred after separation. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort design used administrative data to identify dates of deployment for all service members (October 7, 2001, to December 31, 2007) and suicide data (October 7, 2001, to December 31, 2009) to estimate rates of suicide-specific mortality. Hazard ratios were estimated from time-dependent Cox proportional hazards regression models to compare deployed service members with those who did not deploy. MAIN OUTCOMES AND MEASURES Suicide mortality from the Department of Defense Medical Mortality Registry and the National Death Index. RESULTS Deployment was not associated with the rate of suicide (hazard ratio, 0.96; 99% CI, 0.87-1.05). There was an increased rate of suicide associated with separation from military service (hazard ratio, 1.63; 99% CI, 1.50-1.77), regardless of whether service members had deployed or not. Rates of suicide were also elevated for service members who separated with less than 4 years of military service or who did not separate with an honorable discharge. CONCLUSIONS AND RELEVANCE Findings do not support an association between deployment and suicide mortality in this cohort. Early military separation (<4 years) and discharge that is not honorable were suicide risk factors.

Behavioral screening measures delivered with a smartphone app: psychometric properties and user preference.

Abstract The smartphone is an increasingly widespread technological vehicle for general health and psychological health promotion, evaluation, education, and sometimes intervention. However, the psychometric performance of behavioral health screening measures has not been commonly evaluated for the new, small-format, touch-screen medium. Before mobile-based applications for behavioral health screening can be disseminated confidently, the reliability and the validity of measures administered by the smartphone must be evaluated. We compared psychometric properties (i.e., internal consistency and test-retest reliability) of seven behavioral health measures completed on paper, a computer, and an iPhone by 45 army soldiers. The results showed the internal consistencies of the smartphone-delivered measures to be equivalent and very high across all three modalities and the test-retest reliability of the iPhone measures also to be very high. Furthermore, completion of the behavioral screening measures by the iPhone was highly preferred over the other modalities and was reported to be easy and convenient. Our findings help corroborate the use of smartphones and other small mobile devices for behavioral health screening.

Suicides and Suicide Attempts in the U.S. Military, 2008-2010.

The Department of Defense Suicide Event Report Program collects extensive information on suicides and suicide attempts from the U.S. Air Force, Army, Marine Corps, and Navy. Data are compiled on demographics, suicide event details, behavioral health treatment history, military history, and information about other potential risk factors such as psychosocial stressors that were present at the time of the event. The ultimate goal of this standardized suicide surveillance program is to assist suicide prevention in the U.S. military. Descriptive data are presented on 816 suicides and 1,514 suicide attempts reported through the program between 2008 and 2010.

SYNCHRONOUS TELEHEALTH TECHNOLOGIES IN PSYCHOTHERAPY FOR DEPRESSION: A META-ANALYSIS

Many patients suffering from depression lack immediate access to care. The use of synchronous telehealth modalities to deliver psychotherapy is one solution to this problem. This meta‐analysis examined differences in treatment efficacy for psychotherapy administered via synchronous telehealth as compared to standard nontelehealth approaches.

Precipitating Circumstances of Suicide among Active Duty U.S. Army Personnel Versus U.S. Civilians, 2005–2010

To help understand suicide among soldiers, we compared suicide events between active duty U.S. Army versus civilian decedents to identify differences and inform military prevention efforts. We linked 141 Army suicide records from 2005 to 2010 to National Violent Death Reporting System (NVDRS) data. We described the decedents’ military background and compared their precipitators of death captured in NVDRS to those of demographically matched civilian suicide decedents. Both groups commonly had mental health and intimate partner precipitating circumstances, but soldier decedents less commonly disclosed suicide intent.

Comparing U.S. Army suicide cases to a control sample: initial data and methodological lessons

Identification of risk and protective factors for suicide is a priority for the United States military, especially in light of the recent steady increase in military suicide rates. The Department of Defense Suicide Event Report contains comprehensive data on suicides for active duty military personnel, but no analogous control data is available to permit identification of factors that differentially determine suicide risk. This proof-of-concept study was conducted to determine the feasibility of collecting such control data. The study employed a prospective case-control design in which control cases were randomly selected from a large Army installation at a rate of four control participants for every qualifying Army suicide. Although 111 Army suicides were confirmed during the study period, just 27 control soldiers completed the study. Despite the small control sample, preliminary analyses comparing suicide cases to controls identified several factors more frequently reported for suicide cases, including recent failed intimate relationships, outpatient mental health history, mood disorder diagnosis, substance abuse history, and prior self-injury. No deployment-related risk factors were found. These data are consistent with existing literature and form a foundation for larger control studies. Methodological lessons learned regarding study design and recruitment are discussed to inform future studies.

A Virtual Hope Box: Randomized Controlled Trial of a Smartphone App for Emotional Regulation and Coping With Distress

OBJECTIVE The purpose of this study was to assess the impact of the Virtual Hope Box (VHB), a smartphone app to improve stress coping skills, suicidal ideation, and perceived reasons for living among patients at elevated risk of suicide and self-harm. METHODS The authors conducted a parallel-group randomized controlled trial with two groups of U.S. service veterans in active mental health treatment who had recently expressed suicidal ideation. Between March 2014 and April 2015, 118 patients were enrolled in the study. Participants were assigned to use the VHB (N=58) or to a control group that received printed materials about coping with suicidality (N=60) to supplement treatment as usual over a 12-week period. Three measures-the Coping Self-Efficacy Scale, Beck Scale for Suicidal Ideation, and Brief Reasons for Living Inventory-were collected at baseline (before randomization) and three, six, and 12 weeks. Secondary measures-the Interpersonal Needs Questionnaire, Perceived Stress Scale, and Columbia-Suicide Severity Rating Scale-were collected at baseline and 12 weeks. RESULTS VHB users reported significantly greater ability to cope with unpleasant emotions and thoughts (Coping Self-Efficacy Scale) at three (b=2.41, 95% confidence interval [CI]=.29-4.55) and 12 weeks (b=2.99, 95% CI=.08-5.90) compared with the control group. No significant advantage was found on other outcome measures for treatment augmented by the VHB. CONCLUSIONS The VHB is a demonstrably useful accessory to treatment-an easily accessible tool that can increase stress coping skills. Because the app is easily disseminated across a large population, it is likely to have broad, positive utility in behavioral health care.

Risk factors for self-directed violence in US Soldiers: A case-control study

Military suicide has escalated in recent years, however almost no research has used military surveillance data to examine suicide risk factors. The aims of the current study were to compare suicide risk factors among US Soldiers who died by suicide, attempted suicide, and controls using a prospective case-control design. Controls were 247 Soldiers completing standard post-deployment assessment procedures. Cases were 276 suicide decedents (n=85) or suicide attempters (n=191), drawn from the Department of Defense Suicide Event Report. Compared to controls, suicide attempters and decedents had greater odds of failed intimate relationships, legal problems, and substance abuse problems in the past 90 days. Suicide attempters and decedents also had greater odds of a history of a mood disorder and prior suicide attempt compared to controls. Suicide decedents had greater odds of exposure to legal problems in the past 90 days and lower odds of ever having an anxiety disorder, compared to suicide attempters. Vigilance toward early detection of modifiable suicide risk factors such as relationship dissolution, mood disorders, substance abuse, and legal problems may help reduce suicide risk among US Soldiers.

Gender differences in suicide and suicide attempts among US Army soldiers

In order to best tailor suicide prevention initiatives and programs, it is critical to gain an understanding of how service members׳ suicide risk factors may differ by gender. We aimed to better understand gender differences in suicide and suicide attempts among soldiers, including demographic, military, mental health, and other risk factors. We also examined risk factors uniquely associated with suicide and suicide attempts. We conducted a retrospective study of 1857 US Army soldiers who died by suicide or attempted suicide between 2008 and 2010 and had a Department of Defense Suicide Event Report. Female and male soldiers had more similarities than differences when examining risk factors associated with suicide. The only gender difference approaching significance was workplace difficulties, which was more strongly associated with suicide for female soldiers, compared to their male counterparts. Among suicide decedents, the most common risk factor was having a failed intimate relationship in the 90 days prior to suicide. Among those who attempted suicide, the most common risk factor was a major psychiatric diagnosis. Better understanding both gender differences and risk factors uniquely associated with suicide has critical prevention and public health implications as we work to better understand preventable mortality in our youngest generation of service members.