Holly B. Herberman Mash

Risk for suicidal behaviors associated with PTSD, depression,and their comorbidity in the U.S. Army

BACKGROUND Suicide rates have risen considerably in the United States Army in the past decade. Suicide risk is highest among those with past suicidality (suicidal ideation or attempts). The incidence of posttraumatic stress disorder (PTSD) and depressive illnesses has risen concurrently in the U.S. Army. We examined the relationship of PTSD and depression, independently and in combination, and rates of past-year suicidality in a representative sample of U.S. Army soldiers. METHODS This study used the DoD Survey of Health Related Behaviors Among Active Duty Military Personnel (DoD HRB) (N=5927). Probable PTSD and depression were assessed with the PTSD Checklist (PCL) and the 10-item short form of the Center for Epidemiologic Studies Depression Scale (CES-D), respectively. Past-year suicidality was assessed via self-report. RESULTS Six percent of Army service members reported suicidality within the past year. PTSD and MDD were each independently associated with past-year suicidality. Soldiers with both disorders were almost three times more likely to report suicidality within the past year than those with either diagnosis alone. Population-attributable risk proportions for PTSD, depression, and both disorders together were 24%, 29%, and 45%, respectively. LIMITATIONS The current study is subject to the limitations of a cross-sectional survey design and the self-report nature of the instruments used. CONCLUSIONS PTSD and depression are each associated with suicidality independently and in combination in the active duty component of the U.S. Army. Soldiers presenting with either but especially both disorders may require additional outreach and screening to decrease suicidal ideation and attempts.

Nonfatal Suicidal Behaviors in U.S. Army Administrative Records, 2004–2009: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

Objective: Although the U.S. Army suicide rate is known to have risen sharply over the past decade, information about medically documented, nonfatal suicidal behaviors is far more limited. Here we examine trends and sociodemographic correlates of suicide attempts, suspicious injuries, and suicide ideation among regular Army soldiers. Methods: Data come from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) Historical Administrative Data Study (HADS), which integrates administrative records for all soldiers on active duty during the years 2004 through 2009 (n = 1.66 million). Results: We identified 21,740 unique regular Army soldiers with a nonfatal suicidal event documented at some point during the HADS study period. There were substantial increases in the annual incidence rates of suicide attempts (179–400/100,000 person-years) and suicide ideation (557–830/100,000 person-years), but not suspicious injuries. Using hierarchical classification rules to identify the first instance of each soldier’s most severe behavior, we found increased risk of all outcomes among those who were female, non-Hispanic White, never married, lower-ranking enlisted, less educated, and of younger age when entering Army service. These sociodemographic associations significantly differed across outcomes, despite some patterns that appear similar. Conclusion: Results provide a broad overview of nonfatal suicidal trends in the U.S. Army during 2004 through 2009 and demonstrate that integration of multiple administrative data systems enriches analysis of the predictors of such events.

Predicting suicides after outpatient mental health visits in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

The 2013 US Veterans Administration/Department of Defense Clinical Practice Guidelines (VA/DoD CPG) require comprehensive suicide risk assessments for VA/DoD patients with mental disorders but provide minimal guidance on how to carry out these assessments. Given that clinician-based assessments are not known to be strong predictors of suicide, we investigated whether a precision medicine model using administrative data after outpatient mental health specialty visits could be developed to predict suicides among outpatients. We focused on male nondeployed Regular US Army soldiers because they account for the vast majority of such suicides. Four machine learning classifiers (naive Bayes, random forests, support vector regression and elastic net penalized regression) were explored. Of the Army suicides in 2004–2009, 41.5% occurred among 12.0% of soldiers seen as outpatient by mental health specialists, with risk especially high within 26 weeks of visits. An elastic net classifier with 10–14 predictors optimized sensitivity (45.6% of suicide deaths occurring after the 15% of visits with highest predicted risk). Good model stability was found for a model using 2004–2007 data to predict 2008–2009 suicides, although stability decreased in a model using 2008–2009 data to predict 2010–2012 suicides. The 5% of visits with highest risk included only 0.1% of soldiers (1047.1 suicides/100 000 person-years in the 5 weeks after the visit). This is a high enough concentration of risk to have implications for targeting preventive interventions. An even better model might be developed in the future by including the enriched information on clinician-evaluated suicide risk mandated by the VA/DoD CPG to be recorded.

Mitigating flood exposure

Introduction. In 2011, following heavy winter snowfall, two cities bordering two rivers in North Dakota, USA faced major flood threats. Flooding was foreseeable and predictable although the extent of risk was uncertain. One community, Fargo, situated in a shallow river basin, successfully mitigated and prevented flooding. For the other community, Minot, located in a deep river valley, prevention was not possible and downtown businesses and one-quarter of the homes were inundated, in the city’s worst flood on record. We aimed at contrasting the respective hazards, vulnerabilities, stressors, psychological risk factors, psychosocial consequences, and disaster risk reduction strategies under conditions where flood prevention was, and was not, possible. Methods. We applied the “trauma signature analysis” (TSIG) approach to compare the hazard profiles, identify salient disaster stressors, document the key components of disaster risk reduction response, and examine indicators of community resilience. Results. Two demographically-comparable communities, Fargo and Minot, faced challenging river flood threats and exhibited effective coordination across community sectors. We examined the implementation of disaster risk reduction strategies in situations where coordinated citizen action was able to prevent disaster impact (hazard avoidance) compared to the more common scenario when unpreventable disaster strikes, causing destruction, harm, and distress. Across a range of indicators, it is clear that successful mitigation diminishes both physical and psychological impact, thereby reducing the trauma signature of the event. Conclusion. In contrast to experience of historic flooding in Minot, the city of Fargo succeeded in reducing the trauma signature by way of reducing risk through mitigation.

Risk of Suicide Attempt Among Soldiers in Army Units With a History of Suicide Attempts

Importance Mental health of soldiers is adversely affected by the death and injury of other unit members, but whether risk of suicide attempt is influenced by previous suicide attempts in a soldier’s unit is unknown. Objective To examine whether a soldier’s risk of suicide attempt is influenced by previous suicide attempts in that soldier’s unit. Design, Setting, and Participants Using administrative data from the Army Study to Assess Risk and Resilience in Servicemembers (STARRS), this study identified person-month records for all active-duty, regular US Army, enlisted soldiers who attempted suicide from January 1, 2004, through December 31, 2009 (n = 9650), and an equal-probability sample of control person-months (n = 153 528). Data analysis was performed from August 8, 2016, to April 10, 2017. Main Outcomes and Measures Logistic regression analyses examined the number of past-year suicide attempts in a soldier’s unit as a predictor of subsequent suicide attempt, controlling for sociodemographic features, service-related characteristics, prior mental health diagnosis, and other unit variables, including suicide-, combat-, and unintentional injury–related unit deaths. The study also examined whether the influence of previous unit suicide attempts varied by military occupational specialty (MOS) and unit size. Results Of the final analytic sample of 9512 enlisted soldiers who attempted suicide and 151 526 control person-months, most were male (86.4%), 29 years or younger (68.4%), younger than 21 years when entering the army (62.2%), white (59.8%), high school educated (76.6%), and currently married (54.8%). In adjusted models, soldiers were more likely to attempt suicide if 1 or more suicide attempts occurred in their unit during the past year (odds ratios [ORs], 1.4-2.3; P < .001), with odds increasing as the number of unit attempts increased. The odds of suicide attempt among soldiers in a unit with 5 or more past-year attempts was more than twice that of soldiers in a unit with no previous attempts (OR, 2.3; 95% CI, 2.1-2.6). The association of previous unit suicide attempts with subsequent risk was significant whether soldiers had a combat arms MOS or other MOS (ORs, 1.4-2.3; P < .001) and regardless of unit size, with the highest risk among those in smaller units (1-40 soldiers) (ORs, 2.1-5.9; P < .001). The population-attributable risk proportion for 1 or more unit suicide attempts in the past year indicated that, if this risk could be reduced to no unit attempts, 18.2% of attempts would not occur. Conclusions and Relevance Risk of suicide attempt among soldiers increased as the number of past-year suicide attempts within their unit increased for combat arms and other MOSs and for units of any size but particularly for smaller units. Units with a history of suicide attempts may be important targets for preventive interventions.

Complicated grief and depression in young adults: personality and relationship quality.

Abstract Young adults experience problematic responses to loss more often than is commonly recognized. Few empirical studies have examined the contribution of intrapersonal and interpersonal characteristics to grief and depression in bereaved young adults. This study investigated the association of dependency and quality of the relationship with the deceased (i.e., depth and conflict) with complicated grief (CG) and depression. Participants were 157 young adults aged 17 to 29 years who experienced loss of a family member or close friend within the past 3 years (mean = 1.74 years). Participants completed the Inventory of Complicated Grief, Beck Depression Inventory, Depth and Conflict subscales of the Quality of Relationships Inventory, and the Dependency subscale of the Depressive Experiences Questionnaire. Relationships among dependency and interpersonal depth and conflict and CG and depression were examined through analyses of covariance. Sixteen percent of participants met criteria for CG and 34% had mild to severe depression. Dependency and depth were independently related to CG and dependency was related to depression, but the pattern of associations was somewhat different for each outcome. Greater depth was associated with CG, at both high and low levels of dependency. High levels of dependency were related to more depressive symptoms. Interpretation of the findings is limited by the relatively small sample size and cross-sectional design. CG and depression are related but distinct responses to loss. Although dependency is associated with both CG and depression after loss, relationships between the bereaved and deceased that are characterized by high levels of depth are particularly related to the development of CG symptoms.

Suicidal Behaviors and the Use of Mental Health Services Among Active Duty Army Soldiers

OBJECTIVE U.S. Army personnel experience a significant mental health burden, particularly during times of war and multiple deployments. This study identified rates of suicidality (seriously considering or attempting suicide) and types of mental health services used in the past 12 months by active duty Army soldiers. METHODS This study used the 2008 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel, which sampled 10,400 Army soldiers from a total population of 508,088 soldiers. Mental health service utilization included receiving counseling or therapy from a general medical doctor, receiving counseling or therapy from a mental health professional, and being prescribed medications for depression, anxiety, or sleep. Suicidality was assessed via self-report questions. RESULTS Thirteen percent had seriously considered or attempted suicide at some point in their lives, 7% since joining the military. One percent who reported suicidality since joining the Army reported having considered or attempted suicide in the past year. After the analyses adjusted for sociodemographic factors, soldiers who seriously considered or attempted suicide since joining the military versus those who did not were 1.71 times more likely to have used a mental health service, 2.33 times more likely to have used two or more types of services, 1.82 times more likely to have seen a mental health specialist, and 1.67 times more likely to have received medication in the past year. CONCLUSIONS Understanding the relationship between suicidal thoughts and behaviors and the specific levels and types of mental health services received in this military population is important for health care provision and planning.

Identification with terrorist victims of the Washington, DC sniper attacks: posttraumatic stress and depression

In October 2002, a series of sniper attacks in the Washington, DC area left 10 people dead and 3 wounded. We examined the association between identification with terrorist victims and psychological and behavioral outcomes. Participants were 1,238 residents of the Washington, DC area (ages 18-90 years; M = 41.73, SD = 12.56) who completed the Impact of Event Scale-Revised, Patient Health Questionnaire-9, and items pertaining to identification with attack victims approximately 3 weeks following the first sniper shooting. We examined 3 types of identification with the victims: (a) as like oneself, (b) as like a friend, and (c) as like a family member. The relationships of identification to posttraumatic stress and depressive symptoms were examined using linear regression analyses. Greater total identification was associated with more posttraumatic stress and depressive symptoms (B = 0.27, p < .001, and B = 0.44, p < .001, respectively), after adjusting for demographics. Those who specifically identified with the victims as either self (B = 0.24, p < .001), friend (B = 0.30, p < .001), or family member (B = 0.27, p < .001) reported more PTSD symptoms (n = 1,101). Identifying with victims as like a friend or family member, but not as like oneself, was associated with increased depressive symptoms (B = 0.61, p < .001, and B = 0.45, p = .01, respectively; n = 1,222). Presence and type of identification play a differential role in psychological and behavioral responses during traumatic events.

Distress of Routine Activities and Perceived Safety Associated with Post-Traumatic Stress, Depression, and Alcohol Use: 2002 Washington, DC, Sniper Attacks

OBJECTIVE For over 3 weeks in October 2002, a series of sniper attacks in the Washington, DC, area left 10 people dead and 3 wounded. This study examined the relationship of distress associated with routine activities and perceived safety to psychological and behavioral responses. METHODS Participants were 1238 residents of the Washington, DC, metropolitan area (aged 18 to 90 years, mean=41.7 years) who completed an Internet survey including the Impact of Event Scale-Revised, Patient Health Questionnaire-9, and items pertaining to distress related to routine activities, perceived safety, and alcohol use. Data were collected at one time point approximately 3 weeks after the first sniper shooting and before apprehension of the suspects. Relationships of distress and perceived safety to post-traumatic stress, depressive symptoms, and increased alcohol use were examined by using linear and logistic regression analyses. RESULTS Approximately 8% of the participants met the symptom criteria for probable post-traumatic stress disorder, 22% reported mild to severe depression, and 4% reported increased alcohol use during the attacks. Distress related to routine activities and perceived safety were associated with increased post-traumatic stress and depressive symptoms and alcohol use. CONCLUSION Distress and perceived safety are associated with specific routine activities and both contribute to psychological and behavioral responses during a terrorist attack. These findings have implications for targeted information dissemination and risk communication by community leaders.

Documented family violence and risk of suicide attempt among U.S. Army soldiers

Suicide attempt (SA) rates in the U.S. Army increased substantially during the wars in Afghanistan and Iraq. This study examined associations of family violence (FV) history with SA risk among soldiers. Using administrative data from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), we identified person-month records of active duty, Regular Army, enlisted soldiers with medically documented SAs from 2004 to 2009 (n = 9650) and a sample of control person-months (n = 153,528). Logistic regression analyses examined associations of FV with SA, adjusting for socio-demographics, service-related characteristics, and prior mental health diagnosis. Odds of SA were higher in soldiers with a FV history and increased as the number of FV events increased. Soldiers experiencing past-month FV were almost five times as likely to attempt suicide as those with no FV history. Odds of SA were elevated for both perpetrators and those who were exclusively victims. Male perpetrators had higher odds of SA than male victims, whereas female perpetrators and female victims did not differ in SA risk. A discrete-time hazard function indicated that SA risk was highest in the initial months following the first FV event. FV is an important consideration in understanding risk of SA among soldiers.