James A. Naifeh

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

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.

Design of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).

The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multi‐component epidemiological and neurobiological study designed to generate actionable evidence‐based recommendations to reduce US Army suicides and increase basic knowledge about the determinants of suicidality. This report presents an overview of the designs of the six components of the Army STARRS. These include: an integrated analysis of the Historical Administrative Data Study (HADS) designed to provide data on significant administrative predictors of suicides among the more than 1.6 million soldiers on active duty in 2004–2009; retrospective case‐control studies of suicide attempts and fatalities; separate large‐scale cross‐sectional studies of new soldiers (i.e. those just beginning Basic Combat Training [BCT], who completed self‐administered questionnaires [SAQs] and neurocognitive tests and provided blood samples) and soldiers exclusive of those in BCT (who completed SAQs); a pre‐post deployment study of soldiers in three Brigade Combat Teams about to deploy to Afghanistan (who completed SAQs and provided blood samples) followed multiple times after returning from deployment; and a platform for following up Army STARRS participants who have returned to civilian life. Department of Defense/Army administrative data records are linked with SAQ data to examine prospective associations between self‐reports and subsequent suicidality. The presentation closes with a discussion of the methodological advantages of cross‐component coordination. Copyright

Predicting Suicides After Psychiatric Hospitalization in US Army Soldiers

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.

PTSD risk is associated with BDNF Val66Met and BDNF overexpression

Brain-derived neurotrophic factor (BDNF), which regulates neuronal survival, growth, differentiation and synapse formation, broadly regulates the stress response.1 A common single-nucleotide polymorphism in the BDNF gene (Val66Met) influences hippocampal volume,2 memory3 and appears related to susceptibility to a variety of neuropsychiatric disorders, including posttraumatic stress disorder (PTSD).1 Therefore, we hypothesized that BDNF may be an important mediator of the abnormal stress response contributing to PTSD. We analyzed genetic variation in 461 and the plasma levels of BDNF in 68 US. Army Special Operations soldiers deployed during the Iraq and Afghanistan wars. A probable-PTSD diagnosis was made if subjects endorsed Diagnostic and Statistical Manual of Mental Disorders-IV PTSD criteria (at least one re-experiencing, three avoidance and two hyper-arousal symptoms) and had a total PTSD check list (PCL) score of 50 or above (see Supplementary Methods). We found that 42 (9%) participants met criteria for probable-PTSD, while the remaining 419 (91%) subjects did not. In those with probable-PTSD, the frequency of Met/Met was nearly threefold higher than in the controls. The allelic frequency of Met was twofold higher in individuals with probable-PTSD than in controls (Supplementary Information). BDNF levels in plasma of the subjects with PTSD were significantly higher than those in the non-PTSD controls. These results agree with evidence suggesting that BDNF is involved in the development of PTSD.1 Met carriers have a smaller hippocampus volume, relative to controls2 and perform more poorly than controls (Val/Val) on memory tasks.4 Veterans with psychotic PTSD carry more Met alleles than non-psychotic veterans with PTSD or veterans without PTSD,5 even though a case–control genetic association study showed no relationship between BDNF gene Val66Met and PTSD diagnosis.6

Heterogeneity in the latent structure of PTSD symptoms among Canadian veterans.

The current study used factor mixture modeling to identify heterogeneity (i.e., latent classes) in 2 well-supported models of posttraumatic stress disorders (PTSD) factor structure. Data were analyzed from a clinical sample of 405 Canadian veterans evaluated for PTSD. Results were consistent with our hypotheses. Each PTSD factor model was best represented by 2 latent classes of participants, differing with respect to PTSD symptom severity. Furthermore, classes were most strongly distinguished by factor scores related to emotional numbing or dysphoria. For both factor models, class membership was significantly predicted by age and depression diagnosis. Implications of these findings are discussed.

PREVALENCE AND CORRELATES OF SUICIDAL BEHAVIOR AMONG NEW SOLDIERS IN THE U.S. ARMY: RESULTS FROM THE ARMY STUDY TO ASSESS RISK AND RESILIENCE IN SERVICEMEMBERS (ARMY STARRS)

The prevalence of suicide among U.S. Army soldiers has risen dramatically in recent years. Prior studies suggest that most soldiers with suicidal behaviors (i.e., ideation, plans, and attempts) had first onsets prior to enlistment. However, those data are based on retrospective self‐reports of soldiers later in their Army careers. Unbiased examination of this issue requires investigation of suicidality among new soldiers.

Prevalence of DSM-IV Major Depression Among U.S. Military Personnel: Meta-Analysis and Simulation

A meta-analysis of 25 epidemiological studies estimated the prevalence of recent Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) major depression (MD) among U.S. military personnel. Best estimates of recent prevalence (standard error) were 12.0% (1.2) among currently deployed, 13.1% (1.8) among previously deployed, and 5.7% (1.2) among never deployed. Consistent correlates of prevalence were being female, enlisted, young (ages 17-25), unmarried, and having less than a college education. Simulation of data from a national general population survey was used to estimate expected lifetime prevalence of MD among respondents with the sociodemographic profile and none of the enlistment exclusions of Army personnel. In this Simulated sample, 16.2% (3.1) of respondents had lifetime MD and 69.7% (8.5) of first onsets occurred before expected age of enlistment. Numerous methodological problems limit the results of the meta-analysis and simulation. The article closes with a discussion of recommendations for correcting these problems in future surveillance and operational stress studies.

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

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.

Clinical reappraisal of the Composite International Diagnostic Interview Screening Scales (CIDI-SC) in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).

A clinical reappraisal study was carried out in conjunction with the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) All‐Army Study (AAS) to evaluate concordance of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM‐IV) diagnoses based on the Composite International Diagnostic Interview Screening Scales (CIDI‐SC) and post‐traumatic stress disorder (PTSD) checklist (PCL) with diagnoses based on independent clinical reappraisal interviews (Structured Clinical Interview for DSM‐IV [SCID]). Diagnoses included: lifetime mania/hypomania, panic disorder, and intermittent explosive disorder; six‐month adult attention‐deficit/hyperactivity disorder; and 30‐day major depressive episode, generalized anxiety disorder, PTSD, and substance (alcohol or drug) use disorder (abuse or dependence). The sample (n = 460) was weighted for over‐sampling CIDI‐SC/PCL screened positives. Diagnostic thresholds were set to equalize false positives and false negatives. Good individual‐level concordance was found between CIDI‐SC/PCL and SCID diagnoses at these thresholds (area under curve [AUC] = 0.69–0.79). AUC was considerably higher for continuous than dichotomous screening scale scores (AUC = 0.80–0.90), arguing for substantive analyses using not only dichotomous case designations but also continuous measures of predicted probabilities of clinical diagnoses. Copyright

Lifetime Prevalence of DSM-IV Mental Disorders Among New Soldiers in the U.S. Army: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

The prevalence of 30‐day mental disorders with retrospectively reported early onsets is significantly higher in the U.S. Army than among socio‐demographically matched civilians. This difference could reflect high prevalence of preenlistment disorders and/or high persistence of these disorders in the context of the stresses associated with military service. These alternatives can to some extent be distinguished by estimating lifetime disorder prevalence among new Army recruits.