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MDD, noncombat trauma associated with suicide ideation among deployed soldiers
Major depressive disorder and noncombat trauma can serve as identifiers of suicide ideation risk among United States Army soldiers during combat deployment, according to results of a survey study published in JAMA Network Open.
“Clinically, it is important to recognize that among deployed soldiers, suicide ideation may be present without meeting full diagnostic criteria and that during deployment, it is associated with increased risk of suicide attempt in the future,” Robert J. Ursano, MD, of the department of psychiatry at Uniformed Services University of the Heath Sciences in Maryland, told Healio Psychiatry. “In addition, the final model that was found significant in predicting those with suicide ideation is another step toward identifying personalized medicine approaches to predicting risk of suicide ideation. Importantly, not only was major depression a predictor in that model but lifetime noncombat trauma was as well.”
According to Ursano and colleagues, research into risk factors associated with suicide ideation among service members is rapidly growing, and these include sociodemographic characteristics, traumatic and life stressors and medical diagnosis. However, it is unclear whether these risk factors are differentially associated with suicide ideation during deployment, when soldiers are exposed to the context of threat and unique stressors that may impact established mechanisms of suicide risk, the researchers wrote. Further, they noted that identification of risk factors during this period is critical because of the elevated risk for suicidal behaviors in mid-deployment.
The researchers used self-administered questionnaires to obtain data from 3,597 soldiers deployed to Afghanistan in July 2012, and they weighted the sample to represent all 87,032 soldiers serving there. They determined prevalence of lifetime, past-year and 30-day suicide ideation and mental disorders and used logistic regression analyses to examine risk factors associated with suicide ideation.
Ursano and colleagues found that lifetime, past-year and 30-day suicide ideation prevalence estimates were 11.7%, 3% and 1.9%, respectively. More than 44% of soldiers with suicide ideation had MDD and 19.3% had PTSD in the past 30-day period. In a series of analyses of the 23 grouped variables potentially associated with suicide ideation, the final model revealed several factors — sex, race/ethnicity, lifetime noncombat trauma, past 12-month relationship problems, legal problems and death or illness of a friend or family member, as well as MDD. This model also revealed that white race/ethnicity (OR = 3.1; 95% CI, 1.8-5.1), lifetime noncombat trauma (OR = 2.1; 95% CI, 1.1-4) and MDD (past 30-days OR = 31.8; 95% CI, 15-67.7) were associated with suicide ideation. From survey administration through 12 months after returning from deployment among the 85 soldiers with past 30-day suicide ideation, 6% had a documented suicide attempt vs. 0.14% of the 3,872 soldiers without suicide ideation.
“We appreciated being able to examine risk in a way that allows us to speak about the population of deployed soldiers as a whole, not as a ‘convenience sample,’ and also to have used excellent measures of mental health diagnosis,” Ursano said. – by Joe Gramigna
Disclosures: Ursano reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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Since Sept. 11, 2001, the Army has conducted an unprecedented amount of research on the mental health of its soldiers. Prior studies have ranged from those involving theater Mental Health Advisory Teams, to epidemiological consultation teams, to population-based analyses of suicide attempts. Many of these are referenced in the present study.
When I was stationed at the Pentagon, we spent a lot of time briefing the “line”, often the most senior three- and four-star generals. Significant improvements have been made based on these studies, mostly focused on removing barriers to and improving the quality of mental health care.
The term “actionable intelligence” is often used by the military when receiving information. In civilian terms, that would be: 1) What are the problems we can do something about; and 2) What are the pros and cons of different courses of action?
The results of this study show that MDD and noncombat trauma are important factors in identifying suicide ideation risk during combat deployment. The results are consistent with the other studies. The question is this: What can we do about the problem, and will it help or hurt?
The military already has extensive screening efforts before accession, and before, during and after deployment to war zones. Whether this is useful is another question. Soldiers report what they want to. If they want to stay in the Army, soldiers may minimize any symptoms of distress. To “make rank” (get promoted), they go where the action is, which is combat.
The military also wants to decrease stigma and encourage help-seeking. Singling out soldiers with depression and histories of non-combat trauma and preventing them from deploying and advancing their careers only increases reluctance to seek mental health care.
For many years, psychiatrists and psychologists have been deployed along with the troops. For example, I went with the 528th combat stress control detachment to Operation Restore Hope in Somalia in 1993. These efforts, known as “embedded mental health,” have increased further in the last 19 years of war. This is a good thing, usually, although it reduces the amount of those mental health providers to soldiers and families back home.
There are some “out of the box” strategies, such as when we sent therapy dogs and battlefield acupuncturists to the war zone. But they only reached a small number of soldiers.
This article is helpful in outlining the extent of the current problem. As is true in so much in both war and psychiatry, there are pros and cons to courses of action, and few perfect solutions.