Hostname: page-component-5d84bcc8dc-c74nz Total loading time: 0 Render date: 2026-08-17T15:18:03.044Z Has data issue: false hasContentIssue false
  • English
  • Français

Prospective association of attachment style with suicide attempts among US Army soldiers

Published online by Cambridge University Press:  31 August 2023

James A. Naifeh Open the ORCID record for James A. Naifeh [Opens in a new window] ,
Robert J. Ursano Open the ORCID record for Robert J. Ursano [Opens in a new window] ,
Murray B. Stein ,
Jing Wang ,
Holly B. Herberman Mash Open the ORCID record for Holly B. Herberman Mash [Opens in a new window] ,
Pablo A. Aliaga ,
Carol S. Fullerton ,
Hieu M. Dinh ,
Tzu-Cheg Kao  and
Nancy A. Sampson
...Show all authors
James A. Naifeh
Affiliation:
Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD, USA Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
Robert J. Ursano*
Affiliation:
Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
Murray B. Stein
Affiliation:
Department of Psychiatry and School of Public Health, University of California San Diego, La Jolla, CA, USA VA San Diego Healthcare System, San Diego, CA, USA
Jing Wang
Affiliation:
Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD, USA Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
Holly B. Herberman Mash
Affiliation:
Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD, USA Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
Pablo A. Aliaga
Affiliation:
Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD, USA Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
Carol S. Fullerton
Affiliation:
Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
Hieu M. Dinh
Affiliation:
Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD, USA Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
Tzu-Cheg Kao
Affiliation:
Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
Nancy A. Sampson
Affiliation:
Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
Ronald C. Kessler
Affiliation:
Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
*
Corresponding author: Robert J. Ursano; Email: robert.ursano@usuhs.edu
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

Insecure attachment styles are associated with retrospectively reported suicide attempts (SAs). It is not known if attachment styles are prospectively associated with medically documented SAs.

Methods

A representative sample of US Army soldiers entering service (n = 21 772) was surveyed and followed via administrative records for their first 48 months of service. Attachment style (secure, preoccupied, fearful, dismissing) was assessed at baseline. Administrative medical records identified SAs. Discrete-time survival analysis examined associations of attachment style with future SA during service, adjusting for time in service, socio-demographics, service-related variables, and mental health diagnosis (MH-Dx). We examined whether associations of attachment style with SA differed based on sex and MH-Dx.

Results

In total, 253 respondents attempted suicide. Endorsed attachment styles included secure (46.8%), preoccupied (9.1%), fearful (15.7%), and dismissing (19.2%). Examined separately, insecure attachment styles were associated with increased odds of SA: preoccupied [OR 2.5 (95% CI 1.7–3.4)], fearful [OR 1.6 (95% CI 1.1–2.3)], dismissing [OR 1.8 (95% CI 1.3–2.6)]. Examining attachment styles simultaneously along with other covariates, preoccupied [OR 1.9 (95% CI 1.4–2.7)] and dismissing [OR 1.7 (95% CI 1.2–2.4)] remained significant. The dismissing attachment and MH-Dx interaction was significant. In stratified analyses, dismissing attachment was associated with SA only among soldiers without MH-Dx. Other interactions were non-significant. Soldiers endorsing any insecure attachment style had elevated SA risk across the first 48 months in service, particularly during the first 12 months.

Conclusions

Insecure attachment styles, particularly preoccupied and dismissing, are associated with increased future SA risk among soldiers. Elevated risk is most substantial during first year of service but persists through the first 48 months. Dismissing attachment may indicate risk specifically among soldiers not identified by the mental healthcare system.

Keywords

attachment stylemilitarysuicidesuicide attempt

Information

Type
Original Article
Information
Psychological Medicine , Volume 54 , Issue 4 , March 2024 , pp. 785 - 793
Check for updates
Copyright
Copyright © The Author(s), 2023. Published by Cambridge University Press

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Article purchase

Temporarily unavailable

References

Adam, K. S., Sheldon-Keller, A. E., & West, M. (1996). Attachment organization and history of suicidal behavior in clinical adolescents. Journal of Consulting and Clinical Psychology, 64(2), 264–272. doi: 10.1037//0022-006x.64.2.264CrossRefGoogle ScholarPubMed
Anderson, L., Campbell-Sills, L., Ursano, R. J., Kessler, R. C., Sun, X., Heeringa, S. G., … Stein, M. B. (2019). Prospective associations of perceived unit cohesion with postdeployment mental health outcomes. Depression and Anxiety, 36(6), 511–521. doi: 10.1002/da.22884CrossRefGoogle ScholarPubMed
Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among young adults: A test of a four-category model. Journal of Personality and Social Psychology, 61(2), 226–244. doi: 10.1037//0022-3514.61.2.226CrossRefGoogle ScholarPubMed
Bartholomew, K., & Shaver, P. R. (1998). Methods of assessing adult attachment: Do they converge? In Simpson, J. A. & Rholes, W. S. (Eds.), Attachment theory and close relationships (pp. 25–45). New York: Guilford Press.Google Scholar
Black, S. A., Gallaway, M. S., Bell, M. R., & Ritchie, E. C. (2011). Prevalence and risk factors associated with suicides of army soldiers 2001–2009. Military Psychology, 23(4), 433–451. doi: 10.1037/h0094766Google Scholar
Bowlby, J. (1969). Attachment and loss (Vol. 1). New York: Basic Books.Google Scholar
Brennan, K. A., Clark, C. L., & Shaver, P. R. (1998). Self-report measurement of adult attachment: An integrative overview. In Simpson, J. A. & Rholes, W. S. (Eds.), Attachment theory and close relationships (pp. 46–76). New York: The Guilford Press.Google Scholar
Centers for Disease Control and Prevention. (2013). The International Classification of Diseases, ninth revision, Clinical Modification (ICD-9-CM). Retrieved from https://www.cdc.gov/nchs/icd/icd9cm.htmGoogle Scholar
Centers for Disease Control and Prevention. (2019). The International Classification of Diseases, tenth revision, Clinical Modification (ICD-10-CM). Retrieved from https://www.cdc.gov/nchs/icd/icd10cm_browsertool.htmGoogle Scholar
Centers for Disease Control and Prevention. (2022). WISQARS™ – Web-based Injury Statistics Query and Reporting System. Retrieved from https://www.cdc.gov/injury/wisqars/index.htmlGoogle Scholar
Chu, C., Buchman-Schmitt, J. M., Stanley, I. H., Hom, M. A., Tucker, R. P., Hagan, C. R., … Joiner, T. E. (2017). The interpersonal theory of suicide: A systematic review and meta-analysis of a decade of cross-national research. Psychological Bulletin, 143(12), 1313–1345. doi: 10.1037/bul0000123CrossRefGoogle ScholarPubMed
Gahm, G. A., Reger, M. A., Kinn, J. T., Luxton, D. D., Skopp, N. A., & Bush, N. E. (2012). Addressing the surveillance goal in the national strategy for suicide prevention: The department of defense suicide event report. American Journal of Public Health, 102(Suppl 1), S24–S28. doi: 10.2105/AJPH.2011.300574CrossRefGoogle ScholarPubMed
Gibson, N., Corrigan, E., Kateley, K., Youmans Watkins, E., & Pecko, J. A. (2017). Surveillance of suicidal behavior: January through December 2016. Retrieved from Aberdeen Proving Ground, MD: https://phc.amedd.army.mil/news/Pages/PublicationDetails.aspx?type=Surveillance+of+Suicidal+Behavior+PublicationGoogle Scholar
Hazan, C., & Shaver, P. (1987). Romantic love conceptualized as an attachment process. Journal of Personality and Social Psychology, 52(3), 511–524. doi: 10.1037/0022-3514.52.3.511CrossRefGoogle ScholarPubMed
Hedegaard, H., Schoenbaum, M., Claassen, C., Crosby, A., Holland, K., & Proescholdbell, S. (2018). Issues in developing a surveillance case definition for nonfatal suicide attempt and intentional self-harm using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD–10–CM) coded data. National Health Statistics Reports, 108, 1–19. Retrieved from https://pubmed.ncbi.nlm.nih.gov/29616901/Google Scholar
Joiner, T. E. (2005). Why people die by suicide. Cambridge, MA: Harvard University Press.Google Scholar
Kessler, R. C., Heeringa, S. G., Colpe, L. J., Fullerton, C. S., Gebler, N., Hwang, I., … Ursano, R. J. (2013). Response bias, weighting adjustments, and design effects in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). International Journal of Methods in Psychiatric Research, 22(4), 288–302. doi: 10.1002/mpr.1399CrossRefGoogle ScholarPubMed
Lafontaine, M.-F., Brassard, A., Lussier, Y., Valois, P., Shaver, P. R., & Johnson, S. M. (2015). Selecting the best items for a short-form of the Experiences in Close Relationships questionnaire. European Journal of Psychological Assessment, 32(2), 140–154. doi: 10.1027/1015-5759/a000243CrossRefGoogle Scholar
Lessard, J. C., & Moretti, M. M. (1998). Suicidal ideation in an adolescent clinical sample: Attachment patterns and clinical implications. Journal of Adolescence, 21, 383–395. doi: 10.1006/jado.1998.0169CrossRefGoogle Scholar
Miniati, M., Callari, A., & Pini, S. (2017). Adult attachment style and suicidality. Psychiatria Danubina, 29(3), 250–259. doi: 10.24869/psyd.2017.250CrossRefGoogle ScholarPubMed
Naifeh, J. A., Ursano, R. J., Stein, M. B., Herberman Mash, H. B., Aliaga, P. A., Fullerton, C. S., … Kessler, R. C. (2022). Association of premilitary mental health with suicide attempts during U.S. Army service. JAMA Network Open, 5(6), e2214771. doi: 10.1001/jamanetworkopen.2022.14771CrossRefGoogle ScholarPubMed
Nock, M. K., Kessler, R. C., & Franklin, J. C. (2016). Risk factors for suicide ideation differ from those for the transition to suicide attempt: The importance of creativity, rigor, and urgency in suicide research. Clinical Psychology: Science and Practice, 23(1), 31–34. doi: 10.1111/cpsp.12133Google Scholar
Palitsky, D., Mota, N., Afifi, T. O., Downs, A. C., & Sareen, J. (2013). The association between adult attachment style, mental disorders, and suicidality: Findings from a population-based study. Journal of Nervous and Mental Disease, 201(7), 579–586. doi: 10.1097/NMD.0b013e31829829abCrossRefGoogle ScholarPubMed
Pruitt, L. D., Smolenski, D. J., Tucker, J., Issa, F., Chodacki, J., McGraw, K., & Kennedy, C. H. (2018). DoDSER: Department of Defense Suicide Event Report: Calendar Year 2017 Annual Report. Retrieved from Falls Church, VA: http://www.dspo.mil/Prevention/Data-Surveillance/DoDSER-Annual-Reports/Google Scholar
Rosellini, A. J., Heeringa, S. G., Stein, M. B., Ursano, R. J., Chiu, W. T., Colpe, L. J., … Kessler, R. C. (2015). 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). Depression and Anxiety, 32(1), 13–24. doi: 10.1002/da.22316CrossRefGoogle ScholarPubMed
Rugo, K. F., Leifker, F. R., Drake-Brooks, M. M., Snell, M. B., Bryan, C. J., & Bryan, A. O. (2020). Unit cohesion and social support as protective factors against suicide risk and depression among National Guard service members. Journal of Social and Clinical Psychology, 39(3), 214–228. doi: 10.1521/jscp.2020.39.3.214CrossRefGoogle Scholar
SAS Institute Inc. (2013). SAS® 9.4 software. Cary, NC: SAS Institute Inc.Google Scholar
Scharfe, E., & Bartholomew, K. (1994). Reliability and stability of adult attachment patterns. Personal Relationships, 1, 23–43. doi: 10.1111/j.1475-6811.1994.tb00053.xCrossRefGoogle Scholar
Singer, J. D., & Willett, J. B. (2003). Applied longitudinal data analysis: Modeling change and event occurrence. New York, NY: Oxford University Press.CrossRefGoogle Scholar
Smith, J. D., Schaughency, K. C. L., Christopher, P., Watkins, E. Y., & Anke, K. M. (2021). Time to suicide and suicide attempt among army enlisted soldiers’ first year of service. Military Behavioral Health, 9(2), 198–205. doi: 10.1080/21635781.2020.1860169CrossRefGoogle Scholar
Stepp, S. D., Morse, J. Q., Yaggi, K. E., Reynolds, S. K., Reed, L. I., & Pilkonis, P. A. (2008). The role of attachment styles and interpersonal problems in suicide-related behaviors. Suicide and Life-Threatening Behavior, 38(5), 592–607. doi: 10.1521/suli.2008.38.5.592CrossRefGoogle ScholarPubMed
Tucker, J., Smolenski, D. J., & Kennedy, C. H. (2019). DoDSER: Department of Defense Suicide Event Report: Calendar Year 2018 Annual Report. Retrieved from https://www.pdhealth.mil/research-analytics/department-defense-suicide-event-report-dodserGoogle Scholar
Ursano, R. J., Colpe, L. J., Heeringa, S. G., Kessler, R. C., Schoenbaum, M., & Stein, M. B. (2014). The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Psychiatry, 72(2), 107–119. doi: 10.1521/psyc.2014.77.2.107CrossRefGoogle Scholar
Ursano, R. J., Heeringa, S. G., Stein, M. B., Jain, S., Raman, R., Sun, X., … Kessler, R. C. (2015a). Prevalence and correlates of suicidal behavior among new soldiers in the US Army: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Depression and Anxiety, 32(1), 3–12. doi: 10.1002/da.22317CrossRefGoogle ScholarPubMed
Ursano, R. J., Kessler, R. C., Heeringa, S. G., Cox, K. L., Naifeh, J. A., Fullerton, C. S., … Stein, M. B. (2015b). 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). Psychiatry, 78(1), 1–21. doi: 10.1080/00332747.2015.1006512CrossRefGoogle ScholarPubMed
Ursano, R. J., Kessler, R. C., Naifeh, J. A., Herberman Mash, H. B., Nock, M. K., Aliaga, P. A., … Stein, M. B. (2018). Risk factors associated with attempted suicide among U.S. Army soldiers without a history of mental health diagnosis. JAMA Psychiatry, 75(10), 1022–1032. doi: 10.1001/jamapsychiatry.2018.2069CrossRefGoogle ScholarPubMed
Ursano, R. J., Kessler, R. C., Stein, M. B., Naifeh, J. A., Aliaga, P. A., Fullerton, C. S., … Heeringa, S. G. (2015c). Suicide attempts in the U.S. Army during the wars in Afghanistan and Iraq, 2004–2009. JAMA Psychiatry, 72(9), 917–926. doi: 10.1001/jamapsychiatry.2015.0987CrossRefGoogle Scholar
Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S. R., Selby, E. A., & Joiner, T. E. (2010). The interpersonal theory of suicide. Psychological Review, 117(2), 575–600. doi: 10.1037/a0018697CrossRefGoogle ScholarPubMed
Wang, J., Naifeh, J. A., Herberman Mash, H. B., Morganstein, J. C., Fullerton, C. S., Cozza, S. J., … Ursano, R. J. (2022). Attachment style and risk of suicide attempt among new soldiers in the U.S. Army. Psychiatry, 85, 387–398. doi: 10.1080/00332747.2022.2062661CrossRefGoogle ScholarPubMed
Willett, J. B., & Singer, J. D. (1993). Investigating onset, cessation, relapse, and recovery: Why you should, and how you can, use discrete-time survival analysis to examine event occurrence. Journal of Consulting and Clinical Psychology, 61(6), 952–965. doi: 10.1037//0022-006x.61.6.952CrossRefGoogle ScholarPubMed
Wolter, K. M. (1985). Introduction to variance estimation. New York, NY: Springer-Verlag.Google Scholar
Wright, J., Briggs, S., & Behringer, J. (2005). Attachment and the body in suicidal adolescents: A pilot study. Clinical Child Psychology and Psychiatry, 10(4), 477–491. doi: 10.1177/1359104505056310CrossRefGoogle Scholar
Wyman, P. A., Pickering, T. A., Pisani, A. R., Cero, I., Yates, B., Schmeelk-Cone, K., … Pflanz, S. E. (2022). Wingman-Connect Program increases social integration for Air Force personnel at elevated suicide risk: Social network analysis of a cluster RCT. Social Science and Medicine, 296, 114737. doi: 10.1016/j.socscimed.2022.114737CrossRefGoogle ScholarPubMed
Wyman, P. A., Pisani, A. R., Brown, C. H., Yates, B., Morgan-DeVelder, L., Schmeelk-Cone, K., … Pflanz, S. E. (2020). Effect of the Wingman-Connect upstream suicide prevention program for Air Force personnel in training: A cluster randomized clinical trial. JAMA Network Open, 3(10), e2022532. doi: 10.1001/jamanetworkopen.2020.22532CrossRefGoogle ScholarPubMed
Supplementary material: File

Naifeh et al. supplementary material

Naifeh et al. supplementary material
Download Naifeh et al. supplementary material(File)
File 28.5 KB