Hostname: page-component-76fb5796d-zzh7m Total loading time: 0 Render date: 2024-04-28T17:08:20.379Z Has data issue: false hasContentIssue false
  • English
  • Français

Associations of vulnerability to stressful life events with suicide attempts after active duty among high-risk soldiers: results from the Study to Assess Risk and Resilience in Servicemembers-longitudinal study (STARRS-LS)

Published online by Cambridge University Press:  27 May 2022

Carol Chu ,
Ian H. Stanley ,
Brian P. Marx ,
Andrew J. King ,
Dawne Vogt ,
Sarah M. Gildea ,
Irving H. Hwang ,
Nancy A. Sampson ,
Robert O'Brien  and
Murray B. Stein
...Show all authors
Carol Chu
Affiliation:
Minneapolis VA Health Care System, Minneapolis, MN, USA Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN, USA
Ian H. Stanley
Affiliation:
National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
Brian P. Marx
Affiliation:
National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
Andrew J. King
Affiliation:
Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
Dawne Vogt
Affiliation:
National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
Sarah M. Gildea
Affiliation:
Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
Irving H. Hwang
Affiliation:
Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
Nancy A. Sampson
Affiliation:
Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
Robert O'Brien
Affiliation:
VA Health Services Research and Development Service, Washington, DC, USA
Murray B. Stein
Affiliation:
Department of Psychiatry, University of California San Diego, La Jolla, CA, USA School of Public Health, University of California San Diego, La Jolla, CA, USA VA San Diego Healthcare System, La Jolla, CA, USA
Robert J. Ursano
Affiliation:
Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
Ronald C. Kessler*
Affiliation:
Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
*
Author for correspondence: Ronald C. Kessler, E-mail: kessler@hcp.med.harvard.edu
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

The transition from military service to civilian life is a high-risk period for suicide attempts (SAs). Although stressful life events (SLEs) faced by transitioning soldiers are thought to be implicated, systematic prospective evidence is lacking.

Methods

Participants in the Army Study to Assess Risk and Resilience in Servicemembers (STARRS) completed baseline self-report surveys while on active duty in 2011–2014. Two self-report follow-up Longitudinal Surveys (LS1: 2016–2018; LS2: 2018–2019) were subsequently administered to probability subsamples of these baseline respondents. As detailed in a previous report, a SA risk index based on survey, administrative, and geospatial data collected before separation/deactivation identified 15% of the LS respondents who had separated/deactivated as being high-risk for self-reported post-separation/deactivation SAs. The current report presents an investigation of the extent to which self-reported SLEs occurring in the 12 months before each LS survey might have mediated/modified the association between this SA risk index and post-separation/deactivation SAs.

Results

The 15% of respondents identified as high-risk had a significantly elevated prevalence of some post-separation/deactivation SLEs. In addition, the associations of some SLEs with SAs were significantly stronger among predicted high-risk than lower-risk respondents. Demographic rate decomposition showed that 59.5% (s.e. = 10.2) of the overall association between the predicted high-risk index and subsequent SAs was linked to these SLEs.

Conclusions

It might be possible to prevent a substantial proportion of post-separation/deactivation SAs by providing high-risk soldiers with targeted preventive interventions for exposure/vulnerability to commonly occurring SLEs.

Keywords

Predictive analyticsSTARRSsuicide attemptstransitional servicesveterans
Type
Original Article
Information
Psychological Medicine , Volume 53 , Issue 9 , July 2023 , pp. 4181 - 4191
Check for updates
Copyright
Copyright © The Author(s), 2022. 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.)

References

116th Congress. (2020). Commander John Scott Hannon Veterans Mental Health Care Improvement Act of 2019. Retrieved from https://www.congress.gov/bill/116th-congress/senate-bill/785.Google Scholar
Adams, R. S., Meerwijk, E. L., Larson, M. J., & Harris, A. H. S. (2021). Predictors of veterans health administration utilization and pain persistence among soldiers treated for postdeployment chronic pain in the military health system. BMC Health Services Research, 21(1), 494. doi:10.1186/s12913-021-06536-8CrossRefGoogle ScholarPubMed
Ash, S. (2018). Jackknife and other replication methods with a reduced number of replicates. Retrieved from http://www.asasrms.org/Proceedings/y2018/files/867226.pdf.Google Scholar
Brugha, T., Bebbington, P., Tennant, C., & Hurry, J. (1985). The list of threatening experiences: A subset of 12 life event categories with considerable long-term contextual threat. Psychological Medicine, 15(1), 189–194. doi:10.1017/s003329170002105xCrossRefGoogle ScholarPubMed
Bryan, C. J., & Bryan, A. O. (2019). Financial strain, suicidal thoughts, and suicidal behavior among US military personnel in the national guard. Crisis, 40(6), 437–445. doi:10.1027/0227-5910/a000592CrossRefGoogle ScholarPubMed
Bryan, C. J., McNaugton-Cassill, M., Osman, A., & Hernandez, A. M. (2013). The associations of physical and sexual assault with suicide risk in nonclinical military and undergraduate samples. Suicide and Life-Threatening Behavior, 43(2), 223–234. doi:10.1111/sltb.12011CrossRefGoogle ScholarPubMed
Bullman, T., Hoffmire, C., Schneiderman, A., & Bossarte, R. (2015). Time dependent gender differences in suicide risk among operation enduring freedom and operation Iraqi freedom veterans. Annals of Epidemiology, 25(12), 964–965. doi:10.1016/j.annepidem.2015.09.008CrossRefGoogle ScholarPubMed
Chevan, A., & Sutherland, M. (2009). Revisiting Das Gupta: Refinement and extension of standardization and decomposition. Demography, 46(3), 429–449. doi:10.1353/dem.0.0060CrossRefGoogle Scholar
Classen, T. J., & Dunn, R. A. (2012). The effect of job loss and unemployment duration on suicide risk in the United States: A new look using mass-layoffs and unemployment duration. Health Economics, 21(3), 338–350. doi:10.1002/hec.1719CrossRefGoogle ScholarPubMed
Department of Defense Office of Inspector General. (2021). Evaluation of the Department of Defense's Implementation of Suicide Prevention Resources for Transitioning Uniformed Service Members (DODIG-2022-030). Retrieved from https://www.dodig.mil/reports.html/Article/2841764/evaluation-of-the-department-of-defenses-implementation-of-suicide-prevention-r/.Google Scholar
Dowd, B. E., Greene, W. H., & Norton, E. C. (2014). Computation of standard errors. Health Services Research, 49(2), 731–750. doi:10.1111/1475-6773.12122CrossRefGoogle ScholarPubMed
Ewing, L., Hamza, C. A., & Willoughby, T. (2019). Stressful experiences, emotion dysregulation, and nonsuicidal self-injury among university students. Journal of Youth and Adolescence, 48(7), 1379–1389. doi:10.1007/s10964-019-01025-yCrossRefGoogle ScholarPubMed
Faurer, J., Rogers-Brodersen, A., & Bailie, P. (2014). Managing the re-employment of military veterans through the transition assistance program (TAP). Journal of Business & Economic Research, 12(1), 55–60. doi:10.19030/jber.v12i1.8378Google Scholar
Franklin, J. C., Ribeiro, J. D., Fox, K. R., Bentley, K. H., Kleiman, E. M., Huang, X., … Nock, M. K. (2017). Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychological Bulletin, 143(2), 187–232. doi:10.1037/bul0000084CrossRefGoogle ScholarPubMed
Geraci, J. (2020). Bridging the deadly gap with the ETS sponsorship program. Retrieved from https://www.queri.research.va.gov/centers/ExpirationTermService.pdf.Google Scholar
Geraci, J. C., Mobbs, M., Edwards, E. R., Doerries, B., Armstrong, N., Porcarelli, R., … Goodman, M. (2020). Expanded roles and recommendations for stakeholders to successfully reintegrate modern warriors and mitigate suicide risk. Frontiers in Psychology, 11, 1907. doi:10.3389/fpsyg.2020.01907CrossRefGoogle ScholarPubMed
Ghahramanlou-Holloway, M., Brown, G. K., Currier, G. W., Brenner, L., Knox, K. L., Grammer, G., … Stanley, B. (2014). Safety planning for military (SAFE MIL): Rationale, design, and safety considerations of a randomized controlled trial to reduce suicide risk among psychiatric inpatients. Contemporary Clinical Trials, 39(1), 113–123. doi:10.1016/j.cct.2014.07.003CrossRefGoogle ScholarPubMed
Gradus, J. L., Shipherd, J. C., Suvak, M. K., Giasson, H. L., & Miller, M. (2013). Suicide attempts and suicide among marines: A decade of follow-up. Suicide and Life-Threatening Behavior, 43(1), 39–49. doi:10.1111/j.1943-278X.2012.00126.xCrossRefGoogle Scholar
Heeringa, S. G., Gebler, N., Colpe, L. J., Fullerton, C. S., Hwang, I., Kessler, R. C., … Ursano, R. J. (2013). Field procedures in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). International Journal of Methods in Psychiatric Research, 22(4), 276–287. doi:10.1002/mpr.1400CrossRefGoogle ScholarPubMed
Holliday, R., Borges, L. M., Stearns-Yoder, K. A., Hoffberg, A. S., Brenner, L. A., & Monteith, L. L. (2020). Posttraumatic stress disorder, suicidal ideation, and suicidal self-directed violence among U.S. military personnel and veterans: A systematic review of the literature from 2010 to 2018. Frontiers in Psychology, 11, 1998. doi:10.3389/fpsyg.2020.01998CrossRefGoogle ScholarPubMed
Hooley, J. M., Franklin, J. C., & Nock, M. K. (2014). Chronic pain and suicide: Understanding the association. Current Pain and Headache Reports, 18(8), 435. doi:10.1007/s11916-014-0435-2CrossRefGoogle ScholarPubMed
Howarth, E. J., O'Connor, D. B., Panagioti, M., Hodkinson, A., Wilding, S., & Johnson, J. (2020). Are stressful life events prospectively associated with increased suicidal ideation and behaviour? A systematic review and meta-analysis. Journal of Affective Disorders, 266, 731–742. doi:10.1016/j.jad.2020.01.171CrossRefGoogle ScholarPubMed
Hyman, J., Ireland, R., Frost, L., & Cottrell, L. (2012). Suicide incidence and risk factors in an active duty US military population. American Journal of Public Health, 102(S1), S138–S146. doi:10.2105/ajph.2011.300484CrossRefGoogle Scholar
Kamarck, K. N. (2018). Military Transition Assistance Program (TAP): An overview. Retrieved from https://sgp.fas.org/crs/natsec/IF10347.pdf1.Google Scholar
Kang, H. K., Bullman, T. A., Smolenski, D. J., Skopp, N. A., Gahm, G. A., & Reger, M. A. (2015). Suicide risk among 1.3 million veterans who were on active duty during the Iraq and Afghanistan wars. Annals of Epidemiology, 25(2), 96–100. doi:10.1016/j.annepidem.2014.11.020CrossRefGoogle ScholarPubMed
Kessler, R. C., Colpe, L. J., Fullerton, C. S., Gebler, N., Naifeh, J. A., Nock, M. K., … Heeringa, S. G. (2013a). Design of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). International Journal of Methods in Psychiatric Research, 22(4), 267–275. doi:10.1002/mpr.1401CrossRefGoogle ScholarPubMed
Kessler, R. C., Heeringa, S. G., Colpe, L. J., Fullerton, C. S., Gebler, N., Hwang, I., … Ursano, R. J. (2013b). 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
Kline, A., Ciccone, D. S., Falca-Dodson, M., Black, C. M., & Losonczy, M. (2011). Suicidal ideation among national guard troops deployed to Iraq: The association with postdeployment readjustment problems. The Journal of Nervous and Mental Disease, 199(12), 914–920. doi:10.1097/NMD.0b013e3182392917CrossRefGoogle ScholarPubMed
Klonsky, E. D., May, A. M., & Saffer, B. Y. (2016). Suicide, suicide attempts, and suicidal ideation. Annual Review of Clinical Psychology, 12, 307–330. doi:10.1146/annurev-clinpsy-021815-093204CrossRefGoogle ScholarPubMed
Larson, G. E., & Norman, S. B. (2014). Prospective prediction of functional difficulties among recently separated Veterans. Retrieved from https://apps.dtic.mil/sti/pdfs/ADA618146.pdf.Google Scholar
LeDell, E., van der Laan, M. J., & Petersen, M. (2016). AUC-maximizing ensembles through metalearning. The International Journal of Biostatistics, 12(1), 203–218. doi:10.1515/ijb-2015-0035CrossRefGoogle ScholarPubMed
Long, J. S., & Mustillo, S. A. (2018). Using predictions and marginal effects to compare groups in regression models for binary outcomes. Sociological Methods & Research, 50(3), 1284–1320. doi:10.1177/0049124118799374CrossRefGoogle Scholar
Mansfield, A. J., Bender, R. H., Hourani, L. L., & Larson, G. E. (2011). Suicidal or self-harming ideation in military personnel transitioning to civilian life. Suicide and Life-Threatening Behavior, 41(4), 392–405. doi:10.1111/j.1943-278X.2011.00039.xCrossRefGoogle ScholarPubMed
McFeeters, D., Boyda, D., & O'Neill, S. (2015). Patterns of stressful life events: Distinguishing suicide ideators from suicide attempters. Journal of Affective Disorders, 175, 192–198. doi:10.1016/j.jad.2014.12.034CrossRefGoogle ScholarPubMed
Miller, M. A., & Kearney, L. K. (2020). Implementation of the public health approach in suicide prevention: Our roles now and over time to save lives. Retrieved from https://www.apadivisions.org/division-18/sections/veterans/suicide-prevention-presentation-slides.pdf.Google Scholar
Millner, A. J., Lee, M. D., & Nock, M. K. (2015). Single-item measurement of suicidal behaviors: Validity and consequences of misclassification. PLoS ONE, 10(10), e0141606. doi:10.1371/journal.pone.0141606CrossRefGoogle ScholarPubMed
Mobbs, M. C., & Bonanno, G. A. (2018). Beyond war and PTSD: The crucial role of transition stress in the lives of military veterans. Clinical Psychology Review, 59, 137–144. doi:10.1016/j.cpr.2017.11.007CrossRefGoogle ScholarPubMed
Monteith, L. L., Smith, N. B., Holliday, R., Dorsey Holliman, B. A., LoFaro, C. T., & Mohatt, N. V. (2020). “We're afraid to say suicide”: Stigma as a barrier to implementing a community-based suicide prevention program for rural veterans. The Journal of Nervous and Mental Disease, 208(5), 371–376. doi:10.1097/nmd.0000000000001139CrossRefGoogle ScholarPubMed
Morin, R. (2011). The difficult transition from military to civilian life. Retrieved from https://www.pewresearch.org/social-trends/2011/12/08/the-difficult-transition-from-military-to-civilian-life/.Google Scholar
Murdoch, M., Sayer, N. A., Spoont, M. R., Rosenheck, R., Noorbaloochi, S., Griffin, J. M., … Hagel, E. M. (2011). Long-term outcomes of disability benefits in US veterans with posttraumatic stress disorder. Archives of General Psychiatry, 68(10), 1072–1080. doi:10.1001/archgenpsychiatry.2011.105CrossRefGoogle ScholarPubMed
Nock, M. K., Deming, C. A., Fullerton, C. S., Gilman, S. E., Goldenberg, M., Kessler, R. C., … Ursano, R. J. (2013). Suicide among soldiers: A review of psychosocial risk and protective factors. Psychiatry: Interpersonal and Biological Processes, 76(2), 97–125. doi:10.1521/psyc.2013.76.2.97CrossRefGoogle ScholarPubMed
Næss, E. O., Mehlum, L., & Qin, P. (2021). Marital status and suicide risk: Temporal effect of marital breakdown and contextual difference by socioeconomic status. SSM – Population Health, 15, 100853–100853. doi:10.1016/j.ssmph.2021.100853CrossRefGoogle ScholarPubMed
Pease, J. L., Billera, M., & Gerard, G. (2016). Military culture and the transition to civilian life: Suicide risk and other considerations. Social work, 61(1), 83–86. doi:10.1093/sw/swv050CrossRefGoogle ScholarPubMed
Polley, E. C., Rose, S., & van der Laan, M. J. (2011). Super learning. In Rose, S. & van der Laan, M. J. (Eds.), Targeted learning: Causal inference for observational and experimental data (pp. 43–66). New York: Springer.CrossRefGoogle Scholar
Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A., … Mann, J. J. (2011). The Columbia-suicide severity rating scale: Initial validity and internal consistency findings from three multisite studies with adolescents and adults. The American Journal of Psychiatry, 168(12), 1266–1277. doi:10.1176/appi.ajp.2011.10111704CrossRefGoogle ScholarPubMed
Ravindran, C., Morley, S. W., Stephens, B. M., Stanley, I. H., & Reger, M. A. (2020). Association of suicide risk with transition to civilian life among US military service members. JAMA Network Open, 3(9), e2016261. doi:10.1001/jamanetworkopen.2020.16261CrossRefGoogle ScholarPubMed
Reger, M. A., Smolenski, D. J., Skopp, N. A., Metzger-Abamukang, M. J., Kang, H. K., Bullman, T. A., … Gahm, G. A. (2015). Risk of suicide among US military service members following operation enduring freedom or operation Iraqi freedom deployment and separation from the US military. JAMA Psychiatry, 72(6), 561–569. doi:10.1001/jamapsychiatry.2014.3195CrossRefGoogle ScholarPubMed
Schmied, E. A., Larson, G. E., Highfill-McRoy, R. M., & Thomsen, C. J. (2016). Reciprocal relationships between stressors and mental health problems in military veterans. Journal of Social & Clinical Psychology, 35(9), 705–721. doi:10.1521/jscp.2016.35.9.705CrossRefGoogle Scholar
Shen, Y. C., Cunha, J. M., & Williams, T. V. (2016). Time-varying associations of suicide with deployments, mental health conditions, and stressful life events among current and former US military personnel: A retrospective multivariate analysis. The Lancet Psychiatry, 3(11), 1039–1048. doi:10.1016/s2215-0366(16)30304-2CrossRefGoogle ScholarPubMed
Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256–264. doi:10.1016/j.cbpra.2011.01.001CrossRefGoogle Scholar
Stanley, I. H., Chu, C., Gildea, S. M., Hwang, I. H., King, A. J., Kennedy, C. J., … Kessler, R. C. (2022). Predicting suicide attempts among U.S. Army soldiers after leaving active duty using information available before leaving active duty: Results from the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS). Molecular Psychiatry, 27(3), 1631–1639. doi:10.1038/s41380-021-01423-4CrossRefGoogle Scholar
STATACorp LLC. (2022). Marginal means, adjusted predictions, and marginal effects. Retrieved from https://www.stata.com/features/overview/marginal-analysis/.Google 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: Interpersonal and Biological Processes, 77(2), 107–119. doi:10.1521/psyc.2014.77.2.107CrossRefGoogle ScholarPubMed
U.S. Department of Defense. (2020). Annual suicide report (Appendix H). Retrieved from https://www.dspo.mil/Portals/113/Documents/CY20%20Suicide%20Report/CY%202020%20Annual%20Suicide%20Report.pdf?ver=0OwlvDd-PJuA-igow5fBFA%3D%3D.Google Scholar
U.S. Department of Veteran Affairs. (2018). The military to civilian transition 2018: A review of historical, current, and future trends. Retrieved from https://benefits.va.gov/TRANSITION/docs/mct-report-2018.pdf.Google Scholar
U.S. Department of Veterans Affairs. (2020). VA Solid Start. Retrieved from https://www.benefits.va.gov/transition/solid-start.asp.Google Scholar
Vogt, D. (2021). Measurement-Based Transition Assistance (MBTA): Evaluating the Promise of a Web-Based Approach to Promoting Veterans’ Support Seeking, VA Health Services Research and Development Service (SDR 21-075). Retrieved from https://www.hsrd.research.va.gov/research/pre-funded.cfm.Google Scholar
Whitworth, J., Smet, B., & Anderson, B. (2020). Reconceptualizing the U.S. military's transition assistance program: The success in transition model. Journal of Veterans Studies, 6(1), 25–35. doi:10.21061/jvs.v6i1.144CrossRefGoogle Scholar
Supplementary material: File

Chu et al. supplementary material

Chu et al. supplementary material

Download Chu et al. supplementary material(File)
File 99.8 KB