Suicidal ideation among US soldiers begins before enlistment

The following article was published March 2014 by NIMH. What are your thoughts?

Early interventions might hold the key to reducing the high Army suicide rate Nearly 60% of soldier suicide attempts can be traced to pre-enlistment mental disorders, which are much more common among nondeployed U.S. Army soldiers than demographically similar populations of civilians (25.1% vs. 11.6%), according to a major new study. The vast majority (76.6%) of soldiers with mental disorders say their conditions started before enlistment, researchers found. These are among the initial results published online today in JAMA Psychiatry based on a survey carried out as part of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), the largest study of mental health risk and resilience ever conducted among U.S. Army personnel. Althoughthe suicide death rate in the U.S. Army has historically been below the civilian rate, the Army rate began climbing at the beginning of the Iraq and Afghanistan conflicts, and by 2008, it exceeded the demographically matched civilian rate (20.2 suicide deaths per 100,000 vs. 19.2). Concerns about this increase led to Army STARRS, a partnership between the Army and the NIMH designed to help understand and address this issue. The initial findings published today include three papers that use different strategies to evaluate suicide risk and protective factors among service people, including an analysis comparing the prevalence of mental disorders among Army and civilian populations. "Some of the differences in disorder rates are truly remarkable," said Ronald Kessler, McNeil Family Professor of Health Care Policy at Harvard Medical School and senior author of the paper on mental disorder prevalence. "The rate of major depression is 5 times as high among soldiers as civilians, intermittent explosive disorder 6 times as high, and PTSD nearly 15 times as high." The most common disorders in the Army STARRS survey were attention deficit hyperactivity disorder (ADHD) and intermittent explosive disorder (IED), or recurrent and uncontrollable anger attacks, Kessler said. The findings suggest that soldiers did not have higher rates of most "internalizing disorders" (anxiety disorders and depression) than civilians before enlistment, but rather developed high rates of these disorders only after they enlisted in the Army. The situation was different, though, for "behavioral disorders" (ADHD, IED and substance abuse), which were much more common among young people who subsequently enlisted in the Army than those who did not. Rates for these disorders increased even more after enlistment. Nearly half of current soldier internalizing disorders and 80% of behavioral disorders started before enlistment "These results are a wake-up call highlighting the importance of outreach and intervention for new soldiers who enter the Army with pre-existing mental disorders," said Robert Ursano, Chair of the Department of Psychiatry at the Uniformed Services University of the Health Sciences and co-principal investigator of Army STARRS. A second Army STARRS paper appearing today in JAMA Psychiatry revealed that 13.9% of soldiers considered suicide at some point in their lifetime, 5.3% had made a suicide plan, and 2.4% had attempted suicide, with between 47% to 60% of these outcomes first occurring prior to enlistment. Pre-existing mental disorders were found to be by far the strongest predictors of these suicidal behaviors. "It is striking that nearly 50% of the soldiers who attempted suicide made their first attempt before joining the Army, as applicants are asked about any history of suicide attempts in recruitment interviews and those who report such a history typically are excluded from service," said Matthew Nock, professor of psychology at Harvard University and lead author of this report on soldier suicidality. Nock noted that the most practical implication of this finding might be that the Army should develop outreach and intervention programs for new soldiers based on the realization that a nontrivial proportion of new soldiers come into the Army with a history of mental disorder and suicidality, and that applicants are not always forthcoming about these concerns during the recruitment process. The researchers added that intermittent explosive disorder is of special importance because it was the only disorder found to predict suicide attempts after developing suicidal thoughts, which has important implications for screening and prevention. This important finding shows that it is not only depression and PTSD that predict suicide attempts. A third JAMA Psychiatry article by lead author Michael Schoenbaum of NIMH examined the suicide and accident death rates in relation to basic sociodemographic and Army experience factors in the 975,057 regular Army soldiers who served between Jan. 1, 2004, and Dec. 31, 2009, charting variations in the rates based on a variety of factors including sex, race, education level and rank. ### Written by Jake Miller The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is funded by the U.S. Army and the National Institute of Mental Health. The study is led by co-principal investigators Robert J. Ursano (Uniformed Services University of the HealthSciences) and Murray B. Stein (University of California, San Diego), with site investigators Steven G. Heeringa (University of Michigan) and Ronald C. Kessler (Harvard Medical School), and with collaborating scientists Lisa J. Colpe (NIMH), and Michael Schoenbaum (NIMH). More information at: http://www.armystarrs.org/media_room ADDITIONAL CONTACT INFORMATION Army STARRS Co-Principal Investigator Robert J. Ursano, MD, Uniformed Services University of the Health Sciences: Contact: Sharon Willis, 301-295-3578, sharon.willis@usuhs.edu Army STARRS Co-Principal Investigator Murray B. Stein. MD, MPH, University of California, San Diego: Contact: Debra Kain, 619-543-6202, DDKain@ucsd.edu Lead author and Army STARRS Site Principal Investigator Ronald C. Kessler, PhD, Harvard Medical School: Contact: David Cameron, (617) 432-0441, david_cameron@hms.harvard.edu Lead author and Army STARRS Site Co-Principal Investigator Matthew Nock, PhD, Harvard University: Contact: Peter Reuell, (617) 495-1585, preuell@harvard.edu For commentary on the significance of the Army STARRS reports: Lieutenant General (Retired) Eric Schoomaker, MD, former Surgeon General of the United States Army and Commanding General, United States Army Medical Command Contact: Sharon Holland (301) 295-3578, sharon.holland@usuhs.edu REFERENCES Thirty-day prevalence of DSM-IV mental disorders among non-deployed soldiers in the U.S. Army: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Kessler RC, Heeringa SG, Stein MB, Colpe LJ, Fullerton CS, Hwang I, Naifeh JA, Nock MK, Petukhova M, Sampson NA, Schoenbaum M, Zaslavsky AM, Ursano RJ. JAMA Psychiatry. Prevalence and correlates of suicidal behavior among soldiers: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Nock MK, Stein MB, Heeringa SG, Ursano RJ, Colpe LJ, Fullerton CS, Hwang I, Naifeh JA, Sampson NA, Schoenbaum M, Zaslavsky AM, Kessler RC. JAMA Psychiatry. Predictors of suicide and accident death in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Schoenbaum M, Kessler RC, Gilman SE, Colpe LJ, Heeringa SG, Stein MB, Ursano RJ, Cox KL. JAMA Psychiatry. For more information on combat PTSD and other mental health information, please visit Continuing Education for Counselors

Bullying Exerts Psychiatric Effects into Adulthood

Once considered a childhood rite of passage, bullying lingers well into adulthood. Bullies and victims alike are at risk for psychiatric problems such as anxiety, depression, substance abuse, and suicide when they become adults, reported a study partially funded by the National Institute of Mental Health (NIMH) that was published in the April issue of JAMA Psychiatry. Background Bullying is a repetitive, aggressive act done to abuse or intimidate others. It can take on various forms—primarily verbal, emotional, and physical, although cyberbullying is also on the rise. Typically these scenes occur inside school or on the playground, but they can also happen at home or at work. A power imbalance usually is involved in which one child or a group of children torments another child who is considered “weaker.” Methods employed by bullies include threats, rumor-spreading, and exclusion. Most of what experts know about the effects of bullying comes from short-term observational studies. These studies reflect general society’s view that most people overcome these events by the time they become adults. “Initially I too was skeptical about these long-term effects,” says study author William Copeland, Ph.D., at Duke University, who as an epidemiologist knew of other traumatic events that do not linger psychologically, such as maltreatment and physical abuse. “Yet this is something that stays with people. A large number of people express lasting effects decades after their childhood experiences.” Copeland and his colleagues tapped into a local population sample of 1,420 children from 11 Western North Carolina counties. Starting at the ages of 9, 11, and 13, the kids, along with their parents, were interviewed annually until the age of 16, fielding questions about peer relations and home and community settings. The participating children were again interviewed at 19, 21, and 24 to 26 years of age. Four groups emerged from this longitudinal study: people who were never involved in bullying, people who were victims, people who were bullies, and people who were both. Results of the Study More than half of the study’s youth reported being neither a bully nor a victim. Around a quarter of the study group claimed that they were victimized. About 7 percent confessed to being a bully. A similar percentage said that they were both, a group the researchers labeled as “bully-victims.” Compared to those who went through childhood unscathed, victims had four times the prevalence of agoraphobia, generalized anxiety, and panic disorder when they became adults. Overall, bullies had four times the risk of developing antisocial personality disorder. These disorders still stood even after other factors were taken into account, such as preexisting psychiatric problems or family hardships. Bully-victims fared the worst. Also known as “loners,” these individuals start out with less developed social skills and are seen as more impulsive and aggressive. When picked on, they respond by picking on others. Their numbers, compared to those never involved in bullying, tell the story: 14 times the risk of panic disorder, 5 times the risk of depressive disorders, and 10 times the risk of suicidal thoughts and behavior. “Victims report the greatest anxiety problems. They might become successful people later on, but they still think about the event and hold onto it. Bullies are socially adept and may find ways in adulthood to use these skills in a pro-social manner. Folks really underestimate who are the bully-victims. These are the ones who end up having the most significant emotional problems including suicidality,” explained Copeland, who is also a father of two Social Worker Continuing Education Significance All these disorders impart a great emotional and financial cost to society. Lowering and/or preventing bullying could possibly reduce human suffering and long-term health costs—not to mention creating a safer environment for children to grow up in. Research into resilience or why some are able to bounce back in adulthood is ongoing. Some key molecules and brain circuit pathways have been identified in animals. Other research areas under exploration include physiology, genetics, epigenetics, and cognitive therapies. What’s Next Studies looking into which interventions work best for bullying are underway. Once these interventions are identified, research is needed to see at what stages in life they should they be administered. Lastly, other factors that play a role in bullying and victimization, such as sexual orientation, need exploration. “This study suggests that we should pay attention to what’s going on between peers,” said Copeland, adding that kids spend more time each day with their peers, including school and online, than with their parents. “What happens to kids when they’re with their peers is as important, or may be more important, than what happens at home,” said Copeland. Reference Copeland WE, Wolke D, Angold A, Costello EJ. Adult Psychiatric Outcomes of Bullying and Being Bullied by Peers in Childhood and Adolescence. JAMA Psychiatry, published April 2013. Grant number: K23 MH080230