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Post by Former NIMH Director Thomas Insel: Army Suicide Study Kicks into Gear

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Recently the U.S. Army released an extraordinary report titled, Health Promotion, Risk Reduction, Suicide Prevention.  The report, complete with a call to action from Army Vice Chief of Staff General Peter Chiarelli, should have an impact beyond the Army, even beyond the military, to a nation that has not effectively addressed suicide as a public health crisis.

The background is important.  Nationally, suicide mortality is nearly double the rate of homicide mortality. But rates of suicide in the Army have traditionally been lower than rates for civilians in the same age range.  The rate in the Army began to increase in 2004, doubling by 2008, and reached 160 deaths in 2009, exceeding the comparable civilian rate and ranking as the third largest cause of death.

For the month of June 2010, the Army reported an astonishing 32 suspected suicides—a record high.  Commenting on the high rates of 2009, the report notes, “If we include accidental death which is frequently the result of high risk behavior (drinking and driving, drug overdose, etc.), we find that less young men and women die in combat than die by their own hands.  Simply stated, we are often more dangerous to ourselves than the enemy.”(p. 11)

While we do not yet have 2008 or 2009 suicide numbers for the civilian population, the Centers for Disease Control and Prevention (CDC) reports 34,598 suicides in 2007,i a slight increase over previous years, and a conspicuous difference from the trends in numbers of homicides and motor vehicle deaths, which have dropped markedly in the past decade.  It is possible that civilian suicides have increased during the recent recession – we will not have 2008 and 2009 data from CDC surveillance for another year.  But we cannot wait to ask about the reasons for this dramatic increase in suicide in the Army, nor should we wait to intervene.

For that reason, the Army Study to Assess Risk and Resilience in Service members (Army STARRS) was officially launched in late 2008 when NIMH and the U.S. Army partnered to address the increasing rate of suicide.  Over the early months of this effort, both parties realized the need to focus on resilience as well as risk.  We modeled the Army STARRS approach after the Framingham study of cardiac death to conduct a broad investigation of factors leading to adverse outcomes, including suicide, depression, PTSD, and high risk self-destructive behaviors.  Accordingly, Army STARRS will have many components, from retrospective studies of completed suicides to prospective studies that will identify the most important predictors of risk and resilience.

What do we know right now? We know that one explanation will not suffice.  As General Chiarelli said in Senate testimony, “Every suicide is as different and as unique as the people themselves. And, the reality is there is no one reason a person decides to commit suicide. That decision reflects a complex combination of factors and events ….”  

While nothing is typical about suicide, the report notes the typical suicide victim within the Army would be a “23 year old Caucasian, junior-enlisted male Soldier.  Whereas 86.6 percent of the Army population is male, 96.9 percent of the suicide deaths in 2009 were male. Although 62.7 percent of the Army population is Caucasian, 76.7 percent of the suicide deaths were Caucasian victims.  Interestingly, marriage or one or more deployments appears to decrease risk. However, analysis of prior deployments can be confounded by higher attrition from service following deployment resulting in a self-selection process whereby those who remain in service after deployment tend to be a relatively healthy segment of the population.  We have learned that suicide risk is highest for currently deployed soldiers, and lowest for those who have never deployed. In addition, suicide risk appears to be higher during the first year of service or deployment compared to other times, suggesting that Commanders may need to be extra vigilant about monitoring their soldiers during these times.”(p. 18)

There are many hypotheses: multiple deployments, lowered standards for recruiting, lowered discipline, etc.  In fact, the report raises more questions than answers, leaving much of the work to the Army STARRS project.  Some will, no doubt, ask about the role of stress in today’s Army.  A footnote in the report mentions that “at 24 years of age, a Soldier, on average, has moved from home, family and friends and has resided in two other states; has traveled the world (deployed); been promoted four times; bought a car and wrecked it; married and had children; has had relationship and financial problems; seen death; is responsible for dozens of Soldiers; maintains millions of dollars worth of equipment; and gets paid less than $40,000 a year.”(p. 2) Army STARRS will explore stressors and individual differences in how soldiers respond to them.

In the next few weeks, researchers from the Uniformed Services University of the Health Services, University of Michigan, Harvard University and Columbia University as well as the U.S. Army and NIMH will begin surveying soldiers (including Mobilized Army Reserve and National Guard soldiers) at several installations across the country. The team plans to work with soldiers who are deployed as well. 

Army STARRS is about saving lives. By working with as many soldiers as possible—up to 400,000 over the course of the five-year study—NIMH  and the rest of the research team hope to  identify the risk and protective factors that affect a soldier’s psychological resilience, mental health, and potential for self-harm.  Researchers are committed to reporting their findings to the Army as quickly as possible so that they may inform the Army’s ongoing efforts to protect soldiers’ well-being.  

A new Army STARRS Web site has been created to describe and document the project as it progresses. I encourage everyone to visit the Army STARRS web site frequently to keep abreast of this unprecedented project.  In the meantime, read this report.  General Chiarelli and his team have taken an aggressive stance to reduce stigma and prevent suicide.  In an earlier war, the Army helped the nation to overcome discrimination based on race.  Today, the Army appears to be leading the way for our nation to reduce discrimination based on mental distress. And, we are hopeful that the lessons learned from Army STARRS will help our nation address the tragedy of suicide among civilians as well as soldiers.

iCenters for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). Accessed August 11, 2010.