Post by Former NIMH Director Thomas Insel: Clues to Risk and Resilience: Army STARRS
Back in 2008 I got a call from Pete Geren, who was then Secretary of the Army. Soldiers in the U.S. Army were killing themselves at an alarming rate, and Secretary Geren was looking for an explanation. While traditionally the suicide rate for the military was well below that of civilians, by 2008 the suicide rate in the Army exceeded the rate for civilians even after adjusting for Army demographics (younger compared to the civilian population, and predominantly male). Secretary Geren asked for NIMH to help him figure out what was driving his soldiers to kill themselves, at a rate that was about to surpass the rate of combat deaths.
Out of this crisis the Army Study to Assess Risk and Resilience in Servicemembers (or Army STARRS) was born. We started out thinking of this as an opportunity to launch a study modeled on the classic Framingham Heart Study. Over more than six decades, the Framingham study has taught us about risk factors for cardiovascular disease, resulting in interventions to lower blood pressure, weight, and cholesterol, with dramatic reductions in morbidity and mortality. But there was one key difference—we didn’t have 60 years to figure out the risk factors for suicide. In response to this challenge, in July 2009 we launched Army STARRS. NIMH and the Army partnered with four universities (the Uniformed Services University of the Health Sciences; University of California, San Diego; University of Michigan; and Harvard Medical School) to carry out the largest study of suicide risk and resilience ever conducted among military personnel.
Three journal articles this week in JAMA Psychiatry give a sense of the scope of this project.1 Consider what these first three data papers are built upon: A historical database of over 1 billion anonymized records from 1.6 million Soldiers who served on active duty in the U.S. Army from 2004 to 2009. Surveys conducted on over 110,000 Soldiers, in a little over two years, from all walks of Army life, including during their deployment, at over 75 Army installations around the world.
Early on, one of the most valuable contributions of the project was “myth busting.” Indeed, most of our assumptions about what was driving the suicide rate up—multiple deployments, intense combat, changes in recruitment standards—were incomplete or even wrong. For example, it wasn’t just Soldiers who had gone to war in Iraq and Afghanistan who were at increased risk—the suicide rate even for Soldiers who had never deployed was rising. And it wasn’t that the Army had accepted more Soldiers into the Army under a waiver program (accepting enlistees who at other times would have been turned away because of conduct or prior drug use, for example)—there was no significant difference in the suicide rate between the Soldiers in those groups and the rest of the Army.
A sample of findings from these papers:
- There was a disproportionate rise in suicide risk among deployed female Soldiers.
- Risk was higher in Soldiers demoted in the last 2 years, and those without a high school diploma or GED. Risk was inversely related to rank and to length of Army service.
- Married Soldiers had a lower suicide risk during deployment.
- More than one-third of post-enlistment suicide attempts are associated with pre-enlistment mental disorders.
- Of the 25 percent of non-deployed Soldiers who met criteria for a mental disorder in the previous 30 days, almost 80 percent reported that the disorder was present prior to enlistment.
News articles and books have chronicled the intensity of combat, the severity of injuries—including traumatic brain injuries—with which modern soldiers are surviving to return home, and the tremendous challenges they face—with or without serious physical injuries—post-deployment, either in continuing their military career, or readjusting to life as a civilian. Research can’t change the profile of war, but it can help us understand the many other factors that shape how each individual weathers the experience of it.
The central goal of Army STARRS is to provide the Army with actionable data to help them drive the suicide rate down. As has been true many times in the past, what we learn from the military’s experience will also serve the greater public—in this case, by informing broader measures to prevent suicide, even among those who have never seen the inside of a military base, much less combat.
These articles are nothing more than a down payment on what we hope that Army STARRS delivers to the Department of the Army and, more importantly, to the men and women who have volunteered to put themselves in harm’s way in the service of our country. From the very beginning, we all recognized that Army STARRS was not “business as usual.” Army STARRS is intended to serve the men and women who have served and continue to serve and protect our country.
1Schoenbaum M, et al. Predictors of Suicide and Accident Death in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS): Results From the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry. 2014 March 3. doi:10.1001/jamapsychiatry.2013.4417. [Epub ahead of print]
Kessler RC, et al. Thirty-Day Prevalence of DSM-IV Mental Disorders Among Nondeployed Soldiers in the US Army: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry. 2014 March 3. doi:10.1001/jamapsychiatry.2014.28. [Epub ahead of print]
Nock MK, et al. Prevalence and Correlates of Suicidal Behavior Among Soldiers: Results From the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry 2014 March 3. doi:10.1001/jamapsychiatry.2014.30. [Epub ahead of print]