“Risk Factors Associated with Suicide in Current and Former US Military Personnel” by Cynthia Leardmann

I was drawn to this article after I posted a paper I wrote several years ago about troop combat survivability. With the advances in weaponry and battlefield medicine, soldiers are able to survive much more brutal injuries. The past years, we have seen improvised explosive devices destroy the limbs of soldiers and many others affected by Post-Traumatic Stress Disorder. While they are able to survive their injuries, they are left with an enormous amount of psychological trauma. Instead of dying of gangrene caused by infection as was the fate of many during the Civil War period, many injured warriors cannot cope with the mental toll their injuries have caused. There have been efforts to develop more resilient warriors mentally but not even the soldier with the strongest growth mindset has an easy road to recovery when their life is changed so dramatically. Unfortunately, many of these brave men turn to suicide as a solution. Here is the abstract to follow:

Importance  Beginning in 2005, the incidence of suicide deaths in the US military began to sharply increase. Unique stressors, such as combat deployments, have been assumed to underlie the increasing incidence. Previous military suicide studies, however, have relied on case series and cross-sectional investigations and have not linked data during service with postservice periods.

Objective  To prospectively identify and quantify risk factors associated with suicide in current and former US military personnel including demographic, military, mental health, behavioral, and deployment characteristics.

Design, Setting, and Participants  Prospective longitudinal study with accrual and assessment of participants in 2001, 2004, and 2007. Questionnaire data were linked with the National Death Index and the Department of Defense Medical Mortality Registry through December 31, 2008. Participants were current and former US military personnel from all service branches, including active and Reserve/National Guard, who were included in the Millennium Cohort Study (N = 151 560).

Main Outcomes and Measures  Death by suicide captured by the National Death Index and the Department of Defense Medical Mortality Registry.

Results  Through the end of 2008, findings were 83 suicides in 707 493 person-years of follow-up (11.73/100 000 person-years [95% CI, 9.21-14.26]). In Cox models adjusted for age and sex, factors significantly associated with increased risk of suicide included male sex, depression, manic-depressive disorder, heavy or binge drinking, and alcohol-related problems. None of the deployment-related factors (combat experience, cumulative days deployed, or number of deployments) were associated with increased suicide risk in any of the models. In multivariable Cox models, individuals with increased risk for suicide were men (hazard ratio [HR], 2.14; 95% CI, 1.17-3.92; P = .01; attributable risk [AR], 3.5 cases/10 000 persons), and those with depression (HR, 1.96; 95% CI, 1.05-3.64; P = .03; AR, 6.9/10 000 persons), manic-depressive disorder (HR, 4.35; 95% CI, 1.56-12.09; P = .005; AR, 35.6/10 000 persons), or alcohol-related problems (HR, 2.56; 95% CI, 1.56-4.18; P <.001; AR, 7.7/10 000 persons). A nested, matched case-control analysis using 20:1 control participants per case confirmed these findings.

Conclusions and Relevance  In this sample of current and former military personnel observed July 1, 2001-December 31, 2008, suicide risk was independently associated with male sex and mental disorders but not with military-specific variables. These findings may inform approaches to mitigating suicide risk in this population.

Despite universal access to health care services, mandatory suicide prevention training, and other preventive efforts, suicide has become one of the leading causes of death in the US military in recent years.1- 3 Suicide rates across the population of active-duty US military personnel began to increase sharply in 2005 from a baseline rate of 10.3 to 11.3 per 100 000 persons to a rate of 16.3 per 100 000 persons in 2008, with the highest rates among Marine Corps and Army personnel (19.9 and 19.3 per 100 000 persons).4 Since 2009, suicide rates among those on active-duty status have stabilized at approximately 18 per 100 000.

Despite this increase, suicide remains a rare outcome that is challenging to study. Studies among military populations have not been able to adequately examine the association between deployment characteristics and suicide following military discharge.2,5,6 Military separations due to medical or administrative reasons (eg, mental disorders, substance misuse, misconduct) are likely to bias incidence figures and risk-factor estimates in studies that fail to link records between active service and postmilitary periods.6 Separation of service members with mental disorders, for example, could lead to underestimates of incidence or risks associated with these conditions in studies based only on active-duty members, and possibly overestimates in studies that only involve veterans.6,7 Previous studies have not linked US Department of Defense data with national death records, thus limiting the ability to conduct comprehensive studies across inservice and postservice time periods.

Understanding the circumstances and factors leading to suicide in military members and identifying appropriate interventions is of high priority to military and civilian leaders. This study prospectively examined and quantified factors associated with suicide risk in a large population of active, Reserve, and National Guard members across all branches of the military during and following service.

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