Novel 'Wingman' Program Cuts Suicide Risk in Air Force Members

Pauline Anderson

October 26, 2020

A novel program that strengthens bonds, boosts morale, and encourages supportive networks among US Air Force personnel cuts suicidal ideation and depressive symptoms after 1 month, new research shows.

The so-called Wingman-Connect initiative also had a beneficial impact on work performance, and the benefits were apparent at 6-month follow-up.

Dr Peter Wyman

"This study suggests that group training can teach skills that help with occupational functioning and reduce the likelihood of experiencing elevated depression and suicidal ideation, at least in the short term," lead author Peter A. Wyman, PhD, professor, Department of Psychiatry, University of Rochester School of Medicine, Rochester, New York, told Medscape Medical News.

The study was published online October 21 in JAMA Network Open.

Significant Rise in Suicide Rates

Suicide rates among active duty military populations have increased "significantly" in the past 15 years and have exceeded rates for the general population when comparing groups of the same age and gender, said Wyman.

The study included new personnel who were taking classes at a single training center between October 2017 and October 2019.

Participants were randomly assigned to the Wingman-Connect program or to a stress management program.

The Wingman-Connect intervention involved three 2-hour blocks of group classes that focused on building skills in areas such as healthy relationships and maintaining balance. Group exercises emphasized cohesion, shared purpose, and the value of a healthy unit.

Participants in the stress management group received an overview of the stress response system, information on the effect of stress on health, and cognitive and behavioral strategies to reduce stress.

Primary outcomes included the scores on the suicide scale and the depression inventory of the Computerized Adaptive Test for Mental Health.

The study included 1485 participants (82.3% men; mean age, 20.9 years). At the 1-month follow-up, participants in Wingman-Connect classes reported less severe suicidal ideation (effect size [ES], −0.23; 95% CI, −39 to −0.09; P = .001) and depressive symptoms (ES, −0.24; 95% CI, −0.41 to −0.08; P = .002).

Unlike most suicide prevention programs, the Wingman intervention didn't target only high-risk participants. "You'd expect smaller effect sizes" because many people were already doing well, said Wyman.

He noted that the effects at 1 month were similar to other state-of-the-art prevention programs.

Another primary endpoint was self-reported occupational impairment. A poor outcome here, said Wyman, could mean having to repeat a class or falling short of expectations behaviorally or academically.

Investigators found a 50% reduction ― from approximately 10% to 5% ― among the participants in the Wingman-Connect group who had occupational problems or performance concerns, said Wyman.

About 84% of participants in both study arms participated in the 6-month follow-up. At this time point, Wingman-Connect participants reported significantly lower depressive symptoms (ES, −0.16; 95% CI, −0.34 to −0.02; P = .03), but suicidal ideation severity scores were not significantly lower (ES, −0.13; 95% CI, −0.29 to 0.01; P = .06).

Universally Beneficial

A beneficial effect on occupational problems was not evident after 6 months. This suggests that this type of training should be continued in later stages of military careers, said Wyman.

"This is not a one-time inoculation that will likely prevent all future problems," he said.

Study participants experienced improvements in protective factors such as cohesion, morale, and bonds to classmates. The program was also associated with reduced anxiety and anger.

Overall, the Wingman-Connect group was about 20% less likely than the stress management group to report elevated depression at either follow-up period. In addition, on average, participants in the active intervention group were 19% less likely to have elevated suicidal ideation scores, although the difference was not significant.

The "logical interpretation" of this lack of statistical significance is that because depression was more common than suicidal ideation, "the intervention could have a slightly larger and more lasting effect on depression," said Wyman.

There was no indication that men or women or those who started out at higher risk experienced greater benefit.

"Overall, the effects seemed to be distributed across airmen, independent of how they started," said Wyman.

Wyman emphasized the unique nature of the Wingman-Connect program. "It's universal prevention for all airmen ― for those thriving and those struggling," he said.

"We don't know who necessarily will become at risk later on, or 6 months later, so it's important to provide this kind of training for everyone."

The "key mechanism" by which the program may prevent mental health problems is use of "units of military people working together day to day," said Wyman.

The study did not reveal whether the intervention reduced suicidal behavior. This, say the authors, will need to be determined in future studies, as will determining which personnel are most likely to benefit.

A "Particular Challenge"

In an accompanying editorial, Roy H. Perlis, MD, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, and Stephan D. Fihn, MD, Department of Medicine, University of Washington, Seattle, noted that suicide represents a "particular challenge" in the military.

This is "because soldiers are placed in extremely stressful situations, often without adequate physical or emotional support."

The new study "adds to a literature that group-based interventions are effective in reducing depressive symptoms and may have advantages in resource-constrained environments," they write.

Perlis and Finn note that it remains to be seen whether targeted strategies to reduce suicide "are worthwhile, rather than simply developing better treatments for depression."

Commenting on the study for Medscape Medical News, Elspeth Cameron Ritchie, MD, former military psychiatrist and chair of the Department of Psychiatry, Medstar Washington Hospital Center, Washington, DC, said the study "is based on quite a sound premise."

Ritchie referred to the "long history" of research "repeatedly showing that units with good cohesion and morale have fewer difficulties of all kinds."

However, the current study didn't investigate the "converse of that," said Ritchie. "There's a high likelihood for suicidal ideation among those who are expelled" from the unit for various reasons.

Ritchie noted that a variety of different prevention initiatives have been launched in all military services over the years.

"Often, they have worked for a little while when there's a champion behind them and there's a lot of enthusiasm, and then they kind of fade out," she said.

Ritchie agreed that such initiatives should continue throughout a person's military career. She noted that suicide risk is elevated during periods of transition, for example, "leaving training base and going to your first duty station," as well as when approaching retirement.

She appreciated the universal nature of the approach used in the study.

"Often, suicides are in those who have not been identified as high risk," she said. However, she questioned whether the study's follow-up period was long enough.

The study was supported by the Office of the Assistant Secretary of Defense for Health Affairs. Wyman, Perlis, and Cameron have disclosed no relevant financial relationships.

JAMA Netw Open. Published online October 21, 2020. Full text, Editorial

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