Suicidal Thoughts in Soldiers: 'Who Should I Worry About Most?'

Megan Brooks

September 09, 2021

New research sheds light on soldiers who are at greatest risk for suicide attempts, offering an opportunity for targeted prevention.

Investigators found that the risk for suicide attempt in this population is highest within 30 days after first suicidal thoughts. In addition, they found that those who had previously been diagnosed with anxiety disorder, as well as combat medics, and female soldiers, are at greatest risk of experiencing progression from thoughts to action.

This study addresses the "too often difficult task of the clinician once a patient is diagnosed with suicide ideation ― who should I worry about the most," Robert Ursano, MD, director, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, Maryland, told Medscape Medical News.

"Knowing the who, the when, and the where of suicide risk is one of the best ways we can target interventions," Ursano added in a news release.

The study was published online September 1 in the American Journal of Psychiatry.

Novel Data

The investigators note that to their knowledge, no other studies have examined soldiers with documented suicidal ideation and risk for imminent suicide attempt (within 30 days) to understand the progression from ideation to attempt.

Using administrative data from the Army Study to Assess Risk and Resilience in Servicemembers, they identified 11,178 active-duty soldiers (2006–2009) with medically documented suicidal ideation and no prior medically documented suicide attempts.

Roughly half (53%) of the soldiers were in their first 2 years of service; 58% had never been deployed, and 27% were assigned to combat units. About 80% of the soldiers had had at least one outpatient healthcare visit in the previous 2 months.

The most common psychiatric diagnoses among all soldiers with suicidal ideation were depression and related disorders, tobacco use disorder, anxiety disorder, and adjustment disorder.

Among all 11,178 soldiers with initial documented suicidal ideation, 830 (7.4%) subsequently attempted suicide, and nearly half (46.3%) attempted suicide within 30 days of ideation.

In multivariate analysis, soldiers most likely to attempt suicide within 30 days of ideation were women (odds ratio [OR]: 1.3; 95% CI: 1.0 – 1.8), combat medics (OR: 1.6; 95% CI: 1.1 – 2.2), those who had been diagnosed with an anxiety disorder prior to suicidal ideation (OR: 1.3, 95% CI: 1.0 – 1.6), and those diagnosed with a sleep disorder on the same day as the documented suicidal ideation (OR: 2.3, 95% CI: 1.1 – 4.6).

Targeted Intervention

"The fact that of soldiers with a first diagnosis of suicide ideation who will attempt suicide (about 7%), half will do so within 30 days emphasizes the importance of targeted and intensive work with those at highest risk during this 30-day period," said Ursano.

"The findings also highlighted that sleep disorders present at the time of a diagnosis of suicide ideation is one element that can indicate increased need for intervention and follow-up over the following 30 days," he noted.

Depression-related diagnoses were common among the soldiers with suicide ideation, but they were not associated with an increased risk for suicide attempt during the first month.

Major depression was diagnosed in 24% of soldiers with suicide ideation. For nearly 60% of soldiers, depression-related diagnoses were made on the same day that suicide ideation was diagnosed.

A diagnosis of posttraumatic stress disorder was not associated with an increased risk for imminent suicide attempt.

The researchers note that although most soldiers who attempt suicide have no medical history of formally documented suicidal ideation, there is a "significant minority" whose suicidal thoughts are diagnosed prior to their attempt.

"This group is particularly important to the health care system as they fall within the purview of clinicians who assess suicide risk and deliver evidence-based treatments," they say.

A limitation of the analysis is the focus on the period from 2006 to 2009. The findings may not generalize to other periods.

"Research to replicate these findings using different military cohorts or registries is recommended and should include the Army National Guard and Army Reserve soldiers, as well as veterans," the researchers suggest.

Reached for comment, retired US Army psychiatrist Elspeth Cameron Ritchie, MD, chief of psychiatry at Medstar Washington Hospital Center, Washington, DC, said she is not particularly surprised by the findings in that the study covered "a period in Iraq when we were not doing well. The surge happened in 2006, and that meant longer and extended deployments."

Ritchie also said the findings in this study "reinforce" the fact that anxiety and insomnia are often precursors to suicide attempts. It's "always good to have more data, better data, bigger data, and well-analyzed data. We also know that women are more likely to have suicide attempts," she said.

The finding that suicide risk was highest within 30 days of ideation among combat medics "make some sense," Ritchie said, because combat medics undergo "high-stress training."

The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) was sponsored by the Department of the Army and was funded under cooperative agreement (2009–2015) with the National Institute of Mental Health. Ursano and Ritchie have disclosed no relevant financial relationships.

Am J Psychiatry. Published online September 1, 2021. Full text

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