The risk for suicidal behavior is significantly increased in soldiers who are members of units with a history of suicide attempts, regardless of whether the unit has experienced combat, new research shows.
“Our study indicates that risk of suicide attempt among US Army soldiers is influenced by a history of suicide attempts within a soldier’s unit and that higher numbers of unit suicide attempts are related to greater individual suicide risk, particularly in smaller units,” the authors, led by Robert J. Ursano, MD, Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, Maryland, write.
“Attention to unit characteristics by leadership and service professionals may be a component in suicide attempt reduction efforts,” the authors add.
The study was published online July 26 in JAMA Psychiatry.
Suicide Contagion?
For the study, the researchers evaluated data from the Army Study to Assess Risk and Resilience in Service Members (STARRS) on 9512 US Army enlisted soldiers who had attempted suicide between January 2004 and December 2009. The soldiers’ data were compared with an equal-probability sample of control person-months (n = 153,528).
After adjusting for various confounders, soldiers in units in which one or more suicide attempts had occurred in the past year were significantly more likely to attempt suicide (odds ratio [OR], 1.4 – 2.3; P < .001), with the increased risk corresponding with the higher number of suicide attempts.
“The odds of suicide attempt among soldiers in a unit with five or more past-year attempts was more than twice that of soldiers in a unit with no previous attempts (OR, 2.3; 95% confidence interval [CI], 2.1 – 2.6),” the authors report.
Although the risk was highest in smaller units of one to 40 soldiers (OR, 5.9), larger units also showed increases in suicide attempts when previous attempts had occurred (P < .001).
Suicidality risk was not limited to soldiers in combat military occupational specialties but was increased in other specialties as well (OR, 1.4- 2 .3; P < .001).
A key question the findings raise is whether the suicide attempts themselves influence others to follow suit – an effect known as suicide contagion – or whether the cluster of suicide attempts is more likely the result of shared stresses or traumatic experiences, known as joint exposure, said Dr Ursano.
“Clusters [with joint exposure] can occur because a unit as a whole is experiencing some stress, such as deployment, moving, changes in organization, or leadership, etc,” he told Medscape Medical News.
The finding of an increased risk for suicide attempts, even in larger units, suggests that the effect is not necessarily suicide contagion, he added. Contagion typically involves knowledge of either the person who attempted suicide or the event, which may be more likely in smaller units.
Interestingly, contrary to previous research, the investigators found no link between unit deaths of any type – including suicide – and the subsequent risk for suicide attempts in other soldiers.
However, said Dr Ursano, the low number of deaths could play a role in those findings.
“There was no influence of suicide deaths, but deaths are less common, so it would be much less likely for there to be many in a unit, and also it is more difficult to find effects when the outcome is so rare.”
Nevertheless, the findings underscore the fact that suicide attempts in a unit should raise a red flag and signal a potential need to step up psychiatric assistance in the unit, the authors note.
“Intervention efforts that track unit suicide attempts regardless of whether unit members were acquainted with the attempter may help identify at-risk groups,” they write.
They add that the higher risk for suicidality, particularly in smaller units, underscores the unique dynamics of those units.
“Small military units, with their shared culture, structure, and cohesion, may profoundly affect soldiers’ functioning and well-being,” the authors note.
“Unit characteristics that persist over time, including leadership quality, extent of social support and cohesion, and presence of bullying, may influence unit culture and affect the likelihood of and responses to unit suicide attempts,” they add.
Conversely, they note, supportive cohesion and leadership within a unit has been associated with reduced distress, increased resilience, and positive states of mind.
Actionable Information
An accompanying editorial, with lead author Charles W. Hoge, MD, Colonel, US Army (retired), who is an internationally recognized expert in posttraumatic stress disorder, notes that in 2009, 1 year after the study’s data cutoff point, significant and transformative efforts were initiated in the US military to step up mental health services in the wake of an alarming spike in suicides that occurred between 2005 and 2009, when the United States was heavily involved in fighting in Iraq and Afghanistan.
“This transformation has included population-wide screening, significant increases in mental health personnel, standardization of services, routine clinical outcome measures, and, most importantly, the restructuring of care delivery in a way that directly influences how units attend to soldiers with mental health conditions and respond to suicidal behaviors.”
The STARRS study was among the major measures implemented in response to the increase in suicides. Although earlier research using data from the study produced contradictory conclusions and has been criticized for lacking actionable relevance, the new study is of more potential value, the editorialists note.
“The findings from this [current] study certainly reflect actionable information, raising tantalizing questions about the influence of military social structure and leadership on suicide risk factors as well as the potential for contagion of suicidal behaviors within Army units.”
They add that the study offers new insights to improve the many new measures that have been implemented to address soldiers’ mental health.
“While these changes have occurred since the Army STARRS study period, the study highlights the need for clinicians embedded in these brigades to remain aware of the possibility of clustering and to review processes for ensuring that soldiers known to be at risk receive the support they need.”
Commenting on the findings for Medscape Medical News, Yeates Conwell, MD, professor and vice chair of psychiatry at the University of Rochester Medical Center, New York, agreed that the study is an important contribution to understanding the fallout from suicidal behaviors.
“This is an important issue for its implications for suicide prevention in the military. The identification with one’s unit, if that is a factor here, should then also be a key to developing prevention messaging and interventions that leverage that same identification to save lives,” he said.
He added that the findings also have important implications in other “bounded” populations beyond the military.
“We know that this phenomenon of clustering, whether due to contagion or shared exposure, is real and impacts some groups more than others,” said Dr Conwell.
“The reasons why it happens remain unknown. This paper gives some extra specificity to the problem that can then lead to more informed study about mechanisms and potential approaches to interventions.”
Elspeth Ritchie, MD, MPH, a retired military psychiatrist based in Washington, DC, who has written extensively on suicide in the military, said the findings likely are not a surprise to anyone involved in the mental health of military personnal, but they underscore the importance of effective interventions.
“The data support the need for aggressive suicide prevention efforts, whether it’s more screening or having the mental health leadership and providers in the units with the soldiers,” Dr Ritchie told Medscape Medical News.
Having embedded mental health professionals, in particular, has been shown to be beneficial, she noted.
“People don’t like to be sent to the ‘shrink’ – there is a lot of stigma about that, especially in the military,” said Dr Ritchie.
“What I have found is, if you’re out with the troops, eating in the mess hall with them and going to the range with them, then you can build a better relationship of trust, and that becomes very important at times when they may be in distress. So this paper supports that idea of embedded mental health leadership.”
The US Army STARRS was sponsored by the US Department of the Army and was funded through the US Department of Health and Human Services, the National Institutes of Health, and the National Institute of Mental Health. The STARRS-Longitudinal Study was sponsored and funded by the Uniformed Services University of the Health Sciences from the US Department of Defense. Dr Ursano has disclosed no relevant financial relationships. Relevant financial relationships of coauthors are listed in the original article. Dr Conwell and Dr Richie have disclosed no relevant financial relationships.
JAMA Psychiatry. Published July 26, 2017. Full text, Editorial
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