THE ARMY STUDY TO ASSESS RISK AND RESILIENCE IN SERVICEMEMBERS(Army STARRS)
andTHE STUDY TO ASSESS RISK AND RESILIENCE IN SERVICEMEMBERS – LONGITUDINAL STUDY(STARRS-LS)
2009 – 2025
Robert J. Ursano, M.D. (Uniformed Services University) Co-Principal Investigator
Murray B. Stein, M.D., M.P.H. (University of California, San Diego) Co-Principal Investigator
Ronald C. Kessler, Ph.D. (Harvard Medical School) Site Principal Investigator
James Wagner, Ph.D. (University of Michigan) Site Principal Investigator

This document is an ongoing continuous summary of Army STARRS and STARRS-LS publications

INTRODUCTION:
Army STARRS (2009-2015) was the largest and most comprehensive research project of mental
health ever conducted in the U.S. Army. The project was designed to examine a broad range ofrisk and resilience (protective) factors across a complex set of outcomes. The Army STARRS
research team created a series of extensive databases with the potential to achieve
groundbreaking results. These databases allow scientists to investigate a diverse combinationof factors including demographic, psychological, biological, neurological, behavioral, and social
domains to help identify risk and resilience factors for Soldier suicidal behaviors and associatedmental health issues. The project was designed using an adaptive approach which means it
evolved as new information became available over the course of the project. With the goal ofgenerating actionable findings, the research team shared preliminary findings with the Army as
they become available so that the Army could apply them to its ongoing health promotion, risk
reduction, and suicide prevention efforts.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

1

The Army STARRS research project included the following component studies:1) the Historical Administrative Data Study (HADS) of Army and Department of Defense(DoD) administrative data systems (including records of suicidal behaviors) for all
Soldiers on active duty from 2004 to 2009 aimed at finding administrative record
predictors of suicides and suicide-related behaviors;
2) two retrospective case-control studies of nonfatal (Soldier Health Outcomes Study A)
and fatal (Soldier Health Outcomes Study B) suicidal behaviors;
3) a study of new Soldiers (New Soldier Study) assessed just before beginning basic combat
training (BCT) with self-administered questionnaires (SAQ), neurocognitive tests, andblood samples;4) a cross-sectional study of Soldiers (All Army Study) representative of all other active
duty Soldiers (exclusive of BCT);
5) a longitudinal study (Pre-Post Deployment Study) of Soldiers in Brigade Combat Teams
assessed (including blood samples) shortly before deployment to Afghanistan, and reassessed approximately one, three and nine months after returning from deployment.
Soldier Sample Size of Army STARRS Component Studies:
Historical Administrative Data Study (HADS)>1.6 million
Soldier Health Outcomes Study A (SHOS-A)
186 cases and 375 controls
Soldier Health Outcomes Study B (SHOS-B)
150 cases and 270 controls
New Soldier Study (NSS)
55,814All Army Study (AAS)
41,210Pre-Post Deployment Study (PPDS)
10,116
In addition, Army/DoD administrative data were linked prospectively to the large-scale survey
data to examine predictors of subsequent suicidality and related mental health outcomes.
STARRS-LS (2015-2020 and 2020-2025) involves the continuation, extension and expansion of
the Army STARRS research to discover additional findings for the Army and the DoD. Under
STARRS-LS, the Historical Administrative Data Study (HADS) cohort is being expanded andextended through 2019 to include approximately three million Soldiers who were on active
duty from 2004 to 2019. STARRS-LS also includes following a cohort of approximately 72
thousand Army STARRS participants from the All Army Study (AAS), New Soldier Study (NSS)and Pre-Post Deployment Study (PPDS) by continuing to link their survey data to Army/DoD
administrative data and National Death Index (NDI) data through 2019. STARRS-LS also involves
following a cohort of approximately 15 thousand Soldiers subsampled from the 72 thousand
Soldier cohort. These 15 thousand Soldiers are being followed through a multi-wave
longitudinal study involving additional data collection by administering a series of four surveys(one approximately every two years) and by linking the survey data to Army/DoD
administrative data and National Death Index (NDI) data through 2019.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

2

SUMMARY OF FINDINGS:
The following is a brief summary of published findings to-date from Army STARRS and STARRSLS. Findings followed by an asterisk (*) were included in USU press releases.
1. The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)(Ursano, et al 2014)•

Component study cooperation rates are comparatively high.

•Sample biases are relatively small.

•

Inefficiencies introduced into parameter estimates by using nonresponse adjustment
weights and time-space clustering are small.

•

Initial findings show that the suicide death rate, which rose over 2004–2009, increased
for those deployed, those never deployed, and those previously deployed.

•

Analyses of administrative records show that those deployed or previously deployed
were at greater suicide risk.

•

Receiving a waiver to enter the Army was not associated with increased risk.

•

Being demoted in the past two years was associated with increased risk.

•

Time in current deployment, length of time since return from most recent
deployment, total number of deployments, and time interval between most recent
deployments (known as dwell time) were not associated with suicide risk.

•

Initial analyses of survey data show that 13.9% of currently active non-deployed
regular Army Soldiers considered suicide at some point in their lifetime, while 5.3%
had made a suicide plan, and 2.4% had attempted suicide.*•47–60% of these outcomes first occurred prior to enlistment.*•

Prior mental disorders (in particular major depression and intermittent explosive
disorder) were the strongest predictors of these self-reported suicidal behaviors.

•

Most onsets of plans-attempts among ideators (58.3–63.3%) occurred within the yearof onset of ideation.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

3•

About 25.1% of non-deployed U.S. Army personnel met 30-day criteria for a DSM-IV
anxiety, mood, disruptive behavior, or substance disorder (15.0% an internalizing
disorder; 18.4% an externalizing disorder) and 11.1% for multiple disorders.*•

Three-fourths of these disorders had pre-enlistment onsets.*•

Integration across component studies creates strengths going well beyond those inconventional applications of the same individual study designs.

•

These design features create a strong methodological foundation from which Army
STARRS can pursue its substantive research goals.

•

The early findings reported here illustrate the importance of the study and its
approach as a model of studying rare events particularly of national security concern.

•

Continuing analyses of the data will inform suicide prevention for the U.S. Army.

2. Sociodemographic and Career History Predictors of Suicide Mortality in the UnitedStates Army 2004–2009 (Gilman, et al 2014)•

Several novel results were found that could have intervention implications.

•

Significantly elevated suicide rates among enlisted Soldiers deployed either during
their first year of service or with less than expected (based on time in service) juniorenlisted rank (69.6–80.0 suicides per 100,000 person-years compared with 18.5
suicides per 100,000 person-years in the total Army)•

Substantially greater rise in suicide among women than men during deployment•

Protective effect of marriage against suicide only during deployment.

•

Career history approach produces several actionable insights missed in less textured
analyses of administrative data predictors.

•

Expansion of analyses to a richer set of predictors might help refine understanding ofintervention implications.

3. Predictors of Suicide and Accident Death in the Army Study to Assess Risk andResilience in Servicemembers (Army STARRS) (Schoenbaum, et al, 2014)•

The suicide rate rose between 2004 and 2009 among never deployed and currently
and previously deployed Regular Army Soldiers.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

4

•The accident death rate fell sharply among currently deployed Soldiers, remained
constant among the previously deployed, and trended upward among the neverdeployed.

•

Increased suicide risk was associated with being a man (or a woman during
deployment), white race/ethnicity, junior enlisted rank, recent demotion, and current
or previous deployment.

•

Sociodemographic and Army experience predictors were generally similar for suicides
and accident deaths.

•

Time trends in these predictors and in the Army’s increased use of accession waivers(which relaxed some qualifications for new Soldiers) do not explain the rise in Armysuicides.

•Predictors of Army suicides were largely similar to those reported elsewhere forcivilians, although some predictors distinct to Army service emerged that deserve
more in-depth analysis.

•

The existence of a time trend in suicide risk among never-deployed Soldiers argues
indirectly against the view that exposure to combat-related trauma is the exclusive
cause of the increase in Army suicides.

4. Thirty-Day Prevalence of DSM-IV Mental Disorders among Nondeployed Soldiers in the
U.S. Army: Results from the Army Study to Assess Risk and Resilience inServicemembers (Army STARRS) (Kessler, et al 2014)•

A total of 25.1% of respondents met criteria for any 30-day disorder (15.0%
internalizing; 18.4% externalizing) and 11.1% for multiple disorders.

•

A total of 76.6% of cases reported pre-enlistment age at onset of at least one 30-day
disorder (49.6% internalizing; 81.7% externalizing).*•

12.8% of respondents reported severe role impairment.

•

Controlling for sociodemographic and Army career correlates (which were broadly
consistent with other studies) 30-day disorders with pre-enlistment and postenlistment ages at onset both significantly predicted severe role impairment•

Pre-enlistment disorders were more consistent powerful predictors than postenlistment disorders.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

5

•

Population-attributable risk proportions of severe role impairment were 21.7% forpre-enlistment disorders, 24.3% for post-enlistment disorders, and 43.4% for all
disorders.

•Interventions to limit accession or increase resilience of new Soldiers with preenlistment mental disorders might reduce prevalence and impairments of mental
disorders in the U.S. Army.

5. Prevalence and Correlates of Suicidal Behavior among Soldiers: Results from the Army
Study to Assess Risk and Resilience in Servicemembers (Army STARRS) (Nock, et al
2014)•

The lifetime prevalence estimates of suicidal ideation, suicide plans, and suicide
attempts are 13.9%, 5.3%, and 2.4%.*•

Most reported cases (47.0%-58.2%) had pre-enlistment onsets.*•

Pre-enlistment onset rates were lower than in a prior national civilian survey (withimputed/simulated age at enlistment).

•

Post-enlistment onsets of ideation and plans were higher, and post-enlistment firstattempts were equivalent to civilian rates.

•

Most reported onsets of plans and attempts among ideators (58.3%-63.3%) occur
within the year of onset of ideation.

•

Post-enlistment attempts are positively related to being a woman, lower rank, andpreviously deployed, and are negatively related to being unmarried and assigned toSpecial Operations Command.

•

Five mental disorders predict post-enlistment first suicide attempts in multivariate
analysis:
o
o
o
o
o

pre-enlistment panic disorderpre-enlistment posttraumatic stress disorder
post-enlistment depression
pre-enlistment intermittent explosive disorder
post-enlistment intermittent explosive disorder•

4 of these 5 (posttraumatic stress disorder is the exception) predict ideation.

•

Only post-enlistment intermittent explosive disorder predicts attempts among
ideators.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

6

•

Population-attributable risk proportions of lifetime mental disorders predicting postenlistment suicide attempts are:o 31.3% for pre-enlistment onset disorders
o 41.2% for post-enlistment onset disorders
o 59.9% for all disorders•

The fact that approximately one-third of post-enlistment suicide attempts areassociated with pre-enlistment mental disorders suggests that pre-enlistment mental
disorders might be targets for early screening and intervention.

•

The possibility of higher fatality rates among Army suicide attempts than among
civilian suicide attempts highlights the potential importance of means control (i.e.,
restricting access to lethal means [such as firearms]) as a suicide prevention strategy.

6. Risk Factors for Accident Death in the U.S. Army, 2004-2009 (Lewandowski-Romps, et al
2014)•

Delayed rank progression or demotion and being male, unmarried, in a combat arms
specialty, and of low rank/service length increased odds of accident death for enlisted
Soldiers.

•

Unique to officers was high risk associated with aviation specialties.

•

Accident death risk decreased over time for currently deployed, enlisted Soldiers andincreased for those never deployed.

•

Mental health diagnosis was associated with risk only for previous and neverdeployed, enlisted Soldiers.

•

Models did not discriminate not-line-of-duty from line-of-duty accident deaths.

•

Adding more refined person-level and situational risk indicators to current models
could enhance understanding of accident death risk specific to Soldier rank anddeployment status.

•

Stable predictors could help identify high risk of accident deaths in future cohorts ofRegular Army Soldiers.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

77. Predicting Suicides after Psychiatric Hospitalization in U.S. Army Soldiers: The Army
Study to Assess Risk and Resilience in Servicemembers (Army STARRS) (Kessler, et al
2015)•

Sixty-eight Soldiers died by suicide within 12 months of hospital discharge (12.0% of all
U.S. Army suicides), equivalent to 263.9 suicides per 100,000 person-years comparedwith 18.5 suicides per 100,000 person-years in the total U.S. Army.

•

The strongest predictors included sociodemographics:
o
o
o
o
o

male sexlate age of enlistment
criminal offenses (verbal violence and weapons possession)prior suicidality
aspects of prior psychiatric inpatient and outpatient treatment (e.g., number ofantidepressant prescriptions filled in the past 12 months), and disorders
diagnosed during the focal hospitalizations (e.g., non-affective psychosis)•

A total of 52.9% of post-hospitalization suicides occurred after the 5% of
hospitalizations with highest predicted suicide risk (3,824.1 suicides per 100,000
person-years).*•

These highest-risk hospitalizations also accounted for significantly elevatedproportions of several other adverse post-hospitalization outcomes (unintentional
injury deaths, suicide attempts, and subsequent hospitalizations).*•

The high concentration of risk of suicide and other adverse outcomes might justify
targeting expanded post-hospitalization interventions to Soldiers classified as having
highest post-hospitalization suicide risk, although final determination requires carefulconsideration of intervention costs, comparative effectiveness, and possible adverse
effects.

8. Lifetime Prevalence of DSM-IV Mental Disorders among New Soldiers in the U.S. Army:
Results from the Army Study to Assess Risk and Resilience in Servicemembers (ArmySTARRS) (Rosellini, et al 2015)•

Lifetime prevalence of having at least one internalizing, externalizing, or either type ofdisorder did not differ significantly between new Soldiers and civilians•

Three specific disorders (generalized anxiety, posttraumatic stress, and conductdisorders) and multi-morbidity were significantly more common among new Soldiersthan civilians.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

8•Several socio-demographic characteristics were significantly associated with disorderprevalence and persistence (these associations were uniformly weak).

•

New Soldiers differ somewhat, but not consistently, from civilians.

9. Prevalence and Correlates of Suicidal Behavior among New Soldiers in the U.S. Army:
Results from the Army Study to Assess Risk and Resilience in Servicemembers (ArmySTARRS) (Ursano, et al 2015)•

Lifetime prevalence estimates of pre-enlistment suicide ideation, plans, and attempts
were 14.1, 2.3, and 1.9%, respectively.

•

Most reported onsets of suicide plans and attempts (73.3–81.5%) occurred within thefirst year after onset of ideation.

•

Odds of these lifetime suicidal behaviors among new Soldiers were positively, but
weakly associated with being female, unmarried, religion other than Protestant or
Catholic, and a race/ethnicity other than non-Hispanic White, non-Hispanic Black, orHispanic.

•

Lifetime prevalence estimates of suicidal behaviors among new Soldiers are consistent
with retrospective reports of pre-enlistment prevalence obtained from Soldiers laterin their Army careers.

•

Given that prior suicidal behaviors are among the strongest predictors of latersuicides, consideration should be given to developing methods of obtaining valid
reports of pre-enlistment suicidality from new Soldiers to facilitate targeting of
preventive interventions.

10. Mental Disorders, Comorbidity, and Pre-enlistment Suicidal Behavior Among New
Soldiers in the U.S. Army: Results from the Army Study to Assess Risk and Resilience inServicemembers (Army STARRS) (Nock, et al 2015)•

Most new Soldiers with a pre-enlistment history of suicide attempt reported a priormental disorder (59.0%).

•

Each disorder examined was associated with increased odds of suicidal behavior.

•

Only PTSD and disorders characterized by irritability and impulsive/aggressive
behavior (i.e., bipolar disorder, conduct disorder, oppositional defiant disorder, andattention-deficit/hyperactivity disorder) predicted unplanned attempts among
ideators.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

9•

Mental disorders are important predictors of pre-enlistment suicidal behavior among
new Soldiers and should figure prominently in suicide screening and prevention
efforts.

11. Understanding the Elevated Suicide Risk of Female Soldiers during Deployments(Street, et al 2015)•

The suicide rate of currently deployed women (14.0/100,000 person-years) was 3.1 to
3.5 times the rates of other (i.e., never-deployed/previously deployed) women.

•

The suicide rate of currently deployed men (22.6/100,000 person years) was 0.9 to 1.2
times the rates of other men.

•

The adjusted (for time trends, sociodemographics, and Army career variables) female
to male odds ratio comparing the suicide rates of currently deployed vs. other womenvs. men was 2.8 (95% confidence interval 1.1–6.8), became 2.4 after excluding Soldierswith Direct Combat Arms occupations, and remained elevated (in the range 1.9–2.8)
after adjusting for the hypothesized explanatory variables.

•

None of the explanatory variables considered could fully account for thedisproportionately elevated female suicide rate during deployment among Regular
Army enlisted Soldiers over the years 2004–2009.

•

These results are valuable in excluding otherwise plausible hypotheses for theelevated suicide rate of deployed women and point to the importance of expanding
future research on the psychological challenges of deployment for women.

12. Nonfatal Suicidal Behaviors in U.S. Army Administrative Records, 2004-2009: Resultsfrom the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)(Ursano, et al 2015)•

U.S. Army suicide rate is known to have risen sharply over the past decade, but
information about medically documented, non-fatal suicidal behaviors (suicide
attempts, suspicious injuries, and suicide ideation) is far more limited.

•

There were 21,740 unique Regular Army Soldiers with a non-fatal suicidal event atsome point during 2004-2009.

•

There were substantial increases in the annual incidence rates of suicide attempts(179–400/100,000 person-years) and suicide ideation (557–830/100,000 personyears), but not suspicious injuries.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

10

•Using hierarchical classification rules to identify the first instance of each Soldier’s
most severe behavior, there was an increased risk of all outcomes among those who
were female, Non-Hispanic White, never married, lower-ranking enlisted, lesseducated, and of younger age when entering Army service.

•

Socio-demographic associations significantly differed across outcomes, despite somepatterns that appear similar.

13. Suicide Attempts in the U.S. Army during the Wars in Afghanistan and Iraq, 2004-2009(Ursano, et al 2015)•

The study included 9,791 medically documented suicide attempts among Regular
Army Soldiers during the period 2004 to 2009. Predictor variables were constructedfrom Army personnel and medical records.

•

Enlisted Soldiers accounted for 98.6% of all suicide attempts, with an overall rate of
377/100,000 person-years, versus 27.9/100,000 person-years for officers.*•

Significant predictors among enlisted Soldiers included socio-demographic
characteristics (female gender, older age at Army entry, younger current age, lower
education, non-Hispanic white), short length of service, never or previously deployed,
and the presence and recency of mental health diagnoses. Risk was highest early in
the Army career.*•Among officers, only socio-demographic characteristics (female gender, older age atArmy entry, younger current age, and low education) and the presence and recency ofmental health diagnoses were significant.*•

The results represent the most comprehensive accounting of U.S. Army suicide
attempts to date and reveal unique risk profiles for enlisted Soldiers and officers, andhighlight the importance of focusing research and prevention efforts on enlisted
Soldiers in their first tour of duty.*

14. Occupational Differences in U.S. Army Suicide Rates (Kessler, et al 2015)•

Military research has found elevated suicide rates in combat arms occupations, but
has not evaluated variation in this pattern by deployment history which is theindicator of occupational stress widely considered responsible for the recent rise inmilitary suicide rates.

•

This study analyzed associations of Army occupation and deployment history in
predicting suicide among 729,337 male enlisted Regular Army Soldiers in 2004-2009.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

11

•

There were 496 suicides (22.4/100,000 person-years) during the study period and only
two occupational categories (both in combat arms) had significantly elevated suicide
rates: infantrymen (37.2/100,000 person-years) and combat engineers (38.2/100,000
person-years).

•

Suicide rates in these two occupational categories were significantly lower whencurrently deployed (30.6/100,000 person-years) than never deployed or previously
deployed (41.2-39.1/100,000 person years).

•

The suicide rate of other Soldiers was significantly higher when currently deployed andpreviously deployed (20.2-22.4/100,000 person-years) than never deployed(14.5/100,000 person-years).

•

Adjusted suicide rate for infantrymen and combat engineers was most elevated whennever deployed (OR=2.9, 95% CI=2.1-4.1), less so when previously deployed (OR=1.6,
95% CI=1.1-2.1) and not at all when currently deployed (OR=1.2, 95% CI=0.8-1.8).

•

Adjustment for a differential “healthy warrior effect” cannot explain this variation in
the relative suicide rates of never deployed infantrymen and combat engineers bydeployment status.

15. Prospective Longitudinal Evaluation of the Effect of Deployment-Acquired Traumatic
Brain Injury on Posttraumatic Stress and Related Disorders: Results from the Army
Study to Assess Risk and Resilience in Servicemembers (Army STARRS) (Stein, et al
2015)•

Approximately one in five Soldiers reported exposure to TBI during the index
deployment (mild TBI 18.0% and more-than-mild TBI 1.2%).

•

Even after adjusting for other risk factors (e.g., pre-deployment mental health status,
severity of deployment stress, prior TBI history), deployment-acquired TBI was
associated with elevated adjusted odds of PTSD, generalized anxiety disorder, andmajor depressive episode.

16. Predicting Non-Familial Major Physical Violent Crime Perpetration in the U.S. Armyfrom Administrative Data (Rosellini, et al 2015)•

A machine learning model was developed aimed at predicting which Soldiers would
subsequently commit a severe, physical violent crime.

•

Model was based on an analysis of administrative data for all 975,057 Regular Army
Soldiers on active duty from 2004 to 2009. Hundreds of potential predictors were
examined from the extensive administrative records available.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

12

•5,771 of these Soldiers committed a first founded major physical violent crime(murder-manslaughter, kidnapping, aggravated arson, aggravated assault, robbery)over that time period.

•

The 5% of Soldiers classified by the model as having highest predicted risk accounted
for 36.2% of all major physical violent crimes committed by men, and 33.1% by
women, over the six years of study.

•

When the model was applied to a more recent cohort in 2011-2013 (a validation
sample), the 5% of Soldiers with highest predicted risk accounted for 50.5% of all
major physical violent crimes.

•

Key predictors were indicators of disadvantaged social/socio-economic status, early
career stage, prior crime, and mental disorder treatment. Area under the receiver
operating characteristic curve was .80-.82 in 2004-2009 and .77 in 2011-2013.

•

Although these results suggest that the model could be used to target Soldiers at highrisk of violent crime perpetration for preventive interventions, final implementation
decisions would require further validation and weighing of predicted effectivenessagainst intervention costs and competing risks.

17. Mental Health Treatment among Soldiers with Current Mental Disorders in the Army
Study to Assess Risk and Resilience in Servicemembers (Army STARRS) (Colpe, et al
2015)•

This analysis included a representative sample of 5,428 non-deployed Regular Army
Soldiers who completed a self-administered questionnaire (SAQ) and consented tolinking SAQ data with administrative records.

•

The SAQ included information about prevalence and treatment of mental disorders
among respondents with current Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV) internalizing (anxiety, mood) and externalizing(disruptive behavior, substance) disorders.

•

21.3% of Soldiers with any current disorder reported current treatment.

•

Seven significant predictors of being in treatment were identified.
o Four were indicators of psychopathology (bipolar disorder, panic disorder,
post-traumatic stress disorder, 8 or more months duration of disorder).
o Two were sociodemographics (history of marriage, not being non-Hispanic
Black).

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

13

o The final predictor was history of deployment.
•

Treatment rates varied between 4.7 and 71.5% depending on how many positive
predictors the Soldier had. The vast majority of Soldiers had a low number of thesepredictors.

•

These results document that most non-deployed Soldiers with mental disorders are
not in treatment and that untreated Soldiers are not concentrated in a particularsegment of the population that might be targeted for special outreach efforts. Analysis
of modifiable barriers to treatment is needed to help strengthen outreach efforts.

18. Prognostic Indicators of Persistent Post-Concussive Symptoms after DeploymentRelated Mild Traumatic Brain Injury: A Prospective Longitudinal study in U.S. Army
Soldiers (Stein, et al 2016)•

Persistent and severe post-concussive symptoms (PCS) were found among Soldiers
who experienced a mild TBI while deployed to Afghanistan.

•The study sample consisted of 4,518 Soldiers from three Brigade Combat Teams who
deployed an average of 10 months to Afghanistan in 2012. Of these Soldiers, 822
experienced a mild TBI during the deployment.

•

Based on surveys administered 1, 3, and 9 months following redeployment, theSoldiers with mild TBI were three times more likely to report PCS than other Soldiersin the BCTs.

•

More severe symptoms were reported by Soldiers with a history of TBI(s) or mental
health problems (depression, anxiety, irritability, etc.) prior to this deployment, ormore severe deployment-related stress.

•

Persistent and more severe symptoms were also more likely when there was loss of
consciousness or memory problems associated with the TBI (versus being “dazed”
only).

•

Female Soldiers were more likely than male Soldiers to experience poor recovery
following mild TBI.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

1419. Genome-Wide Association Studies of Posttraumatic Stress Disorder in 2 Cohorts of U.S.
Army Soldiers (Stein, et al 2016)•

The analysis was designed to discover genetic loci associated with lifetime PTSD risk in
the U.S. Army. Two coordinated genome-wide association studies (GWAS) of mental
health were conducted for nearly 13,700 consenting Soldiers in two cohorts from
Army STARRS.*•

These were the largest genome-wide association studies (GWAS) of PTSD to date.*•

GWAS were performed on 3,167 Soldiers with PTSD (cases) and 4,607 trauma-exposed
control Soldiers from the New Soldier Study (NSS), and 947 Soldiers with PTSD (cases)
and 4,969 trauma-exposed control Soldiers from the Pre/Post Deployment Study(PPDS). The primary analysis compared lifetime DSM-IV PTSD cases to trauma-exposed
controls without lifetime PTSD.*•

Two statistically significant genetic variants were found associated with PTSD among
Soldiers who were part of the NSS. One variant, in samples from African American
Soldiers with PTSD, was in a gene (ANKRD55) on chromosome 5. In prior research, thisgene has been found to be associated with various autoimmune and inflammatory
disorders, including multiple sclerosis, type 2 diabetes, celiac disease, and rheumatoid
arthritis. The other variant was found on chromosome 19 in European American
samples.*•

There were no significant genetic correlations observed between PTSD and six mental
disorders and nine immune-related disorders. However there was significant evidenceof pleiotropy (i.e., genetic factors having effects on multiple traits) for PTSD andrheumatoid arthritis, and to a lesser extent, psoriasis.*•

Further efforts are needed to replicate the genome-wide significant association
researchers found with the gene ANKRD55, and to clarify the nature of the genetic
overlap observed between PTSD and rheumatoid arthritis and psoriasis.*

20. Risk Factors, Methods, and Timing of Suicide Attempts among U.S. Army Soldiers(Ursano, et al 2016)•

This analysis used Army STARRS historical administrative data for more than 1.6
million Soldiers on active duty from 2004 to 2009. The study identified 9,650 incident
suicide attempts among regular Army Soldiers (excluding National Guard and Reserve)
during 2004-2009.*

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

15

•The 40% of enlisted Soldiers who had never deployed accounted for 61% of enlisted
suicide attempters. Regardless of deployment status, suicide attempts were more
likely among Soldiers who were female, in their first 2 years of service, or had recently
received a mental health diagnosis.*•

Risk among never deployed Soldiers was highest the 2nd month of service. Risk among
currently deployed Soldiers on their 1st deployment was highest at the 6th month of
deployment. Previously deployed Soldiers were at highest risk at 5 months after
return.*•Drug overdose was the most common method of suicide attempt and accounted formore than 50% of all attempts. Although not overall very frequent, the use of firearms
was most likely to occur among currently deployed (21/100,000 person-years) or
previously deployed Soldiers (14/100,000 person-years), compared to 5/100,000
person-years among Soldiers who had never deployed.*•

As in other studies, a history of any mental health diagnosis was associated withsuicide attempts in all deployment groups. The highest odds occurred in the monthfollowing the most recent diagnosis and then decreased over time.*•

Soldiers with depression in the previous month had the highest odds of suicide
attempt across the deployment groupings.*•

PTSD and substance use disorder were associated with suicide attempts, but varied bydeployment status with the greatest risk among the never deployed Soldiers.

•

The odds of a suicide attempt increased with the number of mental health diagnoses a
Soldier received. The effect of multiple diagnoses was most pronounced among
currently deployed Soldiers.

•

Suicide attempt has rarely been studied with data as comprehensive as the data usedin this research. The findings highlight the complexity of risk and protective factors in
different settings and contexts, and the importance of life and career history inunderstanding suicide attempts in the U.S. Army.

•

A better understanding of suicide attempts may provide opportunities for theprevention of suicidal behavior in the Army as well as in other populations.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

16

21. Predicting Suicides after Outpatient Mental Health Visits in the Army Study to Assess
Risk and Resilience in Servicemembers (Army STARRS) (Kessler, et al 2016)•

Given that clinician-based assessments are not known to be strong predictors ofsuicide, this study investigated whether a precision medicine model using
administrative data after outpatient mental health specialty visits could be developed
to predict suicides among outpatients.

•

This analysis used Army STARRS historical administrative data for more than 1.6
million Soldiers on active duty from 2004 to 2009 and focused on male non-deployed
Regular U.S. Army Soldiers because they account for the vast majority of such suicides.

•

The study calculated the observed proportions of suicide deaths within 5 weeks ofeach ventile (5% grouping) of specialty mental health outpatient visits ranked by
predicted suicide risk based on the optimal prediction model out of the population of
all such visits made by male non-deployed Regular U.S. Army Soldiers in 2004-2009.

•41.5% of Army suicides in 2004-2009 occurred among the 12.0% of Soldiers seen as
outpatient by mental health specialists, with risk especially high within 26 weeks ofvisits.

•An elastic net classifier with 10-14 predictors optimized sensitivity (45.6% of suicide
deaths occurring after the 15% of visits with highest predicted risk).

•

The 5% of visits with highest risk included only 0.1% of Soldiers (1047.1
suicides/100,000 person-years in the 5 weeks after the visit).

•

This is a high enough concentration of risk to have implications for targeting
preventive interventions. An even better model might be developed in the future byincluding the enriched information on clinician-evaluated suicide risk mandated by the
VA/DoD CPG to be recorded.

22. Cross-Phenotype Polygenic Risk Score Analysis of Persistent Post-Concussive Symptoms
in U.S. Army Soldiers with Deployment-Acquired Traumatic Brain Injury (Polimanti, et
al 2016)•This study used a prospective longitudinal survey of three Brigade Combat Teams toassess deployment-acquired TBI and persistent physical, cognitive, and emotional
post-concussive symptoms (PCS).

•

A cross-phenotype high-resolution polygenic risk score (PRS) analysis of persistent
post-concussive symptoms (PCS) was conducted in 845 U.S. Army Soldiers who
sustained TBI during deployment.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

17

•

PRS was derived from summary statistics of large genome-wide association studies of
Alzheimer’s disease, Parkinson’s disease, schizophrenia, bipolar disorder, and major
depressive disorder; and for years of schooling, college completion, childhood
intelligence, infant head circumference (IHC), and adult intracranial volume.

•

Although the study had more than 95% of statistical power to detect moderate-tolarge effect sizes, no association was observed with neurodegenerative and psychiatricdisorders, suggesting that persistent PCS does not share genetic components withthese traits to a moderate-to-large degree.

•

Subjects with high IHC PRS recovered better from cognitive/emotional persistent PCS
than the other individuals.

•

Enrichment analysis identified two significant Gene Ontology (GO) terms related tothis result: GO:0050839~Cell adhesion molecule binding andGO:0050905~Neuromuscular process.

•The study indicated that the genetic predisposition to persistent PCS after TBI does
not have substantial overlap with neurodegenerative and psychiatric diseases, butmechanisms related to early brain growth may be involved.

23. An Examination of Potential Misclassification of Army Suicides: Results from the Army
Study to Assess Risk and Resilience in Servicemembers (Cox, et al 2016)•

Systematic review of CID investigative files for 510 suicides, and 488 accident,
homicide and undetermined deaths from 2005-2009.

•

Using research criteria, 35 of 488 (8.2%) of non-suicides were reclassified to “definite,probable, or possible” suicide.

•

Only 1 of 488 (0.2%) was reclassified to definite suicide.

•

CID investigative practices reflect the “true” population of Army suicides. Flagrant
misclassification was uncommon.

24. Barriers to Initiating and Continuing Mental Health Treatment Among Soldiers in the
Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) (Naifeh, etal 2016)•

Army Soldiers with mental disorders report a variety of barriers to initiating andcontinuing treatment.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

18

•This study involved a representative sample of 5,428 non-deployed Regular Army
Soldiers who completed a self-administered questionnaire and consented to linking
their questionnaire data with administrative records.

•

The study examined reported treatment barriers (perceived need, structural reasons,attitudinal reasons) among respondents with current Diagnostic and Statistical Manualof Mental Disorders, Fourth Edition, mental disorders who either did not seek
treatment in the past year (n = 744) or discontinued treatment (n = 145).

•

82.4% of Soldiers who did not initiate treatment, and 69.5% of Soldiers who
discontinued treatment, endorsed at least two barriers.

•

69.8% of never-treated Soldiers reported no perceived need.

•

Attitudinal reasons were cited more frequently than structural reasons among nevertreated Soldiers with perceived need (80.7% vs. 62.7%) and Soldiers who discontinued
treatment (71.0% vs. 37.8%).

•

Multivariate associations with socio-demographic, Army career, and mental healthpredictors varied across barrier categories.

•

These findings suggest most Soldiers with mental disorders do not believe they needtreatment and those who do typically face multiple attitudinal and, to a lesser extent,
structural barriers.

•

Improved understanding of these treatment barriers can help direct mental healthservices to Soldiers in need.

25. Developing a Risk Model to Target High-Risk Preventive Interventions for Sexual
Assault Victimization Among Female U.S. Army Soldiers (Street, et al 2016)•

Sexual violence victimization is a significant problem among female U.S. military
personnel. Preventive interventions for high-risk individuals might reduce prevalence
but would require accurate targeting.

•This study attempted to develop a targeting model for female Regular U.S. Army
Soldiers based on theoretically guided predictors abstracted from administrative data
records.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

19

•

Because administrative reports of sexual assault victimization are known to beincomplete, parallel machine learning models were developed to predictadministratively recorded (in the population) and self-reported (in a representative
survey) victimization. Capture–recapture methods were used to combine predictions
across models.

•Key predictors included low status, crime involvement, and treated mental disorders.

•Area under the receiver operating characteristic curve was .83–.88.

•

Between 33.7% and 63.2% of victimizations occurred among Soldiers in the highest
risk ventile (5%).

•

This high concentration of risk suggests that the models could be useful in targeting
preventive interventions, although final determination would require careful weighingof intervention costs, effectiveness, and competing risks.

26. Using Administrative Data to Identify U.S. Army Soldiers at High-Risk of Perpetrating
Minor Violent Crimes (Rosellini, et al 2016)•

Interventions exist to reduce violent crimes in high-risk populations, but optimal
implementation requires evidence-based targeting.

•

The goal of this study was to use machine learning methods to develop models to
predict minor violent crime perpetration among U.S. Army Soldiers.

•

Predictors were abstracted from administrative data available for all 975,057 Soldiersin the U.S. Army from 2004 to 2009. There were 25,966 men and 2,728 women who
committed a first founded minor violent crime (simple assault, blackmail-extortionintimidation, rioting, or harassment).

•

Temporally prior administrative records measuring socio-demographic, Army career,
criminal justice, medical/pharmacy, and contextual variables were used to build
separate male and female prediction models that were then tested in an independent
sample of U.S. Army Soldiers from 2011 to 2013.

•

Final model predictors included young age, low education, early career stage, priorcrime involvement, and outpatient treatment for diverse emotional and substance use
problems.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

20•

30.5–28.9% (men-women) of all administratively-recorded crimes in 2004–2009 werecommitted by the 5% of Soldiers having highest predicted risk, with similar
proportions (28.5–29.0%) when the 2004–2009 coefficients were applied to the 2011–2013 test sample.

•

These results suggest that it may be possible to target Soldiers at high-risk of violence
perpetration for preventive interventions.

•Final decisions about such interventions would require weighing predictedeffectiveness against intervention costs and competing risks.

27. Neurocognitive Function and Suicide in U.S. Army Soldiers (Naifeh, et al 2016)•

This study used administrative data from 2004 to 2009 to examine associations
between neurocognitive functioning and subsequent suicidal events among Regular
Army enlisted Soldiers.

•

Cases were all Soldiers who completed the Army’s Automated Neuropsychological
Assessment Metrics (ANAM) computerized testing battery prior to documented
suicide attempt (n = 607), ideation (n = 955), or death (n = 57). Controls were an
equal-probability sample of 9,893 person-months from other Soldiers.

•

Exploratory factor analysis of five ANAM tests identified a general neurocognitive
factor that excluded the mathematic processing test (MTH). When examined
separately in logistic regression analyses that controlled for sociodemographics andprior mental health diagnosis, both the general neurocognitive factor and MTH wereassociated with all outcomes.

•

When both predictors were examined simultaneously, the general neurocognitive
factor continued to be associated with all outcomes and MTH continued to be
associated with suicide attempt and ideation.

•

These small but robust associations suggest that future research must continue toexamine the extent to which objective neurocognitive tests may enhance
understanding and prediction of suicide risk.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

21

28. Alcohol Misuse and Co-Occurring Mental Disorders Among New Soldiers in the U.S.
Army (Stein, et al 2016)•

This study used cross-sectional survey data from Soldiers reporting for basic combat
training to retrospectively assess lifetime alcohol consumption and substanceabuse/dependence, enabling estimation of the prevalence of lifetime binge drinking
and heavy drinking in a sample of 30,583 Soldiers and of probable alcohol use disorder(AUD) among 26,754 Soldiers with no or minimal lifetime use of other drugs.

•

Co-occurrence of mental disorders and other adverse outcomes with binge drinking,heavy drinking, and AUD was examined. Discrete-time survival analysis, with personyear the unit of analysis and a logistic link function, was used to estimate associationsof AUD with subsequent onset of mental disorders and vice versa.

•

Prevalence of lifetime binge drinking was 27.2% among males and 18.9% amongfemales; respective estimates for heavy drinking were 13.9% and 9.4%.

•

Among Soldiers with no or minimal drug use, 9.5% of males and 7.2% of females had
lifetime AUD.

•

Relative to no alcohol misuse, binge drinking, heavy drinking, and AUD wereassociated with increased odds of all mental disorders and other adverse outcomesunder consideration.

•

Prior mental disorders and suicidal ideation were associated with onset of AUD, andprior AUD was associated with onset of mental disorders and suicidal ideation.

•

Strong bidirectional associations between alcohol misuse and mental disorders wereobserved. Recognition of alcohol misuse and mental disorders upon enlistment may
provide opportunities for risk mitigation early in a Soldier's career.

29. Medically Documented Suicide Ideation Among U.S. Army Soldiers (Ursano, et al 2016)•

This study used administrative data to examine predictors of medically documented
suicide ideation (SI) among Regular Army Soldiers from 2006 through 2009. The study
included 10,466 ideators and 124,959 control person-months.

•

Enlisted ideators (97.8% of all cases) were more likely than controls to be female,younger, older when entering service, less educated, never or previously deployed,
and have a recent mental health diagnosis.

•

Officer ideators were more likely than controls to be female, younger, younger whenentering service, never married, and have a recent mental health diagnosis.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

22

•

Risk among enlisted Soldiers peaked in the second month of service then declined
steadily, whereas risk among officers remained relatively stable over time.

•

Risk of SI is highest among enlisted Soldiers early in Army service, females, and thosewith a recent mental health diagnosis.

•

Most cases of medically documented SI in the U.S. Army occurred among enlisted
Soldiers in their first tour of duty.

•

Risk was particularly elevated among enlisted Soldiers during the initial months oftraining, and among Soldiers with a mental health diagnosis recorded during a recent
health care encounter.

•

Given apparent similarities between our findings on SI and recently publishedevidence on suicide attempts, it is important for future studies to examine how risk
may differ across suicide-related outcomes of increasing severity.

30. Genetic Risk Variants for Social Anxiety (Stein, et al 2017)•

This study used genome-wide association analysis (GWAS) to determine SNP-based
heritability of social anxiety, discern genetic risk loci for social anxiety, and determine
shared genetic risk with neuroticism and extraversion.

•

GWAS were conducted within ancestral groups, European Americans (EUR), African
Americans (AFR) and Latin Americans (LAT), using linear regression models for each of
the three component studies in Army STARRS, and then meta-analyzed across studies.

•

SNP-based heritability for social anxiety was significant in EUR. One meta-analyticallygenome-wide significant locus was seen in each of the EUR and AFR samples.

•

Social anxiety was significantly genetically correlated (negatively) with extraversion
but not with neuroticism or with an anxiety disorder factor score from external GWAS
meta-analyses.

•

This first GWAS of social anxiety confirms a genetic basis for social anxiety, sharedwith extraversion but possibly less so with neuroticism.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

23

31. Frequency of Improvised Explosive Devices and Suicide Attempts in the U.S. Army
(Ursano, et al 2017)•

This study examined the association of monthly IED rates with risk of Soldier suicide
attempt among those deployed and non-deployed among all active duty Regular Armysuicide attempters 2004-2009 (n = 9,791) and an equal-probability sample of control
Soldiers.

•

Logistic regression analyses examined Soldiers’ risk of attempting suicide as a functionof monthly IED frequency, controlling for socio-demographics, service-relatedcharacteristics, rate of deployment/redeployment, combat deaths and injuries. The
association of IED frequency with suicide attempt was examined overall and by time inservice and deployment status.

•

Soldiers’ risk of suicide attempt increased with increasing numbers of IEDs. Suicide
attempt was 26% more likely for each 1,000 IED increase in monthly frequency.

•

The association of IED frequency with suicide attempt was greater for Soldiers in theirfirst 2 years of service than for those with 3 or more years of service.

•

Among Soldiers in their first 2 years of service, the association was constant,regardless of deployment status. Among soldiers with 3 or more years of service, theassociation was higher for those never deployed and currently deployed than for
those previously deployed.

•

To our knowledge, this is the first study to examine and demonstrate an association
between the aggregate frequency of IEDs and risk of suicide attempts among U.S.
Army Soldiers. The findings suggest that the threat of new weapons may increasestress burden among Soldiers. Targeting risk perception and perceived preparedness,particularly early in a Soldier’s career, may improve psychological resilience andreduce suicide risk.

32. A Genome-Wide Gene-by-Trauma Interaction Study of Alcohol Misuse in Two
Independent Cohorts Identifies PRKG1 as a Risk Locus (Polimanti, et al 2017)•

Traumatic life experiences are associated with alcohol use problems, an associationthat is likely to be moderated by genetic predisposition.

•

To better understand these interactions, a gene-by-environment genome-wide
interaction study (GEWIS) of alcohol use problems was conducted in two independentcohorts: Army STARRS (N=16,361) and Yale-Penn (N=8,084).

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

24

•In African-American subjects, an interaction of PRKG1 with trauma exposure in the
STARRS cohort was identified and replicated in the Yale-Penn cohort.

•

PRKG1 encodes cyclic GMP-dependent protein kinase 1, which is involved in learning,memory and circadian rhythm regulation.

•

Considering the loci identified in stage-1 that showed same effect directions in stage2, the gene ontology (GO) enrichment analysis showed several significant results,
including calcium-activated potassium channels, cognition, locomotion and Stat3
protein regulation.

•

This was the largest GEWIS performed in psychiatric genetics, and the first GEWIS
examining risk for alcohol misuse. The results add to a growing body of literature
highlighting the dynamic impact of experience on individual genetic risk.

33. Sexual Assault Victimization and Mental Health Treatment, Suicide Attempts, andCareer Outcomes among Women in the U.S. Army (Rosellini, et al 2017)•

This study examined associations of administratively recorded sexual assault
victimization during military service with subsequent mental health and negative
career outcomes among U.S. Army women controlling for non-random victimization
exposure.

•

Used propensity score methods to match all 4,238 female Regular Army Soldiers withadministratively recorded sexual assault victimization during 2004 to 2009 to fivecontrols per case with similar composite victimization risk.

•

Examined associations of this victimization measure with administratively recorded
mental health treatment, suicide attempt, and Army career outcomes over thesubsequent 12 months by using survival analysis for dichotomous outcomes andconditional generalized linear models for continuous outcomes.

•

Women with administratively recorded sexual assault had significantly elevated odds
ratios of subsequent mental health treatment, posttraumatic stress disorder
treatment, suicide attempt, demotion, and attrition.

•

Conclusion was sexual assault victimization is associated with considerable sufferingand likely decreased force readiness.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

25

34. Health Care Contact and Suicide Risk Documentation Prior to Suicide Death: Resultsfrom the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)(Ribeiro, et al 2017)•

Prior research has shown that a substantial portion of suicide decedents access healthcare in the weeks and months before their death. This study examined whether this istrue among Soldiers.

•

The sample included the 569 Regular Army Soldiers in the U.S. Army who died bysuicide on active duty between 2004 and 2009 compared to 5,690 matched controls.

•

Analyses examined the prevalence and frequency of health care contacts anddocumentation of suicide risk (i.e., the presence of prior suicidal thoughts andbehaviors) over the year preceding suicide death. Predictors of health care contact
and suicide risk documentation were also examined.

•

Approximately 50% of suicide decedents accessed health care in the month prior totheir death, and more than 25% of suicide decedents accessed health care in the weekprior to their death.

•

Mental health encounters were significantly more prevalent among suicide decedents.
Despite this, risk documentation was rare among suicide decedents (4 weeks: 13.8%;
52 weeks: 24.5%).

•

Suicide decedents who were male, never married, and non-Hispanic Black were lesslikely to access care prior to death. Number of mental health encounters was the only
predictor of suicide risk documentation among decedents at 4 weeks and 52 weeks
prior to their death.

•

Conclusion was many Soldiers who die by suicide access health care shortly before
death, presenting an opportunity for suicide prevention. However, in most cases,
there was no documentation of prior suicidal thoughts or behaviors, highlighting theneed for improvements in risk detection and prediction. Increasing the frequency,
scope, and accuracy of risk assessments, especially in mental health care settings, may
be particularly useful.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

26

35. Associations of Childhood Bullying Victimization with Lifetime Suicidal Behaviors
among New U.S. Army Soldiers (Campbell-Sills, et al 2017)•

Prior studies have documented associations of childhood bullying victimization withsuicidal behaviors. Many failed to adjust for concomitant risk factors and none
investigated this relationship in military personnel. The aim of this study was toestimate independent associations of childhood bullying victimization with suicidal
behaviors among U.S. Army soldiers.

•

Soldiers reporting for basic training completed a cross-sectional survey assessing
mental disorders, suicidal behaviors, and childhood adversities including two types ofbullying victimization: (1) Physical Assault/Theft and (2) Bullying Comments/Behaviors.

•

Associations of childhood bullying experiences with suicidal behaviors were estimatedusing discrete-time survival analysis of person–year data from 30,436 Soldiers. Models
adjusted for sociodemographic factors, childhood maltreatment by adults, and mental
disorders.

•After comprehensive adjustment for other risk factors, more frequent PhysicalAssault/Theft by peers during childhood was associated with increased odds oflifetime suicidal ideation and attempt.

•More frequent Bullying Comments/Behaviors were associated with increased risk ofideation, plan, attempt, and onset of plan among ideators.

•

Relative to no bullying victimization, exposure to the most persistent bullying was
associated with two- to fourfold increase in risk for suicidal behaviors.

•

The conclusion was childhood bullying victimization is associated with lifetime suicidal
behaviors in new Soldiers. Exposure to Bullying Comments/Behaviors during childhood
is associated with progression from suicidal ideation to plan. Improved recognition ofthese relationships may inform risk mitigation interventions for Soldiers.

36. Using Self-Report Surveys at the Beginning of Service to Develop Multi-Outcome Risk
Models for New Soldiers in the U.S. Army (Rosellini, et al 2017)•

The Army uses universal preventive interventions for several negative outcomes (e.g.,suicide, violence, sexual assault) with especially high risks in the early years of service.
More intensive interventions exist, but would be cost-effective only if targeted at
high-risk Soldiers. This study developed models for such targeting from self-reportsurveys administered at the beginning of Army service.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

27

•The study included 21,832 new Soldiers who completed a self-administeredquestionnaire (SAQ) in 2011–2012 and consented to link administrative data to SAQ
responses. Penalized regression models were developed for 12 administratively
recorded outcomes occurring by December 2013: suicide attempt, mental
hospitalization, positive drug test, traumatic brain injury (TBI), other severe injury,
several types of violence perpetration and victimization, demotion, and attrition.

•

The best-performing models were for TBI, major physical violence perpetration, sexualassault perpetration, and suicide attempt. Although predicted risk scores weresignificantly correlated across outcomes, prediction was not improved by including risk
scores for other outcomes in models.

•

40.5% of suicide attempts occurred among the 10% of new Soldiers with highest
predicted risk, 57.2% of male sexual assault perpetrations among the 15% with highest
predicted risk, and 35.5% of female sexual assault victimizations among the 10% withhighest predicted risk.

•

The conclusion was data collected at the beginning of service in self-report surveys
could be used to develop risk models that define small proportions of new Soldiers
accounting for high proportions of negative outcomes over the first few years ofservice.

37. Childhood Adversity, Adult Stress, and the Risk of Major Depression or Generalized
Anxiety Disorder in U.S. Soldiers: a Test of the Stress Sensitization Hypothesis (Bandoli,
et al 2017)•

The stress sensitization theory hypothesizes that individuals exposed to childhood
adversity will be more vulnerable to mental disorders from proximal stressors. This
study aimed to test this theory with respect to risk of 30-day major depressive episode(MDE) and generalized anxiety disorder (GAD) among new U.S. Army Soldiers.

•

The sample consisted of 30,436 new Soldier recruits in the Army Study to Assess Risk
and Resilience (Army STARRS). Generalized linear models were constructed, andadditive interactions between childhood maltreatment proﬁles and level of 12-monthstressful experiences on the risk of 30-day MDE and GAD were analyzed.

•

Stress sensitization was observed in models of past 30-day MDE and GAD. Thissensitization only occurred at high (3+) levels of reported 12-month stressful
experiences.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

28

•

In pairwise comparisons for the risk of 30-day MDE, the risk difference between 3+
stressful experiences and no stressful experiences was signiﬁcantly greater for all
maltreatment proﬁles relative to no maltreatment.

•

Similar results were found with the risk for 30-day GAD with the exception of the risk
difference for episodic emotional and sexual abuse, which did not differ statisticallyfrom no maltreatment.

•This study found that new Soldiers are at an increased risk of 30-day MDE or GAD
following recent stressful experiences if they were exposed to childhood
maltreatment.

•

Particularly in the military with an abundance of unique stressors, attempts to identify
this population and improve stress management may be useful in the effort to reduce
the risk of mental disorders.

38. Psychological Autopsy Study Comparing Suicide Decedents, Suicide Ideators, andPropensity Score Matched Controls: Results from the Study to Assess Risk andResilience in Service Members (Army STARRS) (Nock, et al 2017)•

The suicide rate has increased significantly among U.S. Army Soldiers over the past
decade. This study reports the first results from a large psychological autopsy study
using two control groups designed to reveal risk factors for suicide death among
Soldiers beyond known socio-demographic factors and the presence of suicide
ideation.

•

Informants were next-of-kin and Army supervisors for 135 suicide cases, 137 control
Soldiers propensity-score-matched on known socio-demographic risk factors for
suicide and Army history variables, and 118 control Soldiers who reported suicide
ideation in the past year.

•

Results revealed that most (79.3%) Soldiers who died by suicide have a prior mental
disorder; mental disorders in the prior 30-days were especially strong risk factors for
suicide death.

•

Approximately half of suicide decedents tell someone that they are considering
suicide.

•Virtually all of the risk factors identified in this study differed between suicide casesand propensity-score-matched controls, but did not significantly differ between
suicide cases and suicide ideators.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

29

•The most striking difference between suicides and ideators was the presence in theformer of an internalizing disorder (especially depression) and multi-morbidity (i.e., 3+
disorders) in the past 30 days.

•

This study found that most Soldiers who die by suicide have identifiable mental
disorders shortly before their death and tell others about their suicidal thinking,suggesting that there are opportunities for prevention and intervention. However, few
risk factors distinguish between suicide ideators and decedents, pointing to an
important direction for future research.

39. Childhood Maltreatment and Lifetime Suicidal Behaviors among New Soldiers in the
U.S. Army: Results from the Army Study to Assess Risk and Resilience inServicemembers (Army STARRS) (Stein, et al 2017)•

Understanding suicide risk is a priority for the U.S. military. This study aimed toestimate associations of childhood maltreatment with pre-enlistment suicidal
behaviors in new Army Soldiers using cross-sectional survey data from 38,237 Soldiersreporting for basic training from April 2011 through November 2012.

•

Scales assessing retrospectively reported childhood abuse and neglect were derived
and subjected to latent class analysis, which yielded 5 profiles: No Maltreatment,
Episodic Emotional Maltreatment, Frequent Emotional/Physical Maltreatment,
Episodic Emotional/Sexual Abuse, and Frequent Emotional/Physical/Sexual
Maltreatment.

•

Discrete-time survival analysis was used to estimate associations of maltreatment
profiles with suicidal behaviors (assessed with a modified Columbia-Suicide Severity
Rating Scale), adjusting for socio-demographics and mental disorders.

•

Nearly 1 in 5 new Soldiers was classified as experiencing childhood maltreatment.

•

Relative to No Maltreatment, all multivariate maltreatment profiles were associatedwith elevated odds of lifetime suicidal ideation, attempt, and onset of plan among
those with ideation.

•

Several profiles also predicted attempts among those with plans, and Frequent
Emotional/Physical/Sexual Maltreatment predicted unplanned attempts among
ideators.

•

Adjustment for mental disorders attenuated but did not eliminate these associations.

•Childhood maltreatment is strongly associated with suicidal behavior among new
Soldiers, even after adjusting for intervening mental disorders.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

30

•Among soldiers with lifetime ideation, certain maltreatment profiles are associatedwith elevated odds of subsequently planning and/or attempting suicide.

•

Focus on childhood maltreatment might reveal avenues for risk reduction among new
Soldiers.

40. Suicide Attempts in U.S. Army Combat Arms, Special Forces and Combat Medics(Ursano, et al 2017)•

The U.S. Army suicide attempt rate increased sharply during the wars in Iraq and
Afghanistan. Risk may vary according to occupation, which significantly influences thestressors that Soldiers experience.

•

Using administrative data from the Army Study to Assess Risk and Resilience inServicemembers (Army STARRS), this study identified person-month records for all
active duty Regular Army enlisted Soldiers who had a medically documented suicide
attempt from 2004 through 2009 (n = 9,650) and an equal-probability sample ofcontrol person-months (n = 153,528).

•

Logistic regression analyses examined the association of combat occupation (combat
arms, special forces, combat medics) with suicide attempt, adjusting for sociodemographics, service-related characteristics, and prior mental health diagnosis.

•

In adjusted models, the odds of attempting suicide were higher in combat arms andcombat medics, but lower in special forces, compared to all other occupations.

•Combat arms and combat medics had higher odds of suicide attempt than otheroccupations if never deployed or previously deployed, but not when currently
deployed.

•

Occupation was associated with suicide attempt in the first ten years of service, but
not beyond.

•In the first year of service, primarily a time of training, combat medics had higher odds
of suicide attempt than both combat arms and other occupations.

•

Discrete-time hazard functions revealed that these occupations had distinct patternsof monthly risk during the first year of service.

•

This study found that military occupation can inform the understanding suicide
attempt risk among Soldiers.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

3141. Lifetime Suicidal Behaviors and Career Characteristics Among U.S. Army Soldiers(Millner, et al 2017)•

This study presented data on lifetime prevalence of suicide ideation and non-fatal
attempts as reported by the large representative sample of U.S. Army Soldiers who
participated in the Consolidated All Army Study (n = 29,982). The study also examinedassociations of key Army career characteristics with these outcomes.

•

Prevalence estimates for lifetime suicide ideation were 12.7% among men and 20.1%
among women, and for lifetime suicide attempts were 2.5% and 5.1%, respectively.

•

Retrospective age-of-onset reports suggested that 53.4% to 70% of these outcomes
had pre-enlistment onsets.

•

Results revealed that, for both men and women, being in the Regular Army, comparedwith being in the National Guard or Army Reserve, and being in an enlisted rank,compared with being an officer, is associated with increased risk of suicidal behaviors
and that this elevated risk is present both before and after joining the Army.

42. Risk of Suicide Attempt Among Soldiers in Army Units With a History of Suicide
Attempts (Ursano, et al 2017)•

This study examined whether a Soldier’s risk of suicide attempt is influenced byprevious suicide attempts in that Soldier’s unit.

•

Using administrative data from the Army Study to Assess Risk and Resilience inServicemembers (STARRS), this study identified person-month records for all activeduty, regular U.S. Army, enlisted Soldiers who attempted suicide from January 1, 2004
through December 31, 2009 (n = 9,650), and an equal-probability sample of control
person-months (n = 153,528).

•

Logistic regression analyses examined the number of past-year suicide attempts in a
Soldier’s unit as a predictor of subsequent suicide attempt, controlling for sociodemographic features, service-related characteristics, prior mental health diagnosis,
and other unit variables, including suicide-, combat-, and unintentional injury–related
unit deaths.

•

The study also examined whether the influence of previous unit suicide attempts
varied by military occupational specialty (MOS) and unit size.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

32

•Of the final analytic sample of 9,512 enlisted Soldiers who attempted suicide and151,526 control person-months, most were male (86.4%), 29 years or younger(68.4%), younger than 21 years when entering the Army (62.2%), white (59.8%), highschool educated (76.6%), and currently married (54.8%).

•

In adjusted models, Soldiers were more likely to attempt suicide if 1 or more suicide
attempts occurred in their unit during the past year (odds ratios [ORs], 1.4-2.3; P <.001), with odds increasing as the number of unit attempts increased.*•

The odds of suicide attempt among Soldiers in a unit with 5 or more past-year
attempts was more than twice that of Soldiers in a unit with no previous attempts(OR, 2.3; 95%CI, 2.1-2.6).

•

The association of previous unit suicide attempts with subsequent risk was significant
whether Soldiers had a combat arms MOS or other MOS (ORs, 1.4-2.3; P < .001) andregardless of unit size, with the highest risk among those in smaller units (1-40
Soldiers) (ORs, 2.1-5.9; P < .001).*•

The population-attributable risk proportion for 1 or more unit suicide attempts in thepast year indicated that, if this risk could be reduced to no unit attempts, 18.2% ofattempts would not occur.

•

Units with a history of suicide attempts may be important targets for preventive
interventions.

43. Predicting Sexual Assault Perpetration in the U.S. Army Using Administrative Data
(Rosellini, et al 2017)•

This study developed actuarial models to identify male U.S. Army Soldiers at high riskof administratively recorded sexual assault perpetration.

•

This study investigated administratively recorded sexual assault perpetration among
the 821,807 male Army Soldiers serving 2004–2009.

•

Penalized discrete-time (person-month) survival analysis was used to select thesmallest possible number of stable predictors to maximize number of sexual assaults
among the 5% of Soldiers with highest predicted risk of perpetration (top-ventile
concentration of risk). Separate models were developed for assaults against nonfamily and intra-family adults and minors.

•

There were 4,640 male Soldiers found to be perpetrators against non-family adults,
1,384 against non-family minors, 380 against intra-family adults, and 335 against intrafamily minors.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

33

•Top-ventile concentration of risk was 16.2%–20.2% predicting perpetration against
non-family adults and minors, and 34.2%–65.1% against intra-family adults andminors. Final predictors consisted largely of measures of prior crime involvement andthe presence and treatment of mental disorders.

•

Administrative data can be used to develop actuarial models that identify a highproportion of sexual assault perpetrators. If a system is developed to consolidate
administrative predictors routinely, then predictions could be generated periodicallyto identify those in need of preventive intervention. Whether this would be costeffective, though, would depend on intervention costs, effectiveness, and competingrisks.

44. Genome-wide Association Studies of Suicide Attempts in U.S. Soldiers (Stein, et al
2017)•

This study utilized population-based non-clinical cohorts of U.S. military personnel(discovery: n = 473 cases and n = 9778 control subjects; replication: n = 135 cases andn = 6879 control subjects) and a clinical case-control sample of recent suicide
attempters (n = 51 cases and n = 112 control subjects) to conduct GWAS of suicide
attempts (SA).

•Genome-wide association was evaluated within each ancestral group (European-,
African-, Latino-American) and study using logistic regression models.

•Meta-analysis of the European ancestry discovery samples revealed a genome-wide
significant locus in association with SA near MRAP2 (melanocortin 2 receptor
accessory protein 2) and CEP162 (centrosomal protein 162); 12 genome-wide
significant SNPs in the region; peak SNP rs12524136-T, OR = 2.88, p = 5.24E-10.

•

These findings were not replicated in the European ancestry subsamples of thereplication or suicide attempters samples. However, the association of the peak SNP
remained significant in a meta-analysis of all studies and ancestral subgroups (OR =2.18, 95%CI 1.70, 2.80).

•

Polygenic risk score (PRS) analyses showed some association of SA with bipolar
disorder.

•The association with SNPs encompassing MRAP2, a gene expressed in brain andadrenal cortex and involved in neural control of energy homeostasis, points to thislocus as a plausible susceptibility gene for suicidality that should be further studied.
Larger sample sizes will be needed to confirm and extend these findings.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

34

45. Prior Mental Disorders and Lifetime Suicidal Behaviors among U.S. Army Soldiers in the
Army Study to Assess Risk and Resilience in Servicemembers (Millner, et al 2017)•

This study examined associations of prior mental disorders and Army career
characteristics with subsequent first onset of suicidal behaviors in a large,
representative sample of U.S. Army Soldiers from the consolidated All Army Study(n=29,982).

•

Among men and women, all self-reported lifetime disorders measured (some assessedwith screening scales) are associated with subsequent onset of suicide ideation.

•

Among men, three disorders characterized by agitation and impulsiveness(intermittent explosive disorder, panic disorder, and substance disorders) predict thetransition from suicide ideation to attempt.

•

For both men and women, being in the Regular Army (vs. National Guard or Army
Reserve) predicts suicide attempts in the total sample.

•

For men, a history of deployment and junior rank are predictors of suicide attempts
after adjusting for pre-enlistment disorders but not accounting for pre- and postenlistment disorders, suggesting that post-enlistment disorders account for some of
the increased suicide risk among these career characteristics.

•

The results highlight associations between mental disorders and suicidal behaviors,
but underscore limitations predicting which people with ideation attempt suicide.

46. Documented Family Violence and Risk of Suicide Attempt among U.S. Army Soldiers(Ursano, et al 2017)•

Person-month records of active duty, Regular Army, enlisted Soldiers with medically
documented suicide attempts (SA) (n=9,650), and a sample of control person-months(n=153,528), were selected from administrative data in 2004 to 2009 to examine
associations of family violence (FV) history with SA risk among Soldiers. Logistic
regression analyses were used to examine associations of FV with SA, adjusting forsocio-demographics, service-related characteristics, and prior mental health diagnosis.

•

Odds of SA were higher in Soldiers with a FV history and increased as the number of
FV events increased.

•

Soldiers experiencing past-month FV were almost five times as likely to attempt
suicide as those with no FV history.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

35

•

Odds of SA were elevated for both perpetrators and those who were exclusively
victims. Male perpetrators had higher odds of SA than male victims, whereas female
perpetrators and female victims did not differ in SA risk.

•

A discrete-time hazard function indicated that SA risk was highest in the initial months
following the first FV event.

•Findings indicate that FV is an important consideration in understanding risk of SA
among Soldiers.

47. Prospective Risk Factors for Post-Deployment Heavy Drinking and Alcohol or SubstanceUse Disorder among U.S. Army Soldiers (Campbell-Sills, et al 2017)•

This study estimated prevalence of alcohol misuse among 4,645 U.S. Army Soldiers
who participated in a longitudinal survey.

•

Assessment occurred 1–2 months before Soldiers deployed to Afghanistan in 2012
(T0), upon their return to the U.S. (T1), 3 months later (T2), and 9 months later (T3).

•

Weights-adjusted logistic regression was used to evaluate associations ofhypothesized risk factors with post-deployment incidence and persistence of heavy
drinking (HD) (consuming 5 + alcoholic drinks at least 1–2×/week) and alcohol orsubstance use disorder (AUD/SUD).

•

Prevalence of past-month HD at T0, T2, and T3 was 23.3% (S.E. = 0.7%), 26.1% (S.E. =0.8%), and 22.3% (S.E. = 0.7%); corresponding estimates for any binge drinking (BD)were 52.5% (S.E. = 1.0%), 52.5% (S.E. = 1.0%), and 41.3% (S.E. = 0.9%).

•

Greater personal life stress during deployment (e.g., relationship, family, or financial
problems) – but not combat stress – was associated with new onset of HD at T2 [perstandard score increase: adjusted odds ratio (AOR) = 1.20, 95% CI 1.06–1.35, p =0.003]; incidence of AUD/SUD at T2 (AOR = 1.54, 95% CI 1.25–1.89, p < 0.0005); andpersistence of AUD/SUD at T2 and T3 (AOR = 1.30, 95% CI 1.08–1.56, p = 0.005).

•

Any BD pre-deployment was associated with post-deployment onset of HD (AOR =3.21, 95% CI 2.57–4.02, p < 0.0005) and AUD/SUD (AOR = 1.85, 95% CI 1.27–2.70, p =0.001).

•

Alcohol misuse is common during the months preceding and following deployment.
Timely intervention aimed at alleviating/managing personal stressors or curbing risky
drinking might reduce risk of alcohol-related problems post-deployment.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

36

48. Predictive Validity and Correlates of Self-Assessed Resilience among U.S. Army Soldiers(Campbell-Sills, et al 2017)•

This study evaluated the validity of self-assessed resilience among U.S. Army Soldiers,
including whether pre-deployment perceived resilience predicted post-deployment
emotional disorder.

•

Resilience was assessed via self-administered questionnaire among 35,807 new
Soldiers reporting for basic training and 8,558 experienced Soldiers preparing todeploy to Afghanistan. Concurrent validity of self-assessed resilience was evaluatedamong recruits by estimating its association with past-month emotional disorder.

•

Predictive validity was examined among 3,526 experienced Soldiers with no lifetime
emotional disorder pre-deployment. Predictive models estimated associations of predeployment resilience with incidence of emotional disorder through 9 months postdeployment and with marked improvement in coping at 3 months post-deployment.

•

Soldiers characterized themselves as very resilient on average [M = 14.34, SD = 4.20
(recruits); M = 14.75, SD = 4.31 (experienced Soldiers); theoretical range = 0-20].

•

Demographic characteristics exhibited only modest associations with resilience, while
severity of childhood maltreatment was negatively associated with resilience in both
samples.

•Among recruits, resilience was inversely associated with past-month emotional
disorder [adjusted odds ratio (AOR) = 0.65, 95% CI = 0.62-0.68, P < .0005 (per standard
score increase)].

•Among deployed Soldiers, greater pre-deployment resilience was associated withdecreased incidence of emotional disorder (AOR = 0.91; 95% CI = 0.84-0.98; P = .016)
and increased odds of improved coping (AOR = 1.36; 95% CI = 1.24-1.49; P < .0005)
post-deployment.

•

Findings supported validity of self-assessed resilience among Soldiers, although its
predictive effect on incidence of emotional disorder was modest. In conjunction withassessment of known risk factors, measurement of resilience could help predict
adaptation to foreseen stressors like deployment.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

37

49. Medical-encounter Mental Health Diagnoses, Non-fatal Injury and Polypharmacy
Indicators of Risk for Accident Death in the U.S. Army Enlisted Soldiers, 2004-2009(Lewandowski-Romps, et al 2017)•

Accidents are a leading cause of deaths in active duty personnel and understanding
accident deaths during wartime could facilitate future operational planning and informrisk prevention efforts.

•

This study used 2004-2009 military records for enlisted, active duty, Regular Army
Soldiers to identify mental health, injury, and polypharmacy (multiple narcotic and/or
psychotropic medications) predictors of accident deaths for current, previously, andnever deployed groups during the Afghanistan and Iraq wars.

•

Deployed Soldiers with anxiety diagnoses showed higher risk for accident deaths.
More than half had anxiety diagnoses prior to being deployed, suggesting anticipatory
anxiety or symptom recurrence may contribute to high risk.

•

Traumatic brain injury (TBI) indicated higher risk for accident deaths among previously
deployed Soldiers. Two-thirds of these Soldiers had first TBI medical-encounter while
non-deployed, but mild, combat-related TBIs may have been undetected during
deployments.

•

Post-Traumatic Stress Disorder (PTSD) predicted higher risk of accident death fornever deployed Soldiers, as did polypharmacy which may relate to reasons for
deployment ineligibility.

•

The higher risk of accident death predicted by PTSD among those never deployedsuggests the importance of identification, treatment, and prevention of non-combat
traumatic events.

•

Accident death risk predictors overlapped with those identified for suicides whichsuggests effective intervention might reduce both types of deaths.

50. Trauma Exposure Interacts with the Genetic Risk of Bipolar Disorder in Alcohol Misuseof U.S. Soldiers (Polimanti, et al 2017)•

This study investigated whether trauma exposure modified the association of genetic
risks for mental disorders with alcohol misuse and nicotine dependence (ND)
symptoms by calculating high-resolution polygenic risk scores (PRSs) for 10,732 U.S.
Army Soldiers (8,346 trauma-exposed and 2,386 trauma-unexposed) based on
genome-wide association studies of bipolar disorder (BD), major depressive disorder,and schizophrenia.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

38

•The study found a significant BD PRS-by-trauma interaction with respect to alcohol
misuse; a positive correlation between BD PRS and alcohol misuse in trauma-exposed
Soldiers; and a negative correlation in trauma-unexposed Soldiers.

•

The variants included in the BD PRS-by-trauma interaction showed significant
enrichments for gene ontologies related to high voltage-gated calcium channel activity
and for Beta1/Beta2 adrenergic receptor signaling pathways.

•

The results indicated that the genetic overlap between alcohol misuse and BD issignificantly moderated by trauma exposure. This study provides molecular insight
into the complex mechanisms that link substance abuse, psychiatric disorders, andtrauma exposure.

51. Genome-Wide Analysis of Insomnia Disorder (Stein, et al 2018)•

Insomnia is a worldwide problem with substantial deleterious health effects. Twin
studies have shown a heritable basis for various sleep-related traits, including
insomnia, but robust genetic risk variants have just recently begun to be identified.

•This study involved genome-wide association studies (GWAS) of Soldiers in Army
STARRS. GWAS were carried out separately for each ancestral group (EUR, AFR, LAT)
using logistic regression for each of the STARRS component studies (including 3,237
cases and 14,414 controls), and then meta-analysis was conducted across studies andancestral groups.

•

Heritability (SNP-based) for lifetime insomnia disorder was significant in EUR. A metaanalysis including three ancestral groups and three study cohorts revealed a genomewide significant locus on Chr 7 and a genome-wide significant gene-based associationin EUR for RFX3 on Chr 9. Polygenic risk for sleeplessness/insomnia severity in UK
Biobank was significantly positively associated with likelihood of insomnia disorder in
STARRS.

•

Genetic contributions to insomnia disorder in STARRS were significantly positively
correlated with major depressive disorder and type 2 diabetes, and negatively withmorningness chronotype and subjective well-being in external datasets.

•

Insomnia associated loci may contribute to the genetic risk underlying a range ofhealth conditions including psychiatric disorders and metabolic disease.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

39

52. Risk Factors for the Transition from Suicide Ideation to Suicide Attempt: Results fromthe Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) (Nock,et al 2018)•

Prior research has shown that most known risk factors for suicide attempts in thegeneral population actually predict suicide ideation rather than attempts among
ideators. Yet clinical interest in predicting suicide attempts often involves theevaluation of risk among patients with ideation.

•

This study examined a number of characteristics of suicidal thoughts hypothesized to
predict incident attempts in a retrospective analysis of lifetime ideators (N = 3,916)
drawn from a large (N = 29,982), representative sample of U.S. Army Soldiers.

•

The most powerful predictors of first nonfatal lifetime suicide attempt in a
multivariate model controlling for previously known predictors (e.g., demographics,
mental disorders) were: recent onset of ideation, presence and recent onset of asuicide plan, low controllability of suicidal thoughts, extreme risk-taking or “tempting
fate,” and failure to answer questions about the characteristics of one’s suicidal
thoughts.

•

A predictive model using these risk factors had strong accuracy (area under the curve[AUC] = .93), with 66.2% of all incident suicide attempts occurring among the 5% of
Soldiers with highest composite predicted risk.

•This high concentration of risk in this retrospective study suggests that a useful clinicaldecision support model could be constructed from prospective data to identify thosewith highest risk of subsequent suicide attempt.

53. Improving risk prediction accuracy for new soldiers in the U.S. Army by adding selfreport survey data to administrative data (Bernecker, et al 2018)•

The Army STARRS New Soldier Survey was administered to 21,790 Regular Army
Soldiers who agreed to have their survey data linked to their administrative data.
Machine-learning models using administrative data as predictors found that small
proportions of high-risk Soldiers accounted for high proportions of negative outcomes
including mental disorders, suicidality, and interpersonal violence.

•

This study examined the extent to which this survey information increased prediction
accuracy, over models based solely on administrative data, for these outcomes.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

40

•The study used discrete time survival analysis to estimate a series of models predicting
first occurrence, assessing how model fit improved and concentration of risk increased
when adding the predicted risk score based on survey data to the predicted risk scorebased on administrative data.

•

The addition of survey data improved prediction significantly for all outcomes. In themost extreme case, the percentage of reported sexual violence victimization among
the 5% of female soldiers with highest predicted risk increased from 17.5% using only
administrative predictors to 29.4% adding survey predictors, a 67.9% proportional
increase in prediction accuracy. Other proportional increases in concentration of risk
ranged from 4.8% to 49.5% (median = 26.0%).

•

The researchers concluded that the Army may benefit from routinely administering
surveys that assess additional risk factors, such as the New Soldier Survey, because thedata from the surveys could substantially improve accuracy of risk models comparedto models based exclusively on administrative predictors.

54. Associations of Time-Related Deployment Variables with Risk of Suicide Attempt
Among Soldiers (Ursano, et al 2018)•

This study was designed to determine whether risk of suicide attempt (SA) among
Soldiers is associated with time-related deployment characteristics such as time inservice prior to first deployment, length of deployment, and length of time between
deployments (dwell time).*•

It was a longitudinal, retrospective cohort study that used administrative data from2004 through 2009 to identify person-month records of active-duty Regular Armyenlisted Soldiers who had served continuously in the Army for at least 2 years. Study
included 593 medically-documented suicide attempters and 19,034 control personmonths for Soldiers who deployed exactly twice.*•

Findings indicate the risk of SA during or after second deployment was higher for
those who initially deployed within the first 12 months of service, and for those with adwell time of 6 months or less.*•

Length of first deployment was not associated with subsequent SA.

•

Time in service prior to first deployment and dwell time are modifiable risk factors for
SA risk among Soldiers.*•

The Army’s continued focus on dwell time may help mitigate a range of negative
outcomes and reduce risk of suicidal behavior.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

41

55. Nonfatal Suicidal Behaviors in the Administrative Records of Activated U.S. Army
National Guard and Army Reserve Soldiers, 2004–2009 (Ursano, et al 2018)•

The Army suicide rate increased sharply during the wars in Iraq and Afghanistan. Thereis limited information about medically-documented, nonfatal suicidal behaviors
among Soldiers in the Army’s Reserve Component (RC), which is composed of the
Army National Guard and Army Reserve.

•

This study used administrative records for all Soldiers on active duty for the years 2004
through 2009 (n = 1.66 million) to examine trends and socio-demographic correlatesof suicide attempts, suspicious injuries, and suicide ideation among activated RC
Soldiers. The study identified 2,937 unique RC Soldiers with a documented nonfatal
suicidal event.

•The study found increases in the annual incidence rates of suicide attempts (71 to
204/100,000 person-years) and suicide ideation (326 to 425/100,000 person years).
Incidence rates for suspicious injuries also generally increased but were more variable.

•

Using hierarchical classification rules, the study identified the first instance of each
Soldier’s most severe behavior (suicide attempt versus suspicious injury versus suicide
ideation). For each of those suicide- or injury-related outcomes, the study foundincreased risk among those who were female, younger, non-Hispanic White, lesseducated, never married, and lower-ranking enlisted.

•

The socio-demographic associations differed significantly across outcomes, although
the patterns were similar.

•

The results provide a broad overview of nonfatal suicidal trends in the RC during theperiod 2004 through 2009, and demonstrate that integration of multiple
administrative data systems enriches analysis of the predictors of such events.

56. Pre-deployment Predictors of Psychiatric Disorder-Symptoms and Interpersonal
Violence during Combat Deployment (Rosellini, et al 2018)•

Preventing suicides, mental disorders, and noncombat-related interpersonal violence
during deployment are priorities of the U.S. Army.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

42•This study used pre-deployment survey and Army administrative data to develop
actuarial models to identify Soldiers at high risk of these outcomes during combat
deployment. The models were developed for Soldiers in the Pre-Post Deployment
Study, a panel study of Soldiers deployed to Afghanistan in 2012–2013 who completed
self-administered questionnaires before deployment and one month (T1), threemonths (T2), and nine months (T3) after deployment, and consented to linking theirsurvey data to their Army administrative data.

•

Seven “during-deployment” outcomes were assessed using post-deployment surveys
either at T1 (n = 7,048) or at T2–T3 (n = 7,081). Machine learning was used to develop
a model for each outcome from 273 pre-deployment predictors which were comparedto simple logistic regression models.

•

The relative improvement in area under the receiver operating characteristic curve(AUC) obtained by machine learning compared to the logistic models ranged from 1.11
(major depression) to 1.83 (suicidality). The best-performing machine learning models
were for major depression (AUC=0.88), suicidality (0.86), and generalized anxiety
disorder (0.85).

•

Roughly 40% of these outcomes occurred among the 5% of Soldiers with highest
predicted risk.

•

Actuarial models could be used to identify high risk Soldiers either for exclusion from
deployment or preventive interventions. The ultimate value of this approach depends
on the associated costs, competing risks (e.g., stigma), and effectiveness of to-bedetermined interventions.

57. Risk Factors Associated with Attempted Suicide among U.S. Army Soldiers without aHistory of Mental Health Diagnosis (Ursano, et al 2018)•

This study was designed to examine predictors of suicide attempt among Soldiers
without a previous mental health diagnosis.

•

Using Army and DoD administrative data from 2004-2009, the study identified personmonth records for all active duty Regular Army enlisted Soldiers who had a medically
documented suicide attempt (n=9,650), and an equal-probability sample of control
person-months (n=153,528), then examined whether predictors of suicide attempt
varied by history of mental health diagnosis.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

43

•Suicide attempts were identified using DoD Suicide Event Report records and ICD-9
E95x diagnostic codes. Mental health diagnoses and related codes (as well as sociodemographic, service-related, physical healthcare, crime, and family violence
variables) were constructed from Army personnel, medical, legal, and family services
records.

•

The study found 36.3% (n=3,507) of Soldiers who attempted suicide did not have aprevious mental health diagnosis.*•Among Soldiers with no previous diagnosis, the highest adjusted odds of suicide
attempt were for females, less than high school education, in first year of service,previously deployed, promotion delayed 2 months or less, past-year demotion, 8 ormore outpatient physical health care visits in the past 2 months, past-month injuryrelated outpatient and inpatient health care visit, previous combat injury, minor
violent crime victimization, major violent crime perpetration, and family violence.*•

Most of these variables were also associated with suicide attempts among Soldierswith a previous mental health diagnosis, although the strength of associations
differed.*•

The study concluded that suicide attempt risk among Soldiers with unrecognized
mental health problems is a significant and important challenge, and administrative
records from personnel, medical, legal, and family services systems can assist in
identifying Soldiers at risk.*

58. Patterns and Predictors of Persistence of Suicide Ideation: Results from the Army Study
to Assess Risk and Resilience in Servicemembers (Army STARRS) (Nock, et al 2018)•

Persistent suicide ideation (SI) is known to be a risk factor for subsequent suicidal
behaviors. Reducing SI persistence among people with a history of SI may be a usefultarget for preventive intervention, but basic information is lacking about patterns andpredictors of SI persistence.

•

Based on retrospective data on annual SI persistence in a representative sample of
3,501 U.S. Army Soldiers with lifetime SI, age-of-onset and number of years with SI
were used to estimate two definitions of persistence: persistence beyond year-ofonset and proportional annual persistence.

•

For 47.8% of respondents with lifetime SI, their SI did not persist beyond the year-ofonset. For the 52.2% whose SI did persist beyond the year-of-onset, the median (interquartile range) proportional annual persistence was 33% (17-67%).

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

44•Significant predictors of increased persistence were different for respondents withpre-enlistment SI onset (prior histories of attention-deficit/hyperactivity disorder[ADHD], bipolar disorder, and panic disorder) and post-enlistment SI onset (male,combat support military occupation specialty, prior histories of ADHD, panic disorder,
and posttraumatic stress disorder).

•These predictors of persistence are different from the predictors of SI onset,
suggesting that secondary preventive interventions to reduce SI persistence may need
to focus on different factors than primary preventive interventions to reduce SI onset.

59. Attention Deficit Hyperactivity Disorder and Risk of Posttraumatic Stress and Related
Disorders: A Prospective Longitudinal Evaluation in U.S. Army Soldiers (Howlett, et al
2018)•

Aim of this study was to examine whether pre-deployment ADHD is associated withincreased risk of post-deployment PTSD among U.S. Army Soldiers.

•

Soldiers (n=4,612) who completed all assessments in the prospective Pre/Post
Deployment Study of Soldiers deployed to Afghanistan comprised the sample toestimate association of pre-deployment ADHD with post-deployment PTSD.

•

Also examined relationships of pre-deployment ADHD with post-deployment major
depressive episode (MDE), generalized anxiety disorder (GAD), and suicidal ideation.

•

Weighted prevalence of ADHD pre-deployment was 6.1% (SE=0.4%). Adjusting forother risk factors and pre-deployment PTSD, pre-deployment ADHD was associatedwith elevated odds of post-deployment PTSD (AOR= 2.13, 95% CI=1.51–3.00, p<.001).

•

Pre-deployment ADHD was similarly associated with incidence of PTSD among Soldierswith no lifetime history (AOR= 2.50, 95% CI=1.69–3.69, p<.001).

•

ADHD also displayed associations with post-deployment MDE (AOR=2.80, 95%
CI=2.01-3.91, p<0.0005) and GAD (AOR=3.04, 95% CI=2.10-4.42, p<.001), but notsuicidal ideation.

•

Recognition of associations between pre-deployment ADHD and post-deployment
PTSD, MDE, and GAD may inform targeted prevention efforts. Future research should
examine whether treatment of ADHD is protective against PTSD and related disorders
in trauma-exposed individuals.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

45

60. Pre-deployment Insomnia is Associated with Post-deployment PTSD and Suicidal
Ideation in US Army Soldiers (Wang, et al 2018)•

Insomnia is prevalent among military personnel and may increase risk of mental
disorders and suicidal ideation. This study examined associations of pre-deployment
insomnia with post-deployment post-traumatic stress disorder (PTSD) and suicidal
ideation among U.S. Army Soldiers.

•

Study included Soldiers from 3 Brigade Combat Teams who completed surveys 1–2
months before deploying to Afghanistan in 2012 (T0), on return from deployment (T1),
3 months later (T2), and 9 months later (T3). Logistic regression was used to estimate
associations of pre-deployment (T0) insomnia with post-deployment (T2 or T3) PTSD
and suicidal ideation among those who completed surveys at all waves (n = 4,645).

•Pre-deployment insomnia was associated with increased risk of post-deployment PTSD
(adjusted odds ratio [AOR] = 3.14, 95% confidence interval [CI] = 2.58% to 3.82%, p <.0005) and suicidal ideation (AOR = 2.78, 95% CI = 2.07% to 3.74%, p < .0005) inmodels adjusting for socio-demographic characteristics and prior deployment history.

•

Adjustment for other pre-deployment risk factors and deployment experiences
attenuated these associations, but insomnia remained significantly associated with
post-deployment PTSD (AOR = 1.50, 95% CI = 1.19% to 1.89%, p = .001) and suicidal
ideation (AOR = 1.43, 95% CI = 1.04% to 1.95%, p = .027).

•

Subgroup models showed that pre-deployment insomnia was associated with incident
PTSD (AOR = 1.55, 95% CI = 1.17% to 2.07%, p = .003) and suicidal ideation (AOR =1.67, 95% CI = 1.16% to 2.40%, p = .006) among Soldiers with no pre-deployment
history of these problems.

•

Study found that pre-deployment insomnia contributed to prediction of postdeployment PTSD and suicidal ideation in Army Soldiers, suggesting that detection of
insomnia could facilitate targeting of risk mitigation programs.

61. Predicting Suicide Attempts among Soldiers who deny Suicidal Ideation (Bernecker, etal 2018)•

Most non-fatal suicide attempts and suicide deaths occur among patients who denysuicidal ideation (SI) during suicide risk screenings. But little is known about risk
factors for suicidal behaviors among such patients. The study investigated this using a
representative sample of U.S. Army Soldiers who denied lifetime SI in a survey andwere then followed through administrative records for up to 45 months to learn ofadministratively-recorded suicide attempts (SA).

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

46

•Study used a novel two-stage risk assessment approach that combined first-stage
prediction from administrative records to find the subsample of SI deniers withhighest subsequent SA risk, then used survey reports to estimate a second-stage
model identifying the subset of individuals in the high-risk subsample at highest SA
risk.

•

70% of survey respondents denied lifetime SI. Administrative data identified 30% of
this 70% who accounted for 81.2% of subsequent administratively-recorded SAs. A
relatively small number of self-report survey variables were then used to create aprediction model that identified 10% of the first-stage high-risk sample (i.e., 3% of all
Soldiers) at highest SA risk (accounting for 45% of SAs in the total sample).

•

Study discussed potential applications of this approach for identifying future SI deniers
at highest SA risk.

62. Transition to Suicide Attempt from Recent Suicide Ideation in U.S. Army Soldiers(Naifeh, et al 2018)•

Most people with suicide ideation (SI) do not attempt suicide (SA). Understanding thetransition from current/recent SI to SA is important for mental health care. The
objective of this study was to identify characteristics that differentiate SA from 30-day
SI among representative U.S. Army Soldiers.

•

The study used a unique case–control design including Soldiers recently hospitalized
for SA (n = 132) and representative Soldiers from the same four communities (n =10,193) who were administered the same questionnaire.

•

The study systematically identified variables that differentiated suicide attemptersfrom the total population, then examined whether those same variables differentiatedall 30-day ideators (n = 257) from the total population, and attempters from nonattempting 30-day ideators.

•

In univariable analyses, 20 of 23 predictors were associated with SA in the total
population (0.05 level). The best multivariable model included 8 significant predictors:
interpersonal violence, relationship problems, major depressive disorder, posttraumatic stress disorder (PTSD), and substance use disorder (all having positive
associations), as well as past 12-month combat trauma, intermittent explosive
disorder (IED), and any college education (all having negative associations).

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

47

•

Six of these predictors differentiated 30-day ideators from the population. Three ofthese predictors differentiated attempters from ideators: past 30-day PTSD (OR = 6.7[95% CI = 1.1–39.4]), past 30-day IED (OR = 0.2 [95% CI = 0.1–0.5]), and any college
education (OR = 0.1 [95% CI = 0.0–0.6]). The 5% of ideators with highest predicted riskin this final model included 20.9% of attempters, a four-fold concentration of risk.

•

Study concluded that combat exposure did not differentiate attempters from ideators,
many SA risk factors in the Army population are actually risk factors for SI, andprospective Army research examining transition from SI to SA should consider PTSD,
IED, and education.

63. Suicide Attempts among Activated Soldiers in the U.S. Army Reserve Components(Naifeh, et al 2019)•

Although the majority of active duty Soldiers are full-time personnel in the Active
Component (AC), a substantial minority are in the Reserve Components (RCs). These“citizen-Soldiers” (Army National Guard and Army Reserve) experience many of thesame stressors as AC Soldiers as well as stressors that are unique to their intermittent
service. Despite the important role of RC Soldiers, the vast majority of military mental
health research focuses on AC Soldiers. One important goal of Army STARRS was toaddress this gap.

•

This was a longitudinal, retrospective cohort study that examined predictors of suicide
attempts among activated RC Soldiers using individual-level person-month records
from Army and Department of Defense administrative data systems to examine sociodemographic, service-related, and mental health predictors of medically documented
suicide attempts from 2004 to 2009.

•

Analysis used a discrete-time survival framework and included data from all 1,103
activated RC suicide attempters and an equal-probability sample of 69,867 control
person-months.

•

Study found that enlisted Soldiers comprised 84.3% of activated RC Soldiers andaccounted for 95.7% of all activated RC suicide attempts (overall rate = 108/100,000
person-years, more than four times the rate among officers).

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

48

•Multivariable predictors of enlisted RC suicide attempts included being female,entering Army service at age ≥25, current age <30, non-Hispanic white, <high school
education, currently married, having 1–2 years of service, being previously deployed(vs. currently deployed), and history of mental health diagnosis (particularly when
documented in the previous month). Predictors among RC officers (overall rate =26/100,000 person-years) included being female and receiving a mental healthdiagnosis in the previous month.

•

Discrete-time hazard models showed suicide attempt risk among enlisted Soldiers wasinversely associated with time in service.

•

Study concluded that risk factors for suicide attempt in the RCs were similar to thosepreviously observed in the AC, highlighting the importance of research and prevention
focused on RC enlisted Soldiers in the early phases of Army service and those with arecent mental health diagnosis.

64. Prospective Associations of Perceived Unit Cohesion with Post-deployment Mental
Health Outcomes (Anderson, et al 2019)•

Prior investigations have found negative associations between military unit cohesion
and posttraumatic stress disorder (PTSD); however, most relied on cross-sectional
data and few examined relationships of unit cohesion to other mental disorders. This
study evaluated prospective associations of perceived unit cohesion with a range ofmental health outcomes following combat deployment.

•

Soldiers were surveyed approximately 1–2 months before deployment to Afghanistan(T0); and 1 month (T1), 3 months (T2), and 9 months (T3) after return from
deployment. Logistic regression was performed to estimate associations of perceived
unit cohesion at T0 with risk of PTSD, major depressive episode (MDE), generalized
anxiety disorder (GAD), alcohol or substance use disorder (AUD/SUD), and suicidal
ideation at T2 or T3 among 4,645 Soldiers who completed all study assessments.
Models were adjusted for socio-demographic and Army service characteristics, predeployment history of the index outcome, and deployment stress exposure.

•

Higher perceived unit cohesion at T0 was associated with lower risk of PTSD, MDE,
GAD, AUD/SUD, and suicidal ideation at T2 or T3 (AORs = 0.72 to 0.85 per standard
score increase in unit cohesion; P-values < 0.05). Models of incidence of mental
disorders and suicidal ideation among Soldiers without these problems predeployment yielded similar results, except that perceived unit cohesion was not
associated with incident AUD/SUD.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

49

•Soldiers who reported strong unit cohesion before deployment had lower risk of postdeployment mental disorders and suicidal ideation.

•

Awareness of associations of perceived unit cohesion with post-deployment mental
health may facilitate targeting of prevention programs.

65. Nicotine Dependence and Pre-Enlistment Suicidal Behavior Among U.S. Army Soldiers(Campbell-Sills, et al 2019)•

This study investigated associations of nicotine dependence with suicidal behaviors
among incoming Soldiers. Lifetime DSM-IV nicotine dependence, mental disorders,suicidal behaviors, and their ages of onset were retrospectively assessed in Soldiers
entering the Army in 2011−2012.

•

Discrete-time survival analysis of person-year data from 30,436 Soldiers was
performed to evaluate associations of nicotine dependence with subsequent suicidal
ideation, plans, and attempts. Among respondents with lifetime ideation (n=4,060),
models tested associations of nicotine dependence with progression from ideation toﬁrst onset of plan, from plan to ﬁrst attempt, and, among ideators without plans, from
ideation to ﬁrst unplanned attempt. A hierarchy of models incorporated increasing
controls for other risk factors.

•

In models controlling for socio-demographic characteristics, nicotine dependence wasassociated with onset of all suicidal behaviors (AORs, 2.07−4.08, p <0.001) and witheach type of progression of suicidal behavior (AORs, 1.48−2.44, p <0.005). After
adjusting for childhood adversities and mental disorders, nicotine dependence
remained associated with onset of ideation (AOR=1.27, 95%CI=1.10, 1.46, p=0.001)
and attempt (AOR=1.83, 95% CI=1.41, 2.37, p <0.001); and with progression from
ideation to unplanned attempt (AOR=2.03, 95% CI=1.17, 1.74, p <0.001).

•

Nicotine dependence exhibited associations with onset of suicidal ideation and suicide
attempt (and with progression from ideation to unplanned attempt) that wereindependent of other measured risk factors.

•

Awareness of associations of nicotine dependence with suicidal behaviors may informrisk assessment, facilitate targeting of prevention efforts, and provide further impetus
for reducing nicotine dependence.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

50

66. Assessment of a Risk Index for Suicide Attempts among U.S. Army Soldiers with Suicide
Ideation (Zuromski, et al 2019)•

The Department of Veterans Affairs recently began requiring annual suicide ideation(SI) screening of all patients and additional structured questions for patients reporting
SI. Related changes are under consideration at the Department of Defense. Thesechanges will presumably lead to higher SI detection, which will require hiring
additional clinical staff and/or developing a clinical decision support system to focus
in-depth suicide risk assessments on patients considered high risk.

•This study was designed as a proof-of-concept for whether a brief structured question
battery from a survey of Soldiers can help target in-depth suicide risk assessments byidentifying Soldiers with self-reported lifetime SI who are at highest risk of subsequentadministratively recorded nonfatal suicide attempts (SAs).

•

This was a cohort study with prospective observational design involving data collection
from May 2011 to February 2013, and participant follow-up through December 2014.

•

Analyses included a logistic regression model to assess risk for subsequentadministratively recorded nonfatal SAs among a total of 3,649 Soldiers who reported
lifetime SI in surveys and were followed-up for 18-45 months from baseline to assess
administratively reported nonfatal SAs between survey response and December 2014.

•

The 3,649 survey respondents were 80.5% male and had a median (interquartile
range) age of 29 (25-36) years (range, 18-55 years); 69.4% were white non-Hispanic,
14.6% were black, 9.0% were Hispanic, 7.0% were another racial/ethnic group.

•

Sixty-five respondents had administratively recorded nonfatal SAs between survey
response and December 2014. One additional respondent died by suicide without
making a nonfatal SA but was excluded from analysis based on previous evidence thatpredictors are different for suicide death and nonfatal SAs.

•

Significant risk factors were SI recency (odds ratio [OR], 7.2; 95% CI, 2.9-18.0) andpersistence (OR, 2.6; 95% CI, 1.0-6.8), positive screens for mental disorders (OR, 26.2;
95% CI, 6.1-112.0), and Army career characteristics (OR for junior enlisted rank, 30.0;
95% CI, 3.3-272.5 and OR for senior enlisted rank, 6.7; 95% CI, 0.8-54.9). Crossvalidated area under the curve was 0.78. The 10% of respondents with highest
estimated risk accounted for 39.2% of subsequent SAs.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

51

•

Results suggest the feasibility of developing a clinically useful risk index for SA among
Soldiers with SI using a small number of self-report questions. If implemented, acontinuous quality improvement approach should be taken to refine the structured
question series.

67. Prospective Study of Polygenic Risk, Protective Factors, and Incident Depression
following Combat Deployment in US Army Soldiers (Choi, et al 2019)•

This study examined whether trait resilience and/or unit cohesion could protect
against the onset of MDD following combat deployment, even in Soldiers at highpolygenic risk.

•

Study analyzed data from 3,079 Soldiers of European ancestry assessed before andafter their deployment to Afghanistan. Incident MDD was defined as no MDD episodeat pre-deployment, followed by a MDD episode following deployment.

•

Polygenic risk scores were constructed from a large-scale genome-wide association
study of major depression. Study first examined the main effects of the MDD PRS andeach protective factor on incident MDD. Then study tested the effects of eachprotective factor on incident MDD across strata of polygenic risk.

•

Study found that polygenic risk showed a dose–response relationship to depression,
such that Soldiers at high polygenic risk had greatest odds for incident MDD.

•

Both unit cohesion and trait resilience were prospectively associated with reduced risk
for incident MDD. The protective effect of unit cohesion persisted even in Soldiers at
highest polygenic risk.

•

Study concluded that polygenic risk was associated with new-onset MDD in deployed
Soldiers. Unit cohesion (an index of perceived support and morale) was protective
against incident MDD even among those at highest genetic risk, and may represent a
potent target for promoting resilience in vulnerable Soldiers.

•

Findings illustrate the value of combining genomic and environmental data in aprospective design to identify robust protective factors for mental health.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

52

68. Utilization of and Barriers to Treatment among Suicide Decedents: Results from the
Army Study to Assess Risk and Resilience among Servicemembers (Army STARRS)(Zuromski, et al 2019)•

This was a psychological autopsy study that examined suicide decedents’ use ofmental health treatment and perceived barriers to initiating and maintaining
treatment. This study compared suicide decedents (n=135) to Soldiers in two control
conditions: those propensity-score-matched on known socio-demographic and Armyhistory variables (n=137) and those with a history of suicidal thoughts in the past 12
months (n=118). Informants were next-of-kin and Army supervisors.

•

Study results revealed that suicide decedents were significantly more likely to bereferred to services and to use more intensive treatments (e.g., medication, overnight
stay in hospital) than propensity-matched controls. Decedents were also more likely toperceive significant barriers to treatment-seeking.

•All differences observed in this study were between propensity-matched controls anddecedents, with no observed differences between suicide ideators and decedents.

•

The study concluded that many suicide decedents used some form of mental healthcare at some point in their lives, but they also were more likely than propensitymatched controls to perceive barriers that may have prevented service use.

•

The lack of differences between suicide ideators and decedents suggests that more
information is needed, beyond knowledge of treatment utilization or perceived
barriers, to identify and intervene with those at highest risk for suicide.

•

These findings underscore the importance of reducing attitudinal barriers that may
deter suicidal Soldiers from seeking treatment, and also improving risk detection
among those who are attending treatment.

69. Genome-wide Analyses of Psychological Resilience in U.S. Army Soldiers (Stein, et al
2019)•

There is a growing body of preclinical and translational research illuminating a
biological basis for resilience to stress, but little is known about the genetic basis of
psychological resilience in humans.

•

For this study, genome-wide association studies (GWASs) were conducted of selfassessed (by questionnaire) and outcome-based (incident mental disorders from predeployment to post-deployment) resilience among European (EUR) ancestry Soldiers.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

53

•

Self-assessed resilience (n=11,492) was found to have significant common-variant
heritability and to be significantly negatively genetically correlated with neuroticism.

•

GWAS results from the EUR Soldiers revealed a genome-wide significant locus on anintergenic region on Chr 4 upstream from doublecortin-like kinase 2 (DCLK2) (foursingle nucleotide polymorphisms (SNPs) in LD; topSNP: rs4260523 is an eQTL in frontal
cortex), a member of the doublecortin family of kinases that promote survival andregeneration of injured neurons. A second gene, kelch-like family member 36 (KLHL36)
was detected at gene-wise genome-wide significance. A polygenic risk score derived
from the self-assessed resilience GWAS was not significantly associated with outcomebased resilience.

•

In very preliminary results, genome-wide significant association with outcome-based
resilience was found for one locus (top SNP: rs12580015) on Chr 12 downstream fromsolute carrier family 15 member 5 (SLC15A5) in subjects (n=581) exposed to thehighest level of deployment stress.

•

Further study of genetic determinants of resilience has the potential to illuminate themolecular bases of stress-related psychopathology and point to new avenues fortherapeutic intervention.

70. Association of Firearm Ownership, Use, Accessibility, and Storage Practices with Suicide
Risk among U.S. Army Soldiers (Dempsey, et al 2019)•

Since 2004, the suicide rate among Army Soldiers has exceeded the rate of death fromcombat injury. It is critical to establish factors that increase risk of acting on suicidal
thoughts to guide early intervention and suicide prevention.

•

This study included 135 cases of Army Soldiers who died by suicide while on active
duty from Aug 1, 2011 to Nov 1, 2013. Cases were compared with propensitymatched controls and control Soldiers with past year suicidal ideation. Next-of-kin(NOK) and Army supervisors of case and control Soldiers were interviewed. Firearmownership, storage, and accessibility were assessed using items from the World HealthOrganization Composite International Diagnostic Interview screening scales along withitems created for Army STARRS.

•

For the 135 cases, the NOK reported greater accessibility to firearms compared withpropensity-matched controls. Specifically, when compared with propensity-matched
controls, suicide decedents were:o 2 times as likely to own 1 or more handguns
o 4 times as likely to store a loaded gun at home

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

54

o 3 times as likely to publicly carry a gun when not required for military dutyo The combination of these 3 items was associated with 3-fold increase in theodds of suicide deatho Storing a loaded gun with ammunition at home or publicly carrying a gun when
not on duty was associated with 4-fold increase in odds of suicide deatho In addition to gun ownership, ease and immediacy of firearm access wereassociated with an increased suicide risk•

The study concluded that discussion with family members and supervisors about
limiting firearm accessibility should be evaluated for potential intervention.

71. Associations of Lifetime Traumatic Brain Injury Characteristics With Prospective Suicide
Attempt Among Deployed U.S. Army Soldiers (Campbell-Sills, et al 2019)•

This study estimated associations of lifetime traumatic brain injury (TBI) characteristics
with prospective suicide attempt among U.S. Army Soldiers. The data were from the
Army STARRS Pre/Post Deployment Study that surveyed 3 Brigade Combat Teams thatwere deployed to Afghanistan in 2012.

•

Lifetime TBI and past-month post-concussive/post-TBI symptoms were evaluated at
pre-deployment baseline. Recency and number of TBIs were quantified, and TBI
severity was classified on the basis of reports of alteration/loss of consciousness andmemory lapse. Suicide attempt data came from administrative records and surveys
administered after return from deployment.

•

Logistic regression models estimated associations of TBI characteristics withprospective suicide attempt among baseline respondents who were deployed(n=7,677), adjusting for other risk factors including lifetime mental disorder. One
hundred three Soldiers made a suicide attempt over a median follow-up period of 30
months.

•In the final model estimating joint associations of TBI severity/recency and past-month
post-concussive/post-TBI symptoms, only post-concussive/post-TBI symptoms wereassociated with a higher risk of suicide attempt.

•

The study concluded that among the lifetime TBI characteristics evaluated at predeployment baseline, only past-month post-concussive/post-TBI symptoms were
prospectively associated with an increased risk of suicide attempt following
deployment. Detection of post-concussive/post-TBI symptoms could facilitatetargeting of Army suicide prevention programs.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

55

72. The Association of Lifetime and Deployment-Acquired Traumatic Brain Injury With
Postdeployment Binge and Heavy Drinking (Adams, et al 2019)•

This was a prospective, longitudinal study to investigate associations of lifetime
traumatic brain injury (LT-TBI) prior to an index deployment, and/or deploymentacquired TBI (DA-TBI), with post-deployment binge and heavy drinking.

•The study included 4,645 Soldiers from 3 Brigade Combat Teams deployed to
Afghanistan in 2012 who participated in the Pre/Post Deployment Study andcompleted all 4 study assessments: T0 (1-2 months pre-deployment), T1 (upon returnto the U.S.), T2 (3 months post-deployment), and T3 (9 months post-deployment).

•

The measures included self-reported past month binge drinking (5+ alcoholic
beverages on the same day) and past month heavy drinking (binge drinking at least
weekly) at T2 and T3. The study controlled for baseline binge drinking.

•In total, 34.3% screened positive for LT-TBI, and 19.2% screened positive for DA-TBI. At
T2 only, LT-TBI, but not DA-TBI, was associated with increased odds of binge drinking(adjusted odds ratio [AOR] = 1.39, 95% confidence interval [CI]: 1.20-1.60, P < .001)
and heavy drinking (AOR = 1.28, 95% CI: 1.09-1.49, P = .007). Among the subgroupwith LT-TBI, also having DA-TBI was associated with increased risk of heavy drinking at
T3 (AOR = 1.42, 95% CI: 1.03-1.95, P = .047).

•

The study concluded that routine screening for LT-TBI may help target efforts toprevent alcohol misuse among military members.

73. Developing an Optimal Short-Form of the PTSD Checklist for DSM-5 (PCL-5) (Zuromski,
et al 2019)•

Although several short‐forms of the posttraumatic stress disorder (PTSD) checklist(PCL) exist, all were developed using heuristic methods. This study worked with Army
STARRS datasets to create an optimal short‐form PCL for DSM‐5 (PCL‐5) using bothmachine learning and conventional scale development methods.

•

A training dataset (n=8,917) was used to fit short‐form scales with 1 to 8 items using
different statistical methods (exploratory factor analysis, stepwise logistic regression,and a new machine learning method to find an optimal integer‐scored short‐form
scale) to predict dichotomous PTSD diagnoses that were determined using the fullPCL‐5.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

56•

A smaller subset of best short‐form scales was then evaluated in an independentvalidation sample (n=11,728) to select one optimal short‐form scale based on multiple
operating characteristics (area under curve [AUC], calibration, sensitivity, specificity,
net benefit).

•

Inspection of AUCs in the training sample and replication in the validation sample led
to a focus on 4‐item integer‐scored short‐form scales selected with stepwise
regression. Brier scores in the validation sample showed that a number of these scales
had comparable calibration (0.015–0.032) and AUC (0.984–0.994), but that one had
consistently highest net benefit across a plausible range of decision thresholds.

•

The study concluded that the recommended 4‐item integer‐scored short‐form PCL‐5
generated diagnoses that closely parallel those of the full PCL‐5, making it well‐suited
for screening.

74. Postconcussive, Posttraumatic Stress and Depressive Symptoms in Recently Deployed
U.S. Army Soldiers with Traumatic Brain Injury (Agtarap, et al 2019).
•

Prior studies raise questions about whether persistent post-concussive symptoms(PCS) are differentiable from mental health sequelae of traumatic brain injury (TBI).
Using data from the Army STARRS Pre/Post Deployment Study that surveyed 3 Brigade
Combat Teams that were deployed to Afghanistan in 2012, this study evaluated thestructure of post-concussive, posttraumatic stress, and depressive symptoms following
TBI, to investigate whether PCS represented a distinct symptom domain.

•

Data from 1,229 participants who sustained probable TBI during deployment
completed ratings of past-30-day post-concussive, posttraumatic stress, anddepressive symptoms three months after return from deployment. Exploratory factor
analysis (EFA; n=300) and confirmatory factor analysis (CFA; n=929) of symptom
ratings were performed in independent subsamples.

•

EFA suggested a model with three correlated factors resembling PCS, posttraumaticstress, and depression. CFA confirmed adequate fit of the 3-factor model (CFI=.964,
RMSEA=.073 [.070-.075]), contingent upon allowing theoretically defensible crossloadings.

•

Bifactor CFA indicated that variance in all symptoms was explained by a general factor
but also provided evidence of domain factors defined by: (1) reexperiencing/hyperarousal, (2) cognitive/somatic symptoms, and (3) depressedmood/anhedonia.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

57

•

Soldiers with more severe TBI had higher cognitive/somatic scores, while Soldiers withmore deployment stress had higher general and re-experiencing/hyperarousal scores.
The variance in PCS was attributable to both a specific cognitive/somatic symptom
factor and a general factor that also explained variance in posttraumatic stress anddepression.

•

Measurement of specific domains representing cognitive/somatic symptoms, reexperiencing/hyperarousal, and depressed mood/anhedonia may help clarify the
relative severity of PCS, posttraumatic stress, and depression among individuals withrecent TBI.

75. Early First Deployment and Risk of Suicide Attempt Among First-term Enlisted Soldiersin the U.S. Army (Naifeh, et al 2019)•

The study examined early first deployment and subsequent suicide attempt among
U.S. Army Soldiers using 2004–2009 administrative data and person-month records offirst term, Regular Army, enlisted Soldiers with one deployment (89.2% male). The
study identified 1,704 Soldiers with a documented suicide attempt during or after first
deployment and an equal-probability control sample (n = 25,861 person-months).

•

Logistic regression analyses indicated Soldiers deployed within the first 12 months ofservice were more likely than later deployers to attempt suicide (OR = 1.7 [95% CI =1.5–1.8]). Adjusting for sociodemographic characteristics, service-relatedcharacteristics, and previous mental health diagnosis slightly attenuated thisassociation (OR = 1.6 [95% CI = 1.5–1.8]). Results were not modified by gender,
deployment status, military occupation, or mental health diagnosis.

•

The population-attributable risk proportion for deploying within the first 12 months ofservice was 17.8%. Linear spline models indicated similar risk patterns over time forearly and later deployers, peaking at month 9 during deployment and month 5 postdeployment; however, monthly suicide attempt rates were consistently higher forearly deployers.

•

The study concluded that enlisted Soldiers deployed within the first 12 months ofservice had elevated risk of suicide attempt during and after first deployment.
Improved understanding of why early deployment increases risk can inform thedevelopment of policies and intervention programs.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

58

76. Risk Factors and Timing of Suicide Attempts among US Army Reserve Component
Soldiers during Deployment to the Afghanistan and Iraq Wars (Stokes, et al 2019)•

During the wars in Afghanistan and Iraq, suicidal behaviors increased among U.S. Army
Soldiers. Although Reserve Component (RC) Soldiers (National Guard and Army
Reserve) comprise approximately one third of those deployed in support of the wars,
few studies have examined suicidal behaviors among these “citizen-soldiers.” Theobjective of the study was to examine suicide attempt risk factors and timing among
RC enlisted Soldiers.

•

This longitudinal, retrospective cohort study used individual-level person-month
records from Army and Department of Defense administrative data systems to
examine socio-demographic, service-related, and mental health predictors of
medically documented suicide attempts among enlisted RC Soldiers during
deployment from 2004–2009. Data were analyzed using discrete-time survival models.
A total of 230 enlisted RC Soldiers attempted suicide.

•

Overall, the in-theater suicide attempt rate among RC Soldiers was 81/100,000
person-years. Risk was highest in the fifth month of deployment (13.8 per 100,000
person-months). Suicide attempts were more likely among Soldiers who were women(adjusted odds ratio, aOR = 2.5 [95% CI: 1.8–3.5]), less than high school educated (aOR
= 1.8 [95% CI: 1.3–2.5]), in their first 2 years of service (aOR = 2.0 [95% CI: 1.2–3.4]),
were currently married (aOR = 2.0 [95% CI: 1.5–2.7]), and had received a mental
health diagnosis in the previous month (aOR = 24.7 [95% CI: 17.4–35.0]).

•

The study concluded that being female, early in service and currently married areassociated with increased odds of suicide attempt in RC soldiers. Risk of suicide
attempt was greatest at mid deployment. These predictors and the timing of suicide
attempt for RC Soldiers in-theater are largely consistent with those of deployed Active
Component (Regular) Soldiers. Results also reinforce and replicate the findings among
Active Component Soldiers related to the importance of a recent mental healthdiagnosis and the mid-deployment as a period of enhanced risk.

77. Economic Evaluation of Brief Cognitive Behavioral Therapy vs Treatment as Usual for
Suicidal US Army Soldiers (Bernecker, et al 2019)•

Brief cognitive behavioral therapy (BCBT) is a clinically effective intervention for
reducing risk of suicide attempts among suicidal Army Soldiers. Because specialized
treatments can be resource intensive, more information is needed on costs andbenefits of BCBT compared with existing treatments. This study was designed toevaluate the cost-effectiveness of BCBT compared with treatment as usual for suicidal
Army Soldiers.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

59

•This study used a decision analytic model to compare effects and costs of BCBT vstreatment as usual. Input data were drawn from epidemiologic data sets and a clinical
trial of suicidal Soldiers. The study compared treatment as usual alone versus
treatment as usual plus 12 individual BCBT sessions. Treatment as usual could include
a range of pharmacologic and psychological treatment options.

•

BCBT was expected to avert about 23-25 more suicide attempts and 1-3 more suicide
deaths per 100 patients treated than treatment as usual. Sensitivity analyses showed
BCBT to be cost saving in most scenarios. Using the federal discount rate, the DoD wasestimated to save $15,000-$16,630 per patient with BCBT vs treatment as usual. In a
worst-case scenario (i.e., assuming the weakest plausible BCBT effect sizes), BCBT costan additional $1,910 to $2,250 per patient compared with treatment as usual.

•

Results suggest BCBT may be a cost-saving intervention for suicidal active-duty
Soldiers. The costs of ensuring treatment fidelity would also need to be consideredwhen assessing the implications of disseminating BCBT across the entire DoD.

78. Pre-deployment predictors of suicide attempt during and after combat deployment(Zurmoski, et al 2019•

Deployment-related experiences might be risk factors for Soldier suicides in whichcase identification of vulnerable Soldiers before deployment could inform preventive
efforts. This study investigated this possibility by using pre-deployment survey andadministrative data in a sample of US Army Soldiers to develop a risk model for suicide
attempt (SA) during and shortly after deployment.

•

Soldiers in the Pre-Post Deployment Survey (PPDS) completed a baseline survey
shortly before deploying to Afghanistan in 2011–2012. Survey measures were used to
predict SAs, defined using administrative and subsequent survey data, through 30
months after deployment. Models were built using penalized regression and ensemble
machine learning methods.

•

Significant pre-deployment risk factors were history of traumatic brain injury, 9+mental health treatment visits in the 12 months before deployment, young age,female, previously married, and low relationship quality. Cross-validated AUC of thebest penalized and ensemble models were .75–.77.

•

21.3–40.4% of SAs occurred among the 5–10% of Soldiers with highest predicted risk
and positive predictive value (PPV) among these high-risk Soldiers was 4.4–5.7%.

•

Study concluded that SA can be predicted significantly from pre-deployment data, butintervention planning needs to take PPV into consideration.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

60

79. Genome-wide association study of shared liability to anxiety disorders (Hettema, et al
2019)•

Anxiety disorders (ANX), namely generalized anxiety, panic disorder, and phobias, arecommon, etiologically complex syndromes that show increasing prevalence andcomorbidity throughout adolescence and beyond. Few genome-wide association
studies (GWAS) examining ANX risk have been published and almost exclusively inindividuals of European ancestry.

•In this study, participants were phenotyped to approximate DSM-based ANX diagnoses
and each subject was factor-analyzed to create a single dimensional anxiety score.
GWAS were conducted using that score within each of three ancestral groups (EUR,
AFR, LAT) and then meta-analyzed across ancestries (N Total = 16,510).

•

The study sought to (a) replicate prior ANX GWAS findings in ANGST; (b) determine
whether results extended to other ancestry groups; and (c) meta-analyze with ANGST
for increased power to identify novel susceptibility loci.

•

No reliable genome-wide significant SNP associations were detected. However, SNPs
within the CAMKMT gene located in region 2p21 associated with shared ANX risk in
ANGST were replicated in EUR Soldiers but not in other ancestry groups.

•

Combining EUR STARRS and ANGST (N = 28,950) yielded a more robust 2p21
association signal (p = 9.08x10−11). Gene-based analyses supported three genes
within 2p21 and LBX1 on chromosome 10. More powerful ANX genetic studies will be
required to identify further loci.

80. Factors associated with suicide ideation in US Army soldiers during deployment in
Afghanistan (Ursano, et al 2020)•

This study was designed to better understand suicide ideation (SI) during combat
deployment to help inform prevention and treatment during and after deployment.
The study examined associations of sociodemographic characteristics, lifetime andpast-year stressors, and mental disorders with 30-day SI among a representative
sample of US Army Soldiers deployed in Afghanistan.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

61

•Soldiers who were deployed to Afghanistan completed self-administeredquestionnaires and the sample was weighted to represent all 87,032 Soldiers serving
in Afghanistan. Prevalence of lifetime, past-year, and 30-day SI and mental disorders
was determined and logistic regression analyses was used to examine risk factors
associated with SI. The study assessed SI, lifetime and 12-month stressors, and mental
disorders using questionnaires. Administrative records identified sociodemographic
characteristics and suicide attempts.

•

A total of 3,957 Soldiers (3,473 [weighted 87.5%] male; 2,135 [weighted 52.6%] aged
29 years) completed self-administered questionnaires during their deployment in
Afghanistan. Lifetime, past-year, and 30-day SI prevalence estimates were 11.7%,
3.0%, and 1.9%, respectively. Among Soldiers with SI, 44.2% had major depressive
disorder (MDD) and 19.3% had PTSD in the past 30-day period.

•

A series of analyses of the 23 grouped variables potentially associated with SI resulted
in a final model of sex; race/ethnicity; lifetime noncombat trauma; past 12-month
relationship problems, legal problems, and death or illness of a friend or family
member; and MDD. In this final multivariable model, white race/ethnicity, lifetime
noncombat trauma, and MDD were associated with SI. Among the 85 Soldiers withpast 30-day SI, from survey administration through 12 months after returning from
deployment, 6% (5 participants) had a documented suicide attempt vs 0.14% (6participants) of the 3,872 Soldiers without SI.

•

This study suggests that major depressive disorder and noncombat trauma areimportant factors in identifying SI risk during combat deployment.

81. Self-injurious thoughts and behaviors that differentiate soldiers who attempt suicidefrom those with recent suicide ideation (Naifeh, et al 2020)•

Because risk for suicide attempt (SA) versus suicide ideation (SI) is clinically importantand difficult to differentiate, this study examined whether a history of self‐injurious
thoughts and behaviors (SITBs) differentiates Soldiers with a recent SA from nonattempting Soldiers with current or recent SI.

•

This study used a unique case‐control design and administered the samequestionnaire (assessing the history of SITBs and psychosocial variables) torepresentative Soldiers recently hospitalized for SA (n = 132) and Soldiers from thesame Army installations who reported 30‐day SI but did not make an attempt (n =125). Logistic regression analyses examined whether SITBs differentiated attemptersand ideators after controlling for previously identified covariates.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

62•

In separate models that weighted for systematic non-response and controlled forgender, education, post-traumatic stress disorder, and intermittent explosive disorder,
SA was positively and significantly associated with the history of suicide plan and/or
intention to act, difficulty controlling suicidal thoughts during the worst week ofideation, and non-suicidal self‐injury (NSSI). Area under the curve was 0.87 in a fullmodel that combined these SITBs and covariates. The top ventile based on predictedrisk had a sensitivity of 24.7%, specificity of 99.8%, and positive predictive value of
97.5%.

•The study concluded that history of suicide plan/intention, difficult to control ideation,
and NSSI differentiate Soldiers with recent SA from those with current/recent SI
independent of sociodemographic characteristics and mental disorders. Longitudinal
research is needed to determine whether these factors are prospectively associatedwith the short‐term transition from SI to SA.

82. Unit cohesion during deployment and post-deployment mental health: is cohesion an
individual- or unit-level buffer for combat-exposed soldiers? (Campbell-Sills, et al 2020)•

Unit cohesion may protect Soldier mental health by mitigating effects of combat
exposure, but questions remain about the origins of potential stress-buffering effects.

•

This study examined buffering effects associated with two forms of unit cohesion(peer-oriented horizontal cohesion and subordinate-leader vertical cohesion) definedas either individual-level or aggregated unit-level variables.

•

Using mixed-effects regression, the study analyzed longitudinal survey data from
Soldiers who deployed to Afghanistan in 2012. Models evaluated individual- and unitlevel interaction effects of combat exposure and cohesion during deployment on
symptoms of post-traumatic stress disorder (PTSD), depression, and suicidal ideation
reported at 3 months post-deployment (model n’s = 6684 to 6826). Given the small
effective sample size (k = 89), the significance of unit-level interactions was evaluatedat a 90% confidence level.

•

The study found, at the individual-level, buffering effects of horizontal cohesion for
PTSD symptoms and depressive symptoms, while a buffering effect of verticalcohesion was observed for PTSD symptoms only.

•

At the unit-level, buffering effects of horizontal (but not vertical) cohesion wereobserved for PTSD symptoms, depressive symptoms, and suicidal ideation.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

63

•The study concluded that policies and interventions that enhance horizontal cohesion
may protect combat-exposed units against post-deployment mental health problems.
Efforts to support individual Soldiers who report low levels of horizontal or verticalcohesion may also yield mental health benefits.

83. A test of the interpersonal theory of suicide in a large, representative, retrospective
and prospective study (Chu, et al 2020)•

The interpersonal theory of suicide hypothesizes that perceived burdensomeness,thwarted belongingness, and hopelessness lead to active suicidal thoughts andindividuals with active suicidal thoughts and elevated capability for suicide are most
likely to attempt suicide.

•This study retrospectively and prospectively tested this theory in a large sample of
7,677 Soldiers who were followed post-deployment for up to nine months.

•

The study found that interaction of perceived burdensomeness and hopelessness (OR= 2.59) was significantly associated with lifetime suicidal thoughts, and theinteractions of thwarted belongingness and perceived burdensomeness and ofthwarted belongingness and hopelessness were not.

•The study also found that, consistent with the theory, capability for suicide
prospectively predicted suicide attempts during and following deployment (OR = 1.22).
However, among Soldiers reporting lifetime suicidal thoughts, capability did notpredict attempts, only perceived burdensomeness did (OR = 1.36).

•

Study results supported some, but not all, theory hypotheses, suggesting that
additional constructs may be needed to better identify the psychological factors thatlead Soldiers to attempt suicide.

84. Association between neurocognitive functioning and suicide attempts in US Army
Soldiers (Hoffman, et al 2020)•

This study sought to discover objective predictors of suicide and non-fatal suicidal
behaviors by examining the association between neurocognitive functioning and premilitary history of suicide attempts (SA) and post-enlistment onset of SA.

•

The study included 38,507 new Soldiers reporting for Basic Combat Training who
completed a comprehensive computerized neurocognitive assessment battery andself-report questionnaires. A subset of Soldiers (n=6,216) completed a follow-up
survey, including assessment of lifetime SA, 3–7 years later.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

64•

Six hundred eighty-nine Soldiers indicated lifetime SA at baseline and 210 Soldiers
indicated new-onset SA at follow-up. Regression analyses, adjusted for demographic
variables, revealed significant bivariate associations between neurocognitive
performance on measures of sustained attention, impulsivity, working memory, andemotion recognition and lifetime SA at baseline.

•

In a multivariable model including each of these measures as predictors, poorer
impulse control and quicker response times on an emotion recognition measure weresignificantly and independently associated with increased odds of lifetime SA. A
second model predicted new-onset SA at follow-up for Soldiers who did not indicate ahistory of SA at baseline. Poorer impulse control on a measure of sustained attention
was predictive of new-onset SA. Effect sizes were small and of unlikely clinicalpredictive utility.

•

The study simultaneously examined multiple neurocognitive domains as predictors of
SA in a large, representative sample of new Army Soldiers. The study found that
impulsivity most strongly predicted past and future SA over and beyond other
implicated cognitive-emotional domains.

85. Sex differences in US Army suicide attempts during the wars in Iraq and Afghanistan(Naifeh, et al 2021)•

This study examined sex differences in risk for administratively documented suicide
attempt (SA) among US Army Soldiers during the Iraq/Afghanistan wars using
administrative person-month records of Regular Army enlisted Soldiers from 2004 to
2009. The study identified 9,650 person-months with a first documented SA and an
equal-probability control sample (n=153,528 person-months). Person-months were
weighted to the population and pooled over time.

•

After examining the association of sex with SA in a logistic regression analysis,
predictors were examined separately among women and men. The study found thatwomen (an estimated 13.7% of the population) accounted for 25.2% of SAs and weremore likely than men to attempt suicide after adjusting for sociodemographic, servicerelated, and mental health diagnosis (MHDx) variables. Women with increased odds of
SA in a given person-month were younger, non-Hispanic White, less educated, in theirfirst term of enlistment, never or previously deployed (vs. currently deployed), andpreviously received a MHDx.

•

Interactions indicated significant but generally small differences between women andmen on 6 of the 8 predictors, the most pronounced being time in service, deployment
status, and MHDx. Discrete-time survival models were used to examine risk by time in

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

65

service and demonstrated that patterns for women and men were similar, and thatwomen’s initially higher risk diminished as time in service increased.
•

The study concluded that predictors of documented SAs are similar for US Army
women and men. Differences associated with time in service, deployment status, andMHDx require additional research. Future research should consider stressors that
disproportionately affect women.

86. Risk of suicide attempt in reserve versus active component soldiers during deployment
to the wars in Iraq and Afghanistan (Naifeh, et al 2021)•

Little is known about the degree to which Army Soldiers in the Reserve Components(Army National Guard and Army Reserve) and Active Component (Regular Army) differ
with respect to suicide attempt (SA) risk during high-stress times, such as deployment.

•This study used administrative person-month records of enlisted Soldiers on active
duty during 2004 to 2009 to identify 1,170 Soldiers with a medically-documented SA
during deployment and an equal-probability control sample of other deployed Soldiers(n = 52,828 person-months).

•

Logistic regression analyses were used to examine the association of Army component(Guard/Reserve vs. Regular) with SA before and after adjusting for socio-demographic
and service-related predictors.

•

Guard/Reserve comprised 32.1% of enlisted Soldiers and 19.7% of suicide attemptersin-theater, with a SA rate of 81/100,000 person-years (vs. 157/100,000 person-years
among Regular; rate ratio = 0.5 [95% CI = 0.5–0.6]). Risk peaked near mid-deployment
for both groups but was consistently lower for Guard/Reserve throughout
deployment. Guard/Reserve had lower odds of SA after adjusting for covariates (OR =0.7 [95%CI = 0.6–0.8]). Predictors of SA were similar between components.

•

The study concluded that Guard/Reserve and Regular Soldiers had similar patterns andpredictors of SA during deployment, but Guard/Reserve had lower risk, even after
controlling for important risk factors. The authors stated that additional research isneeded to understand the lower SA risk among Guard/Reserve in-theater.

87. Dissecting the heterogeneity of posttraumatic stress disorder: differences in polygenic
risk, stress exposures, and course of PTSD subtypes (Campbell-Sills, et al 2021)•

Definition of disorder subtypes may facilitate precision treatment for post-traumaticstress disorder (PTSD). This study aimed to identify PTSD subtypes and evaluate theirassociations with genetic risk factors, types of stress exposures, comorbidity, andcourse of PTSD.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

66

•The data came from a prospective study of three U.S. Army Brigade Combat Teams
that deployed to Afghanistan in 2012. Soldiers with probable PTSD (PTSD Checklist for
Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition ≥31) at threemonths post-deployment comprised the sample (n = 423) for latent profile analysis
using Gaussian mixture modeling and PTSD symptom ratings as indicators. PTSD
profiles were compared on polygenic risk scores (derived from external genomewide
association study summary statistics), experiences during deployment, comorbidity atthree months post-deployment, and persistence of PTSD at nine months postdeployment.

•

Latent profile analysis revealed profiles characterized by prominent intrusions,avoidance, and hyperarousal (threat-reactivity profile; n = 129), anhedonia andnegative affect (dysphoric profile; n = 195), and high levels of all PTSD symptoms(high-symptom profile; n = 99). The threat-reactivity profile had the most combat
exposure and the least comorbidity. The dysphoric profile had the highest polygenic
risk for major depression, and more personal life stress and co-occurring major
depression than the threat-reactivity profile. The high-symptom profile had thehighest rates of concurrent mental disorders and persistence of PTSD.

•

The study concluded that genetic and trauma-related factors likely contribute to PTSD
heterogeneity, which can be parsed into subtypes that differ in symptom expression,
comorbidity, and course. Future studies should evaluate whether PTSD typology
modifies treatment response and should clarify distinctions between the dysphoric
profile and depressive disorders.

88. Social closeness and support are associated with lower risk of suicide among U.S. Army
Soldiers (Dempsey, et al 2021)•

This case-control study tested the aspects of social support, unit cohesion, andreligiosity hypothesized to be protective factors for suicide among U.S. Service
members.

•

The study compared U.S. Army Soldiers who died by suicide while on active duty (n =135) to two types of controls: controls propensity score-matched on known
sociodemographic risk factors (n = 128); and controls who had thought about, but did
not die by, suicide in the past year (n = 108). Data collection included structured
interviews with next-of-kin (NOK) and Army supervisors (SUP) for each case Soldier
and each control Soldier. Logistic regression analyses were used to examine predictorsof suicide.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

67

•The study found that perceived social closeness and seeking help from others wereassociated with decreased odds of suicide, as reported by SUP (OR = 0.2 [95% CI = 0.1,0.5]) and NOK (OR = 0.4 [95% CI = 0.2, 0.8]). Novel reports by SUP informants of highlevels of unit cohesion/morale decreased odds of suicide (OR = 0.1 [95% CI = 0.0, 0.2]).
Contrary to study hypotheses, no religious affiliation was associated with lower odds
of suicide (OR = 0.3 [95% CI = 0.2, 0.6]).

•

The study concluded that perceived social closeness and unit/group cohesion areassociated with lower odds of suicide. These results point toward social intervention
strategies as testable components of suicide prevention programs.

89. Polygenic risk for major depression is associated with lifetime suicide attempt in U.S.
Soldiers independent of personal and parental history of major depression (Stein, et al
2021)•

Suicide is a major public health problem. The contribution of common genetic variants
for major depressive disorder (MDD) independent of personal and parental history of
MDD has not been established.

•

This study calculated polygenic risk score (using PRS-CS) for MDD for U.S. Army
Soldiers of European ancestry. The study then tested associations between polygenic
risk for MDD and lifetime suicide attempt (SA) in models that also included parental or
personal history of MDD. Models were adjusted for age, sex, tranche (whereapplicable), and 10 principal components reflecting ancestry.

•In the first cohort, 417 (6.3%) of 6,573 Soldiers reported a lifetime history of SA. In a
multivariable model that included personal (OR = 3.83, 95% CI:3.09–4.75) and parental
history of MDD (OR = 1.43, 95% CI:1.13–1.82 for one parent and OR = 1.64, 95%
CI:1.20–2.26 for both parents), MDD PRS was significantly associated with SA (OR =1.22, 95% CI:1.10–1.36).

•

In the second cohort, 204 (4.2%) of 4,900 Soldiers reported a lifetime history of SA. In
a multivariable model that included personal (OR = 3.82, 95% CI:2.77–5.26) andparental history of MDD (OR = 1.42, 95% CI:0.996–2.03 for one parent and OR = 2.21,
95% CI:1.33–3.69 for both parents) MDD PRS continued to be associated (at p = .0601)
with SA (OR = 1.15, 95% CI:0.994–1.33).

•

The study concluded that a Soldier's PRS for MDD conveys information about
likelihood of a lifetime SA beyond that conveyed by two predictors readily obtainable
by interview: personal or parental history of MDD. Results remain to be extended toprospective prediction of incident SA. These findings portend a role for PRS in risk
stratification for suicide attempts.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

6890. Predictors of suicide attempt within 30 days after first medically documented suicidal
ideation in U.S. Army Soldiers (Mash, et al 2021)*•

This study was designed to identify predictors of imminent suicide attempt (within 30days) among U.S. Army Soldiers following their first documented suicidal ideation.

•

From 2006-2009 Army/DoD administrative data, the authors identified 11,178 activeduty Regular Army enlisted Soldiers with medically documented suicidal ideation andno prior medically documented suicide attempts. The study examined risk factors for
suicide attempt within 30 days of first suicidal ideation using logistic regression
analyses, including sociodemographic and service-related characteristics, psychiatricdiagnoses, physical health care visits, injuries, and history of family violence or crime
perpetration or victimization.

•

The study found that among Soldiers with first documented suicidal ideation, 830(7.4%) attempted suicide, 46.3% of whom (n = 387) attempted suicide within 30 days
(rate, 35.4 per 1,000 Soldiers). Following a series of multivariate analyses, the final
model identified females (odds ratio51.3, 95% CI51.0, 1.8), combat medics (oddsratio51.6, 95% CI51.1, 2.2), individuals with an anxiety disorder diagnosis prior tosuicidal ideation (odds ratio = 1.3, 95% CI = 1.0, 1.6), and those who received a sleep
disorder diagnosis on the same day as the recorded suicidal ideation (odds ratio = 2.3,
95% CI = 1.1, 4.6) as being more likely to attempt suicide within 30 days. Black Soldiers(odds ratio = 0.6, 95% CI = 0.4, 0.9) and those who received an anxiety disorderdiagnosis on the same day as suicidal ideation (odds ratio = 0.7, 95% CI = 0.5, 0.9)
were less likely.

•

The study concluded that suicide attempt risk is highest in the first 30 days following
ideation diagnosis and is more likely among women, combat medics, and Soldiers withan anxiety disorder diagnosis before suicidal ideation and a same-day sleep disorderdiagnosis. Black Soldiers and those with a same-day anxiety disorder diagnosis were atdecreased risk. These factors may help identify Soldiers at imminent risk of suicide
attempt.

91. Pre-enlistment anger attacks and post-enlistment mental disorders and suicidality
among U.S. Army Soldiers (Smith, et al 2021)•

This study was designed to explore the associations of pre-enlistment anger attacks
with post-enlistment mental health. The study included a cohort of new Soldierssurveyed at 3 Army installations when they entered basic training from April 2011 toNovember 2012, with a subsample who completed a follow-up survey conducted from
September 2016 to April 2018.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

69

•

History of anger attacks at baseline survey was used to classify new Soldiers as having
non-impairing anger attacks (>2 attacks without interference in work or personal life),
impairing anger attacks (>2 attacks with interference in work or personal life), or no
significant history of anger attacks.

•

Baseline analyses examined sociodemographic and clinical correlates of a history ofanger attacks. Prospective logistic regression models estimated associations ofbaseline history of anger attacks with new onset and persistence of posttraumaticstress disorder, major depressive disorder (MDD), generalized anxiety disorder (GAD),
panic disorder, mania/hypomania, substance use disorder, suicidal ideation, andsuicide attempt at follow-up.

•

Of the 38 507 baseline participants (83.0% male and 17.0% female; mean [SD] age,
20.97 [3.57] years), 6,216 were selected for and completed the follow-up survey.
Baseline prevalence (SE) of non-impairing and impairing anger attacks was 8.83%(0.16%) and 5.75% (0.15%), respectively. Prospective models showed that impairing
anger attacks were associated with new onset of MDD (adjusted odds ratio [AOR],
1.98; 95% CI, 1.31-2.99), GAD (AOR, 2.39; 95% CI, 1.66-3.45), panic disorder (AOR,
2.02; 95% CI, 1.34-3.05), and suicidal ideation (AOR, 2.11; 95% CI, 1.45-3.07). Whenbaseline psychiatric comorbidity was controlled for, impairing attacks remained
associated with onset of GAD (AOR, 1.75; 95% CI, 1.19-2.58) and suicidal ideation(AOR, 1.62; 95% CI, 1.09-2.42). Anger attacks were not significantly associated withpersistence of pre-enlistment mental disorders.

•

The findings from this study suggest that a pre-enlistment history of impairing anger
attacks may be associated with elevated risk of developing GAD, MDD, and suicidality
after enlistment. Detection of impairing anger attacks could aid in assessing
psychiatric risk in new Soldiers.

92. Mental disorders, gun ownership, and gun carrying among Soldiers after leaving theArmy, 2016-2019 (Bossarte, et al 2021)•

This study was designed to examine associations of current mental and substance use
disorders with self-reported gun ownership and carrying among recently separated
Army soldiers. Veterans have high rates of both gun ownership and mental disorders,the conjunction of which might contribute to the high suicide rate in this group.

•

Cross-sectional survey data were collected in 2018–2019 from 5,682 recently
separated Soldiers who participated in the Army Study to Assess Risk and Resilience inServicemembers. Validated measures assessed recent mood, anxiety, substance use,and externalizing disorders. Logistic regression models examined associations of

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

70

sociodemographic characteristics, service characteristics, and mental disorders withgun ownership and carrying.
•

Of the participants, 50% reported gun ownership. About half of owners reported
carrying some or most of the time. Mental disorders were not associated significantlywith gun ownership. However, among gun owners, major depressive disorder, panic
disorder, posttraumatic stress disorder, and intermittent explosive disorder wereassociated with significantly elevated odds of carrying at least some of the time.

•

The study concluded that mental disorders are not associated with gun ownershipamong recently separated Army personnel, but some mental disorders are associatedwith carrying among gun owners.

93. Association between responsibility for the death of others and postdeployment mental
health and functioning in U.S. Soldiers (Khan, et al 2021)•

Rates of suicidal thoughts and behaviors (STBs) in Soldiers have increased sharply
since the terrorist attacks on September 11, 2001, and postdeployment posttraumaticstress disorder (PTSD) remains a concern. Studies show that Soldiers with greater
combat exposure are at an increased risk for adverse mental health outcomes, butlittle research has been conducted on the specific exposure of responsibility for thedeath of others.

•

This study was designed to examine the association between responsibility for thedeath of others in combat and mental health outcomes among active-duty Soldiers at
2-3 months and 8-9 months postdeployment.

•

The study obtained data from a prospective 4-wave survey of 3 Army brigade combat
teams that deployed to Afghanistan in 2012. The sample was restricted to Soldierswith data at all 4 waves (1-2 months predeployment, and 2-3 weeks, 2-3 months, and
8-9 months postdeployment).

•

Primary outcomes were past-30-day PTSD, major depressive episode, STBs, andfunctional impairment at 2-3 vs 8-9 months postdeployment. Combat exposures wereassessed using a combat stress scale. The association of responsibility for the death ofothers during combat was tested using separate multivariable logistic regression
models per outcome adjusted for age, sex, race and ethnicity, marital status, brigade
combat team, predeployment lifetime internalizing and externalizing disorders, andcombat stress severity. A total of 4,645 Soldiers (mean [SD] age, 26.27 [6.07] years;
4358 men [94.0%]) were included in this study.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

71

•

After returning from Afghanistan, 22.8% of Soldiers (n = 1,057) reported responsibility
for the death of others in combat. This responsibility was not associated with any
outcome at 2-3 months postdeployment (PTSD odds ratio [OR]: 1.23 [95% CI, 0.931.63]; P = .14; STB OR: 1.19 [95% CI, 0.84-1.68]; P = .33; major depressive episode OR:
1.03 [95% CI, 0.73-1.45]; P = .87; and functional impairment OR: 1.12 [95% CI, 0.941.34]; P = .19).

•

However, responsibility was associated with increased risk for PTSD (OR, 1.42; 95% CI,
1.09-1.86; P = .01) and STBs (OR, 1.55; 95% CI, 1.03-2.33; P = .04) at 8-9 months
postdeployment. Responsibility was not associated with major depressive episode(OR, 1.30; 95% CI, 0.93-1.81; P = .13) or functional impairment (OR, 1.13; 95% CI, 0.941.36; P = .19).

•

When examining enemy combatant death only, the pattern of results was unchanged
for PTSD (OR, 1.44; 95 CI%, 1.10-1.90; P = .009) and attenuated for STBs (OR, 1.46; 95
CI%, 0.97- 2.20; P = .07).

•

This cohort study found there was an association between being responsible for thedeath of others in combat and PTSD and STB at 8-9 months, but not 2-3 months,
postdeployment in active-duty Soldiers. The results suggest that delivering earlyintervention to those who report such responsibility may mitigate the subsequent
occurrence of PTSD and STBs.

94. Effects of prior deployments and perceived resilience on anger trajectories of combatdeployed Soldiers (Campbell-Sills, et al 2021)•

Problematic anger is frequently reported by Soldiers who have deployed to combat
zones. However, evidence is lacking with respect to how anger changes over a
deployment cycle, and which factors prospectively influence change in anger among
combat-deployed Soldiers.

•

Reports of problematic anger were obtained from 7,298 Army Soldiers who deployed
to Afghanistan in 2012. A series of mixed-effects growth models estimated linear
trajectories of anger over a period of 1–2 months before deployment to 9 months
post-deployment, and evaluated the effects of pre-deployment factors (priordeployments and perceived resilience) on average levels and growth of problematicanger.

•A model with random intercepts and slopes provided the best fit, indicating
heterogeneity in Soldiers’ levels and trajectories of anger. First-time deployers
reported the lowest anger overall, but the most growth in anger over time. Soldiers

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)72

with multiple prior deployments displayed the highest anger overall, which remained
relatively stable over time.
•

Higher pre-deployment resilience was associated with lower reports of anger, but its
protective effect diminished over time. First- and second-time deployers reporting low
resilience displayed different anger trajectories (stable versus decreasing,respectively).

•

The study concluded that change in anger from pre- to post-deployment varies basedon pre-deployment factors. The observed differences in anger trajectories suggest thatefforts to detect and reduce problematic anger should be tailored for first-time versus
repeat deployers. Ongoing screening is needed even for Soldiers reporting highresilience before deployment, as the protective effect of pre-deployment resilience onanger erodes over time.

95. Association of emotion reactivity and distress intolerance with suicide attempts in U.S.
Army Soldiers (Naifeh, et al 2021)•

This study was designed to assess whether emotion reactivity (ER) and distressintolerance (DI) were associated with increased suicide attempt (SA) risk among Army
Soldiers.

•

In this case–control study, 74 Soldiers recently hospitalized for SA (cases) werecompared with 133 control Soldiers from the same Army installations selected basedon either propensity score matching (n=103) or reported 12-month suicide ideation(SI) (n=30). Controls were weighted to represent the total Army population at the
study sites and the subpopulation of 12-month ideators.

•

Participants completed questionnaires assessing ER, DI, and other psychosocial
variables. Logistic regression analyses examined whether ER and DI differentiated SA
cases from the general population and from 12-month ideators before and after
controlling for additional important risk factors (sociodemographic characteristics,
stressors, mental disorders).

•

In univariate analyses, ER differentiated SA cases from both the general population(OR = 2.5 [95%CI = 1.7–3.6]) and Soldiers with 12-month SI (OR = 2.5 [95%CI = 1.3–4.6]). DI also differentiated cases from the general population (OR = 2.9 [95%CI = 2.0–4.1]) and 12-month ideators (OR = 1.9 [95%CI = 1.1–3.5]). These associations persisted
after controlling for sociodemographic variables, stressors, and mental disorders.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

73

•The study concluded that the findings provide evidence that higher ER and DI areassociated with increased risk of SA among Soldiers, even after adjusting for known
risk factors. Prospective research with larger samples is needed.

96. Predicting suicide attempts among U.S. Army Soldiers after leaving active duty using
information available before leaving active duty (Stanley, et al 2022)•

Suicide risk is elevated among military service members who recently transitioned tocivilian life. Identifying high-risk service members before this transition could facilitate
provision of targeted preventive interventions. This study investigated the feasibilityof doing this by attempting to develop a prediction model for self-reported suicide
attempts (SAs) after leaving or being released from active duty in the Study to Assess
Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS).

•

The study included two self-report panel surveys (LS1: 2016–2018, LS2: 2018–2019)
administered to respondents who previously participated while on active duty in oneof three Army STARRS 2011–2014 baseline self-report surveys.

•

The focus was on respondents who left active duty >12 months before their LS survey(n = 8,899). An ensemble machine learning model using predictors available prior toleaving active duty was developed in a 70% training sample and validated in a 30% test
sample.

•The 12-month self-reported SA prevalence (SE) was 1.0% (0.1). Test sample AUC (SE)was 0.74 (0.06). The 15% of respondents with highest predicted risk included nearly
two-thirds of 12-month SAs and over 80% of medically serious 12-month SAs.

•

These results show that it is possible to identify soldiers at high post-transition selfreport SA risk before the transition. Future model development is needed to examine
prediction of SAs assessed by administrative data and using surveys administeredcloser to the time of leaving active duty.

97. Predicting homelessness among U.S. Army Soldiers no longer on active duty (Koh, et al2022)•

The ability to predict and prevent homelessness has been an elusive goal. The purposeof this study was to develop a prediction model that identified U.S. Army Soldiers at
high risk of becoming homeless after transitioning to civilian life based on information
available before the time of this transition.

•

The prospective cohort study consisted of observations from 16,589 Soldiers who
were separated or deactivated from service and who had previously participated in 1

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

74

of 3 baseline surveys of the Army Study to Assess Risk and Resilience inServicemembers in 2011−2014.
•

A machine learning model was developed in a 70% training sample and evaluated in
the remaining 30% test sample to predict self-reported homelessness in 1 of 2
longitudinal study surveys administered in 2016−2018 and 2018−2019. Predictors
included survey, administrative, and geospatial variables available before
separation/deactivation.

•

The study found that the 12-month prevalence of homelessness was 2.9% (SE=0.2%) in
the total longitudinal study sample. The area under the receiver operating
characteristic curve in the test sample was 0.78 (SE=0.02) for homelessness. The 4
highest ventiles (top 20%) of predicted risk included 61% of respondents withhomelessness. Self-reported lifetime histories of depression, trauma of having a loved
one murdered, and post-traumatic stress disorder were the 3 strongest predictors ofhomelessness.

•

The study concluded that a prediction model for homelessness can accurately target
Soldiers for preventive intervention before transition to civilian life.

98. Associations of vulnerability to stressful life events with suicide attempts after active
duty among high-risk Soldiers (Chu, et al 2022)•

The transition from military service to civilian life is a high-risk period for suicide
attempts (SAs). Although stressful life events (SLEs) faced by transitioning Soldiers arethought to be implicated, systematic prospective evidence is lacking.

•Participants in the Army Study to Assess Risk and Resilience in Servicemembers(STARRS) completed baseline self-report surveys while on active duty in 2011–2014.
Two self-report follow-up longitudinal surveys (LS1: 2016–2018; LS2: 2018–2019) were
subsequently administered to probability subsamples of these baseline respondents.

•

As detailed in a previous report, a SA risk index based on survey, administrative, andgeospatial data collected before separation/deactivation identified 15% of the LS
respondents who had separated/deactivated as being high-risk for self-reported postseparation/deactivation SAs. The current report presents an investigation of theextent to which self-reported SLEs occurring in the 12 months before each LS survey
might have mediated/modified the association between this SA risk index and postseparation/deactivation SAs.

•

The study found that the 15% of respondents identified as high-risk had a significantly
elevated prevalence of some post-separation/deactivation SLEs. In addition, theVOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

75

associations of some SLEs with SAs were significantly stronger among predicted highrisk than lower-risk respondents. Demographic rate decomposition showed that 59.5%(S.E. = 10.2) of the overall association between the predicted high-risk index andsubsequent SAs was linked to these SLEs.
•

The study concluded that it might be possible to prevent a substantial proportion of
post-separation/deactivation SAs by providing high-risk Soldiers with targeted
preventive interventions for exposure/vulnerability to commonly occurring SLEs.

99. Association of pre-military mental health with suicide attempts during U.S. Army
service (Naifeh, et al 2022)•

Approximately one-third of U.S. Soldiers who attempt suicide have not received amental health diagnosis (MH-Dx) before their suicide attempt (SA), yet little is known
about risk factors for SA in those with no MH-Dx. This study examined whether premilitary mental health is associated with medically documented SA among U.S. Army
Soldiers who do not receive an MH-Dx before their SA.

•

This cohort study used data from a representative survey of Soldiers in the U.S. Armyentering basic combat training from April 1, 2011 to November 30, 2012, who were
followed up via administrative records for the first 48 months of service. Regular Armyenlisted Soldiers (n = 21,772) recruited from 3 U.S. Army installations during the firstweek of service who agreed to have their administrative records linked to their survey
responses were included in this study.

•

Pre-enlistment lifetime history of mental disorder, suicide ideation, SA, and nonsuicidal self-injury (NSSI) were reported during the baseline survey. Service-acquired
MH-Dx and sociodemographic and service-related variables were identified using
administrative records. Documented SAs were identified using administrative medical
records.

•

The study used a discrete-time survival framework, and linear splines to examine thepattern of SA risk over the first 48 months of service. Logistic regression analysis
examined associations of lifetime baseline survey variables with subsequent, medically
documented SA among Soldiers who did vs did not receive an MH-Dx during service.
Models were adjusted for time in service and sociodemographic and service-related
variables.

•

The study found that of the 21,722 respondents (86.2% male, 20.4% Black, 61.8%
White non-Hispanic), 253 made an SA in the first 48 months of service (male [75.4%];
Black [22.7%], White non-Hispanic [59.9%], or other race or ethnicity [17.4%]). The risk

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

76

of SA peaked toward the end of the first year of service for both those who did and did
not receive an MH-Dx during service.
•

Of the 42.3% of individuals reporting at least 1 of the 4 baseline risk factors, 50.2%
received an administrative MH-Dx during service vs 41.5% of those with none, and1.6% had a documented SA vs 1.0% of those with none. Among individuals with no
MH-Dx, medically documented SAs were associated with suicide ideation (odds ratio[OR], 2.2; 95% CI, 1.1-4.4), SA (OR, 11.3; 95% CI, 4.3-29.2), and NSSI (OR, 3.0; 95% CI,
1.3-6.8). For those who received an MH-Dx, medically documented SAs wereassociated with mental disorder (OR, 1.4; 95% CI, 1.0-1.9), SA (OR, 3.4; 95% CI, 2.15.6), and NSSI (OR, 1.8; 95% CI, 1.1-2.8). Interactions indicated the only explanatory
variable that differed based on history of MH-Dx was pre-enlistment SA (χ 2 = 4.7; P =.03), which had a larger OR among Soldiers with no MH-Dx than among those with an
MH-Dx.

•In this study, the period of greatest SA risk and baseline risk factors for SA were similarin Soldiers with and without an MH-Dx. This finding suggests that knowledge of thetime course and pre-enlistment mental health factors can equally aid in identifying SA
risk in Soldiers who do and do not receive an MH-Dx.

100. Prospective associations of military discharge characterization with post-active duty
suicide attempts and homelessness (Naifeh, et al 2022)•

Active duty service members transitioning to civilian life can experience significant readjustment stressors. Over the past two decades of the United States’ longest
sustained conflict, reducing transitioning veterans’ suicidal behavior and homelessness
became national priorities. However, it remains a significant challenge to identify
which service members are at greatest risk of these post-active duty outcomes.
Discharge characterization, which indicates the quality of an individual’s military
service and affects eligibility for benefits and services at the Department of Veterans
Affairs, is a potentially important indicator of risk.

•This study used data from two self-report panel surveys of STARRS-LS which wereadministered (2016-2019) to respondents who previously participated while on active
duty in one of the three Army STARRS baseline self-report surveys (2011-2014): the
New Soldier Study (NSS), a survey of soldiers entering basic training; All Army Study, asurvey of active duty soldiers around the world; and the Pre-Post Deployment Study, asurvey of soldiers before and after combat deployment.

•This study used modified Poisson regression models to prospectively examine theassociation of discharge characterization (honorable, general, “bad paper” [other thanhonorable, bad conduct, dishonorable], and uncharacterized [due to separation within

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

77the first 180 days of service]) with suicide attempt (subsample of n=4,334
observations) and homelessness (subsample of n=6,837 observations) among those nolonger on active duty (i.e., separated or deactivated). Analyses controlled for othersuicide attempt and homelessness risk factors using standardized risk indices thatwere previously developed using the STARRS-LS survey data.
•

The study found that the twelve-month prevalence rates of self-reported suicide
attempts and homelessness in the total pooled sample were 1.0% and 2.9%,
respectively. While not associated with suicide attempt risk, discharge
characterization was associated with homelessness after controlling for other risk
factors.

•

Compared to soldiers with an honorable discharge, those with a bad paper discharge
had an increased risk of homelessness in the total sample (relative risk [RR]=4.4 [95%CI=2.3-8.4]), as well as within subsamples defined by which baseline survey
respondents completed (NSS vs. All Army Study/Pre-Post Deployment Study), whether
respondents had been separated (vs. deactivated), and how much time had elapsed
since respondents were last on active duty.

•

The study concluded that there is a robust association between receiving a bad paper
discharge and post-separation/deactivation homelessness. Policies that enhancetransition assistance and access to mental healthcare for high-risk soldiers may aid in
reducing post-separation/deactivation homelessness among those who do not receive
an honorable discharge.

101. Social network size and personality traits independently and prospectively predict
distress disorders and suicidal behavior in U.S. Army soldiers (Taylor, et al 2022)•

Personality traits (e.g., neuroticism) and the social environment predict risk forinternalizing disorders and suicidal behavior. Studying these characteristics together
and prospectively within a population confronted with high stressor exposure (e.g.,
U.S. Army soldiers) has not been done, yet could uncover unique and interactive
predictive effects that may inform prevention and early intervention efforts.

•

This study assessed five broad personality traits and social network size via selfadministered questionnaires among experienced soldiers preparing for deployment(n=4,645) and new soldiers reporting for basic training (n=6,216). Using predictivemodels, the study examined associations of baseline personality and social network
variables with recent distress disorders or suicidal behaviors assessed 3- and 9-months
post-deployment and approximately 5 years following enlistment.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

78

•The study found among the personality traits, elevated neuroticism was consistently
associated with increased mental health risk following deployment. Small social
networks were also associated with increased mental health risk following
deployment, beyond the variance accounted for by personality. Limited support was
found for social network size moderating the association between personality andmental health outcomes. Small social networks also predicted distress disorders andsuicidal behavior 5 years following enlistment, whereas unique effects of personality
traits on these more distal outcomes were rare.

•

The study concluded that heightened neuroticism and small social networks predict agreater risk for negative mental health sequelae, especially following deployment.
Social ties may mitigate adverse impacts of personality traits on psychopathology insome contexts. Early identification and targeted intervention for these distinct,
modifiable factors may decrease the risk of distress disorders and suicidal behavior.

102. Prospective associations of emotion reactivity and risk behaviors with suicide
attempts in U.S. Army soldiers (Naifeh, et al 2022)•

Emotion reactivity and risk behaviors (ERRB) are transdiagnostic dimensions
associated with suicide attempt (SA). ERRB patterns may identify individuals at
increased risk of future SAs.

•

For this study, a representative sample of U.S. Army Soldiers entering basic combat
training (n=21,772) was surveyed and followed via administrative records for their first48 months of service. Latent profile analysis of baseline survey items assessing ERRB
dimensions, including emotion reactivity, impulsivity, and risk-taking behaviors,
identified distinct response patterns (classes). SAs were identified using administrative
medical records.

•

A discrete-time survival framework was used to examine associations of ERRB classes
with subsequent SA during the first 48 months of service, adjusting for time in service,socio-demographic and service-related variables, and mental health diagnosis (MHDx). The study examined whether associations of ERRB classes with SA differed by yearof service and for soldiers with and without a MH-Dx.

•

Of the 21,772 respondents (86.2% male, 61.8% White non-Hispanic), 253 made a SA.
Four ERRB classes were identified: ‘Indirect Harming’ (8.9% of soldiers), ‘Impulsive’(19.3%), ‘Risk-Taking’ (16.3%), and ‘Low ERRB’ (55.6%). Compared to Low ERRB,
Impulsive [OR 1.8 (95% CI 1.3–2.4)] and Risk-Taking [OR 1.6 (95% CI 1.1–2.2)] hadhigher odds of SA after adjusting for covariates. The ERRB class and MH-Dx interaction
was non-significant. Within each class, SA risk varied across service time.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

79•The study concluded that SA risk within the four identified ERRB classes varied acrossservice time. Impulsive and Risk-Taking soldiers had increased risk of future SA. MH-Dx
did not modify these associations, which may therefore help identify risk in those notyet receiving mental healthcare.

103. Recent stressful experiences and suicide risk: implications for suicide prevention andintervention in U.S. Army soldiers (Dempsey, et al 2023)•

This study was designed to identify the extent to which the presence of recent
stressful events are risk factors for suicide among active‐duty soldiers as reported byinformants.

•

The study participants included next‐of‐kin (NOK) and Army supervisors (SUP) of active
duty soldiers (n=135) who died by suicide and two groups of living controls:
propensity‐matched soldiers (n=128) and soldiers who reported suicidal ideation (SI)in the past year but did not die (n=108). The data analyzed were collected fromparticipants via structured interviews. Multivariate logistic regression analyses wereused to create a risk score for suicide.

•The odds of suicide increased significantly for soldiers experiencing relationshipproblems, military punishment, and perceived failure or humiliation in the month prior
to death. Suicide risk models with these risk factors predicted suicide death among
those who reported SI in the past year (OR = 5.9, [95% CI = 1.5, 24.0] χ2 = 6.24, p =0.0125, AUC, 0.73 (0.7, 0.8) NOK) and (OR = 8.6, [95% CI = 1.4, 51.5] χ2 = 5.49, p =0.0191, AUC, 0.78 (0.7, 0.8); SUP) suggesting the combination of these recent stressors
may contribute to the transition from ideation to action.

•

The study findings suggest for the first time recent stressors distinguished suicide
ideating controls from suicide decedents in the month prior to death as reported byinformants. Implications for preventive intervention efforts for clinicians, supervisors
and family members in identifying the transition from ideation to action are discussed.

104. Exposure to bullying or hazing during deployment and mental health outcomesamong U.S. Army soldiers (Campbell-Sills, et al 2023)•

Workplace bullying is associated with mental disorders and suicidality in civilians, but
few studies have examined associations of bullying with these outcomes among
military personnel. This study was designed to evaluate associations of being bullied or
hazed during deployment with major depressive disorder (MDD), intermittent
explosive disorder, posttraumatic stress disorder (PTSD), suicidal ideation, andsubstance use disorder (SUD).

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

80

•This cohort study used data from the Army STARRS New Soldier Study (NSS; April 1,
2011,to November 30, 2012) and wave 1 of the STARRS Longitudinal Study (STARRSLS; September 1, 2016, to April 30, 2018). A computerized survey administered at 3
U.S. Army installations (NSS) and a web/telephone survey (STARRS-LS wave 1) wereused to collect the data.

•

Data were analyzed from October 11, 2021 to October 28, 2022. STARRS-LS wave 1
participants were comprised of a probability sample of active-duty soldiers andveterans who had participated in Army STARRS baseline surveys while on active duty
(weighted response rate, 35.6%). Respondents whose baseline was the NSS and who
had deployed to a combat theater at least once were eligible for this study.

•

The exposure was being bullied or hazed during a combat deployment. The primary
outcomes were MDD, intermittent explosive disorder, PTSD, and suicidal ideation in
the 12 months before STARRS-LS wave 1 and SUD in the 30 days before STARRS-LS
wave 1, assessed with items from the Composite International Diagnostic Interview
Screening Scales, PTSD Checklist for Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition, and Columbia-Suicide Severity Rating Scale. Logistic regression
was used to estimate associations of bullying or hazing exposure with the outcomes.

•

The 1,463 participants were predominantly male (weighted percentage [SE], 90.4%[0.9%]) and had a mean (SE) age of 21.1 (0.1) years at baseline. At STARRS-LS wave 1,
188 respondents (weighted percentage [SE], 12.2% [1.1%]) reported bullying or hazing
during deployment. Weighted outcome prevalences were 18.7% (1.3%) for MDD, 5.2%
(0.9%) for intermittent explosive disorder, 21.8% (1.5%) for PTSD, 14.2% (1.2%) for
suicidal ideation, and 8.7% (1.0%) for SUD.

•

In models that adjusted for baseline sociodemographic and clinical characteristics andother potential traumas, exposure to bullying or hazing was significantly associatedwith MDD (adjusted odds ratio [aOR], 2.92; 95% CI, 1.74-4.88), intermittent explosive
disorder (aOR, 2.59; 95% CI, 1.20-5.59), PTSD (aOR, 1.86; 95% CI, 1.23-2.83), suicidal
ideation (aOR, 1.91; 95% CI, 1.17-3.13), and SUD (aOR, 2.06; 95% CI, 1.15-3.70).

•

The study concluded that in this cohort study of combat-deployed soldiers, reports ofbeing bullied or hazed during deployment were associated with mental disorders andsuicidal thoughts. Recognition of these associations may inform efforts to prevent andaddress mental health problems among service members.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

81105. Stressful life events and risk of homelessness after active duty: an assessment of risk
and resilience among service members (Montgomery, et al 2023)•

The transition from military to civilian life may present increased exposure to various
stressful life events (SLEs) that can increase the risk of homelessness (e.g., loss of
employment, dissolution of romantic relationships). This study assessed the extent towhich exposure to SLEs occurring proximal to U.S. Army soldier transitions out ofactive duty was associated with risk of homelessness.

•

The study included a total of 16,589 respondents who were no longer on active duty
but participated while on active duty in 2011-2014 baseline surveys and completed
follow-up surveys in 2016-2018 and 2018-2019. The follow-up surveys assessed SLEs
and homelessness occurring in the past 12 months. The study used modified Poisson
regression models to evaluate how much differential SLE exposure and effects
explained the aggregate association of a risk index with homelessness among a sample
of 6,837 respondents, weighted to represent the full sample.

•

The study found that more than half (n=3,510, 52.8%) of respondents reported
experiencing any SLEs in the past 12 months. Most (60.5%) of the difference inprevalence of homelessness among respondents defined as being at high risk ofhomelessness (vs lower risk) was explained by differential exposure to, and/or effectsof, these SLEs. Personal betrayal by a loved one and economic problems played thelargest roles in adjusted risk differences (0.045 and 0.074, respectively).

•

The study concluded that homelessness might be reduced by gearing interventions
toward soldiers at high risk of homelessness who are transitioning out of active duty
to reduce exposure to and effects of modifiable SLEs on experiencing homelessness.

106. Associations of polygenic risk scores with posttraumatic stress symptom trajectories
following combat deployment (Campbell-Sills, et al 2023)•

Identification of genetic risk factors may inform the prevention and treatment of
posttraumatic stress disorder (PTSD). This study evaluates the associations ofpolygenic risk scores (PRS) with patterns of posttraumatic stress symptoms following
combat deployment.

•

U.S. Army soldiers of European ancestry (n=4,900) provided genomic data and ratingsof posttraumatic stress symptoms before and after deployment to Afghanistan in
2012. Latent growth mixture modeling was used to model posttraumatic stresssymptom trajectories among participants who provided post-deployment data
(n=4,353). Multinomial logistic regression models tested independent associations
between trajectory membership and PRS for PTSD, major depressive disorder (MDD),VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

82

schizophrenia, neuroticism, alcohol use disorder, and suicide attempt, controlling forage, sex, ancestry, and exposure to potentially traumatic events, and weighted toaccount for uncertainty in trajectory classification and missing data.
•

Participants were classified into low-severity (77.2%), increasing-severity (10.5%),
decreasing-severity (8.0%), and high-severity (4.3%) posttraumatic stress symptom
trajectories. Standardized PTSD-PRS and MDD-PRS were associated with greater odds
of membership in the high-severity v. low-severity trajectory [adjusted odds ratios and
95% confidence intervals, 1.23 (1.06–1.43) and 1.18 (1.02–1.37), respectively] and theincreasing-severity v. low-severity trajectory [1.12 (1.01–1.25) and 1.16 (1.04–1.28),
respectively]. Additionally, MDD-PRS was associated with greater odds of membershipin the decreasing-severity v. low-severity trajectory [1.16 (1.03–1.31)]. No otherassociations were statistically significant.

•

The study concluded that higher polygenic risk for PTSD or MDD is associated withmore severe post-traumatic stress symptom trajectories following combat
deployment. PRS may help stratify at-risk individuals, enabling more precise targetingof treatment and prevention programs.

107. A practical risk calculator for suicidal behavior among transitioning U.S. Army
Soldiers (Kearns, et al 2023)•

Risk of suicide-related behaviors is elevated among military personnel transitioning tocivilian life. An earlier report showed that high-risk U.S. Army soldiers could be
identified shortly before this transition with a machine learning model that included
predictors from administrative systems, self-report surveys, and geospatial data.
Based on this result, a Veterans Affairs and Army initiative was launched to evaluate asuicide-prevention intervention for high-risk transitioning soldiers. To make targeting
practical, a streamlined model and risk calculator were needed that used only a shortseries of self-report survey questions.

•This study revised the original model in a sample of n=8,335 STARRS-LS participants
who participated in one of three Army STARRS 2011-2014 baseline surveys while inservice, and in one or more subsequent panel surveys (STARRS-LS wave 1: 2016-2018,
STARRS-LS wave 2: 2018-2019) after leaving service. The study trained ensemble
machine learning models with constrained numbers of item-level survey predictors in
a 70% training sample. The outcome was self-reported post-transition suicide
attempts (SA). The models were validated in the 30% test sample.

•

The study found that twelve-month post-transition SA prevalence was 1.0% (SE=0.1).
The best constrained model, with only 17 predictors, had a test sample ROC-AUC of

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)83

0.85 (SE=.03). The 10-30% of respondents with the highest predicted risk included
44.9-92.5% of 12-month SAs.
•

The study concluded that an accurate SA risk calculator based on a short self-reportsurvey can target transitioning soldiers shortly before leaving service for intervention
to prevent post-transition SA.

108. Genetic, environmental and behavioral correlates of lifetime suicide attempt:
Analysis of additive and interactive effects in two cohorts of U.S. Army Soldiers(Campbell-Sills, et al 2023)•

This study calculated a polygenic risk score for suicide attempt (SA-PRS) for Soldiers ofEuropean ancestry who participated in the Army STARRS New Soldier Study (NSS; n =6,573) or Pre/Post Deployment Study (PPDS; n = 4,900). Multivariable logistic
regression models were fit within each sample to estimate the association of SA-PRS
with lifetime suicide attempt (LSA), and to examine whether SA-PRS displayed additive
or interactive effects with environmental and behavioral risk/protective factors(lifetime trauma burden, childhood maltreatment, negative urgency impulsivity, social
network size, perceived mattering, and dispositional optimism). Age, sex, and withinancestry variation were included as covariates.

•

Observed prevalence of LSA was 6.3% and 4.2% in the NSS and PPDS samples,
respectively. In the NSS model, SA-PRS and environmental/behavioral factors
displayed strictly additive effects on odds of LSA.

•

Results indicated an estimated 21% increase in odds of LSA per 1 SD increase in SA-PRS[adjusted odds ratio (AOR; 95% CI) = 1.21 (1.09–1.35)]. In PPDS, the effect of SA-PRS
varied by reports of optimism [AOR = 0.85 (0.74–0.98) for SA-PRS x optimism effect].
Individuals reporting low and average optimism had 37% and 16% increased odds of
LSA per 1 SD increase in SA-PRS, respectively, whereas SA-PRS was not associated with
LSA in those reporting high optimism.

•

Overall, results suggested the SA-PRS had predictive value over and above several
environmental and behavioral risk factors for LSA. Moreover, elevated SA-PRS may be
more concerning in the presence of environmental and behavioral risk factors (e.g.,high trauma burden; low optimism). Given the relatively small effect magnitudes, thecost and incremental benefits of utilizing SA-PRS for risk targeting must also be
considered in future work.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

84109. Predictors of suicide attempt within 30 days of first medically documented major
depression diagnosis in U.S. Army Soldiers with no prior suicidal ideation (Mash, et al2023)•

Understanding mental health predictors of imminent suicide attempt (SA; within 30days) among Soldiers with depression and no prior suicide ideation (SI) can informprevention and treatment. This case-control study aimed to identify sociodemographic
and service-related characteristics and mental disorder predictors associated withimminent SA among U.S. Army Soldiers following first documented major depression
diagnosis (MDD) with no history of SI.

•

The study used STARRS administrative data to identify 101,046 active-duty Regular
Army enlisted Soldiers (2010–2016) with medically-documented MDD and no prior SI(MDD/No-SI). The study examined risk factors for SA within 30 days of first MDD/No-SI
using logistic regression analyses, including socio-demographic/service-relatedcharacteristics and psychiatric diagnoses.

•

The 101,046 Soldiers with documented MDD/No-SI were primarily male (78.0%), < 29years old (63.9%), White (58.1%), high school-educated (74.5%), currently married(62.0%) and < 21 when first entering the Army (56.9%). Among Soldiers with MDD/NoSI, 2,600 (2.6%) subsequently attempted suicide, 16.2% (n = 421) within 30 days (rate:
416.6/100,000).

•

The final multivariable model identified: Soldiers with less than high school education(χ23 = 11.21, OR = 1.5[95%CI = 1.2–1.9]); combat medics (χ22 = 8.95, OR = 1.5[95%CI =1.1–2.2]); bipolar disorder (OR = 3.1[95%CI = 1.5–6.3]), traumatic stress (i.e., acutereaction to stress/not PTSD; OR = 2.6[95%CI = 1.4–4.8]), and “other” diagnosis (e.g.,
unspecified mental disorder: OR = 5.5[95%CI = 3.8-8.0]) diagnosed same day as MDD;
and those with alcohol use disorder (OR = 1.4[95%CI = 1.0-1.8]) andsomatoform/dissociative disorders (OR = 1.7[95%CI = 1.0- 2.8]) diagnosed before MDD
were more likely to attempt suicide within 30 days.

•

Currently married Soldiers (χ22 = 6.68, OR = 0.7[95%CI = 0.6–0.9]), those in service 10+
years (χ23 = 10.06, OR = 0.4[95%CI = 0.2–0.7]), and a sleep disorder diagnosed same
day as MDD (OR = 0.3[95%CI = 0.1–0.9]) were less likely.

•

The study concluded that SA risk within 30 days following first MDD is more likely
among Soldiers with less education, combat medics, and bipolar disorder, traumaticstress, and “other” disorder the same day as MDD, and alcohol use disorder andsomatoform/dissociative disorders before MDD. These factors identify imminent SA
risk and can be indicators for early intervention.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

85

REFERENCES:
References are numbered to coincide with numbering in “Summary of Findings” section above.
1. Ursano, R. J., Colpe, L. J., Heeringa, S. G., Kessler, R. C., Schoenbaum, M., & Stein, M. B.
(2014). The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).
Psychiatry, 77(2), 107-119. doi: 10.1521/psyc.2014.77.2.107.
2. Gilman, S. E., Bromet, E. J., Cox, K. L., Colpe, L. J., Fullerton, C. S., Gruber, M. J., Heeringa,
S. G., Lewandowski-Romps, L., Millikan-Bell, A. M., Naifeh, J. A., Nock, M. K., Petukhova,
M. V., Sampson, N. A., Schoenbaum, M., Stein, M. B., Ursano, R. J., Wessely, S., Zaslavsky, A.
M., & Kessler R. C. (2014). Sociodemographic and career history predictors of suicidemortality in the United States Army 2004–2009. Psychological Medicine, 44(12), 2579-2592.
doi: 10.1017/S003329171400018X.
3. Schoenbaum, M., Kessler, R. C., Gilman, S. E., Colpe, L. J., Heeringa, S. G., Stein, M. B.,
Ursano, R. J., & Cox, K. L. (2014). 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,71(5), 493-503. doi: 10.1001/jamapsychiatry.2013.4417.
4. Kessler, R. C., Heeringa, S. G., Stein, M. B., Colpe, L. J., Fullerton, C. S., Hwang, I., Naifeh, J.
A., Nock, M. K., Petukhova, M., Sampson, N. A., Shoenbaum, M., Zaslavsky, A. M., & Ursano,R. J. (2014). Thirty-day prevalence of DSM-IV mental disorders among nondeployed soldiersin the U.S. Army: Results from the Army Study to Assess Risk and Resilience inServicemembers (Army STARRS). JAMA Psychiatry, 71(5), 504-513. doi:
10.1001/jamapsychiatry.2014.28.
5. Nock, M. K., Stein, M. B., Heeringa, S. G., Ursano, R. J., Colpe, L. J., Fullerton, C. S., Hwang, I.,
Naifeh, J. A., Sampson, N. A., Schoenbaum, M., Zaslavsky, A. M., & Kessler, R. C. (2014).
Prevalence and correlates of suicidal behavior among soldiers: Results from the Army Study
to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry, 71(5),514-522. doi: 10.1001./jamapsychiatry.2014.30.
6. Lewandowski-Romps, L., Peterson, C., Berglund, P. A., Collins, S., Cox, K., Hauret, K., Jones,
B., Kessler, R. C., Mitchell, C., Park, N., Schoenbaum, M., Stein, M. B., Ursano, R. J., &Heeringa, S. G. (2014). Risk factors for accident death in the U.S. Army, 2004-2009.
American Journal of Preventive Medicine, 47(6), 745-753. doi:
10.1016/j.amepre.2014.07.052.
7. Kessler, R. C., Warner, C. H., Ivany, C., Petukhova, M. V., Rose, S., Bromet, E. J., Brown, M.
3rd, Cai, T., Colpe, L. J., Cox, K. L., Fullerton, C. S., Gilman, S. E., Gruber, M. J., Heeringa, S.
G., Lewandowski-Romps, L., Li, J., Millikan-Bell, A. M., Naifeh, J. A., Nock, M. K., Rosellini, A.
J., Sampson, N. A., Schoenbaum, M., Stein, M. B., Wessely, S., Zaslavsky, A. M., & Ursano,R. J. (2015). Predicting suicides after psychiatric hospitalization in U.S. Army soldiers: theArmy Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA
Psychiatry, 72(1), 49-57. doi: 10.1001/jamapsychiatry.2014.1752.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

86

8. Rosellini, A. J., Heeringa, S. G., Stein, M. B., Ursano, R. J., Chiu, W. T., Colpe, L. J., Fullerton,
C. S., Gilman, S. E., Hwang, I., Naifeh, J. A., Nock, M. K., Petukhova, M., Sampson, N. A.,
Schoenbaum, M., Zaslavsky, A. M., & Kessler, R. C. (2015). Lifetime prevalence of DSM-IV
mental disorders among new soldiers in the U.S. Army: Results from: the Army Study toAssess Risk and Resilience in Servicemembers (Army STARRS). Depression and Anxiety,32(1), 13–24. doi:10.1002/da22316.
9. Ursano, R. J., Heeringa, S. G., Stein, M. B., Jain, S., Raman, R., Sun, X., Chiu, W. T., Colpe, L. J.,
Fullerton, C. S., Gilman, S. E., Hwang, I., Naifeh, J. A., Nock, M. K., Rosellini, A. J., Sampson,
N. A., Schoenbaum, M., Zaslavsky, A. M., & Kessler, R. C. (2015). Prevalence and correlatesof suicidal behavior among new soldiers in the U.S. Army: results from the Army Study toAssess Risk and Resilience in Servicemembers (Army STARRS). Depression and Anxiety,32(1), 3–12. doi:10.1002/da.22317.
10. Nock, M. K., Ursano, R. J., Heeringa, S. G., Stein, M. B., Jain, S., Raman, R., Sun, X., Chiu, W.
T., Colpe, L. J., Fullerton, C. S., Gilman, S. E., Hwang, I., Naifeh, J. A., Rosellini, A. J, Sampson,
N. A., Schoenbaum, M., Zaslavsky, A. M., & Kessler, R. C. (2015). Mental disorders,comorbidity, and pre-enlistment suicidal behavior among new soldiers in the U.S. Army:
Results from the Army Study to Assess Risk and Resilience in Servicemembers (ArmySTARRS). Suicide and Life Threatening Behavior, 45(5), 588-599. doi: 10.1111/sltb.12153.
11. Street, A. E., Gilman, S. E., Rosellini, A. J., Stein, M. B., Bromet, E. J., Cox, K. L., Colpe, L. J.,
Fullerton, C. S., Gruber, M. J., Heeringa, S. G., Lewandowski-Romps, L., Little, R. J. A.,
Naifeh, J. A., Nock, M. K., Sampson, N. A., Schoenbaum, M., Ursano, R. J., Zaslavsky, A. M., &Kessler, R. C. (2015). Understanding the elevated suicide risk of female soldiers during
deployments. Psychological Medicine, 45(4), 717–726. doi: 10.1017/S003329171400258X.
12. Ursano, R. J., Kessler, R. C., Heeringa, S. G., Cox, K. L., Naifeh, J. A., Fullerton, C. S., Sampson,
N. A., Kao, T-C., Aliaga, P. A., Vegella, P., Mash, H. H., Buckley, C., Colpe, L. J., Schoenbaum,
M., & Stein, M. B. (2015). Nonfatal suicidal behaviors in U.S. Army administrative records,
2004-2009: Results from the Army Study to Assess Risk and Resilience in Servicemembers(Army STARRS). Psychiatry: Interpersonal and Biological Processes, 78(1), 1-21. doi:
10.1080/00332747.2015.1006512.
13. Ursano, R. J., Kessler, R. C., Stein, M. B., Naifeh, J. A., Aliaga, P. A., Fullerton, C. S., Sampson,
N. A., Kao, T-C, Colpe, L. J., Schoenbaum, M., Cox, K. L., & Heeringa, S. G. (2015). Suicide
attempts in the U.S. Army during the wars in Afghanistan and Iraq, 2004-2009. JAMA
Psychiatry, 72(9), 917-926. doi: 10.1001/jamapsychiatry.2015.0987.
14. Kessler, R. C., Stein, M. B., Bliese, P. D., Bromet, E. J., Chiu, W. T., Cox, K. L., Colpe, L. J.,
Fullerton, C. S., Gilman, S. E., Gruber, M. J., Heeringa, S. G., Lewandoski-Romps, L., MillikanBell, A., Naifeh, J. A., Nock, M. K., Petukhova, M. V., Rosellini, A. J., Sampson, N. A.,
Schoenbaum, M., Zaslavsky, A. M., & Ursano, R. J. (2015). Occupational differences in U.S.
Army suicide rates. Psychological Medicine, 45(15), 3293-3304. doi:
10.1017/S0033291715001294.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

8715. Stein, M. B., Kessler, R. C., Heeringa, S. G., Jain, S., Campbell-Sills, L., Colpe, L. J., Fullerton, C.
S., Nock, M. K., Sampson, N. A., Schoenbaum, M., Sun, X., Thomas, M. L., & Ursano, R .J.
(2015). Prospective longitudinal evaluation of the effect of deployment-acquired traumaticbrain injury on posttraumatic stress and related disorders: Results from the Army Study toAssess Risk and Resilience in Servicemembers (Army STARRS). American Journal of
Psychiatry, 172(11), 1101-1111. doi: 10.1176/appi.ajp.2015.14121572.
16. Rosellini, A. J., Monahan, J., Street, A. E., Heeringa, S. G., Hill, E. D., Petukhova, M., Reis, B.
Y., Sampson, N. A., Bliese, P., Schoenbaum, M., Stein, M. B., Ursano, R. J., & Kessler, R. C.
(2016). Predicting non-familial major physical violent crime perpetration in the U.S. Armyfrom administrative data. Psychological Medicine, 46(2), 303-316. doi:
10.1017/S0033291715001774.
17. Colpe, L. J., Naifeh, J. A., Aliaga, P., Sampson, N. A., Heeringa, S. G., Stein, M. B., Ursano, R.
J., Fullerton, C. S., Nock, M. K., Schoenbaum, M. L., Zaslavsky, A. M., & Kessler, R. C. (2015).
Mental health treatment among soldiers with current mental disorders in the Army Study toAssess Risk and Resilience in Servicemembers (Army STARRS). Military Medicine, 180(10),1041-1051. doi: 10.7205/MILMED-D-14-00686.
18. Stein, M. B., Ursano, R. J., Campbell-Sills, L., Colpe, L. J., Fullerton, C. S., Heeringa, S. G.,
Nock, M. K., Sampson, N. A., Schoenbaum, M., Sun, X., Jain, S., & Kessler, R. C. (2016).
Prognostic indicators of persistent post-concussive symptoms after deployment-related
mild traumatic brain injury: A prospective longitudinal study in U.S. Army soldiers. Journal of
Neurotrauma, 33(23), 2125-2132. doi: 10.1089/neu.2015.4320.
19. Stein, M. B., Chen, C. Y., Ursano, R. J., Cai, T., Gelernter, J., Heeringa, S. G., Jain, S., Jensen, K.
P., Maihofer, A. X., Mitchell, C., Nievergelt, C. M., Nock, M. K., Neale, B. M., Polimanti, R.,
Ripke, S., Sun, X., Thomas, M. L., Wang, Q., Ware, E. B., Borja, S., Kessler, R. C., & Smoller, J.
W. (2016). Genome-wide association studies of posttraumatic stress disorder in 2 cohorts of
US Army soldiers. JAMA Psychiatry, 73(7), 695-704. doi: 10.1001/jamapsychiatry.2016.0350.
20. Ursano, R. J., Kessler, R. C., Stein, M. B., Naifeh, J. A., Aliaga, P. A., Fullerton, C. S., Wynn, G.
H., Vegella, P. L., Ng, T. H. H., Zhang, B. G., Wryter, C. L., Sampson, N. A., Kao, T. C., Colpe, L.
J., Schoenbaum, M., McCarroll, J. E., Cox, K. L., & Heeringa, S. G. (2016). Risk factors,
methods, and timing of suicide attempts among U.S. Army soldiers. JAMA Psychiatry, 73(7),741-749. doi: 10.1001/jamapsychiatry.2016.0600.
21. Kessler, R. C., Stein, M. B., Petukhova, M. V., Bliese, P., Bossarte, R. M., Bromet, E. J.,
Fullerton, C. S., Gilman, S. E., Ivany, C., Lewandowski-Romps, L., Millikan Bell, A., Naifeh, J. A,
Nock, M. K., Reis, B. Y., Rosellini, A. J., Sampson, N. A., Zaslavsky, A. M., & Ursano, R. J.
(2017). Predicting suicides after outpatient mental health visits in the Army Study to Assess
Risk and Resilience in Servicemembers (Army STARRS). Molecular Psychiatry, 22(4), 544551. doi:10. 1038/mp.2016.110.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

8822. Polimanti, R., Chen, C. Y., Ursano, R. J., Heeringa, S. G., Jain, S., Kessler, R. C., Nock, M. K.,
Smoller, J., Sun, X., Gelernter, J., & Stein, M. B. (2017). Cross-phenotype polygenic risk scoreanalysis of persistent post-concussive symptoms in U.S. Army soldiers with deploymentacquired traumatic brain injury. Journal of Neurotrauma, 34(4), 781-789. doi:
10.1089/neu.2016.4550.
23. Cox, K. L., Nock, M. K., Biggs, Q. M., Borneman, J., Colpe, L., Dempsey, C. L., Heeringa, S. G.,
McCarroll, J. E., Ng, T. H., Schoenbaum, M., Ursano, R. J., Zhang, B. G., & Benedek, D. M.
(2017). An examination of potential misclassification of Army suicides: Results from the
Army Study to Assess Risk and Resilience in Servicemembers. Suicide and Life Threatening
Behavior, 47(3), 257-265. doi: 10.1111/sltb.12280.
24. Naifeh, J. A., Colpe, L. J., Aliaga, P. A., Sampson, N. A., Heeringa, S. G., Stein, M. B., Ursano,R. J., Fullerton, C. S., Nock, M. K., Schoenbaum, M., Zaslavsky, A. M., & Kessler, R. C. (2016).
Barriers to initiating and continuing mental health treatment among soldiers in the Army
Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Military Medicine,181(9), 1021-1032. doi: 10.7205/MILMED-D-15-00211.
25. Street, A. E., Rosellini, A. J., Ursano, R. J., Heeringa, S. G., Hill, E. D., Monahan, J., Naifeh, J.
A., Petukhova, M. V., Reis, B. Y., Sampson, N. A., Bliese, P. F., Stein, M. B., Zaslavsky, A. M., &Kessler, R. C. (2016). Developing a risk model to target high-risk preventive interventions forsexual assault victimization among female U.S. Army soldiers. Clinical Psychological Science,
4(6), 939-956. doi: 10.1177/2167702616639532.
26. Rosellini, A. J., Monahan, J., Street, A. E., Hill, E. D., Petukhova, M., Reis, B. Y., Sampson,
N. A., Benedek, D. M., Bliese, P., Stein, M. B., Ursano, R. J., & Kessler, R. C. (2017). Using
administrative data to identify U.S. Army soldiers at high-risk of perpetrating minor violent
crimes. Journal of Psychiatric Research, 84, 128-136. doi: 10.1016/j.jpsychires.2016.09.028.
27. Naifeh, J. A., Nock, M. K., Ursano, R. J., Vegella, P. L., Aliaga, P. A., Fullerton, C. S., Kessler, R.
C., Wryter, C. L., Heeringa, S. G., & Stein, M. B. (2016). Neurocognitive function and suicidein U.S. Army soldiers. Suicide and Life-Threatening Behavior, 47(5), 589-602. doi:
10.1111/sltb.12307.
28. Stein, M. B., Campbell-Sills, L., Gelernter, J., He, F., Heeringa, S. G., Nock, M. J., Sampson, N.
A., Sun, X., Jain, S., Kessler, R. C., & Ursano, R. J. (2017). Alcohol misuse and co-occurring
mental disorders among new soldiers in the U.S. Army. Alcoholism, Clinical andExperimental Research, 41(1), 139-148. doi: 10.1111/acer.13269.
29. Ursano, R. J., Kessler, R. C., Stein, M. B., Naifeh, J. A., Nock, M. K., Aliaga, P. A., Fullerton, C.
S., Wynn, G. H., Ng, T. H. H., Dinh, H. M., Sampson, N. A., Kao, T. C., Schoenbaum, M.,
McCarroll, J. E., Cox, K. L., & Heeringa, S. G. (2016). Medically documented suicide ideation
among U.S. Army soldiers. Suicide and Life-Threatening Behavior, 47(5), 612-628. doi:
10.1111/sltb.12316.
30. Stein, M. B., Chen, C. Y., Jain, S., Jensen, K. P., He, F., Heeringa, S. G., Kessler, R. C., Maihofer,
A., Nock, M. K., Ripke, S., Sun, X., Thomas, M. L., Ursano, R. J., Smoller, J. W., & Gelernter, J.
(2017). Genetic risk variants for social anxiety. American Journal of Medical Genetics Part B
Neuropsychiatric Genetics, 174(2), 120-131. doi: 10.1002/ajmg.b.32520.
VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

8931. Ursano, R. J., Kessler, R. C., Naifeh, J. A., Herberman-Mash, H., Fullerton, C. S., Bliese, P. D.,
Wynn, G. W., Aliaga, P. A., Wryter, C., Sampson, N. A., Kao, T., Colpe, L. J., Schoenmbaum,
M., Cox, K. L., Heeringa, S. G., & Stein, M. B. (2017). Frequency of improvised explosive
devices and suicide attempts in the U.S. Army. Military Medicine, 182(3), e1697-e1703. doi:
10.7205/MILMED-D-16-00270.
32. Polimanti, R., Kaufman, J., Zhao, H., Kranzler, H.R., Ursano, R.J., Kessler, R.C., Gelernter, J., &Stein, M.B. (2017). A genome-wide gene-by-trauma interaction study of alcohol misuse in
two independent cohorts identifies PRKG1 as a risk locus. Molecular Psychiatry, 23, 154160. doi: 10.1038/mp.2017.24
33. Rosellini, A. J., Street, A. E., Ursano, R. J., Chiu, W. T., Heeringa, S. G., Monahan, J., Naifeh, J.
A., Petukhova, M. V., Reis, B. Y., Sampson, N. A., Bliese, P. D., Stein, M. B., Zaslavsky A. M., &Kessler, R. C. (2017). Sexual assault victimization and mental health treatment, suicide
attempts, and career outcomes among women in the US Army. American Journal of Public
Health, 107(5), 732-739. doi: 10.2105/AJPH.2017.303693.
34. Ribeiro, J. D., Gutierrez, P. M., Joiner, T. E., Kessler, R. C., Petukhova, M. V., Sampson, N. A.,
Stein, M. B., Ursano, R. J., & Nock, M. K. (2017). Health care contact and suicide risk
documentation prior to suicide death: Results from the Army Study to Assess Risk andResilience in Servicemembers (Army STARRS). Journal of Consulting and Clinical Psychology,
85(4), 403-408. doi: 10.1037/ccp0000178.
35. Campbell-Sills, L., Kessler, R. C., Ursano, R. J., Rosellini, A. J., Afifi, T. O., Colpe, L. J., Heeringa,
S. G., Nock, M. K., Sampson, N. A., Sareen, J., Schoenbaum, M., Sun, X., Jain, S., & Stein, M.
B. (2017). Associations of childhood bullying victimization with lifetime suicidal behaviors
among new U.S. Army soldiers. Depression and Anxiety, 34(8), 701-710. doi:
10.1002/da.22621.
36. Rosellini, A. J., Stein, M. B., Benedek, D. M., Bliese, P. D., Chiu, W. T., Hwang, I., Monahan, J.,
Nock, M. K., Petukhova, M. V., Sampson, N. A., Street, A. E., Zaslavsky, A. M., Ursano, R. J., &Kessler, R. C. (2017). Using self-report surveys at the beginning of service to develop multioutcome risk models for new soldiers in the U.S. Army. Psychological Medicine, 47(13),2275-2287. doi: 10.1017/s003329171700071x.
37. Bandoli, G., Campbell-Sills, L., Kessler, R. C., Heeringa, S. G., Nock, M. K., Rosellini, A. J.,
Sampson, N. A., Schoenbaum, M., Ursano, R. J., & Stein, M. B. (2017). Childhood adversity,
adult stress, and the risk of major depression or generalized anxiety disorder in US soldiers:
a test of the stress sensitization hypothesis. Psychological Medicine, 47(13), 2379-2392. doi:
10.1017/s0033291717001064.
38. Nock, M. K., Dempsey, C. L., Aliaga, P. A., Brent, D. A., Heeringa, S. G., Kessler, R. C., Stein,
M. B, Ursano, R. J., & Benedek, D. (2017). Psychological autopsy study comparing suicide
decedents, suicide ideators, and propensity score matched controls: Results from the Study
to Assess Risk and Resilience in Service members (Army STARRS). Psychological Medicine,47(15), 2663-2674. doi: 10.1017/s0033291717001179.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

9039. Stein, M. B., Campbell-Sills, L., Ursano, R. J., Rosellini, A. J., Colpe, L. J., He, F., Heeringa, S.
G., Nock, M. K., Sampson, N. A., Schoenbaum, M., Sun, X., Jain, S., & Kessler, R. C. (2017).
Childhood maltreatment and lifetime suicidal behaviors among new soldiers in the US
Army: Results from the Army Study to Assess Risk and Resilience in Servicemembers (ArmySTARRS). Journal of Clinical Psychiatry, 79(2). doi: 10.4088/JCP.16m10900.
40. Ursano, R. J., Kessler, R. C., Naifeh, J. A., Mash, H. H., Fullerton, C. S., Ng, T. H. H., Aliaga,
P. A., Wynn, G. H., Dinh, H. M., McCarroll, J. E, Sampson, N. A., Kao, T. C., Schoenbaum M.,
Heeringa, S. G., & Stein, M. B. (2017). Suicide attempts in U.S. Army combat arms, special
forces and combat medics. BMC Psychiatry, 17(1), 194. doi: 10.1186/s12888-017-1350-y.
41. Millner, A. J., Ursano, R. J., Hwang, I., King, A. J., Naifeh, J. A, Sampson, N. A., Zaslavsky, A.
M., Stein, M. B., Kessler, R. C., & Nock, M. K. (2017). Lifetime suicidal behaviors and career
characteristics among U.S. Army Soldiers: Results from the Army Study to Assess Risk andResilience in Servicemembers (Army STARRS). Suicide and Life Threatening Behavior, 48(2),230-250. doi: 10.1111/sltb.12363.
42. Ursano, R. J., Kessler, R. C., Naifeh, J. A., Herberman-Mash, H., Fullerton, C. S., Bliese, P. D.,
Zaslavsky, A. M., Ng, T. H. H., Aliaga, P. A., Wynn, G. H., Dinh, H. M., McCarroll, J. E.,
Sampson, N. A., Kao, T. C., Schoenbaum, M., Heeringa, S. G., & Stein, M. B. (2017). Risk ofsuicide attempt among soldiers in army units with a history of suicide attempts. JAMA
Psychiatry, 74(9), 924-931. doi: 10.1001/jamapsychiatry.2017.1925
43. Rosellini, A. J., Monahan, J., Street, A. E., Petukhova, M. V., Sampson, N. A., Benedek, D. M.,
Bliese, P. B., Stein, M. B., Ursano, R. J., & Kessler, R. C. (2017). Predicting sexual assault
perpetration in the U.S. Army using administrative data. American Journal of Preventive
Medicine, 53(5), 661-669. doi: 10.1016/j.amepre.2017.06.022
44. Stein, M. B., Ware, E. B., Mitchell, C., Chen, C. Y., Borja, S., Cai, T., Dempsey, C. L., Fullerton,
C. S., Gelernter, J., Heeringa, S. G., Jain, S., Kessler, R. C., Naifeh, J. A., Nock, M. K., Ripke, S.,
Sun, X., Beckham, J. C., Kimbrel, N. A., VA Mid-Atlantic Mental Illness Research, Education,
and Clinical Center (MIRECC) Workgroup, Ursano, R. J. & Smoller, J. W. (2017). Genomewide
association studies of suicide attempts in U.S. soldiers. American Journal of Medical
Genetics Part B: Neuropsychiatric Genetics, 174(8), 786-797. doi: 10.1002/ajmg.b.32594
45. Millner, A. J., Ursano, R. J., Hwang, I., King, A. J., Naifeh, J. A., Sampson, N. A., Zaslavsky, A.
M., Stein, M. B., Kessler, R. C., & Nock, M. K. (2017). Prior mental disorders and lifetime
suicidal behaviors among US Army soldiers in the Army Study to Assess Risk and Resiliencein Servicemembers (Army STARRS). Suicide and Life Threatening Behavior, 49(1), 3-22. doi:
10.1111/sltb.12394
46. Ursano, R. J., Stein, M. B., Mash, H. B. Herberman, Naifeh, J. A., Fullerton, C. S., Zaslavsky, A.
M., Ng, T. H. H., Aliaga, P. A., Wynn, G. H., Dinh, H. M., McCarroll, J. E., Sampson, N. A., Kao,T. C., Schoenbaum, M., Heeringa, S. G., & Kessler, R. C. (2017). Documented family violence
and risk of suicide attempt among U.S. Army soldiers. Psychiatry Research, 262, 575-582.
doi: 10.1016/j.psychres.2017.09.046

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

9147. Campbell-Sills, L., Ursano, R. J., Kessler, R. C., Sun, X., Heeringa, S. G., Nock, M. K., Sampson,
N. A., Jain, S., & Stein, M. B. (2017). Prospective risk factors for post-deployment heavy
drinking and alcohol or substance use disorder among US Army soldiers. Psychological
Medicine, 48(10), 1624-1633. doi: 10.1017/s0033291717003105
48. Campbell-Sills, L., Kessler, R. C., Ursano, R. J., Sun, X., Taylor, C. T., Heeringa, S. G., Nock, M.
K., Sampson, N. A., Jain, S., & Stein, M. B. (2017). Predictive validity and correlates of selfassessed resilience among U.S. Army soldiers. Depression and Anxiety, 35(2), 122-131. doi:
10.1002/da.22694
49. Lewandowski-Romps, L., Schroeder, H. M., Berglund, P. A., Colpe, L., Cox, K., Hauret, K., Hay,
J. D., Jones, B., Little, R. J. A., Mitchell, C., Schoenbaum, M., Schulz, P., Stein, M. B., Ursano,R. J., & Heeringa, S. G. (2017). Medical-encounter mental health diagnoses, non-fatal injury
and polypharmacy indicators of risk for accident death in the U.S. Army enlisted soldiers,
2004-2009. Preventive Medicine, 111, 299-306. doi: 10.1016/j.ypmed.2017.11.016
50. Polimanti, R., Kaufman, J., Zhao, H., Kranzler, H. R., Ursano, R. J., Kessler, R. C., Stein, M. B.,& Gelernter, J. (2017). Trauma exposure interacts with the genetic risk of bipolar disorder inalcohol misuse of U.S. soldiers. Acta Psychiatrica Scandinavica, 137(2), 148-156. doi:
10.1111/acps.12843
51. Stein, M. B., McCarthy, M. J., Chen, C.-Y., Jain, S., Gelernter, J., He, F., Heeringa, S. G.,
Kessler, R. C, Nock, M. K., Ripke, S., Sun, X., Wynn, G. H., Smoller, J. W., & Ursano, R. J.
(2018). Genome-wide analysis of insomnia disorder. Molecular Psychiatry, 23(11), 22382250. doi: 10.1038/s41380-018-0033-5
52. Nock, M. K., Millner, A. J., Joiner, T. E., Gutierrez, P. M., Han, G., Hwang, I., King, A., Naifeh,
J. A., Sampson, N. A., Zaslavasky, A. M., Stein, M. B., Ursano, R. J., & Kessler, R. C. (2018).
Risk factors for the transition from suicide ideation to suicide attempt: Results from the
Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). J Abnorm
Psychol, 127(2), 139-149. doi: 10.1037/abn0000317
53. Bernecker, S. L., Rosellini, A. J., Nock, M. K., Chiu, W. T., Gutierrez, P. M., Hwang, I., Joiner, T.
E., Naifeh, J. A., Sampson, N. A., Zaslavsky, A. M., Stein, M. B., Ursano, R. J., & Kessler, R. C.
(2018). Improving risk prediction accuracy for new soldiers in the U.S. Army by adding selfreport survey data to administrative data. BMC Psychiatry, 18(1), 87. doi:10.1186/s12888018-1656-4
54. Ursano, R. J., Kessler, R. C., Naifeh, J. A., Mash, H. H., Fullerton, C. S., Aliaga, P. A., Wynn, G.
H., Ng, T. H. H., Dinh, H. M., Sampson, N. A., Kao, T. C., Bliese, P. D. & Stein, M. B. (2018).
Associations of time-related deployment variables with risk of suicide attempt amongsoldiers: Results from the Army Study to Assess Risk and Resilience in Servicemembers(Army STARRS). JAMA Psychiatry, 75(6), 586-604. doi:10.1001/jamapsychiatry.2018.0296
55. Ursano, R. J., Naifeh, J. A., Kessler, R. C., Gonzalez, O. I., Fullerton, C. S., Mash, H. H., RiggsDonovan, C. A., Ng, T. H. H., Wynn, G. H., Dinh, H. M., Kao, T. C., Sampson, N. A., Heeringa,
S. G. & Stein, M. B. (2018). Nonfatal suicidal behaviors in the administrative records ofactivated U.S. Army National Guard and Army Reserve Soldiers, 2004–2009. Psychiatry,81(2), 173-192. doi:10.1080/00332747.2018.1460716

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

9256. Rosellini, A. J., Stein, M. B., Benedek, D. M., Bliese, P. D., Chiu, W. T., Hwang, I., Monahan, J.,
Nock, M. K., Sampson, N. A., Street, A. E., Zaslavsky, A. M., Ursano, R. J., & Kessler, R. C.
(2018). Predeployment predictors of psychiatric disorder-symptoms and interpersonal
violence during combat deployment. Depress Anxiety, 35(11), 1073-1080.
doi:10.1002/da.22807
57. Ursano, R. J., Kessler, R. C., Naifeh, J. A., Mash, H. B. H., Nock, M. K., Aliaga, P. A., Fullerton,
C. S., Wynn, G. H., Ng, T. H. H., Dinh, H. M., Sampson, N. A., Kao, T., Heeringa, S. G., & Stein,
M. B. (2018). Risk factors associated with attempted suicide among U.S. Army soldiers
without a history of mental health diagnosis. JAMA Psychiatry, 75(10), 1022-1032.
doi:10.1001/jamapsychiatry.2018.2069
58. Nock, M. K., Han, G., Millner, A. J., Gutierrez, P. M., Joiner, T. E., Hwang, I., King, A., Naifeh,
J. A., Sampson, N.A., Zaslavsky, A. M., Stein, M. B., Ursano, R. J., & Kessler, R. C. (2018).
Patterns and predictors of persistence of suicide ideation: Results from the Army Study toAssess Risk and Resilience in Servicemembers (Army STARRS). J Abnorm Psychol, 127(7),650-658. doi:10.1037/abn0000379
59. Howlett, J. R., Campbell-Sills, L., Jain, S., Heeringa, S. G., Nock, M. K., Sun, X., Ursano, R. J.,
Stein, M. B. (2018). Attention deficit hyperactivity disorder and risk of posttraumatic stressand related disorders: A prospective longitudinal evaluation in U.S. Army soldiers. Journal ofTraumatic Stress, 31(6), 909-918. doi:10.1002/jts.22347
60. Wang, H. E., Campbell-Sills, L., Kessler, R. C., Sun, X., Heeringa, S. G., Nock, M. K., Ursano, R.
J., Jain, S., & Stein, M. B. (2018). Pre-deployment insomnia is associated with postdeployment PTSD and suicidal ideation in US Army soldiers. Sleep, 42(2).
doi:10.1093/sleep/zsy229
61. Bernecker, S. L., Zuromski, K. L., Gutierrez, P. M., Joiner, T. E., King, A. J., Liu, H., Nock, M. K.,
Sampson, N. A., Zaslavsky, A. M., Stein, M. B., Ursano, R. J. & Kessler, R. C. (2018). Predicting
suicide attempts among soldiers who deny suicidal ideation in the Army Study to Assess Risk
and Resilience in Servicemembers (Army STARRS). Behav Res
Ther. doi:10.1016/j.brat.2018.11.018
62. Naifeh, J. A., Ursano, R. J., Kessler, R. C., Zaslavsky, A. M., Nock, M. K., Dempsey, C. L.,
Bartolanzo, D., Ng, T. H. H., Aliaga, P. A., Zuromski, K. L., Dinh, H. M., Fullerton, C. S., Kao, T.
C., Mash, H. B. H., Sampson, N. A., Wynn, G. H., & Stein, M. B. (2018). Transition to suicide
attempt from recent suicide ideation in U.S. Army soldiers: Results from the Army Study toAssess Risk and Resilience in Servicemembers (Army STARRS). Depress
Anxiety. doi:10.1002/da.22870
63. Naifeh, J. A., Ursano, R. J., Kessler, R. C., Gonzalez, O. I., Fullerton, C. S., Herberman Mash, H.
B., Riggs-Donovan, C. A., Ng, T. H. H., Wynn, G. H., Dinh, H. M., Kao, T. C., Sampson, N. A.,& Stein, M. B. (2019). Suicide attempts among activated Soldiers in the U.S. Army reserve
components. BMC Psychiatry, 19(1), 31. doi:10.1186/s12888-018-1978-2
64. Anderson, L., Campbell-Sills, L., Ursano, R. J., Kessler, R. C., Sun, X., Heeringa, S. G., Nock, M.
K., Bliese, P. D., Gonzalez, O. I., Wynn, G. H., Jain, S., & Stein, M. B. (2019). Prospective
associations of perceived unit cohesion with postdeployment mental healthoutcomes. Depress Anxiety. doi:10.1002/da.22884
VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

9365. Campbell-Sills, L., Kessler, R. C., Ursano, R. J., Sun, X., Heeringa, S. G., Nock, M. K., Jain, S., &Stein, M. B. (2019). Nicotine dependence and pre-enlistment suicidal behavior among U.S.
Army soldiers. Am J Prev Med, 56(3), 420-428. doi:10.1016/j.amepre.2018.09.016
66. Zuromski, K. L., Bernecker, S. L., Gutierrez, P. M., Joiner, T. E., King, A. J., Liu, H., Naifeh, J. A.,
Nock, M. K., Sampson, N. A., Zaslvasky, A. M., Stein, M. B., Ursano, R. J., & Kessler, R. C.
(2019). Assessment of a risk index for suicide attempts among US Army Soldiers with suicide
ideation: Analysis of data from the Army Study to Assess Risk and Resilience inServicemembers (Army STARRS). JAMA Netw Open, 2(3), e190766.
doi:10.1001/jamanetworkopen.2019.0766
67. Choi, K. W., Chen, C. Y., Ursano, R. J., Sun, X., Jain, S., Kessler, R. C., Koenen, K. C., Wang, M.
J., Wynn, G. H., Major Depressive Disorder Working Group of the Psychiatric Genomics
Consortium, Campbell-Sills, L., Stein, M. B., & Smoller, J. W. (2019). Prospective study ofpolygenic risk, protective factors, and incident depression following combat deployment in
US Army soldiers. Psychol Med, 1-9. doi:10.1017/s0033291719000527
68. Zuromski, K. L., Dempsey, C. L., Ng, T. H. H., Riggs-Donovan, C. A., Brent, D. A., Heeringa, S.
G., Kessler, R. C., Stein, M. B., Ursano, R. J., Benedek, M. K. & Nock, M. K. (2019). Utilizationof and barriers to treatment among suicide decedents: Results from the Army Study toAssess Risk and Resilience Among Servicemembers (Army STARRS). J Consult Clin Psychol.
doi:10.1037/ccp0000400
69. Stein, M. B., Choi, K. W., Jain, S., Campbell-Sills, L., Chen, C. Y., Gelernter, J., He, F., Heeringa,
S. G., Maihofer, A. X., Nievergelt, C., Nock, M. K., Ripke, S., Sun, X., Kessler, R. C., Smoller, J.
W., & Ursano, R. J. (2019). Genome-wide analyses of psychological resilience in U.S. Armysoldiers. Am J Med Genet B Neuropsychiatr Genet. doi:10.1002/ajmg.b.32730
70. Dempsey, C. L., Benedek, D. M., Zuromski, K. L., Riggs-Donovan, C., Ng, T. H. H., Nock, M. K.,
Kessler, R. C., & Ursano, R. J. (2019). Association of firearm ownership, use, accessibility,
and storage practices with suicide risk among US Army soldiers. JAMA Netw Open, 2(6),e195383. doi:10.1001/jamanetworkopen.2019.5383
71. Campbell-Sills, L., Stein, M. B., Liu, H., Agtarap, S., Heeringa, S. G., Nock, M. K., Ursano, R. J.
& Kessler, R. C. (2019). Associations of lifetime traumatic brain injury characteristics withprospective suicide attempt among deployed US Army Soldiers. J Head Trauma Rehabil.
doi:10.1097/htr.0000000000000516
72. Adams, R. S., Campbell-Sills, L., Stein, M. B., Sun, X., Larson, M. J., Kessler, R. C., Ursano, R.
J., Jain, S., & Corrigan, J. D. (2019). The association of lifetime and deployment-acquired
traumatic brain injury with postdeployment binge and heavy drinking. J Head Trauma
Rehabil. doi:10.1097/htr.0000000000000508
73. Zuromski, K. L., Ustun, B., Hwang, I., Keane, T. M., Marx, B. P., Stein, M. B., Ursano, R. J., &Kessler, R. C. (2019). Developing an optimal short-form of the PTSD Checklist for DSM-5(PCL-5). Depress Anxiety. doi:10.1002/da.22942
74. Agtarap, S., Campbell-Sills, L., Thomas, M. L., Kessler, R. C., Ursano, R. J., & Stein, M. B.
(2019). Postconcussive, posttraumatic stress and depressive symptoms in recently deployed
U.S. Army soldiers with traumatic brain injury. Psychol Assess. doi:10.1037/pas0000756

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

9475. Naifeh, J. A., Ursano, R. J., Kessler, R. C., Aliaga, P. A., Mash, H. B. H., Fullerton, C. S., Ng, T.
H. H., Dinh, H. M., Gonzalez, O. I., Stokes, C. M., Wynn, G. H., Kao, T. C., Sampson, N. A., &Stein, M. B. (2019). Early first deployment and risk of suicide attempt among first-term
enlisted soldiers in the U.S. Army. Suicide Life Threat Behav. doi:10.1111/sltb.12592.
76. Stokes, C. M., Naifeh, J. A., Kessler, R. C., Stein, M. B., Fullerton, C. S., Mash, H. B. H., RiggsDonovan, C. A., Ng, T. H. H., Aliaga, P.A., Wynn, G. H., Dinh, H. M., Kao, T. C. Gonzalez, O. I.,
Sampson, N. A. & Ursano, R. J. (2019). Risk factors and timing of suicide attempts among US
Army Reserve Component soldiers during deployment to the Afghanistan and Iraq Wars:
Results from Army Study to Assess Risk and Resilience in Servicemembers. Psychiatry, 82(3),240-255. doi:10.1080/00332747.2019.1653056.
77. Bernecker, S. L., Zuromski, K. L., Curry, J. C., Kim, J. J., Gutierrez, P. M., Joiner, T. E., Kessler,
R. C., Nock, M. K., Rudd, M. D., Bryan, C. J. (2019). Economic evaluation of brief cognitive
behavioral therapy vs treatment as usual for suicidal US Army Soldiers. JAMA
Psychiatry. doi: 10.1001/jamapsychiatry.2019.3639
78. Zuromski, K. L., Bernecker, S. L., Chu, C., Wilks, C. R., Gutierrez, P. M., Joiner, T. E., Liu, H.,
Naifeh, J.A., Nock, M. K., Sampson, N. A., Zaslavsky, A. M., Stein, M. B., Ursano, R. J., Kessler,
R. C. (2019). Pre-deployment predictors of suicide attempt during and after combat
deployment: Results from the Army Study to Assess Risk and Resilience in Servicemembers.
Journal of Psychiatric Research, 121:214-221
79. Hettema, J. M., Verhulst, B., Chatzinakos, C., Bacanu, S. A., Chen, C. Y., Ursano, R. J., Kessler,
R. C., Gelernter, J., Smoller, J. W., He, F., Jain, S., & Stein, M. B. (2019). Genome-wide
association study of shared liability to anxiety disorders in Army STARRS. Am J Med Genet B
Neuropsychiatr Genet. doi:10.1002/ajmg.b.32776
80. Ursano, R. J., Herberman Mash, H. B., Kessler, R. C., Naifeh, J. A., Fullerton, C. S., Aliaga, P.
A., Stokes, C. M., Wynn, G. H., Ng, T. H. H., Dinh, H. M., Gonzalez, O. I., Zaslavsky, A. M.,
Sampson, N. A., Kao, T. C., Heeringa, S. G., Nock, M. K., & Stein, M. B. (2020). Factors
associated with suicide ideation in US Army soldiers during deployment in
Afghanistan. JAMA Network Open, 3(1):e1919935.
doi:10.1001/jamanetworkopen.2019.19935
81. Naifeh, J. A., Nock, M. K., Dempsey, C. L., Georg, M. W., Bartolanzo, D., Ng, T. H. H., Aliaga,
P. A., Dinh, H. M., Fullerton, C. S., Mash, H. B. H., Kao, T. C., Sampson, N. A., Wynn, G. H.,
Zaslavsky, A. M., Stein, M. B., Kessler, R. C. & Ursano, R. J. (2020). Self-injurious thoughts
and behaviors that differentiate soldiers who attempt suicide from those with recent
suicide ideation. Depress Anxiety. doi:10.1002/da.23016
82. Campbell-Sills, L., Flynn, P. J., Choi, K. W., Ng, T., Aliaga, P. A., Broshek, C., Jain, S., Kessler, R.
C., Stein, M. B., Ursano, R. J., & Bliese, P. D. (2020). Unit cohesion during deployment andpost-deployment mental health: is cohesion an individual- or unit-level buffer for combatexposed soldiers? Psychological Medicine, 1–11. Advance online publication. doi:
10.1017/S0033291720001786

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

9583. Chu, C., Zuromski, K. L., Bernecker, S. L., Gutierrez, P. M., Joiner, T. E., Liu, H., Naifeh, J. A.,
Stein, M. B., Ursano, R. J., & Nock, M. K. (2020). A test of the interpersonal theory of suicide
in a large, representative, retrospective and prospective study: Results from the Army Study
to Assess Risk and Resilience in Servicemembers (Army STARRS). Behaviour Research andTherapy, 132, 103688. doi: 10.1016/j.brat.2020.103688
84. Hoffman, S. N., Taylor, C. T., Campbell-Sills, L., Thomas, M.L., Sun, X., Naifeh, J. A., Kessler, R.
C., Ursano, R. J., Gur, R. C., Jain, S., Stein, M. B. (2020). Association between neurocognitive
functioning and suicide attempts in U.S. Army Soldiers. J Psychiatr Res: S00223956(20)31071-2
85. Naifeh, J. A., Mash, H., Stein, M. B., Vance, M. C., Aliaga, P. A., Fullerton, C. S., Dinh, H. M.,
Wynn, G. H., Kao, T. C., Sampson, N. A., Kessler, R. C., & Ursano, R. J. (2021). Sex Differencesin US Army Suicide Attempts During the Wars in Iraq and Afghanistan. Medical Care, 59,
S42–S50. doi: 10.1097/MLR.0000000000001425
86. Naifeh, J. A., Ursano, R. J., Stein, M. B., Mash, H., Aliaga, P. A., Fullerton, C. S., Dinh, H. M.,
Vance, M. C., Wynn, G. H., Kao, T. C., Sampson, N. A., & Kessler, R. C. (2021). Risk of suicide
attempt in reserve versus active component soldiers during deployment to the wars in Iraq
and Afghanistan. Suicide & Life-Threatening Behavior, Advance online publication. doi:
10.1111/sltb.12770
87. Campbell-Sills, L., Sun, X., Choi, K. W., He, F., Ursano, R. J., Kessler, R. C., Levey, D. F.,
Smoller, J. W., Gelernter, J., Jain, S., & Stein, M. B. (2021). Dissecting the heterogeneity of
posttraumatic stress disorder: differences in polygenic risk, stress exposures, and course of
PTSD subtypes. Psychological Medicine, 1–9. Advance online publication. doi:
10.1017/S0033291721000428
88. Dempsey, C. L., Benedek, D. M., Nock, M. K., Zuromski, K. L., Brent, D. A., Ao, J., Aliaga, P. A.,
Heeringa, S. G., Kessler, R. C., Stein, M. B., & Ursano, R. J. (2021). Social closeness andsupport are associated with lower risk of suicide among U.S. Army soldiers. Suicide & lifethreatening behavior. Advance online publication. doi: 10.1111/sltb.12778
89. Stein, M. B., Jain, S., Campbell-Sills, L., Ware, E. B., Choi, K. W., He, F., Ge, T., Gelernter, J.,
Smoller, J. W., Kessler, R. C., & Ursano, R. J. (2021). Polygenic risk for major depression isassociated with lifetime suicide attempt in US soldiers independent of personal andparental history of major depression. American Journal of Medical Genetics. Part B,
Neuropsychiatric Genetics doi: 10.1002/ajmg.b.32868
90. Mash, H., Ursano, R. J., Kessler, R. C., Naifeh, J. A., Fullerton, C. S., Aliaga, P. A., RiggsDonovan, C. A., Dinh, H. M., Vance, M. C., Wynn, G. H., Zaslavsky, A. M., Sampson, N. A.,
Kao, T. C., & Stein, M. B. (2021). Predictors of suicide attempt within 30 days after first
medically documented suicidal ideation in U.S. Army Soldiers. American Journal of
Psychiatry, Advance online publication. doi: 10.1176/appi.ajp.2021.20111570
91. Smith, D. M., Meruelo, A., Campbell-Sills, L., Sun, X., Kessler, R. C., Ursano, R. J., Jain, S.,
Stein, M. B., & Army STARRS Team (2021). Pre-enlistment anger attacks and postenlistment mental disorders and suicidality among US Army Soldiers. JAMA Network Open,
4(9), e2126626. https://doi.org/10.1001/jamanetworkopen.2021.26626
VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

9692. Bossarte, R. M., Ziobrowski, H. N., Benedek, D. M., Dempsey, C. L., King, A. J., Nock, M. K.,
Sampson, N. A., Stein, M. B., Ursano, R. J., & Kessler, R. C. (2021). Mental disorders, gunownership, and gun carrying among soldiers after leaving the army, 2016-2019. American
Journal of Public Health, 111(10), 1855–1864
93. Khan, A. J., Campbell-Sills, L., Sun, X., Kessler, R. C., Adler, A. B., Jain, S., Ursano, R. J., &Stein, M. B. (2021). Association between responsibility for the death of others andpostdeployment mental health and functioning in US Soldiers. JAMA Network Open, 4(11),e2130810
94. Campbell-Sills, L., Kautz, J. D., Choi, K. W., Naifeh, J. A., Aliaga, P. A., Jain, S., Sun, X., Kessler,
R. C., Stein, M. B., Ursano, R. J., & Bliese, P. D. (2023). Effects of prior deployments andperceived resilience on anger trajectories of combat-deployed soldiers. Psychological
Medicine, 53(5), 2031–2040
95. Naifeh, J. A., Nock, M. K., Dempsey, C. L., Georg, M. W., Aliaga, P. A., Dinh, H. M., Fullerton,
C. S., Mash, H. B. H., Kao, T.-C., Sampson, N. A., Wynn, G. H., Zaslavsky, A. M., Stein, M. B.,
Kessler, R. C., & Ursano, R. J. (2021). Association of emotion reactivity and distressintolerance with suicide attempts in U.S. Army soldiers. Suicide and Life-Threatening
Behavior
96. Stanley, I. H., Chu, C., Gildea, S. M., Hwang, I. H., King, A. J., Kennedy, C. J., Luedtke, A.,
Marx, B. P., O'Brien, R., Petukhova, M. V., Sampson, N. A., Vogt, D., Stein, M. B., Ursano, R.
J., & Kessler, R. C. (2022). Predicting suicide attempts among U.S. Army soldiers after leaving
active duty using information available before leaving active duty: results from the Study toAssess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS). MolecularPsychiatry
97. Koh, K. A., Montgomery, A. E., O'Brien, R. W., Kennedy, C. J., Luedtke, A., Sampson, N. A.,
Gildea, S. M., Hwang, I., King, A. J., Petriceks, A. H., Petukhova, M. V., Stein, M. B., Ursano, R.
J., & Kessler, R. C. Predicting homelessness among U.S. Army Soldiers no longer on active
duty. American Journal of Preventive Medicine
98. Chu, C., Stanley, I. H., Marx, B. P., King, A. J., Vogt, D., Gildea, S. M., Hwang, I. H., Sampson,
N. A., O'Brien, R., Stein, M. B., Ursano, R. J., & Kessler, R. C. (2022). Associations ofvulnerability to stressful life events with suicide attempts after active duty among high-risksoldiers: results from the Study to Assess Risk and Resilience in ServicemembersLongitudinal study (STARRS-LS). Psychological Medicine, 1–11
99. Naifeh, J. A., Ursano, R. J., Stein, M. B., Mash, H., Aliaga, P. A., Fullerton, C. S., Dinh, H. M.,
Kao, T. C., Sampson, N. A., & Kessler, R. C. (2022). Association of premilitary mental healthwith suicide attempts during U.S. Army service. JAMA Network Open, 5(6)100. Naifeh, J. A., Capaldi, V. F., Chu, C., King, A. J., Koh, K. A., Marx, B. P., Montgomery, A. E.,
O'Brien, R. W., Sampson, N. A., Stanley, I. H., Tsai, J., Vogt, D., Ursano, R. J., Stein, M. B., &Kessler, R. C. (2022). Prospective associations of military discharge characterization with
post-active duty suicide attempts and homelessness: Results from the Study to Assess Risk
and Resilience in Servicemembers-Longitudinal Study (STARRS-LS). Military Medicine,usac232. Advance online publication. https://doi.org/10.1093/milmed/usac232

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

97101. Taylor, C. T., Campbell-Sills, L., Kessler, R. C., Sun, X., Nock, M. K., Ursano, R. J., Jain, S., &Stein, M. B. (2022). Social network size and personality traits independently andprospectively predict distress disorders and suicidal behavior in U.S. Armysoldiers. Psychological Medicine, 1–10. Advance online
publication. https://doi.org/10.1017/S0033291722002082
102. Naifeh, J. A., Ursano, R. J., Stein, M. B., Herberman Mash, H. B., Aliaga, P. A., Fullerton, C.
S., Dinh, H. M., Kao, T.-C., Sampson, N. A., & Kessler, R. C. (2022). Prospective associationsof emotion reactivity and risk behaviors with suicide attempts in U.S. Army soldiers.
Psychological Medicine. Advance online publication.
103. Dempsey, C. L., Benedek, D. M., Zuromski, K. L., Nock, M. K., Brent, D. A., Ao, J., Georg,
M. W., Haller, K., Aliaga, P. A., Heeringa, S. G., Kessler, R. C., Stein, M. B., & Ursano, R. J.
(2023). Recent stressful experiences and suicide risk: implications for suicide prevention andIntervention in U.S. Army soldiers. Psychiatric research and clinical practice, 5(1), 24–36.
104. Campbell-Sills, L., Sun, X., Kessler, R. C., Ursano, R. J., Jain, S., & Stein, M. B. (2023).
Exposure to bullying or hazing during deployment and mental health outcomes among U.S.
Army soldiers. JAMA network open, 6(1), e2252109.
105. Montgomery, A. E., Koh, K. A., King, A. J., O'Brien, R., Sampson, N. A., Petriceks, A., Stein,
M. B., Ursano, R. J., & Kessler, R. C. (2023). Stressful life events and risk of homelessness
after active duty: an assessment of risk and resilience among service members. Publichealth reports (Washington, D.C.: 1974), 333549221149092. Advance online publication.
106. Campbell-Sills, L., Papini, S., Norman, S. B., Choi, K. W., He, F., Sun, X., Kessler, R. C.,
Ursano, R. J., Jain, S., & Stein, M. B. (2023). Associations of polygenic risk scores withposttraumatic stress symptom trajectories following combat deployment. Psychological
medicine, 1–10. Advance online publication.
107. Kearns, J., Edwards, E., Finley, E., Geraci, J., Gildea, S., Goodman, M., . . . Kessler, R.
(2023). A practical risk calculator for suicidal behavior among transitioning U.S. Armysoldiers: Results from the Study to Assess Risk and Resilience in ServicemembersLongitudinal Study (STARRS-LS). Psychological Medicine, 1-10.
doi:10.1017/S0033291723000491
108. Campbell-Sills, L., Sun, X., Papini, S., Choi, K. W., He, F., Kessler, R. C., Ursano, R. J., Jain,
S., & Stein, M. B. (2023). Genetic, environmental, and behavioral correlates of lifetime
suicide attempt: Analysis of additive and interactive effects in two cohorts of US Armysoldiers. Neuropsychopharmacology : official publication of the American College of
Neuropsychopharmacology, 10.1038/s41386-023-01596-2. Advance online
publication. https://doi.org/10.1038/s41386-023-01596-2
109. Mash, H.B. Herberman, Ursano, R.J., Kessler, R.C., Naifeh, J.A., Fullerton, C.S., Aliaga,
P.A., Dinh, H.M., Sampson, N.A., Kao, T.-C., & Stein, M.B. (2023). Predictors of suicide
attempt within 30 days of first medically documented major depression diagnosis in U.S.
Army Soldiers with no prior suicidal ideation. BMC Psychiatry, 23, 392. doi: 10.1186/s12888023-04872-z.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

98

ARMY STARRS METHODS PUBLICATIONS:
1. Gadermann, A. M., Engel, C. C., Naifeh, J. A., Nock, M. K., Petukhova, M., Santiago, P. N.,
Wu, B., Zaslavsky, A. M., & Kessler, R. C. (2012). Prevalence of DSM-IV major depression
among U.S. military personnel: Meta-analysis and simulation. Military Medicine, 177(8), 4759. doi: 10.7205/MILMED-D-12-00103.
2. Gadermann, A. M., Gilman, S. E., McLaughlin, K. A., Nock, M. K., Petukhova, M., Sampson, N.
A., & Kessler, R. C. (2012). Projected rates of psychological disorders and suicidality amongsoldiers based on simulations of matched general population data. Military Medicine,
177(9), 1002-1010. doi: 10.7205/MILMED-D-12-00092.
3. Thomas, M. L., Brown, G. C., Gur, R. C., Hansen, J. A., Nock, M. K., Heeringa, S., Ursano, R. J.,& Stein, M. B. (2013). Parallel psychometric and cognitive modeling analyses of the Penn
Face Memory Test in the Army Study to Assess Risk and Resilience in Servicemembers.
Journal of Clinical and Experimental Neuropsychology, 35(3), 225-245.
doi.10.1080/13803395.2012.762974.
4. Nock, M. K., Deming, C. A., Fullerton, C. S., Gilman, S. E., Goldenberg, M., Kessler, R. C.,
McCarroll, J. E., McLaughlin, K. A., Peterson, C., Schoenbaum, M., Stanley, B., & Ursano, R. J.
(2013). Suicide among soldiers: A review of psychosocial risk and protective factors.
Psychiatry, 76(2), 97-125. doi: 10.1521/psyc.2013.76.2.97.
5. Heeringa, S. G., Gebler, N., Colpe, L. J., Fullerton, C. S., Hwang, I., Kessler, R. C., Naifeh, J. A.,
Nock, M. K., Sampson, N. A., Schoenbaum, M., Zaslavsky, A. M., Stein, M. B., & Ursano, R. J.
(2013). Field procedures in the Army Study to Assess Risk and Resilience in Servicemembers(Army STARRS). International Journal of Methods in Psychiatric Research, 22(4), 276–287.
doi: 10.1002/mpr.1400.
6. Kessler, R. C., Colpe, L. J., Fullerton, C. S., Gebler, N., Naifeh, J. A., Nock, M. K., Sampson, N.
A., Schoenbaum, M., Zaslavsky, A. M., Stein, M. B., Ursano, R. J., & Heeringa, S. G. (2013).
Design of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).
International Journal of Methods in Psychiatric Research, 22(4), 267–275. doi:
10.1002/mpr.1401.
7. Kessler, R. C., Heeringa, S. G., Colpe, L. J., Fullerton, C. S., Gebler, N., Hwang, I., Naifeh, J. A.,
Nock, M. K., Sampson, N. A., Schoenbaum, M., Zaslavsky, A. M., Stein, M. B., & Ursano, R. J.
(2013). Response bias, weighting adjustments, and design effects in the Army Study toAssess Risk and Resilience in Servicemembers (Army STARRS). International Journal of
Methods in Psychiatric Research, 22(4), 288–302. doi: 10.1002/mpr.1399.
8. Kessler, R. C., Santiago, P. N., Colpe, L. J., Dempsey, C. L., First, M. B., Heeringa, S. G., Stein,
M. B., Fullerton, C. S., Gruber, M. J., Naifeh, J. A., Nock, M. K., Sampson, N. A., Schoenbaum,
M., Zaslavsky, A. M., & Ursano, R. J. (2013). Clinical reappraisal of the Composite
International Diagnostic Interview Screening Scales (CIDI-SC) in the Army Study to Assess
Risk and Resilience in Servicemembers (Army STARRS). International Journal of Methods in
Psychiatric Research, 22(4), 303–321. doi: 10.1002/mpr.1398.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

99

9. Gadermann, A. M., Heeringa, S. G., Stein, M. B., Ursano, R. J., Colpe, L. J., Fullerton, C.
S., Gilman, S. E., Gruber, M. J., Nock, M. K., Rosellini, A. J., Sampson, N. A., Schoenbaum,
M., Zaslavsky, A. M., & Kessler, R. C. (2014). Classifying U.S. Army Military Occupational
Specialties using the Occupational Information Network. Military Medicine, 179(7), 752-761.
doi: 10.7205/MILMED-D-13-00446.
10. Rosellini, A. J., Stein, M. B., Colpe, L. J., Heeringa, S. G., Petukhova, M. V., Sampson, N. A.,
Schoenbaum, M., Ursano, R. J., & Kessler, R. C. (2015). Approximating a DSM-5 diagnosis of
PTSD using DSM-IV criteria. Depression and Anxiety, 32(7), 493-501. doi: 10.1002/da.22364.
11. Thomas, M. L., Brown, G. G., Gur, R. C., Moore, T. M., Patt, V. M., Nock, M. K., Naifeh, J. A.,
Heeringa, S., Ursano, R. J., & Stein, M. B. (2015). Measurement of latent cognitive abilities
involved in concept identification learning. Journal of Clinical and Experimental
Neuropsychology, 37(6), 653–669. doi: 10.1080/13803395.2015.1042358.
12. Wagner, J., Schroeder, H. M., Piskorowski, A., Ursano, R. J., Stein, M. B., Heeringa, S. G., &Colpe, L. J. (2017). Timing the mode switch in a sequential mixed-mode survey: An
experimental evaluation of the impact on final response rates, key estimates, and costs.
Social Science Computer Review, 35(2), 262-276. doi: 10.1177/0894439316654611.
13. Moore, T. M., Gur, R. C., Thomas, M .L., Brown, G. G., Nock, M. K., Savitt, A. P., Keilp, J. G.,
Heeringa, S., Ursano, R. J., & Stein, M. B. (2017). Development, administration, andstructural validity of a brief, computerized neurocognitive battery. Assessment, 26(1), 125143. doi: 10.1177/107319111668920.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

100

PUBLICATIONS FROM COLLABORATION WITH THE PSYCHIATRIC GENOMICS CONSORTIUM:
The following publications represent an example of the broader impact of STARRS resulting
from our collaboration and data sharing. STARRS investigators shared STARRS GWAS and otherdata with the NIMH Psychiatric Genomics Consortium (PGC) to yield the largest sample everexamined of the GWAS of PTSD. STARRS was the largest contributor of GWAS data to thiseffort. These publications are based on analyses of pooled data from a consortium ofinvestigators conducting genetic studies on PTSD and other psychiatric disorders.
1. Dunn, E. C., Sofer, T., Gallo, L. C., Gogarten, S. M., Kerr, K. F., Chen, C. Y., Stein, M. B.,
Ursano, R. J., Guo, X., Jia, Y., Qi, Q., Rotter, J. I., Argos, M., Cai, J., Penedo, F. J., Perreira, K.,
Wassertheil-Smoller, S., & Smoller, J. W. Genome-wide association study of generalized
anxiety symptoms in the Hispanic Community Health Study/Study of Latinos. (2017). Am J
Med Genet B Neuropsychiatr Genet. Mar; 174(2): 132-143.
•

This study aimed to discover potential loci by conducting a genome-wide analysis of
GAD symptoms in a large, population-based sample of Hispanic/Latino adults using
data from 12,282 participants, aged 18-74, of the Hispanic Community HealthStudy/Study of Latinos.

•

Using a shortened Spielberger Trait Anxiety measure, the study analyzed: (1) a GAD
symptoms score restricted to the 3 items tapping diagnostic features of GAD as
defined by DSM-V; and (2) a total trait anxiety score based on summing responses toall 10 items. Study first calculated heritability due to common variants (h2SNP) andthen conducted a genome-wide association study (GWAS) of GAD symptoms.
Replication was attempted in 3 independent Hispanic cohorts (Multi-Ethnic Study ofAtherosclerosis, Women's Health Initiative, Army STARRS).

•The GAD symptoms score showed evidence of modest heritability while the total trait
anxiety score did not. One genotyped SNP (rs78602344) intronic to thrombospondin 2(THBS2) was nominally associated in the primary analysis adjusting for psychiatric
medication use and significantly associated with the GAD symptoms score in theanalysis excluding medication users. Meta-analysis of the replication samples did notsupport this association.

•

The study identified a genome-wide significant locus in this sample, but was unable toreplicate this finding. Evidence for heritability was also only detected for GAD
symptoms, and not the trait anxiety measure, suggesting differential genetic
influences within the domain of trait anxiety.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

101

2. Wolf, E. J., Maniates, H., Nugent, N., Maihofer, A. X., Armstrong, D., Ratanatharathorn, A.,
Ashley-Koch, A. E., Garrett, M., Kimbrel, N. A., Lori, A., VA Mid-Atlantic Mirecc Workgroup,
Aiello, A. E., Baker, D. G., Beckham, J. C., Boks, M. P., Galea, S., Geuze, E., Hauser, M. A.,
Kessler, R. C., Koenen, K. C., Miller, M. W., Ressler, K. J., Risbrough, V., Rutten, B. P. F., Stein,
M. B., Ursano, R. J., Vermetten, E., Vinkers, C. H., Uddin, M., Smith, A. K., Nievergelt, C. M.,& Logue, M. W. (2017). Traumatic stress and accelerated DNA methylation age: A metaanalysis. Psychoneuroendocrinology, 92, 123-134. doi: 10.1016/j.psyneuen.2017.12.007.
•

This study involved a meta-analysis of trauma exposure, PTSD diagnosis, and symptom
severity in association with accelerated DNA methylation age using data from 9
cohorts contributing to the PGC-PTSD Epigenetics Workgroup (combined N = 2186).
The study also examined associations between demographic and cellular variables andaccelerated DNA methylation age.

•

The results revealed that childhood trauma exposure, measured with the Childhood
Trauma Questionnaire, and lifetime PTSD severity show significant meta-analytic
associations with accelerated DNA methylation age. The study also found that sex,
CD4T cell proportions, and natural killer cell proportions were significantly associatedwith accelerated DNA methylation age.

•

Findings suggest that traumatic stress is associated with advanced epigenetic age andraises the possibility that cells integral to immune system maintenance andresponsivity play a role in this. The study highlights the need for additional research
into the biological mechanisms linking traumatic stress to accelerated DNA
methylation age and the importance of furthering our understanding of theneurobiological and health consequences of PTSD.

3. Dunn, E. C., Sofer, T., Wang, M., Soare, T. S., Gallo, L. C., Gogarten, S. M., Kerr, K. F., Chen,
C., Stein, M. B., Ursano, R. J., Guo, X., Jia, Y., Yao, J., Rotter, J. I., Argos, M., Cai, J., Perreira,K., Wassertheil-Smoller, S., & Smoller, J. W. Genome-wide association study (GWAS) ofdepressive symptoms in the Hispanic Community Health Study/Study of Latinos(HCHS/SOL). (2018). Journal of Psychiatric Research, 99, 167-176. doi:
10.1016/j.jpsychires.2017.12.010.
•

This study involved a genome-wide analysis of depression in a large, population-based
sample of Hispanics/Latinos. This is the largest GWAS of depression related
phenotypes in Hispanic/Latino adults ever conducted.

•

Three phenotypes were examined: a total depression score, a total score modified toaccount for psychiatric medication use, and a score excluding antidepressant
medication users. The study included a GWAS of the three phenotypes and attempted
replication in three independent Hispanic/Latino cohorts.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

102

•

Sex-stratified analyses were performed, a binary trait indicating probable depression
was analyzed, and 3 trans-ethnic analyses were done. The 3 phenotypes exhibited
significant heritability in the total sample. No SNPs were genome-wide significant inanalyses of the 3 phenotypes or the binary indicator of probable depression. Sexstratified analyses identified 7 genome-wide significant SNPs (1 in females; 6 in males),although none were supported through replication. Four out of 24 loci identified inprior GWAS were nominally associated. No evidence of overlap in genetic risk factors
across ancestry groups was found, although this may have been due to low power.

4. Ratanatharathorn, A., Boks, M. P., Maihofer, A. X., Aiello, A. E., Amstadter, A. B., AshleyKoch, A. E., Baker, D.G., Beckham, J. C., Bromet, E., Dennis, M., Garrett, M. E., Geuze, E.,
Guffanti, G., Hauser, M. A., Kilaru, V., Kimbrel, N. A., Koenen, K. C., Kuan, P. F., Logue, M. W.,
Luft, B. J., Miller, M.W., Mitchell, C., Nugent, N.R., Ressler, K. J., Rutten, B.P.F., Stein, M.B.,
Vermetten, E., Vinkers, C.H., Youssef, N. A., VA Mid-Atlantic MIRECC Workgroup, PGC PTSD
Epigenetics Workgroup, Uddin, M., Nievergelt, C. M., Smith, A.K. Epigenome-wide
association of PTSD from heterogeneous cohorts with a common multi-site analysis
pipeline. (2017). Am J Med Genet B Neuropsychiatr Genet. 174(6), 619-630. doi:
10.1002/ajmg.b.32568.
•

Evidence suggests that epigenetic mechanisms such as DNA methylation play a rolein stress regulation and in the etiologic basis of stress related disorders such as PTSD.
This study describes the purpose and methods of an international consortium
developed to study the role of epigenetics in PTSD.

•

Based on the PGC, this study brought together investigators representing 7 cohorts
with a collective sample size of N = 1147 that included detailed information on trauma
exposure, PTSD symptoms, and genome-wide DNA methylation data. The objective
was to increase the analytical sample size by pooling data and combining expertise sothat DNA methylation patterns associated with PTSD can be identified. Several quality
control and analytical pipelines were evaluated for their control of genomic inflationand technical artifacts with a joint analysis procedure established to derivecomparable data over the cohorts for meta-analysis.

•

The study proposed methods to deal with ancestry population stratification and type I
error inflation, and discussed advantages and disadvantages of applying robust error
estimates.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

103

•

The study reported results from an epigenome-wide association study (EWAS) of age,which is a well-characterized phenotype with known epigenetic associations. While
EWAS is highly complex and subject to similar challenges as genome-wide association
studies (GWAS), the study demonstrated that an epigenetic meta-analysis with arelatively modest sample size can be well-powered to identify epigenetic associations.
The pipeline can be used as a framework for consortium efforts for EWAS.

5. Wang, Y., Karstoft, K. I., Nievergelt, C. M., Maihofer, A. X., Stein, M. B., Ursano, R. J.,
Bybjerg-Grauholm, J., Baekvad-Hansen, M., Hugaard, D. M., Andreassen, O. A., Werge, T.,
Thompson, W. K., & Andersen, S. B. (2019). Post-traumatic stress following military
deployment: Genetic associations and cross-disorder genetic correlations. J Affect Disord,
252, 350-357. doi:10.1016/j.jad.2019.04.070•

Post-traumatic stress disorder (PTSD) is a complex psychiatric disorder that occurs
with relatively high frequency after deployment to warzones (∼10%). While twin
studies have estimated the heritability to be up to 40%, indicating a considerable
genetic component in the etiology, the biological mechanisms underlying risk anddevelopment of PTSD remain unknown.

•

This genome-wide association study (GWAS; N = 2,481) was conducted to identify
genome regions that associate with PTSD in a highly homogenous, trauma-exposed
sample of Danish soldiers deployed to war and conflict zones. Integrated analyses
were performed with gene-expression and chromatin-contact datasets to prioritized
genes. Other large GWAS (N>300,000) were leveraged to investigate genetic
correlations between PTSD and other psychiatric disorders and traits.

•

Study discovered, but did not replicate, one region, 4q31, close to the IL15 gene,which is genome-wide significantly associated with PTSD. Study demonstrated thatgene-set enrichment, polygenic risk score and genetic correlation analyses show
consistent and significant genetic correlations between PTSD and depression,
insomnia and schizophrenia. The limited sample size, the lack of replication, and the
PTSD case definition by questionnaire are limitations to the study.

•

The results suggest that genetic perturbations of inflammatory response may
contribute to the risk of PTSD. In addition, shared genetic components contribute toobserved correlations between PTSD and depression, insomnia and schizophrenia.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

104

6. Smith, A. K., Ratanatharathorn, A., Maihofer, A. X., Naviaux, R. K., Aiello, A. E., Amstadter, A.
B., Ashley-Koch, A. E., Baker, D. G., Beckham, J. C., Boks, M. P., Bromet, E., Dennis, M.,
Galea, S., Garrett, M. E., Geuze, E., Guffanti, G., Hauser, M. A., Katrinli, S., Kilaru, V., Kessler,
R. C., … Nievergelt, C. M. (2020). Epigenome-wide meta-analysis of PTSD across 10 militaryand civilian cohorts identifies methylation changes in AHRR. Nature Communications, 11(1),5965. https://doi.org/10.1038/s41467-020-19615-x•

Epigenetic differences may help to distinguish between PTSD cases and traumaexposed controls. This study is the largest DNA methylation meta-analysis of PTSD to
date.

•

Ten military and civilian cohorts contributed blood-derived DNA methylation datafrom 1,896 PTSD cases and trauma-exposed controls. Four CpG sites within thearylhydrocarbon receptor repressor (AHRR) were associated with PTSD after
adjustment for multiple comparisons, with lower DNA methylation in PTSD cases
relative to controls.

•

Although AHRR methylation is known to associate with smoking, the AHRR association
with PTSD was most pronounced in non-smokers, suggesting the result was
independent of smoking status. Evaluation of metabolomics data reveals that AHRR
methylation is associated with kynurenine levels, which are lower among subjects with
PTSD.

•

This study supports epigenetic differences in those with PTSD and suggests a role fordecreased kynurenine as a contributor to immune dysregulation in PTSD.

7. Giannakopoulou, O., Lin, K., Meng, X., Su, M. H., Kuo, P. H., Peterson, R. E., Awasthi, S.,
Moscati, A., Coleman, J., Bass, N., Millwood, I. Y., Chen, Y., Chen, Z., Chen, H. C., Lu, M. L.,
Huang, M. C., Chen, C. H., Stahl, E. A., Loos, R., Mullins, N., … 23andMe Research Team,
China Kadoorie Biobank Collaborative Group, and Major Depressive Disorder Working
Group of the Psychiatric Genomics Consortium (2021). The Genetic Architecture ofDepression in Individuals of East Asian Ancestry: A Genome-Wide Association Study. JAMA
Psychiatry. Advance online publication. https://doi.org/10.1001/jamapsychiatry.2021.2099•

Most previous genome-wide association studies (GWAS) of depression have used datafrom individuals of European descent. This limits the understanding of the underlying
biology of depression and raises questions about the transferability of findings
between populations.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

105

•

This study investigated the genetics of depression among individuals of East Asian andEuropean descent living in different geographic locations, and with different outcome
definitions for depression by performing genome-wide association analyses followedby meta-analysis, which included data from 9 cohort and case-control data setscomprising individuals with depression and control individuals of East Asian descent.

•

Associations of genetic variants with depression risk were assessed using generalized
linear mixed models and logistic regression. The results were combined across studies
using fixed-effects meta-analyses. These were subsequently also meta-analyzed withthe largest published GWAS for depression among individuals of European descent.
Additional meta-analyses were carried out separately by outcome definition (clinicaldepression vs symptom-based depression) and region (East Asian countries vsWestern countries) for East Asian ancestry cohorts. Depression status was defined
based on health records and self-report questionnaires.

•

There were a total of 194,548 study participants (approximate mean age, 51.3 years;
62.8% women). Participants included 15,771 individuals with depression and 178,777
control individuals of East Asian descent. Five novel associations were identified,including 1 in the meta-analysis for broad depression among those of East Asiandescent: rs4656484 (β = −0.018, SE = 0.003, P = 4.43x10−8) at 1q24.1. Another locus at
7p21.2 was associated in a meta-analysis restricted to geographically East Asianstudies (β = 0.028, SE = 0.005, P = 6.48x10−9 for rs10240457). The lead variants ofthese 2 novel loci were not associated with depression risk in European ancestry
cohorts (β = −0.003, SE = 0.005, P = .53 for rs4656484 and β = −0.005, SE = 0.004,
P = .28 for rs10240457). Only 11% of depression loci previously identified in individualsof European descent reached nominal significance levels in the individuals of East
Asian descent. The transancestry genetic correlation between cohorts of East Asianand European descent for clinical depression was r = 0.413 (SE = 0.159). Clinicaldepression risk was negatively genetically correlated with body mass index inindividuals of East Asian descent (r = −0.212, SE = 0.084), contrary to findings forindividuals of European descent.

•

The authors concluded that these results support caution against generalizing findings
about depression risk factors across populations and highlight the need to increase theancestral and geographic diversity of samples with consistent phenotyping.

8. A. R. Docherty, N. Mullins, A. E. Ashley-Koch, et al. Genome-wide association study metaanalysis of suicide attempt in 43,871 cases identifies twelve genome-wide significant loci.
medRxiv. August 2022. 2022.07.03.22277199

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

106

•

Objective: Suicidal behavior is moderately heritable and a major cause of deathworldwide. Two large-scale genome-wide association studies (GWAS) have recently
discovered and cross-validated genome-wide significant (GWS) loci for suicide attempt(SA). The current study leveraged the genetic cohorts from these two studies to
conduct the largest GWAS meta-analysis of SA to date. Ancestry-specific GWAS metaanalyses were also conducted within African, East Asian, and European ancestries.

•

Methods: This study comprised 22 cohorts, including 43,871 SA cases and 915,025
ancestry-matched controls. Analytical methods across multi-ancestry and African, East
Asian, and European ancestral groups included inverse variance-weighted fixed effects
models, gene/gene set and tissue enrichment testing, drug-gene interaction analyses,
and summary-based Mendelian Randomization with eQTL MetaBrain data.

•

Results: Multi-ancestry and European GWAS meta-analyses identified 12 risk loci,including 28 independent GWS variants at p&amp;lt;5×10−8. Risk loci were mostlyintergenic and implicated DRD2, SLC6A9, FURIN, NLGN1, SOX5, PDE4B, and CACNG2.
The SNP-based heritability estimate of SA was 5.7% on the liability scale (SE=0.003, p =5.70×10−80). Significant brain tissue gene expression and drug set enrichment wasobserved, along with shared genetic variation of SA with ADHD, smoking, and risk
tolerance after conditioning on both major depressive disorder and post-traumaticstress disorder.

•

Conclusions: This multi-ancestry GWAS of suicide attempt identified several locicontributing to risk, and significant shared genetic covariation with relevant clinicalphenotypes that is not accounted for by major depressive disorder or post-traumaticstress disorder. These findings outline molecular pathways of risk for suicide, andprovide new insight into shared genetic architecture with psychiatric phenotypes
across ancestries.

9. Maihofer, A. X., Engchuan, W., Huguet, G., Klein, M., MacDonald, J. R., Shanta, O.,
Thiruvahindrapuram, B., Jean-Louis, M., Saci, Z., Jacquemont, S., Scherer, S. W., Ketema, E.,
Aiello, A. E., Amstadter, A. B., Avdibegović, E., Babic, D., Baker, D. G., Bisson, J. I., Boks, M.
P., Bolger, E. A., … Nievergelt, C. M. (2022). Rare copy number variation in posttraumaticstress disorder. Molecular psychiatry, 10.1038/s41380-022-01776-4•

Posttraumatic stress disorder (PTSD) is a heritable (h2 = 24–71%) psychiatric illness.
Copy number variation (CNV) is a form of rare genetic variation that has been
implicated in the etiology of psychiatric disorders, but no large-scale investigation of
CNV in PTSD has been performed.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

107

•

This was an association study of CNV burden and PTSD symptoms in a sample of
114,383 participants (13,036 cases and 101,347 controls) of European ancestry. CNVs
were called using two calling algorithms and intersected to a consensus set. Quality
control was performed to remove strong outlier samples. CNVs were examined for
association with PTSD within each cohort using linear or logistic regression analysis
adjusted for population structure and CNV quality metrics, then inverse varianceweighted meta-analyzed across cohorts.

•

This study examined the genome-wide total span of CNVs, enrichment of CNVs within
specified gene-sets, and CNVs overlapping individual genes and implicatedneurodevelopmental regions. The total distance covered by deletions crossing overknown neurodevelopmental CNV regions was significant (beta = 0.029, SE = 0.005, P =6.3 × 10−8). The genome-wide neurodevelopmental CNV burden identified explained
0.034% of the variation in PTSD symptoms. The 15q11.2 BP1-BP2 microdeletion region
was significantly associated with PTSD (beta = 0.0206, SE = 0.0056, P = 0.0002).

•

No individual significant genes interrupted by CNV were identified. 22 gene pathways
related to the function of the nervous system and brain were significant in pathway
analysis (FDR q < 0.05), but these associations were not significant once NDD regions
were removed. A larger sample size, better detection methods, and annotatedresources of CNV are needed to explore this relationship further.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

108

STARRS-RELATED PUBLICATIONS:
The following are STARRS-related publications. These publications include members of the
STARRS Research Team as co-authors, except where noted with an asterisk. Some of thesepublications summarize or review previously published STARRS findings and others present new
findings.
1. Gonzalez, O. I., Naifeh, J. A., Mash, H. H. (2018, June). Interpersonal Violence and Suicide
Risk Among U.S. Army Soldiers. ISTSS Stress Points, 32(3). Retrieved from http://sherwoodistss.informz.net/admin31/content/template.asp?sid=60943&brandid=4463&uid=1044618
441&mi=7664760&mfqid=40875668&ptid=&ps=60943
2. Naifeh, J. A., Mash, H. B. H., Stein, M. B., Fullerton, C. S., Kessler, R. C., & Ursano, R. J.
(2018). The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS):
Progress toward understanding suicide among soldiers. Mol Psychiatry, 24, 34-48.
doi:10.1038/s41380-018-0197-z.
3. Levey, D. F., Polimanti, R., Cheng, Z., Zhou, H., Nunez, Y. Z., Jain, S., He, F., Sun, X., Ursano,R. J., Kessler, R. C., Smoller, J. W., Stein, M. B., Kranzler, H. R., & Gelernter, J. (2019).
Genetic associations with suicide attempt severity and genetic overlap with major
depression. Transl Psychiatry, 9(1), 22. doi:10.1038/s41398-018-0340-2
4. Karlsson Linner, R., Biroli, P., Kong, E., Meddens, S. F. W., Wedow, R., Fontana, M. A.,
Lebreton, M., Tino, S. P., Abdellaoui, A., Hammerschlad, A. R., Nivard, M. G., Okbay, A.,
Rietveld, C. A., Timshel, P. N., Trzaskowski, M., Vlaming, R. Zund, C. L., Bao, Y., Buzdugan,
L., Caplin, A. H., Chen, C. Y., Eibich, P., Fontanillas, P., Gonzalez, J. R., Joshi, P. K., Karhunen,
V., Kleinman, A., Levin, R. Z., Lill, C. M., Meddens, G. A., Muntain, G., Sanchez-Roige, S.,
Rooij, F. J. V., Taskesen, E., Wu, Y., Zhang, F. l., Auton, A., Boardman, J. D., Clark, D. W.,
Conlin, A., Dolan, C. C., Fischbacher, U., Groenen, P. J. F., Harris, K. M., Hasler, G., Hofman,
A., Ikram, M. A., Jain, S., Karlsson, R., Kessler, R. C., Kooyman, M., MacKillop, J., Mannikko,
M., Morcillo-Suarez, C., McQueen, M. B., Schmidt, K. M., Smart, M. C., Sutter, M., Thurik, A.
R., Uitterlinden, A. G., White, J., Wit, H., Yang, J., Betram, L., Boomsma, D. I., Esko, T., Fehr,E., Hinds, D. A., Johannesson, M., Kumari, M., Laibson, D., Magnusson, P. K. E., Myer, M. N.,
Navarro, A., Palmer, A. A., Pers, T. H., Posthuma, D., Schunk, D., Stein, M. B., Svento, R.,
Tiemeier, H., Timmers, P. R. H. J., Turley, P., Ursano, R. J., Wagner, G. G., Wilson, J. F.,
Gratten, J., Lee, J. J., Cesarini, D., Benjamin, D. J., Koellinger, P. D., & Beauchamp, J. P.
(2019). Genome-wide association analyses of risk tolerance and risky behaviors in over 1
million individuals identify hundreds of loci and shared genetic influences. Nat Genet, 51,
245-257. doi:10.1038/s41588-018-0309-3.
5. Kessler, R. C., Bossarte, R. M., Luedtke, A., Zaslavsky, A. M., & Zubizarreta, J. R. (2019).
Suicide prediction models: A critical review of recent research with recommendations forthe way forward. Mol Psychiatry. doi:10.1038/s41380-019-0531-0.

VOLUME 7, ISSUE 3 (UPDATED JUNE 7, 2023)

109

6. * Curley, J. M., Penix, E. A., Srinivasan, J., Sarmiento, D. M., McFarling, L. H., Newman, J. B.,& Wheeler, L. A. (2019). Development of the U.S. Army’s Suicide Prevention Leadership
Tool: The Behavioral Health Readiness and Suicide Risk Reduction Review (R4). Mil Med.
doi:10.1093/milmed/usz380
7. * Duncan, J. M., Reed-Fitzke, K., Ferraro, A. J., Wojciak, A. S., Smith, K. M., Sánchez, J.
(2020). Identifying Risk and Resilience Factors Associated With the Likelihood of Seeking
Mental Health Care Among U.S. Army Soldiers-in-Training. Mil Med, Feb 20, pii: usz483
8. Qiu, H., Carone, M., Sadikova, E., Petukhova, M., Kessler, R. C., Luedtke, A. (2020). Optimal
Individualized Decision Rules Using Instrumental Variable Methods. Journal of theAmerican Statistical Association, May 12
9. Chu, C., Wilks, C. R., Zuromski, K. L., Bernecker, S. L., King, A., Gutierrez, P. M., Joiner, T. E.,
Nock, M. K., Ursano, R.J., Kessler, R. C. (2020). Psychological Problems among 12th-Grade
Students Predicting Military Enlistment: Findings from the Monitoring the Future Survey.
Psychiatry, 83:244–258

110