Overview of the Army Study to Assess Risk and Resilience in Servicemembers(Army STARRS)James A. Naifeh,1 Catherine L. Dempsey,1 Carol S. Fullerton,1 David M. Benedek,1 Steven Heeringa,2 Ronald C. Kessler,3 Murray B. Stein,4 Matthew K. Nock,5 Kenneth L. Cox,6 Lisa J. Colpe,7 Michael Schoenbaum,7 & Robert J. Ursano1
1Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences; 2University of Michigan; 3Harvard Medical School; 4University of California, San Diego; 5Harvard University; 6U.S. Army Public Health Command; 7National Institute of Mental Health

Background• U.S. Army suicide rates were historically lower
than those of the U.S. general population,
adjusting for demographic differences

New Soldier Study (NSS)

Special Studies• Survey of new Soldiers as they enter Reception Week at Ft. Jackson, Ft. Benning, & Ft. Leonard Wood

1. Pre-Post Deployment Study (PPDS)• Instruments: Computerized self-administered questionnaire (SAQ) & neurocognitive tests, blood collection• Prospective, multi-wave panel examining suicidality and mental health following combat deployment• Instruments: Computerized and paper-and-pencil SAQs, blood collection• Data collected January 2012 to April 2014

• The suicide rate among Soldiers began rising in
2004 and has exceeded the adjusted civilianrate since 2008

• Pre-deployment participants: ~9,500 Soldiers (~8,000 Soldiers gave blood)• Post-deployment participants: ~10,000 Soldiers at 1 month; ~9,200 at 3 months; ~6,200 at 9 months• The Army engaged the National Institute of
Mental Health (NIMH) for help in addressing thisissue

2. Clinical Reappraisal Study (CRS)• In-depth clinical interviews with Soldiers to examine the diagnostic accuracy of Army STARRS SAQs
• Instruments: Telephone-administered diagnostic interview (Structured Clinical Interview for DSM-IV)• Army STARRS is a direct response to the Army’s request that NIMH enlist the most promising scientificapproaches to better understand psychological resilience, mental health, and risk for self-harm amongSoldiers• Army STARRS was supported under a 5-year NIMH Cooperative Agreement (U01)* mechanism, providing
for substantive NIMH involvement in the execution of the study and the inclusion of Army scientists aspartners• The consortium brings together an internationally known, interdisciplinary team of researchers with expertisein military health, psychiatric epidemiology, survey methodology, genetics & neurobiology, and suicidal
behaviors• Data collected March 2012 to November 2012
• ~460 Soldiers participated

Conceptual Framework: Concentration of Risk.

• Data collected February 2011 to November 2012
• Blood collected September 2011 to November 2012
• ~57,000 Soldiers attended survey sessions• ~35,000 Soldiers gave blood (80% of those asked)

STARRSAll Army Study (AAS)

Army Study to Assess Risk and Resilience in Service Members• Representative cross-sectional survey of active duty Soldiers (including activated Army Reserve and ArmyNational Guard) inside and outside the continental U.S., including in-theater (Kuwait)**• Instruments: Computerized or paper-and-pencil SAQ• Data collected January 2011 to April 2013
• ~35,000 Soldiers attended CONUS & OCONUS survey sessions; ~10,000 attended sessions in-theater

Lisa J. Colpe, PhD, MPH
Michael Schoenbaum, PhD(scientific input)

Army STARRSAll Army Study (AAS) Sites

Secretaryof the Army

Program Staff(oversight)

Joint Base
Lewis-McChord_^

Alaska Inset

United States
Military Academy
Ft. Drum

Vice Chief of Staffof the ArmyRESEARCH CONSORTIUM(scientific leadership, study design, study implementation, data collection, data analysis)!
Ft. Richardson!

!

Deputy Under Secretaryof the Army(oversight)

Ft. Carson_^!

Ft. Leavenworth!! Kansas City

Ft. Riley

Ft. Irwin

Murray B. Stein, MD, MPH
Co-Principal Investigator
University of California, San Diego_^White Sands
Missle Range_^

Ft. Bliss_^!
Ft. Polk

Falls Church Military Medical Center!

Schofield Barracks!
!
!

Kenneth L. Cox, MD, MPH
Steven Cersovsky, MD, MPH(consulting scientists)
Ronald C. Kessler, PhD
Site Principal Investigator
Harvard Medical School

Tripler Army
Medical Center

Steven G. Heeringa, PhD
Site Principal Investigator
University of Michigan

Ft. Bragg_^

See DC/MD/VA
Inset!

Ft. Benning_^!

! Ft. Stewart

Camp H.M.
Smith
Ft. Shafter

Joint-Base!Langley-Eustis! Norfolk Naval
Air Station!

Security, Confidentiality, & Safety

Paper and Pencil Interviewing Site

^ Computer-Assisted Interviewing Site_• Army STARRS data are stored in a secure, Army-approved data enclave at the University of Michigan

Ft. Rucker• Blood samples are stored in a secure, Army-approved biorepository at Rutgers University

Hawaii Inset

Marine Corps
Base Quantico

Ft. Lee !

!!

!Miami!

Multiple Army Commands(support)!
!Ft. Knox_^CampShelby

Ft. Hood!Ft. Detrick
Walter Reed Nationa!!
!
!

! Ft. Sill!

Ft. Myer !!! Washington D.C.
Ft. Belvoir!

CampAtterbury

Ft. Leonard
Wood
Ft. Campbell!
DC/MD/VA Inset

Robert J. Ursano, MD
Co-Principal Investigator
Uniformed Service University! Offut AFB

DugwayProving
Grounds!
! Ft. Hamilton! Ft. Dix

OCONUS Paper and Pencil Interviewing Sites
Supreme Headquarters Allied Powers Europe - Belgium
US Army Garrison Ansbach - Germany
US Army Garrison Grafenwoehr - Germany
US Army Garrison Wiesbaden - Germany
US Army Medical Activity - Germany
Camp Ederle - Italy
Ali Al Salen Air Base (In-theater) - KuwaitCamp Arifjan - KuwaitCamp Casey - South Korea
Camp Humphreys - South Korea• Privacy is a top priority in every study component• Participants’ answers were never shared with anyone in the Army unless the Soldier indicated imminent
danger of self-harm or harming someone else
• When imminent danger was indicated, Army Chaplains were notified within 24 hours• All participants were given a wallet-sized Safety Resource Card with various behavioral health resources• Army Chaplains were on call during each interview session to provide immediate help
• Participants could request a confidential follow-up appointment with an Army ChaplainComponents

Soldier Health Outcomes Study (SHOS)• Two case-control studies (A & B) of Soldiers who engaged in non-fatal and fatal suicidal behavior• Army STARRS has five major components. Participation in all components is completely voluntary• Instruments used in each component assess a broad range of mental health risk and resilience factors

Historical Administrative Data Study (HADS)• Analysis of the de-identified health & administrative records of all active duty Soldiers during 2004–2009• Includes more than 1.6 million Soldiers and more than 1.1 billion records*Army STARRS was sponsored by the Department of the Army and funded under cooperative agreement number U01MH087981 with the U.S. Department ofHealth and Human Services, National Institutes of Health, National Institute of Mental Health (NIH/NIMH). The contents are solely the responsibility of the authors anddo not necessarily represent the views of the Department of Health and Human Services, NIMH, Department of the Army, Department of Defense, Uniformed
Services University of the Health Sciences, or Center for the Study of Traumatic Stress.
**This study was conducted under a protocol reviewed and approved by the U.S. Army Medical Research and Materiel Command Institutional Review Board, and inaccordance with the approved protocol

Communication

1. SHOS-A

2. SHOS-B

Products• Focuses on Soldiers hospitalized for a suicide
attempt at Ft. Bragg, Ft. Hood, JBLM, Ft. Stewart,& WRNMMC• Focuses on Soldiers who died by suicide• Brochures, posters, & postcards• Instruments: Telephone interviews with the next ofkin and Army supervisor of both cases (deceased)
and controls (living)• Website: www.ArmySTARRS.org• Data collected March 2012 to January 2014

• Press releases• Next of kin and/or supervisors provided data for
150 cases and 276 controls• Sample tweets and Facebook posts wereincluded in the Communications Plan for
installations to use with their Facebook
pages and Twitter accounts• Instruments: SAQs, interviews, computerizedneurocognitive tests, blood collection• Data collected November 2011 to December 2013
• 186 cases & 375 controls participated (296 totalSoldiers provided blood samples

Traditional & Social Media