Suicidal Behavior in the U.S. Army:
Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)James A. Naifeh,1 Ronald C. Kessler,2 Steven G. Heeringa,3 Murray B. Stein,4 Stephen E. Gilman,5 Matthew K. Nock,6 Michael Schoenbaum,7 Lisa J. Colpe,7 Carol S. Fullerton,1 & Robert J. Ursano1
1Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences; 2Harvard Medical School; 3University of Michigan; 4University of California, San Diego; 5Harvard School of Public Health; 6Harvard University; 7National Institute of Mental Health

BackgroundMethods & Results

Table 3. Bivariate Associations of Lifetime DSM-IV Mental Disorders with Post-Enlistment First Suicide Attempts in the AAS.

• Longitudinal retrospective cohort study of all active duty Regular Army Soldiers during 2004–2009 (N=975,057Soldiers) using de-identified health & administrative records. Person-month records for 569 suicide deaths and9,791 suicide attempters were compared to an equal-probability sample of control person-months.

• The suicide rate among Soldiers began
rising in 2004, surpassing the adjusted
civilian rate since 2008.

HADS Results – Suicides:• Suicide risk increased for those never,currently, & previously deployed (see figure tothe right). Risk was higher among currently &previously deployed soldiers than those neverdeployed.

• The Army engaged the National Instituteof Mental Health (NIMH) for help inaddressing this issue.

• 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.1• The study 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 interdisciplinary team of researchers with expertise in military health,psychiatric epidemiology, survey methodology, genetics & neurobiology, and suicidal behaviors.

• The rise in suicides was NOT associated withincreased use of accession waivers in any
category (e.g., medical, substance use,conduct), length of time since return from mostrecent deployment, total number ofdeployments, or the interval between the 2
most recent deployments (dwell time).2

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

Program Staff(oversight)

RESEARCH CONSORTIUM(scientific leadership, study design, study implementation, data collection, data analysis)

Vice Chief of Staffof the Army

Deputy Under Secretaryof the Army(oversight)

Robert J. Ursano, MD
Co-Principal Investigator
Uniformed Service University– –4.8 (0.5)
8.1 (0.4)

1.9
–
0.1
1.3
0.3
4.1
0.5
1.7

(0.6–6.3)–(0.0–0.7)*(0.5–3.3)(0.1–1.3)*(1.1–15.7)*(0.2–1.7)(0.6–4.6)

4.3 (2.3–8.1)*
3.9 (2.1–7.3)*
1.2 (0.3–4.8)

6.5
4.1
3.8
3.5
3.3
4.0
6.1
2.8

(2.3–18.8)*(1.4–11.8)*(1.2–11.8)*(1.1–11.1)*(1.6–6.8)*(1.4–11.7)*(1.8–21.4)*(1.0–8.0)– –
5.9 (2.2–15.4)*
3.9 (1.4–10.8)*

NSS Results:• The mean suicide rate was 18.5/100000
person-years.

• Pre-enlistment prevalence estimates of lifetime suicidal ideation, suicide plans, and suicide attempts are
15.1%, 2.3%, and 1.9%.

Total• 90.9% of Regular Army suicides werecompleted by enlisted soldiers.

• Among pre-enlistment ideators, 16.6% had developed a suicide plan and 13.0% had made a suicide attemptprior to enlistment, whereas 44.2% of pre-enlistment ideators with a plan had made an attempt.

First 4 Years

18.4

31.3

29.4

23.6

• 81.5% of the transitions from ideation to plans and 80.4% of the transitions from ideation to unplanned
attempts occurred within 1 year of onset of ideation, whereas 73.3% of the transitions from plans to attempts
occurred within 1 year of onset of plans.6

More than 4 Years

12.1

13.1

20.8

16.8

• Currently and previously deployed enlisted
soldiers in their first 4 years of service had
rates meaningfully higher than this mean
(31.3–29.4/100000 person-years) (Table 1).3

Total

16.3

21.8

23.1

20.1

• 59% of new soldiers with a pre-enlistment history of suicide attempt report having a mental disorder thatbegan before their first attempt. The rate of temporally prior mental disorders is slightly lower among thosewith suicide ideation (41%) or plan (57%).7

HADS Results – Suicide Attempts:• Enlisted soldiers accounted for 98.6% (N=9,650) of all suicide attempt cases during 2004-2009, with an overall
rate of 377.0/100,000 person-years.
• Among enlisted Soldiers, suicide attempts risk was
highest for those who were in their first 2 years ofservice (particularly in the first few months – seefigure below), never or previously deployed, andrecently diagnosed with a mental disorder (Table 2).4

OR (95% CI)

No Diagnosis
1 Month
2–3 Months
4–12 Months≥ 13 Months
Χ24• Army STARRS is a multi-component epidemiological and neurobiological study that seeks to understandthe determinants of suicidality and provide the Army with actionable recommendations. It is the largest
study of mental health risk and resilience ever conducted among Army personnel. Participation in Army
STARRS was completely voluntary.

Standardized Risk(per 100,000
Person-Years)

1.0–18.2 (17.4–19.1)*
5.8 (5.4–6.3)*
2.9 (2.7–3.1)*
1.4 (1.3–1.6)*
15,255.6*

191.0
3,490.7
1,127.7
552.6
276.4

1Results in each section above (I-III) are based on separate multivariate logistic regression

All Army Study (AAS)

Table 4. Bivariate Associations of Prior DSM-IV Mental Disorders with Pre-Enlistment Suicidal Ideation and Suicide Attempts in the NSS.

models that adjusted for sex, age at entry into the Army, current age, race-ethnicity,education, and marital status.
*p<0.05• Representative cross-sectional survey of 5,428 active duty Regular Army Soldiers who completed a selfadministered questionnaire (SAQ).
AAS Results:• Lifetime prevalence estimates of suicidal ideation, suicide plans, and suicide attempts are 13.9%, 5.3%, and2.4%.
• Among ideators, 38.5% had developed suicide plans and 17.1% had attempted suicide.
• 62.4% of transitions from ideation to plans and 58.3% of transitions from ideation to attempts occurred within 1
year of the onset of suicide ideation.5

Bivariate Association
Among Lifetime Suicidal Ideators

Bivariate Associations
In the Total Sample

Table 2. Multivariate Associations with Suicide Attempts among
Enlisted Soldiers in the HADS.1

I. Time in Service
1–2 Years
2.4 (2.2–2.6)*
585.6
3–4 Years
1.5 (1.4–1.6)*
369.7
5–10 Years
1.0–245.1> 10 Years
0.5 (0.4–0.5)*
106.3
χ23589.3*
II. Deployment Status
Never Deployed
2.8 (2.6–3.0)*
443.9
Currently Deployed
1.0–165.7
Previously Deployed
2.6 (2.4–2.8)*423.8
2χ2839.3*
III. Time Since Most Recent Mental Health Diagnosis

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

(0.7)
(0.3)
(0.5)
(0.9)
(1.0)
(0.4)
(0.3)
(0.6)

Previously
Deployed

Kenneth L. Cox, MD, MPH
Steven Cersovsky, MD, MPH(consulting scientists)• Here we report early results from three of the major Army STARRS component: the Historical
Administrative Data Study (HADS); the All Army Study (AAS); and the New Soldier Study (NSS).

7.0 (0.6)
15.5 (0.7)
6.7 (0.5)

10.3
1.8
8.3
18.9
22.7
7.7
4.1
6.1

Currently
Deployed

Murray B. Stein, MD, MPH
Co-Principal Investigator
University of California, San Diego• Instruments used in each component assess a broad range of mental health risk and resilience factors. Indepth clinical interviews (Structured Clinical Interview for DSM-IV) established the diagnostic accuracy ofArmy STARRS survey measures.

Externalizing Disorders
Attention Deficit/Hyperactivity DisorderIntermittent Explosive Disorder
Substance Use Disorder

(0.5)
(0.3)
(0.4)
(0.8)
(0.6)
(0.4)
(0.7)
(0.8)

Post-Enlistment
Disorders
OR (95% CI)

Never
Deployed

Multiple Army Commands(support)

Ronald C. Kessler, PhD
Site Principal Investigator
Harvard Medical School

11.6
1.9
3.1
13.5
11.2
4.3
9.6
12.2

Pre-Enlistment
Disorders
OR (95% CI)• Representative survey of 38,237 new Soldiers during Reception Week (just prior to entering Basic Training) at
Ft. Jackson, Ft. Benning, & Ft. Leonard Wood, who completed a self-administered questionnaire.

Time in Service

Secretaryof the Army

Internalizing Disorders
Major Depressive Disorder
Bipolar Disorder
Panic Disorder
Generalized Anxiety Disorder
Posttraumatic Stress Disorder
Obsessive-Compulsive DisorderSpecific Phobia
Social Phobia

Post-Enlistment
Disorders% (SE)*p<0.05

Deployment Status

Army Study to Assess Risk and Resilience in Service Members

DSM-IV Mental Disorders

Pre-Enlistment
Disorders% (SE)New Soldier Study (NSS)

Table 1. Suicide Rates among Enlisted Soldiers in the HADS.

STARRS

Bivariate Associations with
Post-Enlistment First Suicide Attempts

Lifetime Prevalence ofMental Disorders

Historical Administrative Data Study (HADS)• U.S. Army suicide rates were historicallylower than those of the U.S. general
population, adjusting for demographic
differences.

DSM-IV Mental Disorders

Suicidal Ideation

Suicide Attempt

Attempt among thosewith a planOR (95% CI)

Attempt among
those without a planOR (95% CI)

OR (95% CI)

OR (95% CI)

Internalizing Disorders
Major Depressive Disorder
Bipolar Disorder
Panic Disorder
Generalized Anxiety Disorder
Posttraumatic Stress Disorder

4.3
4.3
3.6
3.8
2.9

(3.8–4.9)*(3.5–5.2)*(3.0–4.3)*(3.2–4.5)*(2.6–3.3)*

8.6
8.1
7.3
7.6
5.4

(6.7–11.0)*(5.9–11.2)*(5.3–9.9)*(5.7–10.1)*(4.2–7.0)*

1.7
1.3
2.1
1.6
1.5

(1.2–2.4)*(0.7–2.3)(1.2–3.6)*(1.1–2.4)*(1.0–2.2)

1.9
2.6
1.6
2.0
2.0

(1.2–3.0)*(1.5–4.5)*(0.9–2.8)(1.3–3.1)*(1.4–2.9)*

Externalizing Disorders
Attention Deficit/Hyperactivity DisorderIntermittent Explosive Disorder
Substance Use Disorder
Conduct Disorder
Oppositional Defiant Disorder

4.0
3.0
2.6
3.1
3.6

(3.5–4.6)*(2.7–3.2)*(2.2–3.1)*(2.7–3.5)*(3.3–3.9)*

6.1
4.0
5.1
5.8
5.6

(4.7–8.0)*(3.3–4.8)*(3.5–7.3)*(4.6–7.3)*(4.7–6.7)*

1.5
1.2
1.7
1.6
1.2

(0.9–2.5)(0.9–1.7)(1.0–2.9)*(1.1–2.5)*(0.9–1.6)

2.0
1.2
1.3
2.4
2.0

(1.2–3.1)*(0.9–1.7)(0.8–2.3)(1.8–3.3)*(1.5–2.6)**p<0.05

Discussion• Taken together, these findings support prevention efforts focused on enlisted soldiers who are in the earlyphases of their first tour of duty and those with a history of mental disorders.
• Army STARRS is guided by this concentration of risk approach, which aims to produce actionable findings
regarding when, where, and for whom risk of suicidal behaviors is greatest within the Army population.

References
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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, 72(2), 107-119.
Schoenbaum, M., Kessler, R. C., Gilman, S. E., Colpe, L. J., Heeringa, S. G., Stein, M. B., et al. (2014). Predictors of suicide and accident death in the Army Study to Assess Risk andResilience in Servicemembers (Army STARRS). JAMA Psychiatry, 71(5), 493-503.
Gilman, S. E., Bromet, E. J., Cox, K. L., Colpe, L. J., Fullerton, C. S., Gruber, M. J., et al. (2014). Socio-demographic and career history predictors of suicide and suicide mortality in theUnited States Army 2004-2009. Psychological Medicine, 44(12), 2579-2592.
Ursano, R. J., Kessler, R. C., Heeringa, S. G., Cox, K. L., Naifeh, J. A., Fullerton, C. S., et al. (2015). Nonfatal suicidal behaviors in U.S. Army administrative records, 2004–2009: Resultsfrom the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Psychiatry, 78, 1-21.
Nock, M. K., Stein, M. B., Heeringa, S. G., Ursano, R. J., Colpe, L. J., Fullerton, C. S., et al. (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.
Ursano, R. J., Heeringa, S. G., Stein, M. B., Jain, S., Raman, R., Sun, X., et al. (2015). Prevalence and correlates of suicidal behavior among new soldiers in the US Army: Results fromthe Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Depression and Anxiety, 32, 3-12.
Nock, M. K., Ursano, R. J., Heeringa, S. G., Stein, M. B., Jain, S., Raman, R., et al. (in press). 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 (Army STARRS). Suicide and Life-Threatening Behavior.

• Website: www.ArmySTARRS.org