Journal Article Annotations
2018, 4th Quarter

Suicide

Annotations by Kemuel Philbrick, MD, FACLP
January 2019

Transition to suicide attempt from recent suicide ideation in U.S. Army soldiers: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

PUBLICATION #1 — Suicide

Transition to suicide attempt from recent suicide ideation in U.S. Army soldiers: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

Naifeh JA, Ursano RJ, Kessler RC, et al

Abstract: Depress Anxiety 2018 Dec 14 (Epub ahead of print)

Background: Most people with suicide ideation (SI) do not attempt suicide (SA). Understanding the transition from current/recent SI to SA is important for mental health care. Our objective was to identify characteristics that differentiate SA from 30-day SI among representative U.S. Army soldiers.

Methods: Using a unique case-control design, soldiers recently hospitalized for SA (n = 132) and representative soldiers from the same four communities (n = 10,193) were administered the same questionnaire. We systematically identified variables that differentiated suicide attempters from the total population, then examined whether those same variables differentiated all 30-day ideators (n = 257) from the total population and attempters from nonattempting 30-day ideators.

Results: In univariable analyses, 20 of 23 predictors were associated with SA in the total population (0.05 level). The best multivariable model included eight 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). Six of these differentiated 30-day ideators from the population. Three 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 risk in this final model included 20.9% of attempters, a four-fold concentration of risk.

Conclusions: Prospective army research examining transition from SI to SA should consider PTSD, IED, and education. Combat exposure did not differentiate attempters from ideators. Many SA risk factors in the Army population are actually risk factors for SI.

On PubMed: Depress Anxiety 2018 Dec 14 (Epub ahead of print)

Annotation (SEPARATEAUTHOR)

Type of study: Case control

The finding: Gender (female) and education (less than high-school completion) were the two socio-demographic variables of significance for risk of suicide attempt in the multivariable model. Lifetime history of interpersonal violence, legal problems, and relationship problems were the stressor variables most associated with suicide attempt. Major depression, posttraumatic stress disorder and substance use disorder were the psychiatric diagnoses most associated with suicide attempt. When attempting to identify factors that distinguished between those with suicidal ideation and those with suicide attempts, only posttraumatic stress disorder was positively associated whereas a history of intermittent explosive disorder and at least some college education were negatively associated.

Strength and weaknesses: This study was creatively designed in an attempt to shed light on factors that might contribute to the transition of suicidal ideation to action. It is a challenging endeavor in that many, if not most, of the risk factors for suicide attempt are also risk factors for suicidal ideation. The negative multivariable association of intermittent explosive disorder with suicide attempt could reflect that anger may play a different role (potentially adaptive) in military populations; results in a civilian population may be different. All participants in this study were volunteers and might not therefore fully reflect the target population.

Relevance: Consultation psychiatrists regularly face the challenge of discerning likely subsequent risk for suicide in individuals who prompt a consult request due to perceived or expressed suicidal ideation. Although this study was conducted in U.S. Army soldiers, it serves to remind us of the potential effects of comorbid posttraumatic stress disorder in our patients who experience suicidal ideation.