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)

Abstract

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.

Mental disorders and risk of suicide attempt in prisoners

“…Despite the fact that prisoners constitute a particularly vulnerable population when it comes to mental health [53][54][55][56], our data replicate and extend prior communitybased findings, showing that most mental disorders may actually predict suicidal ideation, but not the transition from ideation to action [37][38][39][40][41][42][43][44][45][46][47][48][49][50][51]. Moreover, in the few instances where mental disorders did distinguish attempters from ideators, effect sizes were soberingly small (ORs 1.65-2.09), but nonetheless consistent with recent meta-analytical evidence [52].…”

“…These data suggest that few disorders are associated with suicide attempt above and beyond their association with suicidal ideation. While novel among prisoners, these findings mirror those from more than a dozen of large-scale epidemiological studies in non-incarcerated populations [37][38][39][40][41][42][43][44][45][46][47][48][49][50][51], concluding that most mental disorders are important in the development of suicidal thoughts, but less relevant in predicting which individuals are at greatest risk of acting on these thoughts and progress to a suicide attempt.…”

“…By definition, PTSD involves experiencing and reliving such traumatic and potentially life-threatening events, consequently increasing one's capability for suicide. This might explain the well-established finding that PTSD is one of the few disorders to consistently predict suicide attempt among those with suicidal ideation [47][48][49][50][51][52]. Substance use disorders, on the other hand, could equally increase this capability by exposing users to painful and provocative events through proximal (intravenous administration, symptoms of withdrawal, and overdose) and distal (engaging in risk-taking and impulsive behaviour while intoxicated) effects resulting from the use of psychoactive substances [86,90].…”

“…Fifth, we did not consider the severity or chronicity of each disorder examined, nor did we assess the full range of mental disorders. For example, studies in the general population have shown that obsessive-compulsive disorder [51] and impulse-control disorders (i.e., intermittent explosive disorder, conduct disorder, oppositional defiant disorder, and attention deficit hyperactivity disorder) are associated with suicide attempt among those with ideation [43][44][45][46][47][48][49][50]. These disorders were not included in the study protocol, so we were unable to assess their potential relationship to suicidal outcomes.…”

“…Therefore, identifying those at greatest risk of acting on their suicidal thoughts can help to improve risk assessment and identify potential targets for intervention in the early phases of the suicidal process-that is, before thoughts progress to acts of suicide. In light of this, largescale epidemiological research has sought to identify which mental disorders predict suicide attempt beyond their association with suicidal ideation [37][38][39][40][41][42][43][44][45][46][47][48][49][50][51]. Collectively, results from these methodologically sound studies generally indicate that, in the few instances where mental disorders do predict the transition from ideation to action, these disorders are characterized by anxiety (e.g., posttraumatic stress disorder) and poor impulse control (e.g., substance use disorders).…”