ARMY STARRS/STARRS LS
Understanding Risk and Resilience
Factors for Suicide
Robert J. Ursano, M.D.
Prof/Chair
Dept of Psychiatry
Uniformed Services University
Director
Center for the Study of Traumatic Stress
Disclosures
•
I have no relevant financial relationship with the manufacturers of any
commercial products and/or providers of commercial services discussed in this
CME activity.
•
Neither I nor any member of my immediate family has a financial relationship or
interest with any proprietary entity producing health care goods or services
related to the content of this CME activity.
•
My content will not include reference to commercial products.
•
I do not intend to discuss any unapproved or investigative use of commercial
products or devices.
Trauma and Disasters
Human Made
Natural
Industrial
Accident
Hurricane
War
Terrorism
Epidemic
Suicide
State of Knowledge and Need
“Suicide is among the leading causes of death
and disease burden around the world.
Although there have been significant
advances in suicide research as well as
increases in the treatment of suicidal people,
the rate of suicidal behaviors has not
changed as a result”
Nock M, et al WHO PLoS 2009
Count and Crude Suicide Rates Among Active Duty and
Reserve Service Members
Mortality Surveillance Div, AFMES, AFIP
2010; DoD Suicide Prev Task Force
Psychiatric Responses
to Trauma
Distress
Responses
•
Anxiety
• PTSD
• Depression
• Resilience
Mental
Health/
Illness
• Change in Sleep
• Decrease in
Feeling Safe
• Isolation (staying
at home)
Health Risk
Behaviors
(changed behavior)
• Smoking
• Alcohol
• Over dedication
•Change in travel
•Separation anxiety
The Past…
• “One type of symptomatic behavior associated with
depressions, either neurotic or psychotic in type, is
suicide. Between July, 1940, and June 1946, there
were 2,214 suicides in the Army, 300 of which
occurred among officers.1 ….these figures represent
a sharp drop during the war period from the
peacetime suicide rate in the Army. 2 There was also
a sharp drop in the number of suicides in the Army in
World War “
Menninger, K. Psychiatry in a Troubled
World. Pp. 166-167, 1948
Suicidal Thoughts and Behavior in the
Past Year among Adults Aged 18 or Older:
2008
0.9 Million
Made Plans and
Attempted
Suicide
2.3 Million
Made
Suicide Plans
.
.
.
8.3 Million Adults Had
Serious Thoughts of
Committing Suicide
1.1 Million
Attempted
Suicide
0.2 Million
Made No Plans and
Attempted Suicide
(SAMHSA, 2008)
Army Study to Assess Risk and Resilience in
Servicemembers
(Army STARRS)
Co-Principal Investigators:
Robert J. Ursano MD (USUHS)
Murray B. Stein MD, MPH (UCSD)
on behalf of the Army STARRS Research Team
May 4, 2015
Slide 9
Challenges
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Across agency MOUs (Army, NIMH)
Civilian and DoD Scientists Collaboration (HJF)
Confidentiality (Certificate/Letter from Sec of Army)
Disclosure
Multi Site
“In Theater”
Quarterly reports to senior leadership
GWAS
Complex internal organization
Slide 10
Suicide Trends for Active Duty
Army & Matched Civilians
* Crude suicide rates, using data from Army STARRS (2004-2009) and Army Active Duty Strength reports (2010-2013)
** Civilian data from Centers for Disease Control, adjusted by Army STARRS to 2004 Army distribution of age, sex and race/ethnicity
Slide 11
Active Duty Army Suicide Rates
Source: Army STARRS
calculations
Slide 12
Administration & Funding
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Army STARRS is being conducted by a consortium of investigators from the
Uniformed Services University of the Health Sciences (USUHS), the University of
California-San Diego (UCSD), Harvard Medical School (HMS) & the University of
Michigan (UM) in collaboration with the NIMH.
 Co-PIs: R. Ursano (USUHS) & M. Stein (UCSD)
 Site-PIs: R. Kessler (HMS) & S. Heeringa (UM)
 Collaborating NIMH Scientists: L. Colpe & M. Schoenbaum
 Consulting Army Scientists: K. Cox & S. Cersovsky
Supported by NIH Cooperative Agreement U01MH87981.
Funding provided by the Department of the Army ($50M) with supplemental funds
($15M) from the National Institute of Mental Health (NIMH).
Army STARRS in-theater research was conducted under a protocol reviewed and
approved by the U.S. Army Medical Research and Materiel Command (MRMC)
Institutional Review Board, and in accordance with the approved protocol.
Slide 13
Background and Goals
Background: The persistent rise in Army suicide rate led the
Army to ask NIMH to find academic scientists with the expertise
to design & conduct an independent research program that was
large, creative, and comprehensive enough to address this
complicated problem.
Goals: To identify risk and protective factors that impact Soldiers’
well-being so the Army can use them in risk reduction efforts.
• Identify salient risk and protective factors in Army Soldiers
• Inform development & testing of empirically-derived interventions for
Army Soldiers
• Deliver “actionable” findings to the Army rapidly
• Establish Army cohorts for future follow-up studies & continued benefit to
the Army
Slide 14
Study Design
• Army STARRS is not a single study
• Integrated multi-study design
• Involves seven epidemiologic & neurobiologic
studies to comprehensively investigate risk
factors & protective factors for:
– Suicide
– Suicide-related behavior
– Related mental and behavioral health
Slide 15
Overview of Studies
Study
Overview and Status
Historical
Administrative
Data Study
(HADS)
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To compile, organize & analyze existing administrative Army and DoD data.
Involves huge volume of data, enormous effort, allows analyses never before possible.
Includes more than 1.6 million active duty Soldiers from 2004 to 2009.
Includes more than 1.1 billion de-identified Army/DoD records from ~40 sources.
New Soldier
Study
(NSS)
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To assess health, personal characteristics, and prior experiences of new Soldiers.
Data collected at 3 sites: Ft. Jackson, Ft. Benning & Ft. Leonard Wood.
Data collection began Feb 2011 and ended Nov 2012.
Blood collection began Sep 2011 and ended Nov 2012.
~57,000 Soldiers attended survey sessions.
~35,000 gave blood (80% of those asked).
All Army
Study
(AAS)
In-Theater
AAS (Kuwait)
• To assess Soldiers across all phases of Army service.
• Data collection began Jan 2011 and ended Apr 2013.
• ~35,000 Soldiers attended survey sessions at >50 CONUS and OCONUS sites.
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To include in-theater Soldiers in the AAS.
Data collected from both “outbound” and “inbound” Soldiers during R&R processing.
Data collection began Mar 2012 and ended Sep 2012.
~10,000 Soldiers attended survey sessions.
Slide 16
Overview of Studies
(Continued)
Study
Overview and Status
Soldier
Health
Outcomes
Study A
(SHOS-A)
• To assess Soldiers who were hospitalized for a suicide attempt (cases) and compare to
control Soldiers from the AAS.
• 5 Military Treatment Facilities: JBLM, Walter Reed, Ft. Hood, Ft. Bragg & Ft. Stewart.
• Data collection began Nov 2011 and ended Dec 2013.
• Target enrollment: 450 Soldiers (~150 cases and ~300 controls).
• Actual enrollment: 561 Soldiers (186 cases and 375 controls).
• 296 Soldiers provided blood samples.
Soldier
Health
Outcomes
Study B
(SHOS-B)
• To assess Soldiers who committed suicide (cases) and compare to control Soldiers
from the AAS.
• Interviewing Army supervisors and next-of-kin of cases and controls.
• Data collection began Mar 2012 and ended Jan 2014.
• Target enrollment: 560 total interviews for ~135 cases and ~270 controls.
• Actual enrollment: 603 interviews completed for 150 cases and 276 controls.
• By far the largest psychological autopsy study of a military population, and one of the
largest suicide psychological autopsy studies ever done.
Slide 17
Overview of Studies
(Continued)
Study
Overview and Status
Pre/Post
Deployment
Study
(PPDS)
• To follow deploying Soldiers over time to assess the effects of deployment.
• Longitudinal study of 3 BCTs: JBLM, Ft. Bragg & Ft. Carson.
• Four waves (time-points) of data collection: 1 pre-deployment & 3 post-deployment
1. Pre Time 0 (T0) at ~2-3 weeks before deployment (survey and blood).
2. Post Time 1 (T1) at ~2-3 weeks following redeployment (survey and blood).
3. Post Time 2 (T2) at ~2-3 months following redeployment (survey).
4. Post Time 3 (T3) at ~8-9 months following redeployment (survey).
• Data collection began Jan 2012 and ended Apr 2014.
• T0 data collection : ~9,500 Soldiers (~8,000 Soldiers provided blood samples).
• T1 data collection: ~10,000 Soldiers (~8,800 Soldiers provided blood samples).
• T2 data collection: ~9,200 Soldiers.
• T3 data collection: ~7,000 Soldiers.
Clinical
Reappraisal
Study
(CRS)
• To calibrate clinical survey measures used in AAS and NSS.
• Calibration interviews began Mar 2012 and ended Nov 2012.
• 460 Soldiers participated.
Slide 18
Data Collection Timeline
July 2009 to June 2014
Year 1
Year 2
Year 3
Year 4
Year 5
July 2009-June 2010
July 2010-June 2011
July 2011-June 2012
July 2012-June 2013
July 2013-June 2014
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Design, Develop, Pre-Test
Research Data Enclave and Historical Administrative Data Study (HADS)
New Soldier Study (NSS)
All Army Study (AAS)
CRS
Soldier Health Outcomes Study A (SHOS-A)
Soldier Health Outcomes Study B (SHOS-B)
PPDS T0
PPDS T1
PPDS T2
PPDS T3
Slide 19
AAS Data Collection
Locations
Slide 20
Locations of All Collaborators
Principal Investigators, Other Investigators, Scientific
Advisory Board Members, Labs & Vendors
Slide 21
Data Collection Summary:
Soldiers, Surveys, Blood Samples
For Studies with Data Collection from Soldiers
(HADS not included)
Approx. Number of Blood Samples
Approx. Number Approx. Number
Study
of Soldiers Who
of Surveys
Soldiers Who
Blood Tubes
Blood Vials in
Participated
Collected
Provided Blood
Collected
Frozen Storage
NSS (2 sessions/Soldier)
57,000
114,000
35,000*
35,000
35,000
AAS (incl. Guard & Reserve)
35,000
35,000
AAS Kuwait (in-theater)
10,000
10,000
PPDS pre Time 0
9,500
8,000
24,000
55,000
PPDS post Time 1
10,000
8,800
17,500
57,000
10,000
PPDS post Time 2
9,200
PPDS post Time 3
7,000
SHOS-A
186**
1,200
300
600
600
SHOS-B
150**
600
APPROXIMATE TOTAL
112,000
196,000
52,000
77,000
148,000
* NSS blood collection was added 6 months after study began. Approx. 80% of Soldiers who were asked gave blood.
** Cases Only -- Controls are already counted in AAS
Slide 22
Biomarkers Summary
Analysis Types and Sample Sizes
1. GWAS: ~16,000 Soldiers
• ~8,000 NSS Soldiers
• ~8,000 PPDS Soldiers (pre-deployment)
• Custom chip (whole exome arrays plus ~6K custom features)
2. DNA Methylation: ~400 PPDS Soldiers (pre & post deployment)
3. DNA Telomeres: ~400 PPDS Soldiers (pre & post deployment)
4. RNA Expression: >200 PPDS Soldiers (pre & post deployment)
5. BDNF/Cytokines: ~400 PPDS Soldiers (pre & post deployment)
6. Metabolites: ~250 PPDS Soldiers (pre & post deployment)
7. Genotyping: ~2,800 NSS Soldiers (PsychChip)
8. Genotyping: ~300 SHOS-A Soldiers (PsychChip)
Slide 23
Approach to Producing
Actionable Findings
Concentration of Risk
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Who (e.g., MOS, rank, demographics, mental disorders)
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When (e.g., time in service, deployment status, time pre/post deployment)
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Where (e.g., installations, training, combat zones, transitioning)
Risk variables
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Identify risk sub-groups (who, when, where) so Army can consider programs to
target for intervention
Neurocognitive
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Use neurocognitive tests to identify those at risk and possible neurocognitive
functioning associations with suicidal behavior
Biomarkers
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Identify biomarkers for those at risk and determine possible neurobiologic
mechanisms
Slide 24
SELECTED PUBLISHED/PRESENTED
FINDINGS
Slide 25
Suicidal Thoughts/Behaviors
among New Soldiers (NSS)
Suicide Ideation
Suicide Plan
Suicide Attempt
Lifetime
Past 30 Days
13.5%
1.1%
(n=6,192)
(n=473)
2.7%
0.1%
(n=1,234)
(n=42)
1.9%
0.1%
(n=878)
(n=58)
Slide 26
Risk of Suicide Attempt by Month Since
Entering Army, Enlisted Soldiers & Officers
(HADS, 2004-2009, n=193,617)
The sample of 193,617 person-months includes all Regular Army soldiers (i.e., excluding those in the U.S. Army National Guard and
Army Reserve) with a suicide attempt in the administrative records during the years 2004-2009, plus a 1:200 stratified probability
sample of all other active duty Regular Army person-months in the population exclusive of soldiers with a suicide attempt or other nonfatal suicidal event (e.g., suicidal ideation) and person- months associated with death (i.e., suicides, combat deaths, homicides, and
deaths due to other injuries or illnesses). All records in the 1:200 sample were assigned a weight of 200 to adjust for the undersampling of months not associated with suicide attempt.
Slide 27
Examples of Recent Findings
from Historical Administrative Data Study
2004-2009
Historical Administrative Data Study (>975K regular Army Soldiers in 2004-2009)
• Suicide risk increased for those deployed, never deployed, and previously
deployed; deployed & previously deployed at greater risk.
• Suicide risk lower for females than males (as with civilians), but difference
narrowed substantially during deployment.
• Suicide risk was increased for those demoted in past 2 years.
• Currently & previously deployed in first 4 years of service had greater risk
than never deployed.
• Not associated with increased risk of suicide:
o
o
o
o
Waivers
Length of time since return from most recent deployment
Total number of deployments
Interval between 2 most recent deployments (dwell time)
Schoenbaum, et al. JAMA Psychiatry, 2014
Slide 28
TBI AND SUICIDE RISK
Slide 29
Age at First TBI (in AAS Q2-Q4)
(M. Stein, et al)
Slide 30
Multivariate model predicting
suicidality1
(M. Stein, et al)
Lifetime Suicide
Ideation
Lifetime Suicide
Plan
Lifetime Suicide
Attempt
OR
[95% CI]
OR
[95% CI]
OR
[95% CI]
Antecedent TBI1
1.7
[1.4-2.0]
1.9
[1.5-2.5]
1.6 [1.2-2.2]
Antecedent TBI2 (full model)
1.4
[1.2-1.6]
1.6
[1.1-2.1]
1.3
[0.9-1.8]
1 Multivariate
model predicting suicidality outcomes with TBI (0,1,2) controlling
for all demographics and interaction between "not entered Army yet" and "birth
place"; controlling for years since ideation for outcomes among ideators.
2 As
above and controlling for mental disorders. Note PARP for TBI 20-30%
Slide 31
Mental Health and Suicide
Slide 32
AAS: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 in
Servicemembers (Army STARRS)
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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.
Population-attributable risk proportions of severe role impairment were 21.7% for preenlistment 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.
Kessler, et al. JAMA Psychiatry, 2014
Slide 33
Concentration of Risk
Inpatient: 28 to 263/100,000 to predictor 4/100
vs statins 7.5 ascvd/100 per 10 years
Slide 34
Challenges
•
•
•
•
•
•
•
•
•
Across agency MOUs (Army, NIMH)
Civilian and DoD Scientists Collaboration (HJF)
Confidentiality (Certificate/Letter from Sec of Army)
Disclosure
Multi Site
“In Theater”
Quarterly reports to senior leadership
GWAS
Complex internal organization
Slide 35