Background
Rates of non-fatal suicide attempts and suicide deaths among U.S. Army soldiers increased during the wars in Iraq and Afghanistan [
1‐
3], with elevated risk persisting among veterans who have left the military [
4,
5]. Most research on non-fatal suicide attempts has focused on the full-time soldiers within the Army’s Active Component (AC) (e.g., [
6‐
8]). Suicide attempts among soldiers in the Reserve Components (RCs), which also increased during the wars [
9], have received much less attention. The RCs include the Army National Guard and Army Reserve, comprising approximately 53% of the total Army population (all active and inactive soldiers) in 2017 [
10]. These “citizen-soldiers” augment the AC as needed during wartime, returning to their communities, civilian jobs, and/or college studies after deployment. In addition to their unique role and circumstances, RC soldiers may differ from the AC on mental health outcomes (e.g., stress, anxiety, and depression) and risk for suicide ideation and attempt [
11‐
14]. Improved understanding of suicide attempt risk within the RCs can inform targeted intervention programs for this substantial proportion of the Army population.
Most previous findings on non-fatal suicidal events within the RCs are based on survey research (e.g., [
15‐
17]). Few studies have examined suicide attempts documented in the administrative medical records of RC soldiers, which are particularly important owing to their impact on the Army healthcare system. Univariable analyses indicate that documented attempts are more likely among RC soldiers who are female, younger, less educated, and never married [
9]. Here we used 2004–2009 administrative data from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) to examine multivariable associations of socio-demographic, service-related, and mental health predictors with suicide attempts among activated RC soldiers.
Discussion
By combining multiple administrative data systems, the current study presents the most comprehensive analysis to date of documented suicide attempts among activated RC soldiers during the wars in Iraq and Afghanistan. It complements previous RC research on suicide death [
33‐
35] and ideation (e.g., [
15‐
17]). The findings reveal enlisted soldiers account for the vast majority of RC suicide attempts documented during active duty, with an overall rate more than four times higher than the rate for officers. This rank-based discrepancy in risk was also observed among AC soldiers [
8]. Interestingly, while the rates for RC and AC officers are comparable, the rate for RC enlisted soldiers is far lower than the published rate of 377 per 100,000 person-years for AC enlisted soldiers [
8]. Previous surveys have found mixed results when comparing RC and AC soldiers on prevalence of suicide ideation and attempts [
11,
12,
36]. The lower RC attempt rate in the current study may be attributable to their more limited time on active duty (when suicide attempts are captured by administrative records) relative to AC soldiers. It is also possible that RC soldiers with suicidal thoughts or other mental health symptoms that increase suicide attempt risk are less likely to be activated or remain on active duty for extended periods of time.
Among RC enlisted soldiers, the positive associations of suicide attempt with being female, younger, non-Hispanic white, less educated, and older when entering the Army are consistent with findings from the AC enlisted population, as are the higher odds among enlisted personnel who were in their first two years of service, previously deployed, and recently diagnosed with a mental health disorder [
8]. Of particular note, RC and AC enlisted soldiers have a similar pattern of monthly suicide attempt risk after entering service [
8], with peak risk occurring toward the end of basic training followed by a sharp decline.
Beyond potential differences in the overall attempted suicide rate among activated RC vs. AC enlisted soldiers, our findings indicate two noteworthy differences in predictor variables. First, whereas the multivariable association of marital status with suicide attempt was nonsignificant in the AC enlisted population [
8], currently married RC soldiers were significantly more likely to attempt suicide than those who were never married. Interestingly, previous univariable analyses found that never married RC enlisted soldiers had higher odds of suicide attempt [
9] – a finding that is consistent with the higher crude rate among never married RC soldiers in the current study – indicating that other variables in the adjusted model are influencing the association of marital status. Second, whereas being never deployed had a robust positive association with suicide attempt among AC enlisted soldiers [
7,
8], it was nonsignificant among RC enlisted soldiers in adjusted models despite having the highest crude rate. The reason for this discrepancy between RC and AC soldiers is not yet known but may be attributable to differences in socio-demographic and occupational composition (e.g., the U.S. Army Reserve does not have combat units). A more detailed analysis of risk by deployment status [
7] and military occupation [
37] may improve understanding of how the association of deployment status with suicide attempts may differ between the RCs and AC.
Previous work found few predictors of suicide attempt among AC officers [
8]. Even fewer predictors were identified in this analysis of RC officers, with female gender and recent mental health diagnosis being the only significant variables. However, with only 47 suicide attempt cases, power to detect significant associations among RC officers was limited. We plan to address this limitation in the follow-up study to Army STARRS (STARRS-LS for “longitudinal study”), which will include additional administrative data beyond the original 2004–2009 time period, allowing more officer suicide attempt cases to be captured and increased statistical power.
Several limitations in the current study are noteworthy. First, administratively recorded suicide attempts are limited to events captured by the healthcare system. These records are subject to errors in coding and clinical judgment, as well as changes in policy and procedures. Second, the data are limited to person-months during which individual RC soldiers were federally activated. Consequently, these records do not include suicide attempts or mental health diagnoses that occurred while soldiers were inactive, and time in service should not be interpreted as continuous (e.g., 12 months of active service may not correspond to 12 consecutive calendar months). Third, findings represent activated RC soldiers during 2004–2009 and may not generalize to other time periods or populations. Fourth, deployment and Army attrition are non-random events [
38‐
40], which influences the composition of groups defined by those variables. Therefore, differences based on deployment status and active time in service should not be interpreted as within-person changes over time. For example, it is possible for soldiers who are currently deployed to have also been previously deployed. This means the currently deployed group includes soldiers on their first deployment as well as soldiers on their second deployment, third deployment, etc. Those on their first deployment are likely to have the highest risk of adverse outcomes (which could preclude subsequent deployments), whereas those on their second or third deployment are likely to be more resilient soldiers who were purposefully selected to deploy multiple times (often referred to as the “healthy warrior effect”).
Conclusions
With the limitations in mind, the findings indicate that enlisted soldiers in their first two years of active service account for the majority of suicide attempts in the RC population, and soldiers with a recently documented mental health diagnosis are at substantially elevated risk. Although predictors are largely consistent with those found in the AC [
8], there were some notable differences (e.g., marital status, deployment status). Most significantly, the intermittent nature of RC service creates unique challenges for risk assessment and intervention that are not present in the full-time AC population. AC soldiers in garrison have military healthcare access and can be closely monitored by leaders and clinicians. In contrast, deactivated members of the RCs do not have access to the military healthcare system, and they return to communities that are widely dispersed, often rural, and potentially remote, presenting obstacles to mental health screening and treatment [
41]. Addressing these challenges may require new programs, such as peer-to-peer support [
42], that can reach RC soldiers in their local communities.
Acknowledgments
The Army STARRS Team consists of Co-Principal Investigators: Robert J. Ursano, MD (Uniformed Services University of the Health Sciences) and Murray B. Stein, MD, MPH (University of California San Diego and VA San Diego Healthcare System).
Site Principal Investigators: Steven Heeringa, PhD (University of Michigan), James Wagner, PhD (University of Michigan) and Ronald C. Kessler, PhD (Harvard Medical School).
Army liaison/consultant: Kenneth Cox, MD, MPH (US Army Public Health Center).
Other team members: Pablo A. Aliaga, MS (Uniformed Services University of the Health Sciences); COL David M. Benedek, MD (Uniformed Services University of the Health Sciences); Laura Campbell-Sills, PhD (University of California San Diego); Carol S. Fullerton, PhD (Uniformed Services University of the Health Sciences); Nancy Gebler, MA (University of Michigan); Robert K. Gifford, PhD (Uniformed Services University of the Health Sciences); Paul E. Hurwitz, MPH (Uniformed Services University of the Health Sciences); Sonia Jain, PhD (University of California San Diego); Tzu-Cheg Kao, PhD (Uniformed Services University of the Health Sciences); Lisa Lewandowski-Romps, PhD (University of Michigan); Holly Herberman Mash, PhD (Uniformed Services University of the Health Sciences); James E. McCarroll, PhD, MPH (Uniformed Services University of the Health Sciences); James A. Naifeh, PhD (Uniformed Services University of the Health Sciences); Tsz Hin Hinz Ng, MPH (Uniformed Services University of the Health Sciences); Matthew K. Nock, PhD (Harvard University); Nancy A. Sampson, BA (Harvard Medical School); CDR Patcho Santiago, MD, MPH (Uniformed Services University of the Health Sciences); LTC Gary H. Wynn, MD (Uniformed Services University of the Health Sciences); and Alan M. Zaslavsky, PhD (Harvard Medical School).