I would like to provide some perspective on the recent article on the Army STARRS study.
The article, “Predicting Suicides After Psychiatric Hospitalization in U.S. Army Soldiers: The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)” (JAMA Psychiatry 2014 Nov. 12 [ doi: 10.1001/jamapsychiatry.2014.1754 ]), is one of a series from this multicenter, multiyear study.
My observations focus on four areas: 1) the history behind this research effort, 2) what we learn from the results, 3) how can we change the way we treat service members based on the results? and 4) the change in accession standards.
This research effort was launched after the rate of suicides continued to rise. Then vice chief of staff, Lt. Gen. Peter Chiarelli was frustrated. He developed a contract with the National Institute of Mental Health to fund an ambitious research agenda that included examining all known suicides to find a way to reduce them.
At that time, I was the chief psychiatrist for the Army and was frankly cynical about the STARRS research. We already knew the risk factors for suicide: previous psychiatric or criminal history, relationship difficulties, problems at work, substance abuse, and access to firearms. But, being a good Army Soldier, I saluted and worked to make it happen. After all, maybe the research would bring some clinically useful revelations.
Lt. Gen. Chiarelli also wanted quick results, within a year. Fat chance, I would have muttered under my breath, had I not been a good Soldier.
So, what does the research tell us, 5 years after the inception? Frankly not much that a military psychiatrist does not already know about the risk factors for suicide in military members. However, the article in JAMA Psychiatry does quantify those risk factors mentioned above.
It also stresses the high risk for those recently psychiatrically hospitalized. Civilian as well as military psychiatrists already know that high-risk patients are the ones who get hospitalized. A caveat: Only 12% of Army suicides were post hospitalization.
However, for a military servicemember, the hospitalization may add to their stress, as it often contributes to an exit from the military. Exit may mean a loss of job, housing, health care, and identity.
What is the actionable intelligence from the article? By actionable intelligence, a military term, I mean here what can clinicians do differently as a result of the research? Do you hospitalize less? Probably not.
The authors suggest more posthospitalization interventions but are guarded in their recommendations. More intensive follow-up could lead to more stigmatization and contribute to an accelerated exit from the military.
Nevertheless, that recommendation is where the value of this article lies. The military system is highly stressed with many competing priorities. Many posts, but not all, have posthospitalization easy access to care. As the article recommends, and I concur, there should be more intensive follow-up. This can be done in many ways, including group settings; military members often prefer groups, as then they can help one another.
There is another subtext to the whole suicide discussion: In the early years of the wars in Iraq and Afghanistan, when the Army was desperate for recruits, it relaxed its accession standards. More came in with prior psychiatric diagnoses. Later, the standards were tightened again; those soldiers were disqualified.
The changes in accession standards often happen in times of conflict. It is not surprising that increases in behavioral health difficulties happen when recruiters are strapped for new recruits and take in marginal performers. Now that the military is drawing down, and it is harder to get into the military with a bad background, suicides in the active duty may taper, irrespective of all the research and suicide prevention programs.
So the article cements what we already knew: People with previous psychiatric problems are more likely to suicide. The question is what can we do about it?
Dr. Ritchie is former chief of psychiatry for the U.S. Army and the current chief clinical officer in the department of behavioral health for the District of Columbia.
