Predicting suicides after outpatient mental health visits in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).

The 2013 US Veterans Administration/Department of Defense Clinical Practice Guidelines (VA/DoD CPG) require comprehensive suicide risk assessments for VA/DoD patients with mental disorders but provide minimal guidance on how to carry out these assessments. Given that clinician-based assessments are not known to be strong predictors of suicide, we investigated whether a precision medicine model using administrative data after outpatient mental health specialty visits could be developed to predict suicides among outpatients. We focused on male nondeployed Regular US Army soldiers because they account for the vast majority of such suicides. Four machine learning classifiers (naive Bayes, random forests, support vector regression and elastic net penalized regression) were explored. Of the Army suicides in 2004-2009, 41.5% occurred among 12.0% of soldiers seen as outpatient by mental health specialists, with risk especially high within 26 weeks of visits. An elastic net classifier with 10-14 predictors optimized sensitivity (45.6% of suicide deaths occurring after the 15% of visits with highest predicted risk). Good model stability was found for a model using 2004-2007 data to predict 2008-2009 suicides, although stability decreased in a model using 2008-2009 data to predict 2010-2012 suicides. The 5% of visits with highest risk included only 0.1% of soldiers (1047.1 suicides/100 000 person-years in the 5 weeks after the visit). This is a high enough concentration of risk to have implications for targeting preventive interventions. An even better model might be developed in the future by including the enriched information on clinician-evaluated suicide risk mandated by the VA/DoD CPG to be recorded.

Using self-report surveys at the beginning of service to develop multi-outcome risk models for new soldiers in the U.S. Army.

BACKGROUND: The U.S. Army uses universal preventives interventions for several negative outcomes (e.g. suicide, violence, sexual assault) with especially high risks in the early years of service. More intensive interventions exist, but would be cost-effective only if targeted at high-risk soldiers. We report results of efforts to develop models for such targeting from self-report surveys administered at the beginning of Army service. METHODS: 21 832 new soldiers completed a self-administered questionnaire (SAQ) in 2011-2012 and consented to link administrative data to SAQ responses. Penalized regression models were developed for 12 administratively-recorded outcomes occurring by December 2013: suicide attempt, mental hospitalization, positive drug test, traumatic brain injury (TBI), other severe injury, several types of violence perpetration and victimization, demotion, and attrition. RESULTS: The best-performing models were for TBI (AUC = 0.80), major physical violence perpetration (AUC = 0.78), sexual assault perpetration (AUC = 0.78), and suicide attempt (AUC = 0.74). Although predicted risk scores were significantly correlated across outcomes, prediction was not improved by including risk scores for other outcomes in models. Of particular note: 40.5% of suicide attempts occurred among the 10% of new soldiers with highest predicted risk, 57.2% of male sexual assault perpetrations among the 15% with highest predicted risk, and 35.5% of female sexual assault victimizations among the 10% with highest predicted risk. CONCLUSIONS: Data collected at the beginning of service in self-report surveys could be used to develop risk models that define small proportions of new soldiers accounting for high proportions of negative outcomes over the first few years of service.

Selective prevention of combat-related post-traumatic stress disorder using attention bias modification training: a randomized controlled trial.

BACKGROUND: Efficacy of pre-trauma prevention for post-traumatic stress disorder (PTSD) has not yet been established in a randomized controlled trial. Attention bias modification training (ABMT), a computerized intervention, is thought to mitigate stress-related symptoms by targeting disruptions in threat monitoring. We examined the efficacy of ABMT delivered before combat in mitigating risk for PTSD following combat. METHOD: We conducted a double-blind, four-arm randomized controlled trial of 719 infantry soldiers to compare the efficacy of eight sessions of ABMT (n = 179), four sessions of ABMT (n = 184), four sessions of attention control training (ACT; n = 180), or no-training control (n = 176). Outcome symptoms were measured at baseline, 6-month follow-up, 10 days following combat exposure, and 4 months following combat. Primary outcome was PTSD prevalence 4 months post-combat determined in a clinical interview using the Clinician-Administered PTSD Scale. Secondary outcomes were self-reported PTSD and depression symptoms, collected at all four assessments. RESULTS: PTSD prevalence 4 months post-combat was 7.8% in the no-training control group, 6.7% with eight-session ABMT, 2.6% with four-session ABMT, and 5% with ACT. Four sessions of ABMT reduced risk for PTSD relative to the no-training condition (odds ratio 3.13, 95% confidence interval 1.01-9.22, p < 0.05, number needed to treat = 19.2). No other between-group differences were found. The results were consistent across a variety of analytic techniques and data imputation approaches. CONCLUSIONS: Four sessions of ABMT, delivered prior to combat deployment, mitigated PTSD risk following combat exposure. Given its low cost and high scalability potential, and observed number needed to treat, research into larger-scale applications is warranted. The ClinicalTrials.gov identifier is NCT01723215.

Predicting non-familial major physical violent crime perpetration in the US Army from administrative data.

BACKGROUND: Although interventions exist to reduce violent crime, optimal implementation requires accurate targeting. We report the results of an attempt to develop an actuarial model using machine learning methods to predict future violent crimes among US Army soldiers. METHOD: A consolidated administrative database for all 975 057 soldiers in the US Army in 2004-2009 was created in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Of these soldiers, 5771 committed a first founded major physical violent crime (murder-manslaughter, kidnapping, aggravated arson, aggravated assault, robbery) over that time period. Temporally prior administrative records measuring socio-demographic, Army career, criminal justice, medical/pharmacy, and contextual variables were used to build an actuarial model for these crimes separately among men and women using machine learning methods (cross-validated stepwise regression, random forests, penalized regressions). The model was then validated in an independent 2011-2013 sample. RESULTS: Key predictors were indicators of disadvantaged social/socioeconomic status, early career stage, prior crime, and mental disorder treatment. Area under the receiver-operating characteristic curve was 0.80-0.82 in 2004-2009 and 0.77 in the 2011-2013 validation sample. Of all administratively recorded crimes, 36.2-33.1% (male-female) were committed by the 5% of soldiers having the highest predicted risk in 2004-2009 and an even higher proportion (50.5%) in the 2011-2013 validation sample. CONCLUSIONS: Although these results suggest that the models could be used to target soldiers at high risk of violent crime perpetration for preventive interventions, final implementation decisions would require further validation and weighing of predicted effectiveness against intervention costs and competing risks.

Occupational differences in US Army suicide rates.

BACKGROUND: Civilian suicide rates vary by occupation in ways related to occupational stress exposure. Comparable military research finds suicide rates elevated in combat arms occupations. However, no research has evaluated variation in this pattern by deployment history, the indicator of occupation stress widely considered responsible for the recent rise in the military suicide rate. METHOD: The joint associations of Army occupation and deployment history in predicting suicides were analysed in an administrative dataset for the 729 337 male enlisted Regular Army soldiers in the US Army between 2004 and 2009. RESULTS: There were 496 suicides over the study period (22.4/100 000 person-years). Only two occupational categories, both in combat arms, had significantly elevated suicide rates: infantrymen (37.2/100 000 person-years) and combat engineers (38.2/100 000 person-years). However, the suicide rates in these two categories were significantly lower when currently deployed (30.6/100 000 person-years) than never deployed or previously deployed (41.2-39.1/100 000 person-years), whereas the suicide rate of other soldiers was significantly higher when currently deployed and previously deployed (20.2-22.4/100 000 person-years) than never deployed (14.5/100 000 person-years), resulting in the adjusted suicide rate of infantrymen and combat engineers being most elevated when never deployed [odds ratio (OR) 2.9, 95% confidence interval (CI) 2.1-4.1], less so when previously deployed (OR 1.6, 95% CI 1.1-2.1), and not at all when currently deployed (OR 1.2, 95% CI 0.8-1.8). Adjustment for a differential 'healthy warrior effect' cannot explain this variation in the relative suicide rates of never-deployed infantrymen and combat engineers by deployment status. CONCLUSIONS: Efforts are needed to elucidate the causal mechanisms underlying this interaction to guide preventive interventions for soldiers at high suicide risk.

Efficacy beliefs as a moderator of the impact of work-related stressors: a multilevel study.

This study built on previous exploratory research (S. M. Jex & D. M. Gudanowski, 1992) that examined both self-efficacy and collective efficacy as moderators of stressor-strain relations. Based on survey data collected from 2,273 U.S. Army soldiers representing 36 companies, it was found that both self- and collective efficacy moderated the relationship between stressors and strains. Multilevel random coefficient model results revealed that respondents with strong self-efficacy reacted less negatively in terms of psychological and physical strain to long work hours and work overload than did those reporting low levels of efficacy. In addition, respondents with high levels of self-efficacy responded more positively in terms of job satisfaction to tasks with high significance than did those with low efficacy. The results also revealed that group-level collective efficacy moderated the relationship between work overload and job satisfaction and between task significance and organizational commitment. Limitations of the study and implications of these findings are discussed.

The impact of self-efficacy on stressor-strain relations: coping style as an explanatory mechanism.

The present study was designed to examine whether coping style influences the impact of self-efficacy on stressor-strain relations. It was hypothesized that high self-efficacy would weaken stressor-strain relations when accompanied by frequent use of active coping and infrequent use of avoidance coping. Data collected from 2,293 members of the U.S. Army revealed 3-way interactions among self-efficacy, role clarity, and active coping and among self-efficacy, work overload, and avoidance coping. As predicted, self-efficacy mitigated the effects of low role clarity on strain only when active coping was high. Also as expected, strain levels were lower for participants with high self-efficacy than for participants with lower self-efficacy when work overload was low but avoidance coping was high. Implications of these findings for occupational stress research are discussed.

Post-traumatic stress disorder symptoms among Gulf War veterans.

This study assessed the prevalence of risk for development of post-traumatic stress disorder (PTSD) symptoms among active duty and reserve veterans from Pennsylvania and Hawaii who either deployed (N = 1,524) or did not deploy (N = 2,727) to the Persian Gulf as a result of Operation Desert Storm. All participants anonymously completed a survey questionnaire that included the Impact of Event Scale and the Brief Symptom Inventory. Results indicate the likelihood of PTSD symptoms in approximately 8.0% of active duty veterans and 9.3% of reserve veterans who deployed to the Persian Gulf. PTSD risk comparisons are made with other active duty Army veterans assessed 1 year earlier. Sources of trauma are presented and implications for future military deployments on potential risks for developing PTSD are discussed.

Psychological health of Gulf War-era military personnel.

This study assessed the effects of the Persian Gulf War on the psychological health and adjustment of military personnel in Hawaii and Pennsylvania who either deployed (N = 1,524) or did not deploy (N = 2,727) to the Persian Gulf during Operations Desert Shield/Desert Storm. All participants anonymously completed a questionnaire providing information on demographics, psychological and psychosocial health, deployment stressors, current life problems, current distress, and causal attributions of present problems. Results indicate that deployed veterans experienced significant levels of stress in-theater and continue to report significant stress in their lives today. Although considerable stress is experienced, the majority of veterans are handling it unremarkably. Implications for future deployments and the need for military-normed assessment instruments are discussed.

Physical health symptomatology of Gulf War-era service personnel from the states of Pennsylvania and Hawaii.

We present data on physical health and possible "Gulf War syndrome" from a Congressionally mandated study of over 4,000 active duty and reserve service members from the states of Hawaii and Pennsylvania who served during Operation Desert Storm. We found that deployed veterans report significantly more physical health symptoms than non-deployed veterans that cannot be explained by reasons other than deployment alone. We also identified a subgroup of 178 deployed veterans at risk for possible Gulf War syndrome. We recommend that services collect baseline information from units likely to deploy in the future and update that information regularly.