Do stigma and efficacy mediate the association between training and suicide prevention behavior among Army noncommissioned officers?

INTRODUCTION: Rates of suicide in the Active Component of the military have significantly increased since 2010, with particularly high rates among Army service members. One element of the Army's approach to suicide prevention relies on noncommissioned officers (NCOs) as gatekeepers who have regular contact with soldiers. NCOs receive suicide prevention training, but there is limited evidence that such training leads to behavior change. METHODS: We surveyed 2468 Army NCOs participating in leadership development courses to determine (a) if training on suicide prevention and soft skills (e.g., active listening) was associated with gatekeeper behavior and use of soft skills; and (b) whether that association was explained by two potential barriers, stigma and perceptions of efficacy. RESULTS: Both the number of suicide prevention training topics and soft skills trained were associated with increased gatekeeper behavior; these relationships were explained in part by lower stigma and higher efficacy for use of soft skills. The use of interactive training methods and receiving coaching after training were not associated with stigma or efficacy, though both methods were associated with more frequent use of soft skills. CONCLUSION: Results suggest that the content and format of training is important to preparing NCOs to fulfill a gatekeeper role.

Upstream suicide prevention in the U.S. Army: Noncommissioned officers' perspectives.

The goal of this study was to examine the factors associated with Army noncommissioned officer (NCO) experiences, attitudes, and behaviors in their role of identifying potential suicide risk factors in their fellow soldiers. To better understand the perspectives of NCOs, an anonymous survey was administered to 2,468 Army NCOs. Descriptive statistics and linear regressions were conducted to compare subgroups of NCOs. Most (71%) Army NCOs have received many (11 or more) hours of suicide prevention training, but training in soft skills that may be important for the gatekeeper role was less consistently reported. Active Component soldiers reported greater confidence in their intervention skills (Cohen's d = 0.25) and fewer logistical barriers (e.g., time and space to talk) to intervening with at-risk soldiers (Cohen's d = 0.80) compared to Reserve and National Guard soldiers. Formal coursework in mental health areas like psychology or chaplaincy was associated with a greater level of confidence in intervention skills (Cohen's d = 0.23) and in more frequent intervention behavior (Cohen's d = 0.13). Army NCO trainings should be modified to better equip soldiers with the soft skills (e.g., active listening skills and verbally and nonverbally conveying nonjudgment/acceptance and empathy) needed to have effective conversations with soldiers about suicide risk factors and other sensitive topics. Strategies used within mental health education, which appears to be a strength for NCO gatekeepers, could be used to achieve this goal. Reserve and Guard NCOs may need additional supports and tailored trainings to better fit their operational context. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Firearm Suicide Prevention in the U.S. Military: Recommendations From a National Summit.

The U.S. DoD has identified firearm suicide prevention as a key operational priority. One vital approach to addressing firearm suicides is through promoting lethal means safety, which involves the voluntary use of secure storage for personally owned firearms and/or temporarily moving firearms out of the home during risk periods. Despite promising approaches to lethal means safety, critical gaps remain in research, programming, and communication among and across scientists, DoD programmatic leaders, front-line commanders, and service members. To address these gaps, the first-ever national "Firearm Suicide Prevention in the Military: Messaging and Interventions Summit" was convened in June 2022, bringing together DoD personnel and researchers with expertise in firearm suicide prevention and lethal means safety. The Summit identified 10 recommendations to enhance firearm suicide prevention messaging and interventions in the U.S. military, including (1) repeal or amend prohibitions on questioning service members about personal firearms; (2) develop, examine, and use common language for firearm injury prevention; (3) implement a universal approach to training on comprehensive firearm injury prevention; (4) encourage leadership across disciplines and levels; (5) aim for broad culture change; (6) support innovative research; (7) consider various outcome measures; (8) promote "cultural competence" for better communication; (9) reduce territorialism; and (10) develop creative partnerships. Ultimately, these recommendations can facilitate productive partnerships with a shared goal: to develop, test, and implement strategies that standardize lethal means safety and reduce firearm suicides and other firearm injuries or harm among service members.

Mental Health Service Use Among Lesbian, Gay, and Bisexual Adults Who Report Having Attempted Suicide.

OBJECTIVE: This study estimated mental health service use among lesbian, gay, and bisexual (LGB) adults in the United States who reported having made a suicide attempt. METHODS: Data came from the pooled 2015-2019 National Surveys on Drug Use and Health. Of the 191,954 adult respondents, 1,946 reported a past-year suicide attempt. Survey-weighted descriptive and regression analyses were conducted to compare mental health service use among LGB and heterosexual adults. RESULTS: Three percent of LGB adults (N=598) reported having attempted suicide in the past year, compared with 0.5% of heterosexual adults (N=1,348). Mental health treatment use was significantly higher among LGB adults than among heterosexual adults (64% versus 56%) before analyses were adjusted for sociodemographic characteristics. CONCLUSIONS: Because suicide attempts and mental health use are elevated among LGB adults, clinicians must provide evidence-based approaches for identifying and managing suicide risk to LGB adults in an affirming manner.

Examining Inhalant Use Among Sexual Minority Adults in a National Sample: Drug-Specific Risks or Generalized Risk?

Purpose: The study objective was to compare use of 12 specific inhalants among lesbian, gay, and bisexual (LGB) adults relative to heterosexual adults among a national sample. Methods: Data on 210,392 adults, including 15,007 LGB adults, were from the 2015 to 2019 National Survey on Drug Use and Health. For each inhalant type, logistic regression was used to characterize differences by sexual identity and gender. Unadjusted and demographic adjusted odds ratios are reported. Results: All LGB groups exhibited elevated use of multiple inhalant types (ranging from 5 for gay males to 12 for bisexual females). The largest disparities were for poppers among gay and bisexual males. Gay and bisexual males initiated use at older ages. Conclusion: Observed disparities among LGB adults included inhalants used in a sexual or club context (e.g., poppers) as well as types with particularly elevated fatality risk (e.g., butane, propane, aerosol sprays, and nitrous oxide).

Syndromic Surveillance 2.0: Emerging Global Surveillance Strategies for Infectious Disease Epidemics.

The U.S. Army has a long history of preventing, detecting, and treating infectious diseases. Like other organizations and agencies involved in public health, the Army is increasingly interested in syndromic surveillance strategies-those designed to identify outbreaks before clinical data are available. Researchers use various methods to identify surveillance strategies across the globe, investigate these strategies' benefits and limitations, and recommend actions to aid the Army in their efforts to detect emerging epidemics and pandemics.

What Prevention and Treatment of Substance Dependence Can Tell Us About Addressing Violent Extremism.

In this article, the authors examine similarities between violent extremism and substance dependence. They review evidence from psychology, neuroscience, sociology, and public health that suggests that there are similarities in violent extremism and substance dependence in terms of the underlying neural pathways, social and psychological causes, behavioral patterns, and opportunities for prevention and intervention.

Suicide Among Veterans: Veterans' Issues in Focus.

Suicide is a major public health challenge that disproportionately affects service members and veterans. Researchers have been studying veteran suicide rates and prevention strategies, but there are opportunities to improve risk identification, evaluation, support, and treatments and interventions. These strategies must include community-based efforts to reach veterans outside the U.S. Department of Veterans Affairs system.

Military service branch differences in alcohol use, tobacco use, prescription drug misuse, and mental health conditions.

INTRODUCTION: Rates of substance use and mental health conditions vary across military service branches, yet branches also differ notably in terms of demographics and deployment experiences. This study examines whether branch differences in substance use and mental health outcomes persist after adjustment for a comprehensive set of demographic and deployment-related factors. METHODS: Data on 16,699 Armed Forces Active Duty service members were from the 2015 Department of Defense Health Related Behaviors Survey. Service branch-specific prevalences were estimated for self-reports of heavy episodic drinking (HED), possible alcohol use disorder (AUD), current smoking, e-cigarette use, smokeless tobacco use, prescription drug misuse, probable post-traumatic stress disorder (PTSD), probable depression, and probable anxiety. Using logistic regression, we assessed whether branch differences persisted after adjusting for an extensive array of demographic factors (among full sample) and deployment/combat factors (among ever-deployed subgroup). RESULTS: HED, AUD, smoking, e-cigarette use, smokeless tobacco use, depression, and anxiety were highest in the Marine Corps; prescription drug misuse and PTSD were highest in the Army. HED, AUD, smoking, smokeless tobacco use, PTSD, depression, and anxiety were lowest in the Air Force; e-cigarette use and prescription drug misuse were lowest in the Coast Guard. Demographics and deployment/combat experiences differed across branches. After adjustment, service members in the Army, Marine Corps and Navy exhibited nearly 2-3 times the odds of multiple mental health conditions and substance use behaviors relative to the Air Force. CONCLUSION: Service branch differences were not fully explained by variation in demographics and deployment/combat experiences.

Disparities in Use/Misuse of Specific Illicit and Prescription Drugs among Sexual Minority Adults in a National Sample.

Background: Compared to heterosexual adults, lesbian, gay, and bisexual (LGB) adults have higher rates of any illicit drug use and any prescription drug misuse, yet disparities regarding specific drugs remain poorly characterized. Methods: We examined disparities by sexual identity and sex for 8 illicit and prescription drugs using 2015-2019 National Survey on Drug Use and Health data. Outcomes included past-year use/misuse of cocaine/crack, hallucinogens, inhalants, methamphetamine, heroin, prescription opioids, prescription stimulants, prescription tranquilizers/sedatives, and level of polydrug use/misuse (2 substances; 3+ substances). For each outcome, odds ratios relative to heterosexual adults of same sex were estimated using logistic regression controlling for demographics; significant estimates were interpreted as a disparity. Results: Among gay men, significant disparities were present for all drugs except prescription stimulants and heroin; inhalant use was particularly elevated. Bisexual women exhibited significant disparities for every drug examined, as did bisexual men (except heroin). Among lesbian/gay women, disparities were only present for prescription opioids and stimulants. Relative to heterosexual peers, use of 3+ substances was 3 times higher among gay men and bisexual women and 2 times higher among bisexual men. Conclusions: Consistent with minority stress theory, prevalences of illicit and prescription drug use/misuse were 2-3 times higher among LGB adults than heterosexual adults. Illicit drug use should not be perceived as only impacting gay/bisexual men - bisexual women had similar - or higher - prevalences of hallucinogen, cocaine, methamphetamine, and heroin use. Yet, in contrast to bisexual women, lesbian/gay women did not exhibit disparities for any illicit drugs.

Suicidality Among Sexual Minority Adults: Gender, Age, and Race/Ethnicity Differences.

INTRODUCTION: Lesbian, gay, and bisexual individuals have elevated suicide risk, but there is little information available about how this risk may vary by gender, age, and race/ethnicity. METHODS: This study examined past-year suicide thoughts, plans, and attempts among adult respondents to the 2015-2019 National Surveys on Drug Use and Health (pooled N=191,954). Logistic regression was used to examine the differences between lesbian, gay, and bisexual and heterosexual adults for each outcome, once by gender and age category and once by gender and race/ethnicity category, while controlling for core sociodemographic characteristics. Race/ethnicity and age differences were also estimated within sexual identity groups. RESULTS: Suicide thoughts, plans, and attempts were more common among lesbian, gay, and bisexual adults in almost every age and race/ethnicity category relative to that among corresponding heterosexual adults. In some age and race/ethnicity categories, bisexual women were more likely to report suicidal thoughts than lesbian/gay women. Each outcome decreased significantly across age groups among women of all sexual identity groups and heterosexual men; yet, this age effect was less pronounced among gay and bisexual men. Black women had significantly lower rates of suicidal thoughts and plans than White women in all sexual identity groups. CONCLUSIONS: In light of consistently elevated rates of suicide thoughts and behaviors, lesbian, gay, and bisexual adults may expressly benefit from enhanced prevention, identification, and treatment of suicide risk. Additional research is needed to assess the associations between sexual identity and suicide mortality as well as to understand the heterogeneity in suicide risk among lesbian, gay, and bisexual youth, particularly by race/ethnicity.

Co-occurring alcohol and mental health problems in the military: Prevalence, disparities, and service utilization.

OBJECTIVE: To examine the prevalence of co-occurring alcohol and mental health (MH) problems (COPs), perceived MH service need, and MH service utilization among active duty service members, and to identify differences in gender, race/ethnicity, age, and sexual orientation and gender identity. METHOD: 16,699 active duty service members participated in the Department of Defense's 2015 Health Related Behaviors Survey. Measures included demographics, combat deployment, smoking status, problematic alcohol use (Alcohol Use Disorders Identification Test-C, AUDIT-C), posttraumatic stress disorder (PTSD Checklist, Civilian Version, PCL-C), depression (Patient Health Questionnaire-9, PHQ-9), anxiety (Generalized Anxiety Disorder-7, GAD-7), and perceived need for and use of MH services. We examined groups of service members with probable: COP, alcohol problem only, MH problem only, and neither. RESULTS: Eight percent of service members reported COPs, 26.89% reported alcohol use problem only, and 9.41% reported a MH condition only. COPs were more common among those who were lesbian, gay, bisexual, and transgender (LGBT), those who had three or more combat deployments, and smokers, and less common among those aged 35 years and older, Asian or Black, and in the Air Force and Coast Guard (relative to Navy). Those reporting a probable MH problem only were significantly less likely to report use of past year MH counseling than those with probable COPs; otherwise, patterns of service utilization and perceived need were similar. CONCLUSIONS: COPs are common enough that screening for and attention to their co-occurrence are needed in the military, and some subgroups of service members are at particularly high risk for COPs. Future research and policy should delve deeper into how the needs of service members with COPs can be addressed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Contemporary Issues in Gun Policy: Essays from the RAND Gun Policy in America Project.

In this article, part of RAND's Gun Policy in America project, the authors describe the nuanced picture relating mental illness with gun violence. For example, suicide risk is elevated among people with certain mental illnesses, but suicide among those with such diagnoses is still rare. Homicide risk is also elevated among people with certain mental conditions (e.g., schizophrenia) and among people with co-occurring mental health conditions and substance use disorders, but these individuals still account for the minority of homicides and acts of mass violence in the United States. On the other hand, people with mental health conditions appear to be at increased risk for being victims of interpersonal violence.

Comparing the Army's Suicide Rate to the General U.S. Population: Identifying Suitable Characteristics, Data Sources, and Analytic Approaches.

Over the past 15 years, the suicide rate among members of the U.S. armed forces has doubled, with the greatest increase observed among soldiers in the Army. This increasing rate is paralleled by a smaller increase in the general U.S. population, observed across both genders, in virtually every age group and in nearly every state. An empirical question exists: What is the extent or degree to which the suicide trend in the Army is unique to that service, relative to what is observed in the general U.S. population? The Army has typically attempted to address this question by standardizing the general population to look like the Army on demographic characteristics. However, given the rise in suicide rates over the past decade, the Army wanted to better understand whether standardization based solely on age and gender is enough. Expanding the characteristics on which the general population is standardized to match the Army could be useful to gain a better understanding of the suicide trends in the Army. However, such a change also brings with it some challenges, including the lack of readily available data in the general U.S. population. In addition, even an expanded set of characteristics still results in having a large number of unmeasured factors that cannot be included in this type of analysis. In this study, the authors explore how accounting for age, gender, race/ethnicity, time, marital status, and educational attainment affects suicide rate differences between soldiers and a comparable subset of the general U.S. population.

Editorial: Research Will Help Prepare America for the Rollout of Its New Crisis Hotline.

In Mathieu and colleagues'1 recent systematic review, the authors present important research insights about young people who call hotlines, why they call them, the types of services that callers receive, and the quality of this care. Albeit important on its own, it is particularly timely for American practitioners and policymakers. In December 2020, US President Donald J. Trump signed the National Suicide Designation Act of 2020 into law, designating 9-8-8 as the universal telephone number for accessing the national suicide prevention and mental health crisis hotline. In this editorial, I highlight how the insights provided by Mathieu et al.1 have implications for the rollout of the new 9-8-8 number.

Identifying optimal level-of-care placement decisions for adolescent substance use treatment.

BACKGROUND: Adolescents respond differentially to substance use treatment based on their individual needs and goals. Providers may benefit from guidance (via decision rules) for personalizing aspects of treatment, such as level-of-care (LOC) placements, like choosing between outpatient or inpatient care. The field lacks an empirically-supported foundation to inform the development of an adaptive LOC-placement protocol. This work begins to build the evidence base for adaptive protocols by estimating them from a large observational dataset. METHODS: We estimated two-stage LOC-placement protocols adapted to individual adolescent characteristics collected from the Global Appraisal of Individual Needs assessment tool (n = 10,131 adolescents). We used a modified version of Q-learning, a regression-based method for estimating personalized treatment rules over time, to estimate four protocols, each targeting a potentially distinct treatment goal: one primary outcome (a composite of ten positive treatment outcomes) and three secondary (substance frequency, substance problems, and emotional problems). We compared the adaptive protocols to non-adaptive protocols using an independent dataset. RESULTS: Intensive outpatient was recommended for all adolescents at intake for the primary outcome, while low-risk adolescents were recommended for no further treatment at followup while higher-risk patients were recommended to inpatient. Our adaptive protocols outperformed static protocols by an average of 0.4 standard deviations (95 % confidence interval 0.2-0.6) of the primary outcome. CONCLUSIONS: Adaptive protocols provide a simple one-to-one guide between adolescents' needs and recommended treatment which can be used as decision support for clinicians making LOC-placement decisions.