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1.  Association between psychotic experiences and subsequent suicidal thoughts and behaviors: A cross-national analysis from the World Health Organization World Mental Health Surveys 
JAMA psychiatry  2017;74(11):1136-1144.
Community-based studies have linked psychotic experiences (PEs) with increased risks of suicidal thoughts and behaviors (STBs). However, it is not known if these associations vary across the life-course or if mental disorders (antecedent to the STBs) contribute to these associations.
To examine the temporal association between PEs and subsequent STBs across the life span as well as the influence of mental disorders (antecedent to the STBs) on these associations.
A total of 33,370 adult respondents across 19 countries from the WHO World Mental Health (WMH) Surveys were assessed for PEs, STBs (ideation, plans, and attempts), and 21 DSM-IV mental disorders. Discrete-time survival analysis was used to investigate the associations of PEs with subsequent onsets of STBs.
Prevalence and frequency of STBs with PEs, and odds ratios and 95%CIs.
Of 33 370 included participants, among those with PEs (n = 2488), the lifetime prevalence (SE) of suicidal ideation, plans, and attempts was 28.5%(1.3), 10.8%(0.7), and 10.2%(0.7), respectively. Respondents with 1 or more PEs had 2-fold increased odds of subsequent STBs after adjusting for antecedent or intervening mental disorders (suicidal ideation: odds ratio, 2.2; 95%CI, 1.8-2.6; suicide plans: odds ratio, 2.1; 95%CI, 1.7-2.6; and suicide attempts: odds ratio, 1.9; 95%CI, 1.5-2.5). There were significant dose-response relationships of number of PE types with subsequent STBs that persisted after adjustment for mental disorders. Although PEs were significant predictors of subsequent STB onset across all life stages, associations were strongest in individuals 12 years and younger. After adjustment for antecedent mental disorders, the overall population attributable risk proportions for lifetime suicidal ideation, plans, and attempts associated with temporally prior PEs were 5.3%, 5.7%, and 4.8%, respectively.
PEs are associated with elevated odds of subsequent STBs across the life-course that cannot be explained by antecedent mental disorders. These results highlight the importance of including information about PEs in screening instruments designed to predict STBs.
PMCID: PMC5710219  PMID: 28854302
2.  Prognostic Indicators of Persistent Post-Concussive Symptoms after Deployment-Related Mild Traumatic Brain Injury: A Prospective Longitudinal Study in U.S. Army Soldiers 
Journal of Neurotrauma  2016;33(23):2125-2132.
Mild traumatic brain injury (mTBI), or concussion, is prevalent in the military. The course of recovery can be highly variable. This study investigates whether deployment-acquired mTBI is associated with subsequent presence and severity of post-concussive symptoms (PCS) and identifies predictors of persistent PCS among US Army personnel who sustained mTBI while deployed to Afghanistan. We used data from a prospective longitudinal survey of soldiers assessed 1–2 months before a 10-month deployment to Afghanistan (T0), on redeployment to the United States (T1), approximately 3 months later (T2), and approximately 9 months later (T3). Outcomes of interest were PCS at T2 and T3. Predictors considered were: sociodemographic factors, number of previous deployments, pre-deployment mental health and TBI history, and mTBI and other military-related stress during the index deployment. The study sample comprised 4518 soldiers, 822 (18.2%) of whom experienced mTBI during the index deployment. After adjusting for demographic, clinical, and deployment-related factors, deployment-acquired mTBI was associated with nearly triple the risk of reporting any PCS and with increased severity of PCS when symptoms were present. Among those who sustained mTBI, severity of PCS at follow-up was associated with history of pre-deployment TBI(s), pre-deployment psychological distress, more severe deployment stress, and loss of consciousness or lapse of memory (versus being “dazed” only) as a result of deployment-acquired mTBI. In summary, we found that sustaining mTBI increases risk for persistent PCS. Previous TBI(s), pre-deployment psychological distress, severe deployment stress, and loss of consciousness or lapse of memory resulting from mTBI(s) are prognostic indicators of persistent PCS after an index mTBI. These observations may have actionable implications for prevention of chronic sequelae of mTBI in the military and other settings.
PMCID: PMC5124734  PMID: 26905672
concussion; deployment; mental health; military; stress; traumatic brain injury
3.  Characterizing Implicit Mental Health Associations across Clinical Domains 
Background and objectives
Implicit associations are relatively uncontrollable associations between concepts in memory. The current investigation focuses on implicit associations in four mental health domains (alcohol use, anxiety, depression, and eating disorders) and how these implicit associations: a) relate to explicit associations and b) self-reported clinical symptoms within the same domains, and c) vary based on demographic characteristics (age, gender, race, ethnicity, and education).
Participants (volunteers over age 18 to a research website) completed implicit association (Implicit Association Tests), explicit association (self+psychopathology or attitudes toward food, using semantic differential items), and symptom measures at the Project Implicit Mental Health website tied to: alcohol use (N=12,387), anxiety (N=21,304), depression (N=24,126), or eating disorders (N=10,115).
Within each domain, implicit associations showed small to moderate associations with explicit associations and symptoms, and predicted self-reported symptoms beyond explicit associations. In general, implicit association strength varied little by race and ethnicity, but showed small ties to age, gender, and education.
This research was conducted on a public research and education website, where participants could take more than one of the studies.
Among a large and diverse sample, implicit associations in the four domains are congruent with explicit associations and self-reported symptoms, and also add to our prediction of self-reported symptoms over and above explicit associations, pointing to the potential future clinical utility and validity of using implicit association measures with diverse populations.
PMCID: PMC4871740  PMID: 26962979
implicit associations; alcohol use/abuse; depression; eating disorders; anxiety; Internet research
4.  Using self-report surveys at the beginning of service to develop multi-outcome risk models for new soldiers in the U.S. Army 
Psychological medicine  2017;47(13):2275-2287.
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.
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.
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.
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.
PMCID: PMC5679702  PMID: 28374665
Army; military; predictive modeling; risk assessment; mental health; violence; disciplinary problems
The Journal of clinical psychiatry  2017;78(7):e828-e836.
The primary aims are to: (a) identify patterns of suicidal thoughts and behaviors (STB) during college among students with lifetime pre-matriculation STB and (b) develop a risk-screening algorithm for persistence of pre-matriculation STB during college.
Data come from the Leuven College Surveys, a series of prospective cohort studies of all incoming KU Leuven University freshmen. In the academic year 2012 and 2013, 4,889 incoming freshmen (73.2% response rate) provided baseline data on socio-demographic variables, childhood-adolescent traumatic experiences, 12-month stressful experiences, 12-month mental disorders, 12-month STB, and severity markers of pre-matriculation STB. A total of 2,566 students (69.3% conditional response rate) participated in 12- and 24-month follow-up surveys during the first two college years.
Thirteen percent (weighted n=535) of incoming freshmen reported lifetime pre-matriculation STB. Of those, 28.0% reported 12-month STB in one follow-up assessment and another 27.7% in both follow-up assessments. High persistence of STB (i.e., 12-month STB in two follow-up assessments) was most strongly associated with severity markers of pre-matriculation STB, with odds ratios in the 2.4–10.3 range and population attributable risk proportions between 9.2% and 50.8%. When aiming for less than 50% of false positive cases (PPV=54.4%), a multivariate predictive risk algorithm (cross-validated AUC=0.79) situated 59.9% of highly persistent cases among the 30% respondents with highest baseline predicted risk.
An individualized web-based screening approach is a promising strategy to identify students at the onset of university who may be at high risk for STB persistence during their academic career.
PMCID: PMC5664942  PMID: 28640991
suicide; suicidal thoughts and behaviors (STB); risk-screening algorithm; persistence; college students; cohort study
6.  Measuring the suicidal mind: implicit cognition predicts suicidal behavior 
Psychological science  2010;21(4):511-517.
Suicide is a leading cause of death worldwide, challenging all theories that assume a universal drive for self-preservation. It is difficult to predict and prevent because people who consider killing themselves often are unwilling or incapable of reporting their intention. Advances in the measurement of implicit cognition provide an opportunity to test whether automatic associations of self with death can provide a behavioral marker of suicide risk. We measured implicit associations about death/suicide in 157 people presenting for treatment at a psychiatric emergency department while they awaited medical attention. Results confirmed that suicide attempters hold a significantly stronger implicit association between death/suicide and self than do psychiatrically distressed nonattempters. Moreover, the implicit association of death/suicide with self was associated with an approximately six-fold increase in the odds of making a suicide attempt in the next 6 months, exceeding the predictive validity of known risk factors (e.g., depression or suicide attempt history) and both patients’ and clinicians’ predictions. These results provide the first evidence of a behavioral marker for suicidal behavior and suggest that measures of implicit cognition may be useful for detecting and predicting sensitive clinical behaviors that are unlikely to be reported.
PMCID: PMC5258199  PMID: 20424092
suicide; suicide attempt; prediction; IAT
7.  Revealing the form and function of self-injurious thoughts and behaviors: A real-time ecological assessment study among adolescents and young adults 
Journal of abnormal psychology  2009;118(4):816-827.
Self-injurious behaviors are among the leading causes of death worldwide. However, the basic nature of self-injurious thoughts and behaviors (SITBs) is not well-understood because prior studies have relied on long-term, retrospective, aggregate, self-report assessment methods. We used ecological momentary assessment methods to measure suicidal and non-suicidal SITBs as they naturally occur in real-time. Participants were 30 adolescents and young adults with a recent history of self-injury who completed signal- and event-contingent assessments on handheld computers over a 14-day period, resulting in the collection of data on 1262 thought and behavior episodes. Participants reported an average of 5.0 thoughts of nonsuicidal self-injury (NSSI) per week, most often of moderate intensity and short duration (1–30 minutes), and 1.6 episodes of NSSI per week. Suicidal thoughts occurred less frequently (1.1 per week), were of longer duration, and led to self-injurious behavior (i.e., suicide attempts) less often. Details are reported about the contexts in which SITBs most often occur (e.g., what participants were doing, who they were with, and what they were feeling before and after each episode). This study provides a first glimpse of how SITBs are experienced in everyday life and has significant implications for scientific and clinical work on self-injurious behaviors.
PMCID: PMC5258190  PMID: 19899851
8.  Genomewide Association Studies of Posttraumatic Stress Disorder in Two Cohorts of US Army Soldiers 
JAMA psychiatry  2016;73(7):695-704.
Posttraumatic stress disorder (PTSD) is a prevalent, serious public health concern, particularly in the military. The identification of genetic risk factors for PTSD may provide important insights into the biological basis of vulnerability and comorbidity.
To discover genetic loci associated with lifetime PTSD risk in two cohorts from the Army Study To Assess Risk and Resilience in Servicemembers (Army STARRS).
Design, Setting and Participants
Two coordinated genomewide association studies of mental health in the US military: New Soldier Study (NSS, N=3167 cases and 4607 trauma-exposed controls) and Pre/Post Deployment Study (PPDS, N=947 cases and 4969 trauma-exposed controls). The primary analysis compared lifetime DSM-IV PTSD cases to trauma-exposed controls without lifetime PTSD.
Main Outcomes and Measures
Association analyses were conducted for PTSD using logistic regression models within each of 3 ancestral groups (European, African, Latino) by study and then meta-analyzed. Heritability and genetic correlation and pleiotropy with other psychiatric and immune-related disorders were estimated.
We observed a genomewide significant locus in ANKRD55 on chromosome 5 (rs159572; odds ratio [OR] = 1.62, p-value =2.43×10−8; adjusted for cumulative trauma exposure [AOR] = 1.68, p-value = 1.18×10−8) in the African American samples from NSS. We also observed a genomewide significant locus in or near ZNF626 on chromosome 19 (rs11085374; OR = 0.77, p-value = 4.59 ×10−8) in the European American samples from NSS. We did not find similar results for either SNP in the corresponding ancestry group from the PPDS sample, or in other ancestral groups or trans-ancestral meta-analyses. SNP-based heritability was non-significant, and no significant genetic correlations were observed between PTSD and six mental disorders and nine immune-related disorders. Significant evidence of pleiotropy was observed between PTSD and rheumatoid arthritis and, to a lesser extent, psoriasis.
Conclusions and Relevance
In the largest GWAS of PTSD to date, involving a US military sample, we found limited evidence of association for specific loci. Further efforts are needed to replicate the genomewide significant association with ANKRD55 – associated in prior research with several autoimmune and inflammatory disorders – and to clarify the nature of the genetic overlap observed between PTSD and rheumatoid arthritis and psoriasis.
PMCID: PMC4936936  PMID: 27167565
genomewide association; genetic; immune; inflammatory; military; posttraumatic stress disorder; pleiotropy; risk; trauma
9.  Examining the Course of Suicidal and Nonsuicidal Self-Injurious Thoughts and Behaviors in Outpatient and Inpatient Adolescents 
Suicidal and nonsuicidal self-injurious thoughts and behaviors (SITBs) among youth are major public health concerns. Although a growing body of research has focused on the complex association between nonsuicidal and suicidal self-injury, the temporal relationship between these two classes of behaviors is unclear. The current study addresses this empirical gap by examining the course of SITBs in adolescents receiving outpatient (N = 106; 82.1 % female) and inpatient (N = 174; 75.9 % female) treatment. SITBs (co-occurrence, age-of-onset, and time lag between SITBs) and major psychiatric disorders were assessed at a single time point with well-validated structured interviews. Adolescents in both clinical samples reported high co-occurrence of SITBs: most adolescents reported both lifetime nonsuicidal self-injury (NSSI) and suicidal thoughts. A similar temporal pattern of SITBs was reported in the two samples: thoughts of NSSI and suicide ideation had the earliest age-of-onset, followed by NSSI behaviors, suicide plans, and suicide attempts. However, the age-of-onset for each SITB was younger in the inpatient sample than in the outpatient sample. In terms of time lag between SITBs, suicide ideation occurred on average before initial engagement in NSSI, suggesting that pathways to NSSI and suicidal behavior may occur simultaneously rather than in succession from nonsuicidal to suicidal self-injury. Results also indicated that the time to transition between SITBs was relatively fast, and that a key period for intervention and prevention is within the first 6–12 months after the onset of suicidal thinking. Taken together, these findings have important implications for understanding the time-lagged relationship between nonsuicidal and suicidal self-injury.
PMCID: PMC5397367  PMID: 27761783
Self-injury; Nonsuicidal self-injury; Suicide; Suicide attempts; Adolescence
10.  Mental Disorders, Comorbidity and Pre-Enlistment Suicidal Behavior among New Soldiers in the US Army: Results from the Army Study to Assess Risk and Resilience in Service members (Army STARRS) 
Suicide & life-threatening behavior  2015;10.1111/sltb.12153.
We examined the associations between mental disorders and suicidal behavior (ideation, plans, and attempts) among new soldiers using data from the New Soldier Study (NSS) component of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS; n=38,507). Most new soldiers with a pre-enlistment history of suicide attempt reported a prior mental disorder (59.0%). Each disorder examined was associated with increased odds of suicidal behavior (ORs=2.6–8.6). Only PTSD and disorders characterized by irritability and impulsive/aggressive behavior (i.e., bipolar disorder, conduct disorder, oppositional defiant disorder, and attention-deficit/hyperactivity disorder) predicted unplanned attempts among ideators. Mental disorders are important predictors of pre-enlistment suicidal behavior among new soldiers and should figure prominently in suicide screening and prevention efforts.
PMCID: PMC4515394  PMID: 25622860
11.  Mental disorders among college students in the WHO World Mental Health Surveys 
Psychological medicine  2016;46(14):2955-2970.
Although mental disorders are significant predictors of educational attainment throughout the entire educational career, most research on mental disorders among students has focused on the primary and secondary school years.
The World Health Organization World Mental Health Surveys were used to examine the associations of mental disorders with college entry and attrition by comparing college students (n = 1,572) and nonstudents in the same age range (18–22; n = 4,178), including nonstudents who recently left college without graduating (n = 702) based on surveys in 21 countries (4 low/lower-middle income, 5 upper middle-income, 1 lower-middle or upper-middle at the times of two different surveys, and 11 high income). Lifetime and 12-month prevalence and age-of-onset of DSM-IV anxiety, mood, behavioural and substance disorders were assessed with the Composite International Diagnostic Interview.
One-fifth (20.3%) of college students had 12-month DSM-IV/CIDI disorders. 83.1% of these cases had pre-matriculation onsets. Disorders with pre-matriculation onsets were more important than those with post-matriculation onsets in predicting subsequent college attrition, with substance disorders and, among women, major depression the most important such disorders. Only 16.4% of students with 12-month disorders received any 12-month healthcare treatment for their mental disorders.
Mental disorders are common among college students, have onsets that mostly occur prior to college entry, in the case of pre-matriculation disorders are associated with college attrition, and are typically untreated. Detection and effective treatment of these disorders early in the college career might reduce attrition and improve educational and psychosocial functioning.
PMCID: PMC5129654  PMID: 27484622
Mental Illness; College; Education; College Dropout; College attrition; Epidemiology
12.  Barriers to initiating and continuing mental health treatment among soldiers in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) 
Military medicine  2016;181(9):1021-1032.
U.S. Army soldiers with mental disorders report a variety of barriers to initiating and continuing treatment. Improved understanding of these barriers can help direct mental health services to soldiers in need. A representative sample of 5,428 nondeployed Regular Army soldiers participating in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) completed a self-administered questionnaire (SAQ) and consented to linking SAQ data with administrative records. We examined reported treatment barriers (perceived need, structural reasons, attitudinal reasons) among respondents with current DSM-IV mental disorders who either did not seek treatment in the past year (n=744) or discontinued treatment (n=145). 82.4% of soldiers who did not initiate treatment and 69.5% of those who discontinued treatment endorsed at least two barriers. 69.8% of never-treated soldiers reported no perceived need. Attitudinal reasons were cited more frequently than structural reasons among never-treated soldiers with perceived need (80.7% vs. 62.7%) and those who discontinued treatment (71.0% vs. 37.8%). Multivariate associations with socio-demographic, Army career, and mental health predictors varied across barrier categories. These findings suggest most soldiers with mental disorders do not believe they need treatment, and those who do typically face multiple attitudinal and, to a lesser extent, structural barriers.
PMCID: PMC5120390  PMID: 27612348
military; mental health; treatment; barriers
13.  Improving the Short-Term Prediction of Suicidal Behavior 
American journal of preventive medicine  2014;47(3 Suppl 2):S176-S180.
Aspirational Goal 3 of the National Action Alliance for Suicide Prevention’s Research Prioritization Task Force is to predict who is at risk for attempting suicide in the near future. Despite decades of research devoted to the study of risk and protective factors for suicide and suicidal behavior, surprisingly little is known about the short-term prediction of these behaviors. In this paper, we propose several questions that, if answered, could improve the identification of short-term, or imminent, risk for suicidal behavior. First, what factors predict the transition from suicidal thoughts to attempts? Second, what factors are particularly strong predictors of making this transition over the next hours, days, or weeks? Third, what are the most important objective markers of short-term risk for suicidal behavior? And fourth, what method of combining information about risk and protective factors yields the best prediction? We propose that the next generation of research on the assessment and prediction of suicidal behavior should shift, from cross-sectional studies of bivariate risk and protective factors, to prospective studies aimed at identifying multivariate, short-term prediction indices, examining methods of synthesizing this information, and testing the ability to predict and prevent suicidal events.
PMCID: PMC5258198  PMID: 25145736
14.  Predicting suicides after outpatient mental health visits in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) 
Molecular psychiatry  2016;10.1038/mp.2016.110.
The 2013 U.S. 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 known not 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 non-deployed Regular U.S. Army soldiers because they account for the vast majority of such suicides. Four machine learning classifiers (naïve Bayes, random forests, support vector regression, elastic net penalized regression) were explored. 41.5% of Army suicides in 2004-2009 occurred among the 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.
PMCID: PMC5247428  PMID: 27431294
Army; machine learning; military; predictive modeling; risk assessment; suicide
15.  Suicide Among Soldiers: A Review of Psychosocial Risk and Protective Factors 
Psychiatry  2013;76(2):97-125.
Suicide is difficult to predict and prevent and remains a leading cause of death worldwide. Although soldiers historically have had a suicide rate well below that of the general population, the suicide rate among members of the U.S. Army has increased markedly over the past several years and now exceeds that of the general population. This paper reviews psychosocial factors known to be associated with the increased risk of suicidal behavior in general and describes how some of these factors may be especially important in understanding suicide among soldiers. Moving forward, the prevention of suicide requires additional research aimed at: (a) better describing when, where, and among whom suicidal behavior occurs, (b) using exploratory studies to discover new risk and protective factors, (c) developing new methods of predicting suicidal behavior that synthesize information about modifiable risk and protective factors from multiple domains, and (d) understanding the mechanisms and pathways through which suicidal behavior develops. Although the scope and severity of this problem is daunting, the increasing attention and dedication to this issue by the Armed Forces, scientists, and society provide hope for our ability to better predict and prevent these tragic outcomes in the future.
PMCID: PMC4060831  PMID: 23631542
16.  Prospective Longitudinal Evaluation of the Effect of Deployment-Acquired Traumatic Brain Injury on Posttraumatic Stress and Related Disorders: Results From the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) 
The American journal of psychiatry  2015;172(11):1101-1111.
Traumatic brain injury (TBI) is increasingly recognized as a risk factor for deleterious mental health and functional outcomes. The purpose of this study was to examine the strength and specificity of the association between deployment-acquired TBI and subsequent posttraumatic stress and related disorders among U.S. Army personnel.
A prospective, longitudinal survey of soldiers in three Brigade Combat Teams was conducted 1–2 months prior to an average 10-month deployment to Afghanistan (T0), upon redeployment to the United States (T1), approximately 3 months later (T2), and approximately 9 months later (T3). Outcomes of interest were 30-day prevalence postdeployment of posttraumatic stress disorder (PTSD), major depressive episode, generalized anxiety disorder, and suicidality, as well as presence and severity of postdeployment PTSD symptoms.
Complete information was available for 4,645 soldiers. Approximately one in five soldiers reported exposure to mild (18.0%) or more-than-mild (1.2%) TBI(s) during the index deployment. Even after adjusting for other risk factors (e.g., predeployment mental health status, severity of deployment stress, prior TBI history), deployment-acquired TBI was associated with elevated adjusted odds of PTSD and generalized anxiety disorder at T2 and T3 and of major depressive episode at T2. Suicidality risk at T2 appeared similarly elevated, but this association did not reach statistical significance.
The findings highlight the importance of surveillance efforts to identify soldiers who have sustained TBIs and are therefore at risk for an array of postdeployment adverse mental health outcomes, including but not limited to PTSD. The mechanism(s) accounting for these associations need to be elucidated to inform development of effective preventive and early intervention programs.
PMCID: PMC5125442  PMID: 26337036
Depression and anxiety  2014;32(1):3-12.
The prevalence of suicide among U.S. Army soldiers has risen dramatically in recent years. Prior studies suggest that most soldiers with suicidal behaviors (i.e., ideation, plans, and attempts) had first onsets prior to enlistment. However, those data are based on retrospective self-reports of soldiers later in their Army careers. Unbiased examination of this issue requires investigation of suicidality among new soldiers.
The New Soldier Study (NSS) of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) used fully structured self-administered measures to estimate preenlistment histories of suicide ideation, plans, and attempts among new soldiers reporting for Basic Combat Training in 2011–2012. Survival models examined sociodemographic correlates of each suicidal outcome.
Lifetime prevalence estimates of preenlistment suicide ideation, plans, and attempts were 14.1, 2.3, and 1.9%, respectively. Most reported onsets of suicide plans and attempts (73.3–81.5%) occurred within the first year after onset of ideation. Odds of these lifetime suicidal behaviors among new soldiers were positively, but weakly associated with being female, unmarried, religion other than Protestant or Catholic, and a race/ethnicity other than non-Hispanic White, non-Hispanic Black, or Hispanic.
Lifetime prevalence estimates of suicidal behaviors among new soldiers are consistent with retrospective reports of preenlistment prevalence obtained from soldiers later in their Army careers. Given that prior suicidal behaviors are among the strongest predictors of later suicides, consideration should be given to developing methods of obtaining valid reports of preenlistment suicidality from new soldiers to facilitate targeting of preventive interventions.
PMCID: PMC5113817  PMID: 25338964
military personnel; prevalence; suicide; suicide ideation; suicide attempt
18.  Lifetime Prevalence of DSM-IV Mental Disorders Among New Soldiers in the U.S. Army: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) 
Depression and anxiety  2014;32(1):13-24.
The prevalence of 30-day mental disorders with retrospectively-reported early onsets is significantly higher in the U.S. Army than among socio-demographically matched civilians. This difference could reflect high prevalence of pre-enlistment disorders and/or high persistence of these disorders in the context of the stresses associated with military service. These alternatives can to some extent be distinguished by estimating lifetime disorder prevalence among new Army recruits.
The New Soldier Study (NSS) in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) used fully-structured measures to estimate lifetime prevalence of 10 DSM-IV disorders in new soldiers reporting for Basic Combat Training in 2011-2012 (n=38,507). Prevalence was compared to estimates from a matched civilian sample. Multivariate regression models examined socio-demographic correlates of disorder prevalence and persistence among new soldiers.
Lifetime prevalence of having at least one internalizing, externalizing, or either type of disorder did not differ significantly between new soldiers and civilians, although three specific disorders (generalized anxiety, posttraumatic stress, and conduct disorders) and multi-morbidity were significantly more common among new soldiers than civilians. Although several socio-demographic characteristics were significantly associated with disorder prevalence and persistence, these associations were uniformly weak.
New soldiers differ somewhat, but not consistently, from civilians in lifetime pre-enlistment mental disorders. This suggests that prior findings of higher prevalence of current disorders with pre-enlistment onsets among soldiers than civilians are likely due primarily to a more persistent course of early-onset disorders in the context of the special stresses experienced by Army personnel.
PMCID: PMC5111824  PMID: 25338841
military personnel; mental disorders; prevalence; epidemiology; demographics
19.  Predicting Suicide Attempts in Depressed Adolescents: Clarifying the Role of Disinhibition and Childhood Sexual Abuse 
Suicide is the second leading cause of death among adolescents, and depressed youth are six times more likely to make suicide attempts as compared to non-depressed adolescents. The present study examined the unique and interactive effects of two well-established correlates of suicidality – childhood sexual abuse (CSA) and disinhibition – in predicting suicide attempts among depressed adolescents.
Participants were 163 adolescents (125 females) aged 13 to 18 (M = 15.60, SD = 1.27) diagnosed with Major Depressive Disorder (n = 95, 58.3%) and/or Dysthymia (n = 69, 42.3%) recruited from an acute residential treatment service. Participants completed interviews assessing psychopathology and suicidality, self-report measures of depressive symptoms and CSA, and a computerized disinhibition task.
Consistent with hypotheses, CSA moderated the association between disinhibition and adolescents' report of their past year and lifetime suicide attempts. Specifically, higher disinhibition was associated with a greater likelihood of having made a suicide attempt among adolescents with a history of CSA, but not among those without. The same pattern of results held in analyses of suicide attempt frequency.
Primary findings were based on observational, cross-sectional data, and therefore, causal relationships cannot be inferred. The gender imbalance in the sample precluded stratifying our analyses by gender. CSA was ascertained by self-report; replication of the results with more objective measures is warranted.
Our findings indicate that CSA and disinhibition may work together to predict elevated suicide risk, and these results have implications for early identification efforts in youth at high risk for suicide.
PMCID: PMC4587293  PMID: 26318268
adolescence; impulsivity; depression; suicide; child sexual abuse
20.  Measurement of Latent Cognitive Abilities Involved in Concept Identification Learning 
We used cognitive and psychometric modeling techniques to evaluate the construct validity and measurement precision of latent cognitive abilities measured by a test of concept identification learning: the Penn Conditional Exclusion Test (PCET).
Item response theory parameters were embedded within classic associative- and hypothesis-based Markov learning models and fitted to 35,553 Army soldiers' PCET data from the Army Study To Assess Risk and Resilience in Servicemembers (Army STARRS).
Data were consistent with a hypothesis-testing model with multiple latent abilities— abstraction and set shifting. Latent abstraction ability was positively correlated with number of concepts learned, and latent set shifting ability was negatively correlated with number of perseverative errors, supporting the construct validity of the two parameters. Abstraction was most precisely assessed for participants with abilities ranging from one-and-a-half standard deviations below the mean to the mean itself. Measurement of set shifting was acceptably precise only for participants making a high number of perseverative errors.
The PCET precisely measures latent abstraction ability in the Army STARRS sample, especially within the range of mildly impaired to average ability. This precision pattern is ideal for a test developed to measure cognitive impairment as opposed to cognitive strength. The PCET also measures latent set shifting ability, but reliable assessment is limited to the impaired range of ability reflecting that perseverative errors are rare among cognitively healthy adults. Integrating cognitive and psychometric models can provide information about construct validity and measurement precision within a single analytical framework.
PMCID: PMC5104340  PMID: 26147832
Concept Identification Learning; Penn Conditional Exclusion Test; Latent Variable Measurement; Army STARRS; Item Response Theory; Neuropsychology
21.  Twelve-Month Suicidal Symptoms and Use of Services Among Adolescents: Results From the National Comorbidity Survey 
The study assessed the prevalence of suicidal ideation, suicide plans, and suicide attempts as well as patterns of mental health service use among adolescents.
Data came from the National Comorbidity Survey–Adolescent Supplement, a nationally representative sample of 10,123 adolescents aged 13 to 18 years who participated in computer-assisted, face-to-face interviews between February 2001 and January 2004. Prevalences of suicidal thoughts and behaviors in the past year were determined. Past-year use of any mental health treatment and receipt of four or more visits from one provider among youths with suicidal ideation, plans, or attempts were also assessed. Associations were evaluated by using logistic regression.
During the course of 12 months, 3.6% of adolescents reported suicidal ideation without a plan or attempt, .6% reported a suicide plan without an attempt, and 1.9% made a suicide attempt. Overall, two-thirds of adolescents with suicidal ideation (67.3%) and half of those with a plan (54.4%) or attempt (56.9%) did not have any contact with a mental health specialist in the past year. Different predictors of use of care were identified for each group.
Adolescent suicidality often is untreated in the United States. Increased outreach efforts to improve treatment access for youths with suicidal ideation and attempts are needed.
PMCID: PMC5100004  PMID: 22910768
22.  Improving the Prediction of Suicidal Behavior in Youth 
Suicidal behaviors increase dramatically during adolescence. In order to effectively intervene and ultimately prevent suicide in youth, the field needs to be able to identify and predict which adolescents are at greatest suicide risk. However, present knowledge of risk factors for suicide and techniques for identifying at-risk youth are insufficient. The purpose of the current manuscript is to highlight some of the key, yet unanswered, questions about the prediction of suicidal behavior in youth, and to suggest the types of research advances needed to move the field forward.
PMCID: PMC4557617  PMID: 23850053
suicide; suicide attempt; suicide risk; adolescence; prediction
23.  Early onset alcohol use and self-harm: A discordant twin analysis 
Self-harm has considerable societal and economic costs and has been extensively studied in relation to alcohol involvement. Whereas early onset alcohol use (EAU) has been causally linked to maladaptive clinical outcomes, its association with self-harm is less well characterized. The current study aimed to further examine the link between EAU and both non-suicidal self-injury (NSSI) and suicide attempt (SA), and elucidate shared familial and causal/individual-specific pathways that explain this co-occurrence.
Using data from 6,082 Australian same-sex twin pairs (1,732 MZ and 1,309 DZ), ages 23-40, we examined prevalence rates of NSSI and SA among twin pairs concordant and discordant for EAU. Conditional logistic regression, controlling for early clinical covariates and the influence of zygosity on EAU, was used to examine the odds ratio (OR) of self-harm within twin pairs discordant for EAU.
Prevalence rates of both NSSI and SA were highest among twin pairs concordant for EAU and for twins who reported EAU within discordant twin pairs. Results from discordant twin analyses revealed nearly four-fold increased odds of SA for the twin who endorsed EAU, and this OR was equal across monozygotic (MZ) and dizygotic (DZ) twins. EAU also was associated with elevated odds of NSSI (OR=7.62), although this was only the case for DZ twins in discordant pairs.
The equivalent increase in odds of SA for both MZ and DZ twins suggests that causal or individual-specific influences explain the link between EAU and SA. For NSSI, elevated odds for DZ twins and nonsignificant findings for MZ twins implicate correlated genetic factors in the association between EAU and NSSI. Future studies should test mechanisms through which EAU may causally influence SA, as well as examine whether genetic risk for third variables (e.g., negative urgency, stress reactivity) may explain the genetic overlap between EAU and NSSI.
PMCID: PMC4729363  PMID: 26463647
24.  Mental health treatment among soldiers with current mental disorders in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) 
Military medicine  2015;180(10):1041-1051.
A representative sample of 5,428 non-deployed Regular Army soldiers completed a self-administered questionnaire (SAQ) and consented to linking SAQ data with administrative records as part of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). The SAQ included information about prevalence and treatment of mental disorders among respondents with current DSM-IV internalizing (anxiety, mood) and externalizing (disruptive behavior, substance) disorders. 21.3% of soldiers with any current disorder reported current treatment. Seven significant predictors of being in treatment rates were identified. Four of these 7 were indicators of psychopathology (bipolar disorder, panic disorder, PTSD, 8+ months duration of disorder). Two were socio-demographics (history of marriage, not being Non-Hispanic Black). The final predictor was history of deployment. Treatment rates varied between 4.7 and 71.5% depending on how many positive predictors the soldier had. The vast majority of soldiers had a low number of these predictors. These results document that most non-deployed soldiers with mental disorders are not in treatment and that untreated soldiers are not concentrated in a particular segment of the population that might be targeted for special outreach efforts. Analysis of modifiable barriers to treatment is needed to help strengthen outreach efforts.
PMCID: PMC4602390  PMID: 26444466
mental health; treatment; military; barriers
25.  Thirty-Day Prevalence of DSM-IV Mental Disorders Among Nondeployed Soldiers in the US Army 
JAMA psychiatry  2014;71(5):504-513.
Although high rates of current mental disorder are known to exist in the US Army, little is known about the proportions of these disorders that had onsets prior to enlistment.
To estimate the proportions of 30-day DSM-IV mental disorders among nondeployed US Army personnel with first onsets prior to enlistment and the extent which role impairments associated with 30-day disorders differ depending on whether the disorders had pre-vs post-enlistment onsets.
A representative sample of 5428 soldiers participating in the Army Study to Assess Risk and Resilience in Servicemembers completed self-administered questionnaires and consented to linkage of questionnaire responses with administrative records.
Thirty-day DSM-IV internalizing (major depressive, bipolar, generalized anxiety, panic, and posttraumatic stress) and externalizing (attention-deficit/ hyperactivity, intermittent explosive, alcohol/drug) disorders were assessed with validated self-report scales. Age at onset was assessed retrospectively. Role impairment was assessed with a modified Sheehan Disability Scale.
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). Also, 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 (χ82=131.8, P < .001) and post-enlistment (χ72=123.8, P < .001) ages at onset both significantly predicted severe role impairment, although pre-enlistment disorders were more consistent powerful predictors (7 of 8 disorders significant; odds ratios, 1.6–11.4) than post-enlistment disorders (5 of 7 disorders significant; odds ratios, 1.5–7.7). Population-attributable risk proportions of severe role impairment were 21.7% for pre-enlistment disorders, 24.3% for post-enlistment disorders, and 43.4% for all disorders.
Interventions to limit accession or increase resilience of new soldiers with pre-enlistment mental disorders might reduce prevalence and impairments of mental disorders in the US Army.
PMCID: PMC4057988  PMID: 24590120

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