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1.  Posttraumatic Stress Disorder and Community Collective Efficacy following the 2004 Florida Hurricanes 
PLoS ONE  2014;9(2):e88467.
There is a paucity of research investigating the relationship of community-level characteristics such as collective efficacy and posttraumatic stress following disasters. We examine the association of collective efficacy with probable posttraumatic stress disorder and posttraumatic stress disorder symptom severity in Florida public health workers (n = 2249) exposed to the 2004 hurricane season using a multilevel approach. Anonymous questionnaires were distributed electronically to all Florida Department of Health personnel nine months after the 2004 hurricane season. The collected data were used to assess posttraumatic stress disorder and collective efficacy measured at both the individual and zip code levels. The majority of participants were female (80.42%), and ages ranged from 20 to 78 years (median = 49 years); 73.91% were European American, 13.25% were African American, and 8.65% were Hispanic. Using multi-level analysis, our data indicate that higher community-level and individual-level collective efficacy were associated with a lower likelihood of having posttraumatic stress disorder (OR = 0.93, CI = 0.88–0.98; and OR = 0.94, CI = 0.92–0.97, respectively), even after adjusting for individual sociodemographic variables, community socioeconomic characteristic variables, individual injury/damage, and community storm damage. Higher levels of community-level collective efficacy and individual-level collective efficacy were also associated with significantly lower posttraumatic stress disorder symptom severity (b = −0.22, p<0.01; and b = −0.17, p<0.01, respectively), after adjusting for the same covariates. Lower rates of posttraumatic stress disorder are associated with communities with higher collective efficacy. Programs enhancing community collective efficacy may be an important part of prevention practices and possibly lead to a reduction in the rate of posttraumatic stress disorder post-disaster.
PMCID: PMC3921167  PMID: 24523900
2.  Predicting Sexual Assault Perpetration in the US Army Using Administrative Data 
The Department of Defense uses a universal prevention framework for sexual assault prevention, with each branch implementing their own branch-wide programs. Intensive interventions exist, but would be cost-effective only if targeted at high-risk personnel. This study developed actuarial models to identify male U.S. Army soldiers at high risk of administratively-recorded sexual assault perpetration.
This study investigated administratively-recorded sexual assault perpetration among the 821,807 male Army soldiers serving 2004–2009. Other temporally prior administrative data were used as predictors. Penalized discrete-time (person-month) survival analysis (conducted in 2016) was used to select the smallest possible number of stable predictors to maximize number of sexual assaults among the 5% of soldiers with highest predicted risk of perpetration (top-ventile concentration of risk [COR]). Separate models were developed for assaults against non-family and intra-family adults and minors.
4,640 male soldiers were found to be perpetrators against non-family adults, 1,384 against non-family minors, 380 against intra-family adults, and 335 against intra-family minors. Top-ventile COR was 16.2–20.2% predicting perpetration against non-family adults and minors and 34.2–65.1% against intra-family adults and minors. Final predictors consisted largely of measures of prior crime involvement and the presence-treatment of mental disorders.
Administrative data can be used to develop actuarial models that identify a high proportion of sexual assault perpetrators. If a system is developed to routinely consolidate administrative predictors, predictions could be generated periodically to identify those in need of preventive intervention. Whether this would be cost-effective, though, would depend on intervention costs, effectiveness, and competing risks.
PMCID: PMC5683072  PMID: 28818420
sexual assault; perpetration; military; prediction model; risk model; violence prediction
3.  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
4.  Suicide attempts in U.S. Army combat arms, special forces and combat medics 
BMC Psychiatry  2017;17:194.
The U.S. Army suicide attempt rate increased sharply during the wars in Iraq and Afghanistan. Risk may vary according to occupation, which significantly influences the stressors that soldiers experience.
Using administrative data from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), we identified person-month records for all active duty Regular Army enlisted soldiers who had a medically documented suicide attempt from 2004 through 2009 (n = 9650) and an equal-probability sample of control person-months (n = 153,528). Logistic regression analyses examined the association of combat occupation (combat arms [CA], special forces [SF], combat medic [CM]) with suicide attempt, adjusting for socio-demographics, service-related characteristics, and prior mental health diagnosis.
In adjusted models, the odds of attempting suicide were higher in CA (OR = 1.2 [95% CI: 1.1–1.2]) and CM (OR = 1.4 [95% CI: 1.3–1.5]), but lower in SF (OR = 0.3 [95% CI: 0.2–0.5]) compared to all other occupations. CA and CM had higher odds of suicide attempt than other occupations if never deployed (ORs = 1.1–1.5) or previously deployed (ORs = 1.2–1.3), but not when currently deployed. Occupation was associated with suicide attempt in the first ten years of service, but not beyond. In the first year of service, primarily a time of training, CM had higher odds of suicide attempt than both CA (OR = 1.4 [95% CI: 1.2–1.6]) and other occupations (OR = 1.5 [95% CI: 1.3–1.7]). Discrete-time hazard functions revealed that these occupations had distinct patterns of monthly risk during the first year of service.
Military occupation can inform the understanding suicide attempt risk among soldiers.
Electronic supplementary material
The online version of this article (doi:10.1186/s12888-017-1350-y) contains supplementary material, which is available to authorized users.
PMCID: PMC5445296  PMID: 28545424
Suicide attempt; Military; Occupation
5.  A genome-wide gene-by-trauma interaction study of alcohol misuse in two independent cohorts identifies PRKG1 as a risk locus 
Molecular psychiatry  2017;10.1038/mp.2017.24.
Traumatic life experiences are associated with alcohol use problems, an association that is likely to be moderated by genetic predisposition. To understand these interactions, we conducted a gene-by-environment genome-wide interaction study (GEWIS) of alcohol use problems in two independent samples, the Army STARRS (ASTARRS, N=16,361) and the Yale-Penn (N=8,084) cohorts. Because the two cohorts were assessed using different instruments, we derived separate dimensional alcohol misuse scales and applied a proxy-phenotype study design. In African-American subjects, we identified an interaction of PRKG1 rs1729578 with trauma exposure in the ASTARRS cohort and replicated its interaction with trauma exposure in the Yale-Penn cohort (discovery-replication meta-analysis: z=5.64, p=1.69*10−8). PRKG1 encodes cGMP-dependent protein kinase 1, which is involved in learning, memory, and circadian rhythm regulation. Considering the loci identified in stage-1 that showed same effect directions in stage-2, the gene ontology (GO) enrichment analysis showed several significant results, including calcium-activated potassium channels (GO:0016286; p=2.30*10−5), cognition (GO:0050890; p=1.90*10−6), locomotion (GO:0040011; p=6.70*10−5), and Stat3 protein regulation (GO:0042517; p=6.4*10−5). To our knowledge, this is the largest GEWIS performed in psychiatric genetics, and the first GEWIS examining risk for alcohol misuse. Our results add to a growing body of literature highlighting the dynamic impact of experience on individual genetic risk.
PMCID: PMC5589475  PMID: 28265120
6.  Traits of fear resistance and susceptibility in an advanced intercross line 
The European journal of neuroscience  2013;38(9):3314-3324.
Genetic variability in the strength and precision of fear memory is hypothesized to contribute to the etiology of anxiety disorders, including post-traumatic stress disorder. We generated fear-susceptible (F-S) or fear-resistant (F-R) phenotypes from an F8 advanced intercross line (AIL) of C57BL/6J and DBA/2J inbred mice by selective breeding. We identified specific traits underlying individual variability in Pavlovian conditioned fear learning and memory. Offspring of selected lines differed in the acquisition of conditioned fear. Furthermore, F-S mice showed greater cued fear memory and generalized fear in response to a novel context than F-R mice. F-S mice showed greater basal corticosterone levels and hypothalamic corticotrophin-releasing hormone (CRH) mRNA levels than F-R mice, consistent with higher hypothalamic–pituitary–adrenal (HPA) axis drive. Hypothalamic mineralocorticoid receptor and CRH receptor 1 mRNA levels were decreased in F-S mice as compared with F-R mice. Manganese-enhanced magnetic resonance imaging (MEMRI) was used to investigate basal levels of brain activity. MEMRI identified a pattern of increased brain activity in F-S mice that was driven primarily by the hippocampus and amygdala, indicating excessive limbic circuit activity in F-S mice as compared with F-R mice. Thus, selection pressure applied to the AIL population leads to the accumulation of heritable trait-relevant characteristics within each line, whereas non-behaviorally relevant traits remain distributed. Selected lines therefore minimize false-positive associations between behavioral phenotypes and physiology. We demonstrate that intrinsic differences in HPA axis function and limbic excitability contribute to phenotypic differences in the acquisition and consolidation of associative fear memory. Identification of system-wide traits predisposing to variability in fear memory may help in the direction of more targeted and efficacious treatments for fear-related pathology.
PMCID: PMC5581004  PMID: 23968228
AIL; amygdala; fear conditioning; fear generalization; hippocampus; HPA axis; manganese-enhanced MRI
7.  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
8.  Risk Factors, Methods, and Timing of Suicide Attempts Among US Army Soldiers 
JAMA psychiatry  2016;73(7):741-749.
Suicide attempts in the US Army have risen in the past decade. Understanding the association between suicide attempts and deployment, as well as method and timing of suicide attempts, can assist in developing interventions.
To examine suicide attempt risk factors, methods, and timing among soldiers currently deployed, previously deployed, and never deployed at the time this study was conducted.
This longitudinal, retrospective cohort study of Regular Army–enlisted soldiers on active duty from 2004 through 2009 used individual-level person-month records to examine risk factors (sociodemographic, service related, and mental health), method, and time of suicide attempt by deployment status (never, currently, and previously deployed). Administrative data for the month before each of 9650 incident suicide attempts and an equal-probability sample of 153 528 control person-months for other soldiers were analyzed using a discrete-time survival framework.
Suicide attempts and career, mental health, and demographic predictors were obtained from administrative and medical records.
Of the 9650 enlisted soldiers who attempted suicide, 86.3% were male, 68.4% were younger than 30 years, 59.8% were non-Hispanic white, 76.5%were high school educated, and 54.7% were currently married. The 40.4% of enlisted soldiers who had never been deployed (n = 12 421 294 person-months) accounted for 61.1% of enlisted soldiers who attempted suicide (n = 5894 cases). Risk among those never deployed was highest in the second month of service (103 per 100 000 person-months). Risk among soldiers on their first deployment was highest in the sixth month of deployment (25 per 100 000 person-months). For those previously deployed, risk was highest at 5 months after return (40 per 100 000 person-months). Currently and previously deployed soldiers were more likely to attempt suicide with a firearm than those never deployed (currently deployed: OR, 4.0; 95% CI, 2.9–5.6; previously deployed: OR, 2.7; 95% CI, 1.8–3.9). Across deployment status, suicide attempts were more likely among soldiers who were women (currently deployed: OR, 3.4; 95% CI, 3.0–4.0; previously deployed: OR, 1.5; 95% CI, 1.4–1.7; and never deployed: OR, 2.4; 95% CI, 2.3–2.6), in their first 2 years of service (currently deployed: OR, 1.9; 95% CI, 1.5–2.3; previously deployed: OR, 2.2; 95% CI, 1.9–2.7; and never deployed: OR, 3.1; 95% CI, 2.7–3.6), and had a recently received a mental health diagnosis in the previous month (currently deployed: OR, 29.8; 95% CI, 25.0–35.5; previously deployed: OR, 22.2; 95% CI, 20.1–24.4; and never deployed: OR, 15.0; 95% CI, 14.2–16.0). Among soldiers with 1 previous deployment, odds of a suicide attempt were higher for those who screened positive for depression or posttraumatic stress disorder after return from deployment and particularly at follow-up screening, about 4 to 6 months after deployment (depression: OR, 1.4; 95% CI, 1.1–1.9; posttraumatic stress disorder: OR, 2.4; 95% CI, 2.1–2.8).
Identifying the timing and risk factors for suicide attempt in soldiers requires consideration of environmental context, individual characteristics, and mental health. These factors can inform prevention efforts.
PMCID: PMC4937827  PMID: 27224848
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
10.  Incidence of and Risk for Posttraumatic Stress Disorder and Depression in a Representative Sample of U.S. Reserve and National Guard 
Annals of epidemiology  2016;26(3):189-197.
We aim to determine the incidence rates (IR) of first ever PTSD and depression in a population-based cohort of US Reserve and National Guard service members.
We used data from the US Reserve and National Guard Study (N = 2003) to annually investigate incident and recurrent PTSD and depression symptoms from 2010 to 2013. We estimated the IR and recurrence rate over 4 years and according to several sociodemographic and military characteristics.
From 2010 to 2013, incidence rates were 4.7 per 100 person-years for both PTSD and depression symptoms using the sensitive criteria, 2.9 per 100 person-years using the more specific criteria, recurrence rates for both PTSD and depression were more than 4 times as high as IRs, and IRs were higher among those with past-year civilian trauma, but not past-year deployment.
The finding that civilian trauma, but not past-year military deployment, is associated with an increased risk of PTSD and depression incidence suggest that RNG psychopathology could be driven by other, non-military, traumatic experiences.
PMCID: PMC4799730  PMID: 26907538
Stress Disorder; Post-traumatic; Stress; Psychological; Depression; Mental Disorders; Incidence; Military Personnel; Cohort Studies; Prospective Studies
11.  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
12.  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
13.  Suicide Attempts in the United States Army 
JAMA psychiatry  2015;72(9):917-926.
The U.S. Army suicide attempt rate increased sharply during the wars in Afghanistan and Iraq. Comprehensive research on this important health outcome has been hampered by a lack of integration among Army administrative data systems.
To identify risk factors for Regular Army suicide attempts during the years 2004–2009 using data from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).
Design, Setting, and Participants
There were 9,791 medically documented suicide attempts among Regular Army soldiers during the study period. Individual-level person-month records from Army and Department of Defense administrative data systems were analyzed to identify socio-demographic, service-related, and mental health risk factors distinguishing suicide attempt cases from an equal-probability control sample of 183,826 person-months.
Main Outcome and Measures
Suicide attempts were identified using Department of Defense Suicide Event Report records and ICD-9 E95x diagnostic codes. Predictor variables were constructed from Army personnel and medical records.
Enlisted soldiers accounted for 98.6% of all suicide attempts, with an overall rate of 377/100,000 person-years, versus 27.9/100,000 person-years for officers. Significant multivariate predictors among enlisted soldiers included socio-demographic characteristics (female gender, older age at Army entry, younger current age, low education, non-hispanic white), short length of service, never or previously deployed, and the presence and recency of mental health diagnoses. Among officers, only socio-demographic characteristics (female gender, older age at Army entry, younger current age, and low education) and the presence and recency of mental health diagnoses were significant.
Conclusions and Relevance
Results represent the most comprehensive accounting of U.S. Army suicide attempts to date and reveal unique risk profiles for enlisted soldiers and officers, and highlighting the importance of focusing research and prevention efforts on enlisted soldiers in their first tour of duty.
PMCID: PMC4558209  PMID: 26154106
14.  Approximating a DSM-5 Diagnosis of PTSD Using DSM-IV Criteria 
Depression and anxiety  2015;32(7):493-501.
Diagnostic criteria for DSM-5 posttraumatic stress disorder (PTSD) are in many ways similar to DSM-IV criteria, raising the possibility that it might be possible to closely approximate DSM-5 diagnoses using DSM-IV symptoms. If so, the resulting transformation rules could be used to pool research data based on the two criteria sets.
The Pre-Post Deployment Study (PPDS) of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) administered a blended 30-day DSM-IV and DSM-5 PTSD symptom assessment based on the civilian PTSD Checklist for DSM-IV (PCL-C) and the PTSD Checklist for DSM-5 (PCL-5). This assessment was completed by 9,193 soldiers from three US Army Brigade Combat Teams approximately three months after returning from Afghanistan. PCL-C items were used to operationalize conservative and broad approximations of DSM-5 PTSD diagnoses. The operating characteristics of these approximations were examined compared to diagnoses based on actual DSM-5 criteria.
The estimated 30-day prevalence of DSM-5 PTSD based on conservative (4.3%) and broad (4.7%) approximations of DSM-5 criteria using DSM-IV symptom assessments were similar to estimates based on actual DSM-5 criteria (4.6%). Both approximations had excellent sensitivity (92.6-95.5%), specificity (99.6-99.9%), total classification accuracy (99.4-99.6%), and area under the receiver operating characteristic curve (0.96-0.98).
DSM-IV symptoms can be used to approximate DSM-5 diagnoses of PTSD among recently-deployed soldiers, making it possible to recode symptom-level data from earlier DSM-IV studies to draw inferences about DSM-5 PTSD. However, replication is needed in broader trauma-exposed samples to evaluate the external validity of this finding.
PMCID: PMC4490033  PMID: 25845710
PTSD/posttraumatic stress disorder; Assessment/Diagnosis; Anxiety/Anxiety disorders; measurement/psychometrics; trauma
15.  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
16.  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
17.  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
18.  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
19.  Nonfatal Suicidal Behaviors in U.S. Army Administrative Records, 2004–2009: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) 
Psychiatry  2015;78(1):1-21.
Although the U.S. Army suicide rate is known to have risen sharply over the past decade, information about medically documented, nonfatal suicidal behaviors is far more limited. Here we examine trends and sociodemographic correlates of suicide attempts, suspicious injuries, and suicide ideation among regular Army soldiers.
Data come from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) Historical Administrative Data Study (HADS), which integrates administrative records for all soldiers on active duty during the years 2004 through 2009 (n = 1.66 million).
We identified 21,740 unique regular Army soldiers with a nonfatal suicidal event documented at some point during the HADS study period. There were substantial increases in the annual incidence rates of suicide attempts (179–400/100,000 person-years) and suicide ideation (557–830/100,000 person-years), but not suspicious injuries. Using hierarchical classification rules to identify the first instance of each soldier's most severe behavior, we found increased risk of all outcomes among those who were female, non-Hispanic White, never married, lower-ranking enlisted, less educated, and of younger age when entering Army service. These sociodemographic associations significantly differed across outcomes, despite some patterns that appear similar.
Results provide a broad overview of nonfatal suicidal trends in the U.S. Army during 2004 through 2009 and demonstrate that integration of multiple administrative data systems enriches analysis of the predictors of such events.
PMCID: PMC4503376  PMID: 26168022
20.  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
21.  Risk Factors for Accident Death in the U.S. Army, 2004–2009 
Accidents are one of the leading causes of death among U.S. active duty Army soldiers. Evidence-based approaches to injury prevention could be strengthened by adding person-level characteristics (e.g., demographics) to risk models tested on diverse soldier samples studied over time.
To identify person-level risk indicators of accident deaths in Regular Army soldiers during a time frame of intense military operations, and to discriminate risk of not-line-of-duty (NLOD) from line-of-duty (LOD) accident deaths.
Administrative data acquired from multiple Army/Department of Defense sources for active duty Army soldiers during 2004–2009 were analyzed in 2013. Logistic regression modeling was used to identify person-level sociodemographic, service-related, occupational, and mental health predictors of accident deaths.
Delayed rank progression or demotion and being male, unmarried, in a combat arms specialty, and of low rank/service length increased odds of accident death for enlisted soldiers. Unique to officers was high risk associated with aviation specialties. Accident death risk decreased over time for currently deployed, enlisted soldiers while increasing for those never deployed. Mental health diagnosis was associated with risk only for previous and never-deployed, enlisted soldiers. Models did not discriminate NLOD from LOD accident deaths.
Adding more refined person-level and situational risk indicators to current models could enhance understanding of accident death risk specific to soldier rank and deployment status. Stable predictors could help identify high risk of accident deaths in future cohorts of Regular Army soldiers.
PMCID: PMC4254526  PMID: 25441238
22.  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
23.  Predictors of Suicide and Accident Death in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) 
JAMA psychiatry  2014;71(5):493-503.
The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multicomponent study designed to generate actionable recommendations to reduce Army suicides and increase knowledge of risk and resilience factors for suicidality.
To present data on prevalence, trends, and basic sociodemographic and Army experience correlates of suicides and accident deaths among active duty Regular Army soldiers between January 1, 2004, and December 31, 2009, and thereby establish a foundation for future Army STARRS investigations.
Analysis of trends and predictors of suicide and accident deaths using Army and Department of Defense administrative data systems. Participants were all members of the US Regular Army serving at any time between 2004 and 2009.
Death by suicide or accident during active Army service.
The suicide rate rose between 2004 and 2009 among never deployed and currently and previously deployed Regular Army soldiers. The accident death rate fell sharply among currently deployed soldiers, remained constant among the previously deployed, and trended upward among the never deployed. Increased suicide risk was associated with being a man (or a woman during deployment), white race/ethnicity, junior enlisted rank, recent demotion, and current or previous deployment. Sociodemographic and Army experience predictors were generally similar for suicides and accident deaths. Time trends in these predictors and in the Army’s increased use of accession waivers (which relaxed some qualifications for new soldiers) do not explain the rise in Army suicides.
Predictors of Army suicides were largely similar to those reported elsewhere for civilians, although some predictors distinct to Army service emerged that deserve more in-depth analysis. The existence of a time trend in suicide risk among never-deployed soldiers argues indirectly against the view that exposure to combat-related trauma is the exclusive cause of the increase in Army suicides.
PMCID: PMC4124912  PMID: 24590048
24.  Classifying U.S. Army Military Occupational Specialties Using the Occupational Information Network 
Military medicine  2014;179(7):752-761.
To derive job condition scales for future studies of the effects of job conditions on soldier health and job functioning across Army Military Occupation Specialties (MOSs) and Areas of Concentration (AOCs) using Department of Labor (DoL) Occupational Information Network (O*NET) ratings.
A consolidated administrative dataset was created for the “Army Study to Assess Risk and Resilience in Servicemembers” (Army STARRS) containing all soldiers on active duty between 2004 and 2009. A crosswalk between civilian occupations and MOS/AOCs (created by DoL and the Defense Manpower Data Center) was augmented to assign scores on all 246 O*NET dimensions to each soldier in the dataset. Principal components analysis was used to summarize these dimensions.
Three correlated components explained the majority of O*NET dimension variance: “physical demands” (20.9% of variance), “interpersonal complexity” (17.5%), and “substantive complexity” (15.0%). Although broadly consistent with civilian studies, several discrepancies were found with civilian results reflecting potentially important differences in the structure of job conditions in the Army versus the civilian labor force.
Principal components scores for these scales provide a parsimonious characterization of key job conditions that can be used in future studies of the effects of MOS/AOC job conditions on diverse outcomes.
PMCID: PMC4764059  PMID: 25003860
25.  Predicting U.S. Army suicides after hospitalizations with psychiatric diagnoses in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) 
JAMA psychiatry  2015;72(1):49-57.
The U.S. Army experienced a sharp rise in suicides beginning in 2004. Administrative data show that among those at highest risk are soldiers in the 12 months after inpatient treatment of a psychiatric disorder.
To develop an actuarial risk algorithm predicting suicide in the 12 months after US Army soldier inpatient treatment of a psychiatric disorder to target expanded post-hospital care.
There were 53,769 hospitalizations of active duty soldiers in 2004–2009 with ICD-9-CM psychiatric admission diagnoses. Administrative data available prior to hospital discharge abstracted from a wide range of data systems (socio81 demographic, Army career, criminal justice, medical/pharmacy) were used to predict suicides in the subsequent 12 months using machine learning methods (regression trees, penalized regressions) designed to evaluate cross-validated linear, nonlinear, and interactive predictive associations.
Suicides of soldiers hospitalized with psychiatric disorders in the 12 months after hospital discharge.
68 soldiers died by suicide within 12 months of hospital discharge (12.0% of all Army suicides), equivalent to 263.9 suicides/100,000 person-years compared to 18.5 suicides/100,000 person-years in the total Army. Strongest predictors included socio-demographics (male, late age of enlistment), criminal offenses (verbal violence, weapons possession), prior suicidality, aspects of prior psychiatric inpatient and outpatient treatment, and disorders diagnosed during the focal hospitalizations. 52.9% of post-hospital suicides occurred after the 5% of hospitalizations with highest predicted suicide risk (3,824.1 suicides/100,000 person years). These highest-risk hospitalizations also accounted for significantly elevated proportions of several other adverse post-hospital outcomes (unintentional injury deaths, suicide attempts, re-hospitalizations).
The high concentration of risk of suicides and other adverse outcomes might justify targeting expanded post-hospital interventions to soldiers classified as having highest post-hospital suicide risk, although final determination requires careful consideration of intervention costs, comparative effectiveness, and possible adverse effects.
PMCID: PMC4286426  PMID: 25390793
Army; machine learning; elastic net regression; military; penalized regression; predictive modeling; risk assessment; suicide

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