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PTSD, Suicide, TBI… DSM5 “and Other Trauma Disorders”:
Complex Clinical Care
Robert J. Ursano, M.D.
Professor of Psychiatry and NeuroscienceDirector
Center for the Study of Traumatic StressDept of Psychiatry
Uniformed Services University
“Its bigger than friendship”b hofstede
“Our biology gives us our brain….Our life turns it into our mind “
j eugenides
Our Challenge to knowing how to help..
NBC 2005
Trauma and Disasters
Human Made Natural
War
Terrorism
Hurricane
Epidemic
Industrial Accident
Mental Health Responses to Trauma, Disasters and Public Health Emergencies:
Resilience is most common
Psychiatric Illness
• PTSD• Depression• Complex Grief
Health Risk Behaviors
Distress Responses
• Sense of vulnerability• Change in Sleep • Irritability, distraction•Belief in Exposure•MUPS/MIPS•Isolation
• Smoking• Alcohol• Over dedication
Percent Screening Positive for PTSD by Number of Firefights
0
5
10
15
20
25
0 1 to 2 3 to 5 6 to 9 10+
Hoge, et. al., NEJM July 2004
[%]
Trajectories of PTSD After InjuryN=1084 hospitalized >24hrs
Bryant et al BJP 2015
DSM 5 Key PointsChapters
• Anxiety Disorders
• Obsessive Compulsive and Related Disorders
• Trauma and Stressor-Related Disorders• Dissociative Disorders
?? OTHER:…DSM 5 Persistent Complex Bereavement
Disorder
• One of the “Conditions for Further Study”
• Potential clinical need for the category
• Inclusion in the Appendix to facilitate research
• Substantial empirical evidence, but there remain concerns that need resolution (e.g. Onset > 12 months after death of loved one)
• Considerations of benefit vs. potential harm of the Dx
Cozza et al. 2017
Bereaved Military Children2001-2011
OTHER AGAIN??...U.S. Army Child Neglect Rates Age 1-2 year olds,
1989-2004
0
1
2
3
4
5
6
7
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
Years
Ra
te p
er
1,0
00
1 to 2 Years
McCarroll J et al CSTS USU, 2005
Center for the Study of Traumatic Stress
http://www.centerforthestudyoftraumaticstress.org
What is PTSD?
1)The inability to “digest” early stress symptoms, e.g. impaired “repair” or “return to stasis”
2) Altered “set point”
3) The “glue” that makes the symptoms “stay” or “cluster together”
McNulty, F The Elephant who couldn’t forget., Harper and Row
Pertea & Salzberg, Science 2010
Slide 19
Genomewide Association Studies
(GWAS) of PTSD (NSS & PPDS)
• Largest GWAS of PTSD to date.
• Two genomewide significant single nucleotide polymorphisms (SNPs) were found in
association with PTSD for African American (left panel) & European American (right panel) Soldiers, respectively.
• The SNP in the African American sample is in a gene, ANKRD55, known to be associated
with a variety of inflammatory and immune disorders.
• The study also showed significant pleiotropy (i.e., genes affecting multiple traits)
between PTSD and rheumatoid arthritis and psoriasis.
• Points to a possible biological association between PTSD and these disorders, and consistent with a possible role for inflammatory processes in PTSD.
Treatment : Across The Domains of Illness
PTSD MI Mult.Scler Back Pain
Disorder The Glue
Self Repair
ICU
Symptoms Withdawal
Nightmares
Nitroglycerin
Impairment
Of Function
Marital
Job
Walker
Job Couns.
Disability Job
“phobic”
Lg Trm Plan and
Asst
Co-Morbid
Conditions
Depression
Subst Abuse
Hypertension
Hyper chol.
Trajectory- Prev
of Relapse/Chro
Acute, Chronic,
Delayed
Recoverying
Life Style
Changes
(smoking)
Lifetime Probability of Treatment Contact (USA)
DysthymicDisorder
PanicDisorder
GAD, generalized anxiety disorder.Wang PS, et al. Arch Gen Psychiatry. 2005;62:603-613.
MajorDepression
BipolarDisorder
GAD PTSD
65%
94%
86%
95%
Pat
ien
ts M
akin
g Tr
eatm
en
t Co
nta
ct, %
60
70
80
90
100
88%90%
7% contact within year of PTSD onset and12-year median delay to first treatment contact
“Other trauma disorder…”
Suicidal Thoughts and Behavior in thePast Year among Adults Aged 18 or Older:
2008
.. .
8.3 Million Adults HadSerious Thoughts ofCommitting Suicide
2.3 MillionMade
Suicide Plans
1.1 MillionAttempted
Suicide
0.9 MillionMade Plans and
AttemptedSuicide
0.2 MillionMade No Plans andAttempted Suicide
(SAMHSA, 2008)
• “One type of symptomatic behavior associated with depressions, either neurotic or psychotic in type, is suicide. Between July, 1940, and June 1946, there were 2,214 suicides in the Army, 300 of which occurred among officers.1 ….these figures represent a sharp drop during the war period from the peacetime suicide rate in the Army. 2
There was also a sharp drop in the number of suicides in the Army in World War “
Menninger, K. Psychiatry in a Troubled World. Pp. 166-167, 1948
The Past…
Suicide IdeationWHO Study: 108,664 respondents from 21 countries
A wide range of mental disorders increased the odds of experiencing suicide ideation.
But who will attempt?!
Nock M, et al WHO PLoS 2009
Slide 28
Data Collection Summary:
Soldiers, Surveys, Blood
Samples
NSS (2 sessions/Soldier) 50,000 100,000 35,000* 35,000 35,000
AAS (incl. Guard & Reserve) 34,000 34,000 - - -
AAS Kuwait (in-theater) 6,000 6,000 - - -
PPDS pre Time 0 9,000 8,000 24,000 55,000
PPDS post Time 1 10,000 8,800 17,500 57,000
PPDS post Time 2 9,000 - - -
PPDS post Time 3 (on-going) 8,000 - - -
SHOS-A 185** 600 300 600 600
SHOS-B 150** 600 - - -
* NSS blood collection was added 6 months after study began. Approx. 80% of Soldiers who were asked gave blood.
148,000
NOTE: Red Text = Estimated totals to be enrolled/collected
Approx. Number
of Soldiers
Enrolled
100,000
10,000
** Cases Only -- Controls are already counted in AAS
Approx. Number
of Surveys
Collected
Approx. Number of Blood Samples
Soldiers Who
Provided Blood
Blood Tubes
Collected
Blood Vials in
Frozen Storage
Study
APPROXIMATE TOTAL 177,000 52,000 77,000
Slide 29
New U.S. Army Soldiers
(NSS 2011-2012, N= 38237)
• At enlistment prevalence estimates:
• 14.1% reported lifetime suicidal ideation
• 2.3% reported lifetime suicide plans
• 1.9% reported lifetime suicide attempts
Ursano et al. (2015). Depression and Anxiety
Slide 30
U.S. Army
(AAS Q2–4 2011)
And for the Army as a whole….
• 13.9% reported lifetime suicidal ideation
• 5.3% reported lifetime suicide plans
• 2.4% reported lifetime suicide attempts
• More than half of the transitions from ideation to attempt occurred within a year
Nock et al. (2014). JAMA Psychiatry
Slide 31
U.S. Army Suicide Deaths
(HADS 2004-2009)
Schoenbaum et al. (2014). JAMA Psychiatry
Regular Army suicide deaths per 100,000 person-years of Active duty Army service (12-month moving average)
Slide 32
WHEN: Suicide Deaths by Time in
Service & Deployment Status
(HADS 2004-2009)
• The mean suicide rate for all soldiers, enlisted and officers: 18.5 per 100,000 person-years.
• 90.9% of Regular Army suicides were completed by enlisted soldiers.
• Currently and previously deployed enlisted soldiers in their first 4 years of service had ratesmeaningfully higher than the mean suicide rate for all soldiers (Table 1).
Gilman et al. (2014). Psychological Medicine
Slide 33
Suicide Rates(Enlisted Regular Army, 2004-2009)
Never deployed Currently deployed Previously deployed
0
5
10
15
20
25
Deployment Status
Rat
e (
Suic
ide
/10
00
00
pe
rso
n-y
ear
s)
C RUDE RATES OF SUIC ID E BY DEPLOYMENT HISTORY A MONG ENLISTED, REG ULA R A RMY SOLDIERS IN THE
A RMY STA RRS 2004–2009 HA DS
Gilman, et al. Psychological Medicine, 2014
Slide 34
Suicide Attempt Rates(Enlisted Regular Army, 2004-2009)
Never deployed Currently deployed Previously deployed
0
100
200
300
400
500
600
Deployment Status
Rat
e (
Suic
ide
Att
em
pts
/10
00
00
pe
rso
n-y
ear
s)
C RUDE RATES OF SUIC ID E ATTEMP T BY DEPLOYMENT HISTORY A MONG ENLISTED, REG ULA R A RMY SOLDIERS IN THE
A RMY STA RRS 2004 –2009 HISTORIC A L A DMINISTRATIVE DATA (HA DS)
Ursano, et al. JAMA Psychiatry, 2016
Slide 35
• 98.6% of all suicide attempt cases during 2004-2009 were enlisted soldiers.
• Overall enlisted rate: 377 per 100,000 person-years.
• Suicide attempt risk was higher for females than males (as with civilians).
• After adjusting for socio-demographic and service-related variables, risk of
suicide attempt was highest for enlisted soldiers who were:
• In their first 2 years of service.• Never or previously deployed.
• Recently diagnosed with a mental disorder (Table 2).
Suicide Attempts
(HADS 2004-2009)
1Ursano et al. (2015). JAMA Psychiatry
Slide 36
WHEN:…Suicide Attempt
Risk by
Time in Service
(HADS 2004-2009)
Ursano et al. (2015). JAMA Psychiatry
Slide 37
WHO:…Suicide Attempt (S.A.) Risk:
Combat Arms, Special Forces & Combat
Medics (HADS 2004-2009)
Overall: Combat Arms & Combat
Medics had higher odds of S.A. (1.2,
1.4), & Special Forces had lower odds
(0.3), than other MOSs. MOS associated
with S.A. in first 10 years of service, but
not beyond.
First year of service: Combat Medics
had higher odds of S.A. than Combat
Arms & other occupations.
Deployment: Combat Arms & Combat
Medics had higher odds of S.A. than
other occupations among those never
deployed and those previously
deployed. Combat Medics also had
higher odds of S.A. among deployed.
Military occupation can inform the
understanding of S.A. risk.Ursano, et al. (2017) BMC Psychiatry
Slide 38
Frequency of IEDs & Suicide
Attempts (HADS 2004-2009)
BLUF: Threat of new weapons may increase stress burden as measured by suicide attempt rate among Soldiers. Targeting risk perception & perceived preparedness, particularly early in a Soldier’s career, may improve psychological resilience & reduce suicide ris k.
• Examined association of monthly IED rates with suicide attempt risk in deployed & non-deployed for all active duty Regular Army suicide attempters (n=9,791) & equal-probability sample of control person-months (n=183,826).
• Soldiers’ suicide attempt risk increased with increasing numbers of IEDs.
• Suicide attempt was 26% more likely for each 1,000 IED increase in monthly frequency.
• Association of IED frequency with suicide attempt was greater for Soldiers in first 2 years of service than for those with 3+ years of service.
• Among Soldiers in 1st two years of service, association was constant for all 3 deployment statuses.
• Among Soldiers with 3+ years of service, association was higher for those never deployed & currently deployed, than for those previously deployed.
Ursano, et al. (2017) Military Med
Slide 39
Risk of Suicide Attempt (SA) among
Soldiers in Army Units with a History of
Suicide Attempts (HADS 2004-2009)
• SA risk increased if 1 S.A. in unit in past yr
• Odds increased with # of SAs in unit (OR=1.4 with 1 SA; OR=2.3 with 5+ SAs)
• Association true in combat arms & other MOS
• Highest risk in small units (1-40 Soldiers)
• If risk reduced to 0 SAs in unit in past yr, number of SAs would decrease 18.2%
Conclusion:
• Units with a history of SAs are important targets for preventive interventions
Study included all SAs in enlisted Regular Army Soldiers 2004-2009 (n=9,650) and an equal-probability sample of control person-months (n=153,528)
Ursano, et al. (2017) JAMA Psychiatry
Slide 40
• Hay Stacks…
Slide 41
Concentration of Risk
Slide 42
“Its bigger than friendship”b hofstede
“Our biology gives us our brain….Our life turns it into our mind “j eugenides
Our Challenge to knowing
how to help..
Back Up
…..And…
U.S. Army: Age at First
TBI (AAS Q2-4 2011)
Stein (2012) presented at ACNP Annual Meeting
New, Old and the Same
January 1945European Theater of Operations
Stein MB & McAllister TW. Am J Psychiatry 2009; 166:768-776
Relationship of Brain Regions Implicated in PTSD to Regions Vulnerable to TBI
Slide 49
Example in PPDS: TBI
At 3 months post-deployment:
• Deployment-acquired TBI was strongly associated with increased odds of past-30-day PTSD (AOR= 1.81)
• Deployment-acquired TBI was associated with risk of past-30-day major depressive episode (AOR=1.45) and generalized anxiety disorder (AOR=1.81)
• The association between deployment-acquired TBI and past-30-day suicidality did not reach the threshold for statistical significance (AOR=1.39)
At 9 months post-deployment:
• Deployment-acquired TBI was strongly associated with increased odds of past-30-day PTSD (AOR=1.48)
• Deployment-acquired TBI was associated with risk of past-30-day generalized anxiety disorder (AOR=1.81)
Suicide and TBI..?
Slide 51
Table 3: Multivariate model
predicting suicidality1
Lifetime SuicideIdeation
Lifetime Suicide Plan
Lifetime SuicideAttempt
OR [95% CI] OR [95% CI] OR [95% CI]
Antecedent TBI1 1.7 [1.4-2.0] 1.9 [1.5-2.5] 1.6 [1.2-2.2]
Antecedent TBI2 (full model) 1.4 [1.2-1.6] 1.6 [1.1-2.1] 1.3 [0.9-1.8]
1Multivariate model predicting suicidality outcomes with TBI (0,1,2) controlling for all
demographics and interaction between "not entered army yet" and "birth place";
controlling for years since ideation for outcomes among ideators
2As above and controlling for mental disorders
Slide 52
U.S. Army: Age at First
TBI (AAS Q2-4 2011)
Stein (2012) presented at ACNP Annual Meeting
Slide 53
Suicide Attempt Risk
among Regular Army Enlisted Soldiers
(HADS 2004-2009)
0
50
100
Rat
e P
er
10
0,0
00
Sold
iers
With and Without PTSD Sxs Fol 1st
Deployment (Hazard Rates)
No PTSD Symptoms
Months Since 1st Deployment
Slide 54
Method of Suicide Attempt
By Deployment Status
(HADS 2004-2009, Regular Enlisted Army)
0
5
10
15
20
25
Never Current Previous
Deployment Status
Rat
e O
f Su
icid
Att
em
pt P
er 1
00,
000
Method of Suicide Attempt: Firearm (Crude Yearly Rate)
0
100
200
300
400
500
600
Never Current Previous
Deployment Status
Rat
e O
f Su
icid
Att
em
pt P
er 1
00,
000
Method of Suicide Attempt: Other (Crude Yearly Rate)
US Army
•Lifetime suicide ideation 13.8%
•Lifetime suicide plan 5.5%
•Lifetime suicide attempt 2.7%
Slide 56
Severity of TBI*
Mild: (Concussion)
Altered/loss of consciousness < 30 minutes
Post traumatic amnesia < 24 hours
Normal CT/MRI
Moderate:
Altered/loss of consciousness < 6 hours
Post traumatic amnesia < 7 days
Severe:
Altered/loss of consciousness > 6 hours
Post traumatic amnesia > 7 days*American Congress of Rehabilitation Medicine (ACRM)
Slide 57
Table 1: Traumatic Brain Injuries (TBI)
among AAS Q2-Q4 CONUS Soldiers (N=5428)
Traumatic Brain Injury(TBI)
Ever Happened
Multiple Occurrences (2+ times)
(Among 'Ever Happened’)
Before Army (Among 'Ever Happened’)
% SE % SE % SE
Knocked out < 30min 29.7 0.7 53.9 2.1 . .30min-<=24 hrs 5.8 0.4 27.9 2.6 . .
> 24 hours 1.0 0.2 38.1 4.3 . .
Knocked out for any time 31.0 0.8 54.6 1.7 78.7 1.2Dazed or confused 54.3 0.9 76.5 1.3 73.2 1.1Either knocked out or dazed 58.7 0.8 80.6 1.0 78.2 0.9
Suicidal Thoughts in the Past Year amongAdults Aged 18 or Older, by Age and
Gender: 2008
0
1
2
3
4
5
6
7
8
18 or Older 18 to 25 26 to 49 50 or Older Male Female
Age Group Gender
Perc
ent w
ith
Seri
ous
Tho
ught
s o
fSu
icid
e in
the
Pas
t Ye
ar
3.7
6.7
3.9
2.3
3.43.9
(SAMHSA, 2008)
Slide 59
U.S. Army
(AAS Q2–4 2011)
• Among the 13.9% of Soldiers who reported lifetime suicide ideation:
– 38.5% of ideators had developed suicide plans.
– 17.1% of ideators had made a suicide attempt.
– 34.4% of ideators with plans had made suicide attempts.
– Only 6.3% of ideators without plans had made attempts.
• Analysis of age-at-onset indicated the importance of the past year:
– Within 1 year of the onset of suicide ideation:
62.4% of the transitions from ideation to plans occurred.
58.3% of the transitions from ideation to attempts occurred.
– Within 1 year of the onset of suicide plans:
63.3% of transitions from plans to attempts occurred.
Nock et al. (2014). JAMA Psychiatry
Slide 60
Lifetime Past 30 Days
Suicide Ideation
13.5%
(n=6,192)
1.1%
(n=473)
Suicide Plan
2.7%
(n=1,234)
0.1%
(n=42)
Suicide Attempt
1.9%
(n=878)
0.1%
(n=58)
Suicidal Thoughts/Behaviors
among New Soldiers:
New Soldier Study (NSS)
• Mental disorders strongly predicted suicide ideation, but were less predictive of which ideators go on to make suicide plans or attempts
• Only PTSD & mental disorders characterized by irritability & aggressive/impulsive behavior predict the transition from suicide ideation to unplanned attempts
• These provide targets for interventions
Slide 61
Pre/Post Deployment Study
(PPDS)
• The PPDS dataset is currently the subject of intensive analysis
• In PPDS, there are many cases of PTSD, depression, TBI, Persistent Post-Concussive Symptoms (PCS) and suicidality (5 suicide deaths & nearly 100 suicide attempts) after deployment & redeployment
• Analyzing a wide range of survey, administrative & genetic predictors of these outcomes that could be detected prior to deployment
• Results of these analyses could have important implications for deployment decisions, as well as for interventions for soon-to-deploy and deployed Soldiers
Slide 62
Another Example in PPDS:
Persistent Post-Concussive Symptoms
(PCS) after Deployment-Related Mild
Traumatic Brain Injury (mTBI)
• Deployment-acquired mTBI was associated with nearly triple the risk of any PCS, and with increased severity of PCS when symptoms were present
• Prognostic indicators of persistent PCS after an index mTBI: previous TBI(s), pre-deployment psychological distress, severe deployment stress, and loss of consciousness or lapse of memory resulting from mTBI(s)
• These observations may have actionable implications for prevention of chronic sequelae of mTBI in the military and other settings
Slide 63
Suicide Attempt GWAS
(NSS, PPDS, SHOS-A)
• Novel genomewide significant loci for attempted suicide
– Observed in the European-American sample
• Interesting locus: MRAP2
– Melanocortin-2 Receptor Accessory
– Expressed in brain and adrenal cortex
– M2CR accessory protein
• support MC2R cell-surface expression, producing a functional ACTH-responsive receptor
– Involved with neural control of energy homeostasis
– Loss of function linked to obesity (Asai M et al., Science, 2013)
• Need larger sample size to gain more power to identify genetic components of these phenotypes, which likely have a highly polygenic architecture
• Future studies may gain additional power by
– Stratifying phenotypes differently (e.g., early-onset SA)
– Incorporating informative covariates (e.g., childhood maltreatment history)
– Sequencing to identify causal rare variants
Slide 64
Other Examples for Suicide
& Suicide Attempts
(HADS 2004-2009)
SUICIDE:
• Currently & previously deployed in first 4 years of service had greater risk than never deployed
• Not associated with increased risk of suicide:
o Waivers
o Length of time since return from most recent deployment
o Total number of deployments
o Interval between 2 most recent deployments (dwell time)
SUICIDE ATTEMPTS:
Slide 65
PGC Collaboration
Publications
• Dunn EC, Sofer T, Wang MJ, et al. Genome-wide association study of depressive symptoms in the Hispanic Community Health Study/Study of Latinos. J Psychiatr Res 2017
• Wolf EJ, Maniates H, Nugent N, Maihofer AX, et al. Traumatic stress and accelerated DNA methylation age: A meta-analysis. Psychoneuroendocrinology 2017
• Dunn EC, Sofer T, Gallo LC, et al. Genome-wide association study of generalized anxiety symptoms in the Hispanic Community Health Study/Study of Latinos. Am J Med Genet B Neuropsychiatr Genet 2017
• Duncan LE, Ratanatharathorn A, Aiello AE, et al. Largest GWAS of PTSD (N=20 070) yields genetic overlap with schizophrenia and sex differences in heritability. Mol Psychiatry 2018
Slide 66
Documented Family Violence (FV)
and Risk of Suicide Attempt(HADS 2004-2009)
• Active duty Regular Army enlisted Soldiers (n=9,650 with medically documented SA; n=153,528 control person-months)
• Odds of SA were higher for those with a FV history
• Odds increased as number of FV events increased
• Past-month FV had SA odds ~5 times higher than those with no FV history
• SA odds elevated for both perpetrators and victims
• For males, higher SA risk in perpetrators than victims
• For females, SA risk did not differ between perpetrators & victims
• SA risk highest in initial months after 1st FV event
• Conclusion: FV is an important consideration in understanding risk of SA among Soldiers
Ursano, et al. (2017) Psychiatry Research
Slide 67
Suicide Attempt GWAS
(NSS, PPDS, SHOS-A)
• Novel genomewide significant loci for attempted suicide
– Observed in the European-American sample
• Interesting locus: MRAP2
– Melanocortin-2 Receptor Accessory
– Expressed in brain and adrenal cortex
– M2CR accessory protein
• support MC2R cell-surface expression, producing a functional ACTH-responsive receptor
– Involved with neural control of energy homeostasis
– Loss of function linked to obesity (Asai M et al., Science, 2013)
• Need larger sample size to gain more power to identify genetic components of these phenotypes, which likely have a highly polygenic architecture
• Future studies may gain additional power by
– Stratifying phenotypes differently (e.g., early-onset SA)
– Incorporating informative covariates (e.g., childhood maltreatment history)
– Sequencing to identify causal rare variantsStein, et al. (2017) Am J Hum Genet B
Slide 68
Predictive Models
Developed (n=17)
1. Suicide after inpatient mental health treatment (admin predictor & outcome)
2. Suicide after outpatient mental health treatment (admin predictor & outcome)
3. Major violent crime perpetration (admin predictor & outcome)
4. Minor violent crime perpetration (admin predictor & outcome)
5. Sexual assault victimization in women (admin predictor, AAS survey outcome)
6. Suicide attempt (NSS survey predictor, admin outcome)
7. Mental health hospitalization (NSS survey predictor, admin outcome)
8. Positive drug test (NSS survey predictor, admin outcome)
9. Traumatic brain injury (NSS survey predictor, admin outcome)
10. Other severe injury (NSS survey predictor, admin outcome)
11. Major violence perpetration in men (NSS survey predictor, admin outcome)
12. Minor violence perpetration in men (NSS survey predictor, admin outcome)
13. Sexual assault perpetration in men (NSS survey predictor, admin outcome)
14. Minor violence victimization (NSS survey predictor, admin outcome)
15. Sexual assault victimization in women (NSS survey predictor, admin outcome)
16. Attrition (NSS survey predictor, admin outcome)
17. Demotion (NSS survey predictor, admin outcome) Kessler, et al (2015) JAMA PsychiatryRosellini, et al (2015) Psychological Medicine
Kessler, et al (2016) Molecular PsychiatryStreet, et al (2016) Clinical Psychological Science
Rosellini, et al (2017) Journal of Psychiatric ResearchRosellini, et al (2017) Psychological Medicine
PTSD: an Autoimmune DisorderExposure to Death and the DeadIdentification and PTSD Symptoms
0
2
4
6
8
10
12
14
16
1 4 13Months After Disaster
Intr
usio
n a
nd
Avo
idan
ce S
co
re
Intrusion Identif ier Intrusion Nonidentif ier
Avoidance Identif ier Avoidance Nonidentif ier
Ursano et al AJP, 1999
Slide 70
Suicide Attempt Rates(Enlisted Regular Army, 2004-2009)
0
200
400
600
800
1000
1200
Never deployed Currently deployed Previously deployed
Rat
es
(Att
em
pts
/100
,00
0 p
ers
on
ye
ars)
Deployment Status
STA NDA RDIZED RATES* OF SUIC ID E ATTEMP T BY DEPLOY MENT HISTORY A ND G ENDER A MONG ENLISTED, REG ULA R A RMY
SOLDIERS IN THE A RMY STA RRS 2004–2009 HA DS
Male
Female
* Rates standardized on gender, race, marital status, education, age at entry, current age and service time
Ursano, et al. JAMA Psychiatry, 2016
Slide 71
Suicide Rates(Enlisted Regular Army, 2004-2009)
0
5
10
15
20
25
30
Never deployed Currently deployed Previously deployed
Rat
es
(Su
icid
es/
10
0,00
0 p
ers
on
ye
ars)
Deployment Status
STA NDA RDIZED RATES* OF SUIC ID E (<=4 YEA RS OF SERVIC E) BY DEPLOYMENT HISTORY A ND G ENDER A MONG ENLISTED, REG ULA R
A RMY SOLDIERS IN THE A RMY STA RRS 2004–2009 HA DS
Male
Female
* Rates standardized on deployment and service time
Gilman, et al. Psychological Medicine, 2014
Trajectory of PTSD & SIRiskamong reserve soldiers
PTSD Trajectories of Deploymettraumatic event exposure % Suicide ID
Collective Efficacy and Probability of PTSD
Ursano R et al PLoS 2014.
I would be seen as weak
My unit leadershipmight treat me differently
Members of my unit might haveless confidence in me
It would harm my career
My leaders would blame mefor the problem
*Participants were asked to “rate each of the possible concerns that might affect your decision to receive mental health counseling or services if you ever had a problem.” Hoge CW, et al. N Engl J Med. 2004;351:13-22.
Barriers to Care and Mental Health Risk*
24
20
31
33
31
50
51
59
63
65
0 10 20 30 40 50 60 70 80
Agree or Strongly Agree, %
Screen pos
Screen neg
Is Stigma Unique to Military?
Maybe Less Than One Might Think…!
Kessler RC. J Clin Psychiatry. 2000;61(suppl 5):4-12.
Lack of perceived need
Perceived lack of effectiveness
Fear of forced hospitalization
24
22
40
60
6854
66
66
0 10 20 30 40 50 60 70 80
Agree or Strongly Agree, %
MenWomen
Want to solve on own
Stigma
35
1723
Unsure where to go49
40
