Risk Factors Associated with Attempted Suicide among US Army Soldiers Without a History of Mental Health Diagnosis

Robert J. Ursano*, Ronald C. Kessler, James A. Naifeh, Holly B. Herberman Mash, Matthew K. Nock, Pablo A. Aliaga, Carol S. Fullerton, Gary H. Wynn, Tsz Hin H. Ng, Hieu M. Dinh, Nancy A. Sampson, Tzu Cheg Kao, Steven G. Heeringa, Murray B. Stein

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

34 Scopus citations


Importance: The US Army suicide attempt rate increased sharply during the wars in Afghanistan and Iraq. Although soldiers with a prior mental health diagnosis (MH-Dx) are known to be at risk, little is known about risk among those with no history of diagnosis. Objective: To examine risk factors for suicide attempt among soldiers without a previous MH-Dx. Design, Setting, and Participants: In this retrospective longitudinal cohort study using administrative data from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), person-month records were identified for all active-duty Regular Army enlisted soldiers who had a medically documented suicide attempt from January 1, 2004, through December 31, 2009 (n = 9650), and an equal-probability sample of control person-months (n = 153 528). Data analysis in our study was from September 16, 2017, to June 6, 2018. In a stratified sample, it was examined whether risk factors for suicide attempt varied by history of MH-Dx. Main Outcomes and Measures: Suicide attempts were identified using Department of Defense Suicide Event Report records and International Classification of Diseases, Ninth Revision, Clinical Modification E95 × diagnostic codes. Mental health diagnoses and related codes, as well as sociodemographic, service-related, physical health care, injury, subjection to crime, crime perpetration, and family violence variables, were constructed from Army personnel, medical, legal, and family services records. Results: Among 9650 enlisted soldiers with a documented suicide attempt (74.8% male), 3507 (36.3%) did not have a previous MH-Dx. Among soldiers with no previous diagnosis, the highest adjusted odds of suicide attempt were for the following: female sex (odds ratio [OR], 2.6; 95% CI, 2.4-2.8), less than high school education (OR, 1.9; 95% CI, 1.8-2.0), first year of service (OR, 6.0; 95% CI, 4.7-7.7), previously deployed (OR, 2.4; 95% CI, 2.1-2.8), promotion delayed 2 months or less (OR, 2.1; 95% CI, 1.7-2.6), past-year demotion (OR, 1.6; 95% CI, 1.3-1.8), 8 or more outpatient physical health care visits in the past 2 months (OR, 3.3; 95% CI, 2.9-3.8), past-month injury-related outpatient (OR, 3.0; 95% CI, 2.8-3.3) and inpatient (OR, 3.8; 95% CI, 2.3-6.3) health care visits, previous combat injury (OR, 1.6; 95% CI, 1.0-2.4), subjection to minor violent crime (OR, 1.6; 95% CI, 1.1-2.4), major violent crime perpetration (OR, 2.0; 95% CI, 1.3-3.0), and family violence (OR, 2.9; 95% CI, 1.9-4.4). Most of these variables were also associated with suicide attempts among soldiers with a previous MH-Dx, although the strength of associations differed. Conclusions and Relevance: Suicide attempt risk among soldiers with unrecognized mental health problems is a significant and important challenge. Administrative records from personnel, medical, legal, and family services systems can assist in identifying soldiers at risk..

Original languageEnglish
Pages (from-to)1022-1032
Number of pages11
JournalJAMA Psychiatry
Issue number10
StatePublished - Oct 2018
Externally publishedYes


Dive into the research topics of 'Risk Factors Associated with Attempted Suicide among US Army Soldiers Without a History of Mental Health Diagnosis'. Together they form a unique fingerprint.

Cite this