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Army Study to Assess Risk and Resilience in Servicemembers

ARMY STARRS: VOLUME 8 ISSUE 2, UPDATED April 04, 2024

For further details on study and instruments, visit the STARRS-LS website at starrs-ls.org. 

The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

 Co-Principal Investigators: Robert J. Ursano, M.D. (Uniformed Services University of the Health Sciences) and Murray B. Stein, M.D., M.P.H. (University of California, San Diego)

July 2009 – June 2015

INTRODUCTION:

 Army STARRS is the largest and most comprehensive research project of mental health ever conducted in the U.S. Army.  The project was designed to examine a broad range of risk and resilience (protective) factors across a complex set of outcomes. Army STARRS scientists created a series of extensive databases with the potential to achieve groundbreaking results.  These databases will allow scientists to investigate a diverse combination of factors from demographic, psychological, biological, neurological, behavioral, and social domains to help identify risk and resilience factors for soldier suicidal behaviors and associated mental health issues.  The project was designed using an adaptive approach which means it evolved as new information became available over the course of the project.  With the goal of generating actionable findings, the research team shared preliminary findings with the Army as they become available so that the Army could apply them to its ongoing health promotion, risk reduction, and suicide prevention efforts.

 

Army STARRS includes the following component studies:

1)    the Historical Administrative Data Study (HADS) of Army and Department of Defense (DoD) administrative data systems (including records of suicidal behaviors) for all soldiers on active duty from 2004 to 2009 aimed at finding administrative record predictors of suicides;

2)     two retrospective case-control studies of fatal and nonfatal suicidal behaviors;

3)    a study of new soldiers assessed just before beginning basic combat training (BCT) with self-administered questionnaires (SAQ), neurocognitive tests, and blood samples;

4)    a cross-sectional study of soldiers representative of all other active duty soldiers (exclusive of BCT);

5)    a pre-post deployment study (with blood samples) of soldiers in brigade combat teams about to deploy to Afghanistan, with sub-samples assessed again one, three, and nine months after returning from deployment;

6)    a pilot study to follow-up post-deployment respondents transitioning to civilian life.

 Army/DoD administrative data were linked prospectively to the large-scale survey samples to examine predictors of subsequent suicidality and related mental health outcomes.

SUMMARY OF FINDINGS:

 The following is a brief summary of some of the Amy STARRS findings to-date. Findings followed by an asterisk (*) were included in USU press releases.  

1.      The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) [PubMed]

  • Component study cooperation rates are comparatively high.
  • Sample biases are relatively small.
  • Inefficiencies introduced into parameter estimates by using nonresponse adjustment weights and time-space clustering are small.
  • Initial findings show that the suicide death rate, which rose over 2004–2009, increased for those deployed, those never deployed, and those previously deployed.
  • Analyses of administrative records show that those deployed or previously deployed were at greater suicide risk.
  • Receiving a waiver to enter the Army was not associated with increased risk.
  • Being demoted in the past two years was associated with increased risk.
  • Time in current deployment, length of time since return from most recent deployment, total number of deployments, and time interval between most recent deployments (known as dwell time) were not associated with suicide risk.
  • Initial analyses of survey data show that 13.9% of currently active non-deployed regular Army soldiers considered suicide at some point in their lifetime, while 5.3% had made a suicide plan, and 2.4% had attempted suicide.*
  • 47–60% of these outcomes first occurred prior to enlistment.*
  • Prior mental disorders (in particular major depression and intermittent explosive disorder) were the strongest predictors of these self-reported suicidal behaviors.
  • Most onsets of plans-attempts among ideators (58.3–63.3%) occurred within the year of onset of ideation.
  • About 25.1% of non-deployed U.S. Army personnel met 30-day criteria for a DSM-IV anxiety, mood, disruptive behavior, or substance disorder (15.0% an internalizing disorder; 18.4% an externalizing disorder) and 11.1% for multiple disorders.*
  • Three-fourths of these disorders had pre-enlistment onsets.*
  • Integration across component studies creates strengths going well beyond those in conventional applications of the same individual study designs.
  • These design features create a strong methodological foundation from which Army STARRS can pursue its substantive research goals.
  • The early findings reported here illustrate the importance of the study and its approach as a model of studying rare events particularly of national security concern.
  • Continuing analyses of the data will inform suicide prevention for the U.S. Army.

TABLE 1. Army STARRS Component Studies and Approximate Soldier Sample Size

 Historical Administrative Data Study (HADS)  >1.6 million 
 Soldier Health Outcomes Study A (SHOS-A)  150 cases and 300 controls 
 Soldier Health Outcomes Study B (SHOS-B)  150 cases and 300 controls
 New Soldier Study (NSS)  51,000
 All Army Study (AAS)  35,000
 Pre-Post Deployment Study (PPDS)  9,400
 Pre-Post Separation Study (PPSS)  1,500

 

2.      Sociodemographic and career history predictors of suicide mortality in the United States Army 2004–2009 [PubMed]

  • Several novel results were found that could have intervention implications.
  • Significantly elevated suicide rates (69.6–80.0 suicides per 100,000 person-years compared with 18.5 suicides per 100,000 person-years in the total Army) among enlisted soldiers deployed either during their first year of service or with less than expected (based on time in service) junior enlisted rank
  • Substantially greater rise in suicide among women than men during deployment
  • Protective effect of marriage against suicide only during deployment.
  • Career history approach produces several actionable insights missed in less textured analyses of administrative data predictors.
  • Expansion of analyses to a richer set of predictors might help refine understanding of intervention implications.

3.      Predictors of Suicide and Accident Death in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) [PubMed]

  • 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. 

Study to Assess Risk and Resilience in Service members – Longitudinal Study (STARRS-LS)

 Co-Principal Investigators: Robert J. Ursano, M.D. (Uniformed Services University of the Health Sciences) and Murray B. Stein, M.D., M.P.H. (University of California, San Diego)

July 2015 – June 2025

Due to the great success of Army STARRS, the Center for the Study of Traumatic Stress received funding from the Department of Defense to continue and further develop the STARRS research. Under STARRS-LS, the research team continued to use the data systems and research platforms developed during the initial project period to provide further analyses and follow-up studies of the Soldiers who participated in Army STARRS. This work aims to produce additional benefits to the well-being of Service members. 

The initial five-year STARRS-LS project (2015-2020) was a $30 million award to continue analyses of Army STARRS data, expand the research by extending the historical data through 2016,conduct a longitudinal follow-up study with a cohort of more than 72,000 Service members who participated in Army STARRS and provided consent for researchers to link their STARRS survey data to their DoD and Army administrative records data, contact a subset of the cohort to administer two additional waves of questionnaires to collect further follow-up data, and analyze the Army STARRS data in conjunction with the STARRS-LS data to further the goals of the STARRS family of studies. The five-year STARRS-LS continuation project (2020-2025) is a $35 million award from DoD to continue expanding the historical data and analyzing the data for the more than 3 million Soldiers on active duty from 2004 to 2019, continue following the STARRS-LS cohort of about 72,000 Soldiers, and to continue following the subset of the STARRS-LS cohort by conducting two additional waves of questionnaires to collect further follow-up data. The Research Team responsible for the scientific design and operational conduct of the initial STARRS-LS and the STARRS-LS continuation project is comprised of researchers from USU, the University of California, San Diego (UCSD), Harvard and the University of Michigan under the leadership of the two co-principal investigators, Dr. Robert J. Ursano of USU (Director of CSTS) and Dr. Murray B. Stein of UCSD.

The research team expects the STARRS research to continue beyond 2025.