Showing papers by "Charles W. Hoge published in 2017"

Suicidal Behaviors Within Army Units: Contagion and Implications for Public Health Interventions.

Abstract: Between 2005 and 2009, during the peak war years in Iraq and Afghanistan, the US Army and US Marine Corps, the 2 services with the largest concentration of ground combat forces, experienced a significant increase in suicides. For the first time in decades, suicide rates surpassed civilian levels, and they have remained elevated since. This change precipitated considerable research by several teams to understand the causal factors,1 including the more than $65 million Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), a population-based epidemiological study to identify “actionable recommendations to reduce Army suicides.”2 However, these extensive efforts reached somewhat contradictory conclusions concerning key risk factors, such as the association of deployment with suicide.1 The Army STARRS effort was the most prolific but generated the harshest criticism for its core scientific assumptions, methods, conclusions, and lack of actionable relevance.3-5 To date, none of these studies have been able to definitively answer the overarching question of why suicide rates rose so sharply in Army and Marine personnel but not in Air Force and Navy personnel.1 While the apparent lack of return on investment might appear disconcerting, these studies have opened the door to studying the complexity of suicidal behaviors and the multifactorial nature of risk factors in a way that smaller studies would not have had the power to do. The Army STARRS study notably integrates data from more than 30 administrative health care, personnel, and occupational data systems, permitting sophisticated observational and hypothesisgenerated data trawling. In this issue of JAMA Psychiatry, for the Army STARRS team, Ursano et al6 present a particularly interesting finding that suicide attempts from 2004 to 2009 tended to cluster in Army units in which prior suicide attempts had occurred; this finding was most robust in smaller units. While the researchers did not make an effort to categorically define clustering and lacked power to study clustering of suicide deaths, the correlations were strong, methods solid, and conclusions held up after controlling for potential confounders, including units where suicidal behaviors may be more likely to be concentrated (eg, those consisting of basic trainees or personnel undergoing medical disability evaluations). The findings from this study certainly reflect actionable information, raising tantalizing questions about the influence of military social structure and leadership on suicide risk factors as well as the potential for contagion of suicidal behaviors within Army units. Although the concept of contagion in the field of suicidology evades definitional clarity, there is extensive literature to support its premise, based particularly on clusters involving youth or younger adults (a similar age group who join the military), and evidence of the negative influence of news or social media portrayals of suicidal behavior.7,8 The hypothesized mechanisms, drawn from infectious diseases and social psychology, have provided a valuable framework for designing public health responses to community clusters. Of the various factors linked to suicide risk within groups and the concept of contagion in the broader civilian literature,9 3 key interrelated factors emerge as most salient for considering the Army STARRS findings: the susceptibility of certain individuals (owing to preexisting or underlying mental health problems), the social or community environment (in this case, unit occupational context) that might amplify risk factors or promote imitative behaviors, and communication surrounding suicides.7,9 First, concerning susceptibility, the most consistent and strongest risk factor for suicidal behavior identified across US Department of Defense and Veterans Affairs studies is the presence of underlying mental disorders, which often goes unrecognized or untreated. This knowledge, together with research on the impact of stigma and barriers to care, contributed to an extensive transformation of mental health services in the Army since 2010.5 This transformation has included population-wide screening, significant increases in mental health personnel, standardization of services, routine clinical outcome measures, and, most importantly, the restructuring of care delivery in a way that directly influences how units attend to soldiers with mental health conditions and respond to suicidal behaviors.5 This innovative structure of care involves embedding small teams of mental health professionals within all operational (combat) brigades, fostering enhanced access and greater coordination with unit leaders.5 While these changes have occurred since the Army STARRS study period, the study highlights the need for clinicians embedded in these brigades to remain aware of the possibility of clustering and to review processes for ensuring that soldiers known to be at risk receive the support they need. The findings point to the need to better understand the reasons for clustering and to ensure there are appropriate response plans involving unit, community, and medical stakeholders to mitigate the potential for contagion.7 Second, there is evidence that the military occupational environment shapes soldier mental health. Unit leadership, Related article Opinion

Significant methodological flaws limit conclusions drawn by authors of a recent PTSD mindfulness study.

Abstract: FROM: Polusny MA. Mindfulness-based stress reduction for posttraumatic stress disorder among veterans: a randomized clinical trial. JAMA 2015;314:456–65.[OpenUrl][1][CrossRef][2][PubMed][3] Of six major international post-traumatic stress disorder (PTSD) treatment guidelines, only two mention mindfulness-based treatments, and none recommend their routine use.1 ,2 Few mindfulness-based intervention studies exist for PTSD, and all have significant limitations in design, outcome measures and/or data handling.1 However, these interventions remain widely used. A core-component of PTSD treatment addresses autonomic hyperarousal, and many clinicians apply mindfulness techniques for this or in facilitating treatment for patients too avoidant for trauma-focused psychotherapies (TFPs). This was a 17-week RCT involving 116 US Veteran's Association participants, comparing group mindfulness-based psychotherapy against group present-centred psychotherapy. The primary outcome, change in symptom severity, was assessed using the PTSD checklist (PCL; range, 17–85 with higher scores indicating more severe symptoms). As a secondary efficacy … [1]: {openurl}?query=rft.jtitle%253DJAMA%26rft.volume%253D314%26rft.spage%253D456%26rft_id%253Dinfo%253Adoi%252F10.1001%252Fjama.2015.8361%26rft_id%253Dinfo%253Apmid%252F26241597%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1001/jama.2015.8361&link_type=DOI [3]: /lookup/external-ref?access_num=26241597&link_type=MED&atom=%2Febmental%2F20%2F1%2F30.atom