Newswise — Bethesda, MD–Most mental health disorders and suicidal ideation among U.S. Army soldiers start before enlistment, according to findings published in the March 3, 2014, online version of JAMA Psychiatry.

The study findings are from the Army Study to Assess Risk and Resilience in Servicemembers, or “Army STARRS,” the largest study of mental health risk and resilience ever conducted among U.S. Army personnel.

Army STARRS researchers, led by study co-principal investigators, Robert J. Ursano, MD, chairman of the Department of Psychiatry at the F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, and Murray B. Stein, MD, MPH, Professor of Psychiatry and Family and Preventive Medicine at the University of California, San Diego, found that a majority (58.2%) of soldiers who ever thought of suicide had these thoughts before enlistment, 76.6% of soldiers with current mental disorders had onsets before enlistment, and nearly half (47%) of soldiers who ever made a suicide attempt did so for the first time before enlistment. Nearly 60% of soldier suicide attempts can be traced to pre-enlistment mental disorders, which are more common among non-deployed U.S. Army soldiers than demographically similar populations of civilians (25.1% vs. 11.6%).

These initial published findings include three papers that use different strategies to evaluate suicide risk and protective factors among service people, including an analysis comparing the prevalence of mental disorders among Army and civilian populations.

“Some of the differences in disorder rates are truly remarkable,” said Ronald Kessler, McNeil Family Professor of Health Care Policy at Harvard Medical School and senior author of the paper on mental disorder prevalence. “The rate of major depression is five times as high among soldiers as civilians, intermittent explosive disorder six times as high, and PTSD nearly 15 times as high.”

The most common disorders in the Army STARRS survey were attention-deficit hyperactivity disorder (ADHD) and intermittent explosive disorder (IED; which is characterized by recurrent and uncontrollable anger attacks), Kessler said. The findings suggest that soldiers did not have higher rates of most “internalizing disorders” (anxiety disorders and depression) than civilians before enlistment, but rather developed high rates of these disorders only after they enlisted in the Army. The situation was different, though, for “behavioral disorders” (ADHD, IED, and substance abuse), which were much more common among young people who subsequently enlisted in the Army than those who did not and increased even more after enlistment. Nearly half of current soldier internalizing disorders and 80% of behavioral disorders started before enlistment.

“These results are a wake-up call highlighting the importance of outreach and intervention for new soldiers who enter the Army with pre-existing mental disorders,” said Ursano.

The second of the three Army STARRS papers appearing in JAMA Psychiatry revealed that 13.9% of soldiers considered suicide at some point in their lifetime, 5.3% made a suicide plan, and 2.4% attempted suicide, with between 47 to 60% of these outcomes first occurring prior to enlistment. Prior mental disorders were found to be by far the strongest predictors of these suicidal behaviors.

“It is striking that nearly 50% of the soldiers who attempted suicide made their first attempt before joining the Army, as history of suicide attempts is asked about in recruitment interviews and applicants who report such a history typically are excluded from service,” said Matthew Nock, Professor of Psychology at Harvard University and lead author of this report on soldier suicidality.

Nock noted that the most practical implication of this finding might be that the Army should develop outreach and intervention programs for new soldiers based on the realization that a nontrivial proportion of new soldiers come into the Army with a history of mental disorder and suicidality, and that they are not always forthcoming about these concerns during the recruitment process. Importantly, findings show that that it is not only depression and PTSD that predict suicide attempts.

The third JAMA Psychiatry article by lead author Michael Schoenbaum of the National Institute of Mental Health, National Institutes of Health, examined the suicide and accident death rates in relation to basic socio-demographic and Army experience factors in the 975,057 Regular Army soldiers who served between Jan. 1, 2004 and Dec. 31, 2009, charting variations in the rates based on a variety of factors including sex, race, education level, and rank.

Enhanced screening of applicants and expanded interventions to help new soldiers with mental disorders hold promise for reducing the high suicide rate in the U.S. Army.

About Army STARRS:

Army STARRS is a large-scale epidemiological and neurobiological study of Army suicides and their correlates sponsored by the Department of Army and funded under a cooperative agreement with the U.S. Department of Health and Human Services, National Institutes of Health, and National Institute of Mental Health. In addition to study leaders Ursano and Stein, members include site investigators Steven G. Heeringa, PhD, at the University of Michigan, and Kessler, along with NIMH collaborating scientists Schoenbaum, and Lisa J. Colpe, PhD, MPH. The team brings together international leaders in military health, health and behavior surveys, epidemiology, suicide, and genetic and neurobiological factors involved in psychological health. For more information on Army STARRS, please visit:

About the F. Edward Hébert School of Medicine – “America’s Medical School,” USU:

The F. Edward Hébert School of Medicine, “America’s Medical School,” was established by Congress in 1972 to provide a cadre of career military physicians and leaders for the Uniformed Services. Medical students are active duty uniformed officers in the Army, Navy, Air Force and Public Health Service who receive specialized education in tropical and infectious diseases, TBI and PTSD, disaster response and humanitarian assistance, global health, and acute trauma care in addition to their regular medical school curriculum. A large percentage of the university’s more than 5,000 physician alumni are supporting operations around the world, offering their leadership and expertise. The F. Edward Hébert School of Medicine also has graduate programs in biomedical sciences and public health, most open to civilian and military applicants, and a robust research program that covers a wide range of areas important to both the military and public health. For more information about the F. Edward Hébert School of Medicine, and the Uniformed Services University of the Health Sciences, visit

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JAMA Psychiatry online, Mar. 3, 2014