Risk and Resilience

By Alex Piazza
apiazza@umich.edu

Adam Jando grew up fast.

He was in college when the wars began in Iraq and Afghanistan.

Within a year, he left school and enlisted in the Army National Guard. Jando completed basic training, got married and then deployed to Iraq as an infantryman.

He honed his skills as a rifleman, while the Army prepared him for a leadership role in Afghanistan. But the military culture and high-stakes environment of combat leadership impacted Jando.

“I went from feeling like I was 22 to 42 in the blink of an eye,” said Jando, who served six years in the National Guard.

And his skills as a rifleman and tactical leader did not translate well into civilian life.

“The camaraderie and sense of purpose I felt daily while in uniform disappeared,” he said. “Only those I served with seemed to understand the sense of loss I felt. I don’t want to say I was depressed, but I lost interest in a lot of things I enjoyed before joining the military. I had this pent-up anger about things, which nowadays seem silly to me.”

Jando persevered and accomplished many personal and professional goals, but many of his fellow veterans struggle with mental and behavioral health issues. Up to 20 percent of veterans who served in Operations Iraqi Freedom or Enduring Freedom show signs of posttraumatic stress disorder (PTSD) in a given year, according to the United States Department of Veterans Affairs. And about 20 veterans a day commit suicide nationwide, federal data shows.

Researchers at the University of Michigan play a critical role in a multidisciplinary study that aims to identify factors that protect or pose risks to the emotional wellbeing and mental health of soldiers and veterans.

The Study to Assess Risk and Resilience in Servicemembers (STARRS) began in 2009 with financial support from the U.S. Army and the National Institute of Mental Health, and as part of the study, U-M researchers helped create a database with deidentified administrative data on all Army soldiers from 2004 to 2009.

The database provides researchers at U-M and beyond with access to deidentified records of 1.6 million soldiers on active duty from 2004 to 2009. U-M researchers also collected information directly from more than 110,000 soldiers at various points in their careers from 2010 to 2014, making STARRS the largest study of mental health risk and resilience factors ever conducted among military personnel.

STARRS concluded in 2015, but that same year, researchers launched STARRS-LS (longitudinal study) to re-interview about 72,000 soldiers who participated in the initial study. STARRS-LS runs through 2019, and researchers aim to find answers to the important mental and behavioral health issues facing soldiers and veterans.

“Survey data acquired and maintained by the University of Michigan has provided researchers worldwide with information that can be used to help the Army better understand suicidal behaviors among soldiers, while at the same time disprove many commonly held beliefs about risk factors for suicide,” said James Wagner, a research associate professor at the U-M Institute for Social Research, who also serves as a principal investigator on STARRS-LS.

Jando, meanwhile, did not participate in STARRS, but he supports continued research into suicidal ideation among both combat veterans and those who did not deploy.

He sought treatment for what he calls “cognitive distortion,” and now is able to assist fellow veterans with behavioral and mental health issues as a licensed master social worker for the Military Support Programs and Networks (M-SPAN) at the U-M Depression Center. M-SPAN is a collection of programs for veterans, servicemembers and their families dedicated to mental health, wellness and resilience. There, Jando works as the social worker for the Buddy-to-Buddy Program, which trains volunteer veterans to provide peer support and links to resources for Michigan servicemembers and veterans.

“Service-related PTSD is one of a host of psychosocial stressors that should be included in studies regarding risk factors for suicide in the military and veteran population,” Jando said. “Continued research into transitional stress, especially the rapid and repetitive transition stress prevalent in the National Guard and reserve components of the military, is essential as the military strives to promote healthy behaviors among soldiers and veterans, while increasing efforts to prevent suicide,” said Jando, a research area specialist associate at U-M.

Data collected as part of STARRS has led to numerous research studies that, in some cases, have prompted changes in Army policy.

Suicide Prevalence

Suicide is among the nation’s leading causes of death, claiming the lives of nearly 45,000 people in 2016, according to the Centers for Disease Control and Prevention.

For years, the suicide rate among U.S. Army soldiers fell below the general population. But in recent years, the Army suicide rate has increased, while the civilian rate has remained fairly stable.

A team of researchers, including U-M research scientist Steven Heeringa, examined deidentified survey data from 5,400 non-deployed soldiers to learn more about suicidal thoughts, plans and attempts before and after entering the Army.

Their findings show nearly 14 percent of non-deployed soldiers considered suicide at some time in their life. Five percent of respondents created a suicide plan, while two percent attempted suicide. Researchers estimate 47 to 60 percent of these outcomes first occurred prior to joining the Army.

Non-deployed soldiers who attempted suicide appeared to be lower-ranking, enlisted, female and had been been previously deployed, data shows.

Certain pre-enlistment mental disorders, such as panic disorder and PTSD, were linked to increased rates of suicide attempts after joining the Army. About one-third of post-enlistment suicide attempts were linked to pre-enlistment mental disorders. And pre- and post-enlistment mental disorders accounted for 60 percent of first suicide attempts in the Army.

The Army has applied the results from this study to both review and update existing resilience and suicide prevention training, said Heeringa, a principal investigator on STARRS.

Family Violence

Soldiers with a documented history of family violence were nearly three times as likely to attempt suicide when compared to those with no history of family violence.

The risk of attempt also grew as the number and recency of family violence events increased, according to a separate STARRS study led partly by Heeringa.

As part of the study, researchers analyzed deidentified data from 975,000 Army soldiers in order to shed light on the link between family violence and suicide attempts. They found family violence was associated with suicide attempts in both male and female soldiers, with the risk being higher among men.

Risk of a suicide attempt was highest in the initial months following the first family violence event, data shows, followed by a sharp and steady decline as time elapsed. Both perpetrators of family violence and those who were exclusively victims were at higher risk of a suicide attempt.

Findings from his study led the U.S. Department of Defense to revise its Family Advocacy Program to highlight family violence as a risk factor for suicide and identify resources to help those programs deter suicide, Heeringa said.

Despite these serious and concerning findings, university programs and centers like M-SPAN and the Depression Center, the U.S. Department of Veterans Affairs and a host of other credible and evidence-based providers offer mental and behavioral help for servicemembers and veterans.