军人自杀危险因素与平民相似

《美国医学会杂志》8月6日在线发表的一篇报告显示，现役、退役军人自杀风险与精神心理疾病的关联类似于平民，而并非主要与军事经历有关(JAMA 2013;310:496-506)。

研究者利用一项大型前瞻性纵向队列研究的数据，对美军所有分支机构的人员进行了分析。结果显示，与自杀风险增加关联最强的因素包括：躁狂-抑郁障碍(即双相障碍)、抑郁症和酒精相关问题，而诸如战斗经历、长期部署或多次部署等军队特异性因素则与自杀风险增加无关。


Cynthia LeardMann女士

研究者表示，上述发现提示我们，降低军人自杀风险的最佳方式是筛查心理和物质滥用障碍、获取准确的精神病史、早期发现潜在自杀性行为，并且提供高质量的精神卫生治疗。

自2005年开始，美国军人自杀率急剧上升，直至2009年才趋于平稳，不过目前在现役人员中仍属罕见。为了检验与军人自杀风险相关的因素，LeardMann女士及其同事分析了千禧年队列研究的数据。这项研究在随机选取的军人中前瞻性记录了服役对健康的影响。该队列涉及陆军中的现役、预备役、国民警卫队，海军/海岸警卫队以及空军。

研究者评估了151,560名受试者的记录资料，这些受试者的受访时间为2001~2008年。根据这些资料和全美死亡指数(NDI)、国防部医学死亡登记(DDMMR)的数据，研究者确定了自杀和其他死亡的情况。研究者在分析中考虑到的部署相关因素包括：部署次数；部署持续时间；是否曾遇到尸体或不完整的肢体、目睹他人被杀死、使用武器或感到生命受到严重威胁；是否曾目睹虐待，如折磨、殴打或强奸。非军事性应激性生活事件也在考虑范畴内，如离婚、严重疾病、至亲死亡等。

结果显示，在长达7年的随访期间(相当于707,493人-年)，共有646名受试者死亡，其中83人(12.8%)死于自杀。总体粗自杀率为11.73/10万人-年。粗自杀率最高的人群包括：躁狂-抑郁障碍患者(87.55/10万人-年)、有酒精相关问题者(27.67/10万人-年)和抑郁症患者(26.94/10万人-年)。目前正在被部署的受试者——不论是否有战斗经历——死于自杀的几率并不高于未被部署者。

在对数据进行更深入分析后，研究者发现，自杀风险仍与躁狂-抑郁障碍[危险比(HR)，4.35]、酒精相关问题(HR，2.56)和抑郁症(HR，1.96)存在强相关性，而与任何部署相关因素均无关。

一项额外的巢式病例对照分析显示，躁狂-抑郁障碍[比值比(OR)，7.38]、抑郁症(OR，2.68)和酒精相关问题(OR，2.30)是自杀风险的强烈、独立预测因素。自杀风险与部署相关因素仍然无关。

在一项仅纳入陆军军人的亚组分析中，躁狂-抑郁障碍(HR，5.96)和酒精相关问题(HR，3.86)与自杀风险明显相关。抑郁症则不然，但这可能与该亚组受试者数量偏少而不具备足够统计学效力有关。

研究者指出：“上述发现与人们的猜测并不一致，很多人认为部署相关因素与自杀风险增加之间存在直接关联。然而事实上，军人的自杀危险因素与平民非常相似，包括性别为男和精神心理疾病。”

研究者承认，其分析未能纳入2008年以来的自杀数据，“不排除近期冲突中(伊拉克、阿富汗)多次、长时间部署的累积压力才刚开始反映在自杀率上的可能性”。“不过，这项研究纳入了军人自杀率急剧上升的3年的数据，而且总体证据清晰地表明，部署相关因素对自杀风险没有明显影响。”

这项研究的局限性在于，受试者中仅发生了83例自杀死亡，“因此可能不具备足够统计学效力去构建一个稳定、可重复的多变量模型”。

这项研究获得了美国国防部的支持。LeardMann女士报告称无相关利益冲突，一名合著者承认从默克获得了讲课费。

随刊述评：军人自杀仍然罕见


Charles C. Engel博士

美国健康科学统一服务大学精神病学系的Charles C. Engel博士在随刊述评中指出，军人自杀有时候会表现出流行性，很多人猜测军人自杀率正在攀升且失去了控制，原因是长时间的战斗部署及其相关压力。

但是，尽管近年来军人自杀率明显上升，但此类事件仍然很罕见。应当将军人自杀率上升的趋势放到大环境中进行考量：在同一时期内，美国一般人群的自杀率出现了相似的上升，这与经济恶化和失业增加有关(JAMA 2013:310:484-5)。

LeardMann等人的发现实际上令人欣慰，因为对于军人自杀的主要原因——情绪障碍和酒精滥用，我们都有疗效肯定的干预手段可供使用。

Engel博士报告称无相关利益冲突。

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By: MARY ANN MOON, Internal Medicine News Digital Network

Among current and former military personnel, the risk of suicide is related to the same mental health disorders found in civilian populations rather than to military experience, a report published online Aug. 6 in JAMA suggests.

In an analysis of data from a large prospective longitudinal cohort of personnel from all branches of the service, increased suicide risk was strongly associated with manic-depressive disorder, now commonly called bipolar disorder; depression; and alcohol-related problems but was not associated with military-specific factors such as combat experiences, long deployments, or multiple deployments, reported Cynthia A. LeardMann of the department of deployment health research, Naval Health Research Center, San Diego, and her associates.

Their findings indicate that the best means of mitigating suicide risk in military personnel are screening for mental and substance use disorders, obtaining an accurate psychiatric history, and recognizing potential suicidal behaviors early, together with providing high-quality mental health treatment, the researchers said.

Suicide rates in the military increased sharply beginning in 2005 and continued to rise each year until leveling off in 2009. Yet, suicide still remains a rare outcome in service personnel.

To examine factors associated with suicide risk in the military, Ms. LeardMann and her colleagues analyzed data from the Millennium Cohort Study, which prospectively records the health impact of military service in a randomly selected sample of service members using periodic surveys. The Millennium Cohort includes a large population of active, reserve, and National Guard members in the Army, Navy/Coast Guard, Marine Corps, and Air Force.

For their study, Ms. LeardMann and her associates assessed the records of 151,560 participants in the Millennium Cohort who were surveyed in 2001 through 2008, the last year for which complete data have been collected. Suicides and other deaths were identified through these records as well as through the National Death Index and the Department of Defense Medical Mortality Registry.

Factors related to deployment that were considered in the analyses included the number of deployments; length of deployments; whether or not the subject had encountered dead or decomposing bodies, witnessed people being killed, discharged a weapon, or felt in great danger of being killed; and whether the subject had witnessed abuse such as torture, beating, or rape. Nonmilitary stressful life events also were considered, such as divorce, severe illness, or death of a close loved one.

During up to 7 years of follow-up – the equivalent of 707,493 person-years of observation – 646 of these subjects died, including 83 (12.8% of total deaths) who died from suicide. The overall crude rate of suicide was 11.73 per 100,000 person-years.

Crude suicide rates were highest among study subjects who had manic-depressive disorder (87.55 per 100,000), alcohol-related problems (27.67 per 100,000), and depression (26.94 per 100,000). Subjects who were currently deployed, whether or not they had combat experience, were no more likely than nondeployed subjects to die from suicide, the investigators reported (JAMA 2013;310:496-506).

In a more refined analysis of the data, suicide risk was again strongly associated with manic-depressive disorder (hazard ratio, 4.35), alcohol-related problems (HR, 2.56), and depression (HR, 1.96), and was not associated with any deployment-related factors.

In an additional nested case-control analysis, suicide risk was independently and strongly associated with manic-depressive disorder (odds ratio, 7.38), depression (OR, 2.68), and alcohol-related problems (OR, 2.30). Again, no association was found between suicide risk and deployment factors.

In a subgroup analysis involving only Army personnel, manic-depressive disorder (HR, 5.96) and alcohol-related problems (HR, 3.86) were significantly associated with suicide risk. Depression was not, but that might have been attributable to inadequate statistical power because there were not enough cases in this subgroup, the investigators said.

These findings "are not consistent with the assumption that specific deployment-related characteristics ... are directly associated with increased suicide risk. Instead, the risk factors associated with suicide in this military population are consistent with civilian populations, including male sex and mental disorders," Ms. LeardMann and her associates said.

"Studies have shown a marked increase in the incidence of diagnosed mental disorders in active-duty service members since 2005, paralleling the incidence of suicide. This suggests that the increased rate of suicide in the military may largely be a product of an increased prevalence of mental disorders in this population, possibly resulting from indirect cumulative occupational stresses across both deployed and home-station environments over years of war," they said.

The researchers noted that their analyses could not capture suicides that occurred since 2008. "It is possible that the cumulative strain of multiple and lengthy deployments only began to be reflected in suicide rates toward the later stages of the conflicts [in Iran and Afghanistan]," and thus could not be accounted for in this study.

"However, the study did include the 3 years with the sharpest statistically significant increases in suicides." And the overall evidence clearly "points to the lack of any specific deployment-related effects," they noted.

This study was limited in that all the findings are based on only 83 suicide deaths, so it "may have lacked statistical power to produce a stable and reproducible multivariable model," Ms. LeardMann and her associates added.

This study was supported by the Department of Defense. Ms. LeardMann reported no financial conflicts of interest; one of her associates reported receiving a lecture fee from Merck.

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Military suicides remain rare

Military suicides are sometimes characterized as an epidemic, and many assume that the rate is escalating out of control because of prolonged combat deployments and their associated stresses, said Dr. Charles C. Engel.

But suicide within the military remains rare, despite the worrisome increase that has occurred in recent years. This trend should be viewed in context: A similar increase in suicides has been reported in the general U.S. population during the same time period, and has been linked to declines in the economy and escalating unemployment.

The findings of LeardMann et al. are reassuring in that they identify three leading causes of military suicide – mood disorders and alcohol misuse – for which effective treatments exist, he said.

Charles C. Engel, M.D., is with the department of psychiatry at the Uniformed Services University of the Health Sciences, Bethesda, Md. He reported no financial conflicts of interest. These remarks were taken from his editorial accompanying Ms. LeardMann’s report (JAMA 2013:310:484-5).