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The most common treatment for major depressive disorder (MDD) is antidepressant medication (ADM). Results are reported on frequency of ADM use, reasons for use, and perceived effectiveness of use in general population surveys across 20 countries.
Face-to-face interviews with community samples totaling n = 49 919 respondents in the World Health Organization (WHO) World Mental Health (WMH) Surveys asked about ADM use anytime in the prior 12 months in conjunction with validated fully structured diagnostic interviews. Treatment questions were administered independently of diagnoses and asked of all respondents.
3.1% of respondents reported ADM use within the past 12 months. In high-income countries (HICs), depression (49.2%) and anxiety (36.4%) were the most common reasons for use. In low- and middle-income countries (LMICs), depression (38.4%) and sleep problems (31.9%) were the most common reasons for use. Prevalence of use was 2–4 times as high in HICs as LMICs across all examined diagnoses. Newer ADMs were proportionally used more often in HICs than LMICs. Across all conditions, ADMs were reported as very effective by 58.8% of users and somewhat effective by an additional 28.3% of users, with both proportions higher in LMICs than HICs. Neither ADM class nor reason for use was a significant predictor of perceived effectiveness.
ADMs are in widespread use and for a variety of conditions including but going beyond depression and anxiety. In a general population sample from multiple LMICs and HICs, ADMs were widely perceived to be either very or somewhat effective by the people who use them.
Although non-suicidal self-injury (NSSI) is an issue of major concern to colleges worldwide, we lack detailed information about the epidemiology of NSSI among college students. The objectives of this study were to present the first cross-national data on the prevalence of NSSI and NSSI disorder among first-year college students and its association with mental disorders.
Data come from a survey of the entering class in 24 colleges across nine countries participating in the World Mental Health International College Student (WMH-ICS) initiative assessed in web-based self-report surveys (20 842 first-year students). Using retrospective age-of-onset reports, we investigated time-ordered associations between NSSI and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-IV) mood (major depressive and bipolar disorder), anxiety (generalized anxiety and panic disorder), and substance use disorders (alcohol and drug use disorder).
NSSI lifetime and 12-month prevalence were 17.7% and 8.4%. A positive screen of 12-month DSM-5 NSSI disorder was 2.3%. Of those with lifetime NSSI, 59.6% met the criteria for at least one mental disorder. Temporally primary lifetime mental disorders predicted subsequent onset of NSSI [median odds ratio (OR) 2.4], but these primary lifetime disorders did not consistently predict 12-month NSSI among respondents with lifetime NSSI. Conversely, even after controlling for pre-existing mental disorders, NSSI consistently predicted later onset of mental disorders (median OR 1.8) as well as 12-month persistence of mental disorders among students with a generalized anxiety disorder (OR 1.6) and bipolar disorder (OR 4.6).
NSSI is common among first-year college students and is a behavioral marker of various common mental disorders.
Unit cohesion may protect service member mental health by mitigating effects of combat exposure; however, questions remain about the origins of potential stress-buffering effects. We examined buffering effects associated with two forms of unit cohesion (peer-oriented horizontal cohesion and subordinate-leader vertical cohesion) defined as either individual-level or aggregated unit-level variables.
Longitudinal survey data from US Army soldiers who deployed to Afghanistan in 2012 were analyzed using mixed-effects regression. Models evaluated individual- and unit-level interaction effects of combat exposure and cohesion during deployment on symptoms of post-traumatic stress disorder (PTSD), depression, and suicidal ideation reported at 3 months post-deployment (model n's = 6684 to 6826). Given the small effective sample size (k = 89), the significance of unit-level interactions was evaluated at a 90% confidence level.
At the individual-level, buffering effects of horizontal cohesion were found for PTSD symptoms [B = −0.11, 95% CI (−0.18 to −0.04), p < 0.01] and depressive symptoms [B = −0.06, 95% CI (−0.10 to −0.01), p < 0.05]; while a buffering effect of vertical cohesion was observed for PTSD symptoms only [B = −0.03, 95% CI (−0.06 to −0.0001), p < 0.05]. At the unit-level, buffering effects of horizontal (but not vertical) cohesion were observed for PTSD symptoms [B = −0.91, 90% CI (−1.70 to −0.11), p = 0.06], depressive symptoms [B = −0.83, 90% CI (−1.24 to −0.41), p < 0.01], and suicidal ideation [B = −0.32, 90% CI (−0.62 to −0.01), p = 0.08].
Policies and interventions that enhance horizontal cohesion may protect combat-exposed units against post-deployment mental health problems. Efforts to support individual soldiers who report low levels of horizontal or vertical cohesion may also yield mental health benefits.
The sources and fate of radiocarbon (14C) in the Dead Sea hypersaline solution are evaluated with 14C measurements in organic debris and primary aragonite collected from exposures of the Holocene Ze’elim Formation. The reservoir age (RA) is defined as the difference between the radiocarbon age of the aragonite at time of its precipitation (representing lakeʼs dissolved inorganic carbon [DIC]) and the age of contemporaneous organic debris (representing atmospheric radiocarbon). Evaluation of the data for the past 6000 yr from Dead Sea sediments reveal that the lakeʼs RA decreased from 2890 yr at 6 cal kyr BP to 2300 yr at present. The RA lies at ~2400 yr during the past 3000 yr, when the lake was characterized by continuous deposition of primary aragonite, which implies a continuous supply of freshwater-bicarbonate into the lake. This process reflects the overall stability of the hydrological-climate conditions in the lakeʼs watershed during the late Holocene where bicarbonate originated from dissolution of the surface cover in the watershed that was transported to the Dead Sea by the freshwater runoff. An excellent correlation (R2=0.98) exists between aragonite ages and contemporaneous organic debris, allowing the estimation of ages of various primary deposits where organic debris are not available.
Well-conducted treatment trials and data on predictors of treatment response are both lacking for ADWA, despite the high prevalence of the condition. While benzodiazepines are frequently prescribed for anxiety disorders, etifoxine is also an effective agent not associated with dependence. A randomized controlled trial of etifoxine versus alprazolam for ADWA was undertaken, aiming at comparing efficacy and safety of the two treatments, and investigating predictors of the clinical response.
Two hundred and two adult outpatients with ADWA were enrolled at primary care settings sites in South Africa. Patients were followed for 4 weeks of treatment, and for an additional week after treatment discontinuation. The primary outcome measure was the Hamilton Anxiety Rating Scale (HAM-A) and was assessed by using a non-inferiority analysis. Secondary outcomes included the Sheehan Disability Scale (SDS) and the Clinical Global Impressions-Change Scale (CGI-C). Predictors of response were investigated with a multivariate logistic regression.
Both etifoxine and alprazolam dramatically decreased the HAM-A score at 4 weeks. The difference between treatment groups in HAM-A was of 1.78 [90% CI; 0.23, 3.33] in favor of alprazolam. The two treatments were equally efficacious in patients with more severe anxiety symptoms at baseline. Between week 4 and week 5, after treatment discontinuation, HAM-A scores continued to improve in the etifoxine group, but increased in the alprazolam group (P = 0.019); no difference was found between the two groups regarding the secondary outcomes. No significant predictors of treatment response were found. Patients treated with alprazolam experienced more treatment-related adverse events, mostly of central nervous origin, and especially after medication discontinuation.
This trial confirms the efficacy and safety of etifoxine in the management of ADWA.
This study assessed the efficacy of agomelatine (1,2,3), in the prevention of relapse in non-depressed out-patients with DSM-IV-TR defined Generalized Anxiety Disorder (GAD) and the tolerability.
GAD patients received open label agomelatine (25–50 mg/day). At week 4 the dose was increased for patients with insufficient improvement (blinded criteria). At week 16, responders were randomised to maintenance treatment with either agomelatine, or placebo for a 26 week period. Then, agomelatine treated-patients were re-randomised to an agomelatine arm or to a placebo arm, to confirm the lack of discontinuation symptoms (on the DESS check-list).
The primary outcome was the time to relapse (days) during the 26 week double-blind treatment period, as estimated using the Kaplan-Meier method. Relapse was defined as HAMA total score > = 15 or withdrawal for lack of efficacy (in the investigator's opinion, based on both HAM-A and CGI scores).
477 patients entered the open-label phase and 329 completed this period. 228 patients were randomly assigned to receive agomelatine (114 patients) or placebo (114 patients).
The incidence over time of relapse was significantly lower with agomelatine compared to placebo (19.7% versus 31.7% log rank test p = 0.046) during the double-blind treatment period.
During the double-blind treatment period 12.4% patients with agomelatine and 9.6% with placebo reported at least one emergent adverse event related to the study treatment. There was no discontinuation syndrome in agomelatine treated patients.
Agomelatine was efficacious in preventing relapse in GAD, with maintenance of efficacy over 6 months, and good tolerability.
Anxiety disorders are considered to be the most prevalent of the psychiatric disorders, with generalized anxiety disorder (GAD) being one of the most common in primary care practice. GAD is a chronic and disabling disorder, which is frequently underdiagnosed and undertreated. It is characterized by both psychic symptoms (particularly worry) and somatic symptoms, and often complicated by comorbid conditions such as depression.
Agomelatine, the first melatonergic antidepressant, has been shown to be effective and well tolerated, not only in treating major depressive disorder, but also in treating the anxiety symptoms of depression. These findings give impetus to investigation of its potential anxiolytic properties in GAD.
Two randomized, double-blind, placebo-controlled studies assessed the efficacy of agomelatine in GAD. The first, a 12-week study, used the HAM-A total score as the primary outcome measure. In the second, a relapse prevention study, the responders to a 16-week open treatment period with agomelatine were randomized to maintenance treatment with either agomelatine or placebo for a 26-week period.
In the short-term treatment of GAD,1 agomelatine was superior to placebo with a HAM-A total score difference of 3.28 (P = 0.04). In the maintenance treatment of GAD, the incidence of relapse was significantly lower with agomelatine than with placebo. Agomelatine was well tolerated in both trials.
In summary, these studies showed that the novel antidepressant agomelatine is also efficacious in the treatment of GAD.
To evaluate the clinical characteristics of GAD patients with prominent GI symptoms (GI-high) and their response to pregabalin (PGB) treatment.
Data were pooled from 6 double-blind, placebo-controlled, 4-6 week trials of outpatients who met DSM-IV criteria for GAD with a minimum HAM-A total score ≥18. Treatment response was evaluated for 3 PGB fixed-dosage groups: 150 mg/d, 300-450 mg/d, and 600 mg/d. A GI-high subgroup (high GI symptomatology) was defined by a baseline HAM-A item-11 (GI) score ≥3 (severe/very severe).
At baseline, 261 patients (17%) met criteria for the GI-high subgroup, while 1294 patients (83%) were in the GI-low subgroup. Baseline characteristics were similar for the 4 study treatments in the GI-high subgroup. For the GI-high subgroup, LOCF-endpoint reduction in HAM-A was significantly higher on PGB-150, -13.8±1.7; PGB-300/450 -13.5±1.2; PGB-600, -14.8±1.1; vs PBO, -10.6±1.0 (P<0.0001 for all comparisons). In the GI-high subgroup, the proportion of patients showing a response in GI symptoms (HAM-A item 11 improving from severe/very severe to mild-to-none) was significantly higher on PGB-150 (62%), PGB-300/450 (73%), PGB-600 (68%) vs PBO (56%; P<0.0001 for all comparisons). The incidence of adverse events referable to the GI system was the same on PGB-150 and PBO, 8% higher on PGB-200/450 vs PBO, and 5% higher on PGB-600 vs PBO.
PGB was effective and well-tolerated in the subgroup of GAD patients presenting with severe GI symptoms. Treatment with PGB improved both overall levels of anxiety, as well as specifically improving GI symptoms.
Three adolescent and two adult patients suffering from chronic excited psychoses (either schizophrenia or schizoaffective disorder) resistant to traditional neuroleptics and clozapine were treated with combined clozapine-lithium. Improvement was assessed with the Positive and Negative Symptoms Scale, the Brief Psychiatric Rating Scale and the Clinical Global Impressions, administered before and during combined clozapine-lithium treatment. All patients demonstrated a significant improvement with this combination. There was no occurrence of agranulocytosis, neuroleptic malignant syndrome or other clinically significant adverse effects.
To compare the efficacy of escitalopram 10 or 20 mg/day with placebo in preventing relapse during 24 weeks in outpatients with obsessive-compulsive disorder (OCD) who had responded to an initial 16-week open-label treatment with escitalopram.
A multinational, randomised, double blind, placebo-controlled, flexible to fixed dose relapse prevention study with escitalopram in outpatients with OCD. The study consisted of a 16-week open-label period with 10 to 20 mg escitalopram followed by a 24 week double blind, placebo-controlled period, and a 1 week taper period. Patients who had responded to treatment (≥25% decrease in the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) total score) by the end of the 16-week open-label period were eligible for randomisation to either escitalopram or placebo for a further 24 weeks.
468 patients with OCD were treated with open-label escitalopram (10 mg or 20 mg) for 16 weeks. There were 320 responders (68%) who were randomised to change to placebo (n=157) or to continue with escitalopram (at the assigned dose) for further 24 weeks (n=163). The primary analysis (time to relapse) showed a clear beneficial effect of escitalopram relative to placebo (log-rank test, p<0.001). The proportion of patients who relapsed was statistically significantly higher in the placebo group (52%) than in the escitalopram group (23%) (p<0.001, chi-square test). The risk of relapse was 2.74 times higher for placebo- than for escitalopram-treated patients (chi-square test, p<0.001). Escitalopram was well tolerated.
Escitalopram was effective in preventing relapse of OCD and was well tolerated as continuation treatment.
Adjustment disorder with anxiety (ADWA) is a highly prevalent condition, particularly in primary care practice. Adjustment disorders significantly impair patients’ quality of life, but there are relatively few systematic treatment trials in the area of ADWA, and there are few data on predictors of treatment response. Here we review the limited pharmacotherapy data available on the treatment of ADWA. In primary care settings benzodiazepines are frequently prescribed for psychiatric symptoms, despite their adverse event profile and their potential risk for dependence. The non-benzodiazepine drug etifoxine is a promising agent insofar as it is not associated with dependence. Its efficacy and safety have been evaluated in three double-blind randomized clinical trials in comparison with non-benzodiazepine (buspirone) and benzodiazepines (lorazepam and alprazolam) . The three trials point to the anxiolytic properties of etifoxine, demonstrating an overall clinical improvement of patients, and no risk for dependence or rebound effect. In conclusion, even if benzodiazepines are often used for the treatment of ADWA, other therapeutic options are possible, with a better safety profile.
Two common approaches to identify subgroups of patients with bipolar disorder are clustering methodology (mixture analysis) based on the age of onset, and a birth cohort analysis. This study investigates if a birth cohort effect will influence the results of clustering on the age of onset, using a large, international database.
The database includes 4037 patients with a diagnosis of bipolar I disorder, previously collected at 36 collection sites in 23 countries. Generalized estimating equations (GEE) were used to adjust the data for country median age, and in some models, birth cohort. Model-based clustering (mixture analysis) was then performed on the age of onset data using the residuals. Clinical variables in subgroups were compared.
There was a strong birth cohort effect. Without adjusting for the birth cohort, three subgroups were found by clustering. After adjusting for the birth cohort or when considering only those born after 1959, two subgroups were found. With results of either two or three subgroups, the youngest subgroup was more likely to have a family history of mood disorders and a first episode with depressed polarity. However, without adjusting for birth cohort (three subgroups), family history and polarity of the first episode could not be distinguished between the middle and oldest subgroups.
These results using international data confirm prior findings using single country data, that there are subgroups of bipolar I disorder based on the age of onset, and that there is a birth cohort effect. Including the birth cohort adjustment altered the number and characteristics of subgroups detected when clustering by age of onset. Further investigation is needed to determine if combining both approaches will identify subgroups that are more useful for research.
Obsessive-compulsive disorder (OCD) is a highly disabling condition, with frequent early onset. Adult/adolescent OCD has been extensively investigated, but little is known about prevalence and clinical characterization of geriatric patients with OCD (G-OCD = 65 years). The present study aimed to assess prevalence of G-OCD and associated socio-demographic and clinical correlates in a large international sample.
Data from 416 outpatients, participating in the ICOCS network, were assessed and categorized into 2 groups, age < vs = 65 years, and then divided on the basis of the median age of the sample (age < vs = 42 years). Socio-demographic and clinical variables were compared between groups (Pearson Chi-squared and t tests).
G-OCD compared with younger patients represented a significant minority of the sample (6% vs 94%, P < .001), showing a significantly later age at onset (29.4 ± 15.1 vs 18.7 ± 9.2 years, P < .001), a more frequent adult onset (75% vs 41.1%, P < .001) and a less frequent use of cognitive-behavioural therapy (CBT) (20.8% vs 41.8%, P < .05). Female gender was more represented in G-OCD patients, though not at a statistically significant level (75% vs 56.4%, P = .07). When the whole sample was divided on the basis of the median age, previous results were confirmed for older patients, including a significantly higher presence of women (52.1% vs 63.1%, P < .05).
G-OCD compared with younger patients represented a small minority of the sample and showed later age at onset, more frequent adult onset and lower CBT use. Age at onset may influence course and overall management of OCD, with additional investigation needed.
Despite the progress made in HIV treatment and prevention, HIV remains a major cause of adolescent morbidity and mortality in sub-Saharan Africa. As perinatally infected children increasingly survive into adulthood, the quality of life and mental health of this population has increased in importance. This review provides a synthesis of the prevalence of mental health problems in this population and explores associated factors. A systematic database search (Medline, PsycINFO, Scopus) with an additional hand search was conducted. Peer-reviewed studies on adolescents (aged 10–19), published between 2008 and 2019, assessing mental health symptoms or psychiatric disorders, either by standardized questionnaires or by diagnostic interviews, were included. The search identified 1461 articles, of which 301 were eligible for full-text analysis. Fourteen of these, concerning HIV-positive adolescents, met the inclusion criteria and were critically appraised. Mental health problems were highly prevalent among this group, with around 25% scoring positive for any psychiatric disorder and 30–50% showing emotional or behavioral difficulties or significant psychological distress. Associated factors found by regression analysis were older age, not being in school, impaired family functioning, HIV-related stigma and bullying, and poverty. Social support and parental competence were protective factors. Mental health problems among HIV-positive adolescents are highly prevalent and should be addressed as part of regular HIV care.
Intermittent explosive disorder (IED) is characterised by impulsive anger attacks that vary greatly across individuals in severity and consequence. Understanding IED subtypes has been limited by lack of large, general population datasets including assessment of IED. Using the 17-country World Mental Health surveys dataset, this study examined whether behavioural subtypes of IED are associated with differing patterns of comorbidity, suicidality and functional impairment.
IED was assessed using the Composite International Diagnostic Interview in the World Mental Health surveys (n = 45 266). Five behavioural subtypes were created based on type of anger attack. Logistic regression assessed association of these subtypes with lifetime comorbidity, lifetime suicidality and 12-month functional impairment.
The lifetime prevalence of IED in all countries was 0.8% (s.e.: 0.0). The two subtypes involving anger attacks that harmed people (‘hurt people only’ and ‘destroy property and hurt people’), collectively comprising 73% of those with IED, were characterised by high rates of externalising comorbid disorders. The remaining three subtypes involving anger attacks that destroyed property only, destroyed property and threatened people, and threatened people only, were characterised by higher rates of internalising than externalising comorbid disorders. Suicidal behaviour did not vary across the five behavioural subtypes but was higher among those with (v. those without) comorbid disorders, and among those who perpetrated more violent assaults.
The most common IED behavioural subtypes in these general population samples are associated with high rates of externalising disorders. This contrasts with the findings from clinical studies of IED, which observe a preponderance of internalising disorder comorbidity. This disparity in findings across population and clinical studies, together with the marked heterogeneity that characterises the diagnostic entity of IED, suggests that it is a disorder that requires much greater research.
Epidemiological studies indicate that individuals with one type of mental disorder have an increased risk of subsequently developing other types of mental disorders. This study aimed to undertake a comprehensive analysis of pair-wise lifetime comorbidity across a range of common mental disorders based on a diverse range of population-based surveys.
The WHO World Mental Health (WMH) surveys assessed 145 990 adult respondents from 27 countries. Based on retrospectively-reported age-of-onset for 24 DSM-IV mental disorders, associations were examined between all 548 logically possible temporally-ordered disorder pairs. Overall and time-dependent hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox proportional hazards models. Absolute risks were estimated using the product-limit method. Estimates were generated separately for men and women.
Each prior lifetime mental disorder was associated with an increased risk of subsequent first onset of each other disorder. The median HR was 12.1 (mean = 14.4; range 5.2–110.8, interquartile range = 6.0–19.4). The HRs were most prominent between closely-related mental disorder types and in the first 1–2 years after the onset of the prior disorder. Although HRs declined with time since prior disorder, significantly elevated risk of subsequent comorbidity persisted for at least 15 years. Appreciable absolute risks of secondary disorders were found over time for many pairs.
Survey data from a range of sites confirms that comorbidity between mental disorders is common. Understanding the risks of temporally secondary disorders may help design practical programs for primary prevention of secondary disorders.
Research on post-traumatic stress disorder (PTSD) course finds a substantial proportion of cases remit within 6 months, a majority within 2 years, and a substantial minority persists for many years. Results are inconsistent about pre-trauma predictors.
The WHO World Mental Health surveys assessed lifetime DSM-IV PTSD presence-course after one randomly-selected trauma, allowing retrospective estimates of PTSD duration. Prior traumas, childhood adversities (CAs), and other lifetime DSM-IV mental disorders were examined as predictors using discrete-time person-month survival analysis among the 1575 respondents with lifetime PTSD.
20%, 27%, and 50% of cases recovered within 3, 6, and 24 months and 77% within 10 years (the longest duration allowing stable estimates). Time-related recall bias was found largely for recoveries after 24 months. Recovery was weakly related to most trauma types other than very low [odds-ratio (OR) 0.2–0.3] early-recovery (within 24 months) associated with purposefully injuring/torturing/killing and witnessing atrocities and very low later-recovery (25+ months) associated with being kidnapped. The significant ORs for prior traumas, CAs, and mental disorders were generally inconsistent between early- and later-recovery models. Cross-validated versions of final models nonetheless discriminated significantly between the 50% of respondents with highest and lowest predicted probabilities of both early-recovery (66–55% v. 43%) and later-recovery (75–68% v. 39%).
We found PTSD recovery trajectories similar to those in previous studies. The weak associations of pre-trauma factors with recovery, also consistent with previous studies, presumably are due to stronger influences of post-trauma factors.
Sexual assault is a global concern with post-traumatic stress disorder (PTSD), one of the common sequelae. Early intervention can help prevent PTSD, making identification of those at high risk for the disorder a priority. Lack of representative sampling of both sexual assault survivors and sexual assaults in prior studies might have reduced the ability to develop accurate prediction models for early identification of high-risk sexual assault survivors.
Data come from 12 face-to-face, cross-sectional surveys of community-dwelling adults conducted in 11 countries. Analysis was based on the data from the 411 women from these surveys for whom sexual assault was the randomly selected lifetime traumatic event (TE). Seven classes of predictors were assessed: socio-demographics, characteristics of the assault, the respondent's retrospective perception that she could have prevented the assault, other prior lifetime TEs, exposure to childhood family adversities and prior mental disorders.
Prevalence of Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) PTSD associated with randomly selected sexual assaults was 20.2%. PTSD was more common for repeated than single-occurrence victimization and positively associated with prior TEs and childhood adversities. Respondent's perception that she could have prevented the assault interacted with history of mental disorder such that it reduced odds of PTSD, but only among women without prior disorders (odds ratio 0.2, 95% confidence interval 0.1–0.9). The final model estimated that 40.3% of women with PTSD would be found among the 10% with the highest predicted risk.
Whether counterfactual preventability cognitions are adaptive may depend on mental health history. Predictive modelling may be useful in targeting high-risk women for preventive interventions.
The suicide rate has increased significantly among US Army soldiers over the past decade. Here we report the first results from a large psychological autopsy study using two control groups designed to reveal risk factors for suicide death among soldiers beyond known sociodemographic factors and the presence of suicide ideation.
Informants were next-of-kin and Army supervisors for: 135 suicide cases, 137 control soldiers propensity-score-matched on known sociodemographic risk factors for suicide and Army history variables, and 118 control soldiers who reported suicide ideation in the past year.
Results revealed that most (79.3%) soldiers who died by suicide have a prior mental disorder; mental disorders in the prior 30-days were especially strong risk factors for suicide death. Approximately half of suicide decedents tell someone that they are considering suicide. Virtually all of the risk factors identified in this study differed between suicide cases and propensity-score-matched controls, but did not significantly differ between suicide cases and suicide ideators. The most striking difference between suicides and ideators was the presence in the former of an internalizing disorder (especially depression) and multi-morbidity (i.e. 3+ disorders) in the past 30 days.
Most soldiers who die by suicide have identifiable mental disorders shortly before their death and tell others about their suicidal thinking, suggesting that there are opportunities for prevention and intervention. However, few risk factors distinguish between suicide ideators and decedents, pointing to an important direction for future research.