In the late 1940s, the National Heart Institute (now called the National Heart, Lung, and Blood Institute) launched the Framingham Heart Study, a longitudinal research project to investigate the biological precursors of cardiovascular disease. This study, still going strong, has informed much of what we know about the underlying risks of heart disease and stroke, as well as what we can do to best prevent and treat it. Now the U.S. Army, partnered with the National Institute of Mental Health (NIMH), is embarking on the Army Study To Assess Risk and Resilience in Servicemembers (STARRS), an ambitious series of research studies they hope will one day be considered the Framingham Heart Study of suicide and mental health. Its goal: To find reliable biomarkers for compromised mental health.
In 2008, Army leaders realized that soldier suicides were growing to epidemic proportions, and quickly overtaking the civilian rate. Unfortunately, this trend has continued. The military reported 22 active duty soldiers took their own lives in the month of July 2011—the highest number on record to date.
“We knew back in 2008 that we had to take decisive action,” says Lt. Col. Steve Warren, a spokesperson for the Army’s Vice Chief of Staff Gen. Peter Chiarelli, the driving force behind the STARRS study. “We formed a suicide prevention task force, and soon realized that there just isn’t a lot of research into what causes people in general, or soldiers in particular, to take their own lives. We knew we needed to learn more.”
Gen. Chiarelli and colleagues at the Pentagon contacted Thomas Insel, the NIMH's director, to help learn more about suicide and the brain. As the Army and experts from the NIMH met and discussed the suicide epidemic, they soon realized there was not any single factor driving the increased suicide rate in the military.
“We started with this notion that the increased suicide rates were basically driven by a single factor—and we all had our opinions about what that factor might be,” says Insel, who is also a member of the Dana Alliance for Brain Initiatives. “There were a lot of ideas floating around, especially regarding deployments and time in theater, but we soon realized what we really needed to do was back up and get more information about both risk and resilience in a broad way. And someone said, ‘Hey, this sounds a lot like the Framingham study.’”
The historic Framingham study, a study of risk and resilience in regards to cardiovascular health and disease, began in 1948. Researchers have tracked more than 5,000 people from the city of Framingham, MA, over several decades and, in the process, discovered many risk factors for later stroke and heart attack.
“This one study really transformed the way we think about risk factors in cardiovascular disease,” says Insel. “And it became our model for thinking about how to approach suicide mortality in the Army. In essence, it’s the framework for the STARRS project.”
Looking back to move forward
Suicide, however, is not as common as heart disease. To begin such an ambitious research project, the STARRS researchers soon realized they needed a sound jumping-off point for future work. They decided to take a closer look at the 389 servicemembers who had already committed suicide. They conducted what they termed “psychological autopsies,” delving into these soldiers’ histories to see if there were any common patterns or risk factors.
“It was like a typical mystery, in a sense. We found some very interesting things, surprising things,” says Insel. “Being married seems to be protective against suicide—but only during deployment and only in men. Soldiers who classify as Asian appear to have a higher risk. And one of the most interesting things to me was that, in 2008 and 2009, the suicide rate for servicemembers who had never deployed began to rise. As I said, in the beginning, we had all these ideas of how to explain the growing suicide rate but we soon learned that it was a little more complicated than that.”
Searching for biomarkers
Ultimately, the STARRS team would like to develop a type of simple risk calculator that can help the military identify and help those servicemembers who may be at the highest risk for suicide. Murray Stein, a professor of psychiatry and family and preventive medicine at the University of California San Diego and co-principal investigator on the STARRS project, thinks there may be genetic biomarkers that could help do the trick. A part of the larger project, the New Soldier Study will collect blood, DNA, and neurocognitive measures from approximately 30,000 new recruits and then follow them over the course of their Army careers.
“These are really big numbers for a mental health study,” says Stein. “And by taking what we know about genetic risk factors for depression, aggression, and impulsivity, things that have been linked to suicidal ideation and suicide attempts, we have an idea of where we might look for important genetic markers. But we will also look across the entire genome in an unbiased way to see what other biomarkers there might be.”
Though some people have voiced concerns over how such a risk calculator might be used by the military, all of the parties involved with STARRS say that their goal is simple—identify those at the highest risk and help them before they take their own lives.
“If we know people are at high risk, the Army might be able to provide additional training or other interventions for lowering their risks before they went into combat,” says Stein. “It is all about discovering new ways to reduce risk.”
The STARRS project is nowhere close to being able to provide such a tool at this point. Still, both Insel and Warren believe that STARRS is going to provide invaluable information about suicide not only to the Army, but also to the population at large.
“The advances we’ve seen in prosthetics, trauma treatment, burn treatment, bleeding control—these are medical advances that were made possible by the military yet are applicable to everyone,” says Warren. “It’s our hope that what we discover during the course of the Army STARRS project will also be something that can inform the entire medical community and help everyone who has a stake in suicide prevention.”