Developing a Behavioural Health Readiness & Suicide Risk Reduction Review for Military Personnel

Research Paper Title

Development of the US Army’s Suicide Prevention Leadership Tool: The Behavioural Health Readiness and Suicide Risk Reduction Review (R4).


Although numerous efforts have aimed to reduce suicides in the US Army, completion rates have remained elevated.

Army leaders play an important role in supporting soldiers at risk of suicide, but existing suicide-prevention tools tailored to leaders are limited and not empirically validated.

The purpose of this article is to describe the process used to develop the Behavioral Health Readiness and Suicide Risk Reduction Review (R4) tools for Army leaders that are currently undergoing empirical validation with two US Army divisions.


Consistent with a Secretary of the Army directive, approximately 76 interviews and focus groups were conducted with Army leaders and subject matter experts (SMEs) to obtain feedback regarding existing practices for suicide risk management, leader tools, and institutional considerations.

In addition, reviews of the empirical literature regarding predictors of suicide and best practices for the development of practice guidelines were conducted. Qualitative feedback, empirical predictors of suicide, and design considerations were integrated to develop the R4 tools.

A second series of 11 interviews and focus groups with Army leaders and SMEs was also conducted to validate the design and obtain feedback regarding the R4 tools.


Leaders described preferences for:

  • Tool processes (e.g. incorporating engaged leadership, including multiple risk identification methods);
  • Formatting (e.g. one page);
  • Organisation (e.g. low-intermediate-high risk scoring system);
  • Content (e.g. excluding other considerations related to vehicle safety, including readiness implications); and
  • Implementation (e.g. accounting for leadership judgement, tailoring process to specific leadership echelons, consideration of institutional barriers).

Evidence-based predictors of suicide risk and practice guideline considerations (e.g. design) were integrated with leadership feedback to develop the R4 tools that were tailored to specific leadership echelons.

Leaders provided positive feedback regarding the R4 tools and described the importance of accounting for potential institutional barriers to implementation. This feedback was addressed by including recommendations regarding the implementation of standardized support meetings between different echelons of leadership.


The R4 development process entailed the simultaneous integration of leadership feedback with evidence-based predictors of suicide risk and design considerations.

Thus, the development of these tools builds upon previous Army leadership tools by specifically tailoring elements of those tools to accommodate leader preferences, accounting for potential implementation barriers (e.g. institutional factors), and empirically evaluating the implementation of those tools.

Future studies should consider utilising a similar process to develop empirically based resources that are more likely to be incorporated into the routine practice of leaders supporting soldiers at risk of suicide, very often located at the company level and below.


Curley, J.M., Penix, E.A., Srinivasan, J., Sarmiento, D.S., McFarling, L.H., Newman, J.B. & Wheeler, L.A. (2020) Development of the U.S. Army’s Suicide Prevention Leadership Tool: The Behavioral Health Readiness and Suicide Risk Reduction Review (R4). Military Medicine. 185(5-6), pp.e668-e677. doi: 10.1093/milmed/usz380.

What are the Key Tenets for Developing a Unit-Based Army Resilience Programme?

Research Paper Title

The Process of Developing a Unit-Based Army Resilience Programme.


The researchers review military doctrine, military public health data, medical literature, and educational literature with the intent of condensing key precepts into a succinct, pragmatic description of the essential steps for leaders looking to build a resilience programme to provide secondary prevention services.


Although there continues to be a shortage of high-level evidence in support of specific preventive programmes, there are numerous large-scale reviews of prevention and health promotion efforts.

When combined with population-specific analyses, several essential concepts emerge as most relevant for smaller-scale prevention programmes.


The key tenets that programme leaders should embrace to optimise programme effectiveness include:

  • Utilisation of an instructional design approach;
  • Focus on evidence-based practices, and
  • Teaching resilience skills in order to decrease risk factors and increase protective factors for improved mental health outcomes.


Dragonetti, J.D., Gifford, T.W. & Yang, M.S. (2020) The Process of Developing a Unit-Based Army Resilience Program. Current Psychiatry Reports. 22(9), pp.48. doi: 10.1007/s11920-020-01169-w.

Substance Use & Intervention Programmes: Remember to Address Social Issues Regardless of Deployment History

Research Paper Title

Problems With Social Acceptance and Social Victimization Predict Substance Use Among U.S. Reserve/Guard Soldiers.


The effects of negative social interactions/experiences on substance use have largely been studied in civilian populations, but less is known about United States Army Reserve/National Guard (USAR/NG) soldiers-a high-risk group.


The researchers examined the associations between problems with social acceptance, social victimisation, and substance use among USAR/NG soldiers, and examined potential differences by deployment history.

The sample consisted of soldiers who completed baseline and 1-year follow-up assessments (N = 445) of Operation: SAFETY, an ongoing study of USAR/NG soldiers.

They examined the effects of baseline problems with social acceptance/social victimization on nonmedical use of prescription drugs (NMUPD), illicit drug use, frequent heavy drinking (FHD), and alcohol problems at follow-up.


Significant effects were small in magnitude but consistent in direction.

Greater problems with social acceptance were associated with higher odds of NMUPD and illicit drug use.

Greater social victimisation was associated with higher odds of NMUPD and illicit drug use.

There were no differences by deployment history.


Problems with social acceptance/social victimisation were not associated with FHD or alcohol problems.

Problems with social acceptance/social victimisation may contribute to drug use among USAR/NG soldiers.

Intervention programmes should address social issues, regardless of deployment history.


Hoopsick, R.A., Vest, B.M., Homish, D.L. & Homish, G.G. (2020) Problems With Social Acceptance and Social Victimization Predict Substance Use Among U.S. Reserve/Guard Soldiers. Stress and Health. doi: 10.1002/smi.2934. Online ahead of print.

Are Soldiers-in-training Likely to Seek Help when Experiencing a Problem?

Research Paper Title

Identifying Risk and Resilience Factors Associated With the Likelihood of Seeking Mental Health Care Among U.S. Army Soldiers-in-Training


The Department of Defence aims to maintain mission readiness of its service members. Therefore, it is important to understand factors associated with treatment seeking in order to identify areas of prevention and intervention early in a soldier’s career that can promote positive functioning and increase their likelihood of seeking mental health care when necessary.


Using a theory of planned behaviour lens, this study identified potential barriers (risk) and facilitators (resilience) to treatment seeking among 24,717 soldiers-in-training who participated in the New Soldiers Study component of the “Army Study to Assess Risk and Resilience in Servicemembers” (Army STARRS). Hierarchal linear regression modelling and independent samples t-tests were used to examine associations between demographics and study variables, intersections of risk and resilience, and to explore differences in the likelihood of seeking help based on mental health diagnoses.


A four-stage hierarchical linear regression was conducted, using likelihood of help-seeking as the dependent variable, to identify the most salient factors related to help-seeking. “Step one” of the analysis revealed soldiers-in-training who identified as female, Hispanic or Other ethnicity, and married, divorced, or separated reported a greater likelihood of seeking help. “Step two” of the analysis indicated soldiers-in-training with a history of sexual trauma, experience of impaired parenting, and clinical levels of mental health symptomatology (anxiety, depression, PTSD) reported a greater likelihood of seeking help.

Inversely, soldiers-in-training with a history of emotional trauma and parental absence/separation reported a lower likelihood of seeking help. “Step three” of the analysis demonstrated soldiers-in-training with a prior history of seeking help and larger social networks had a greater likelihood of seeking help. “Step four” of the analysis revealed several interactive effects between risk and resilience factors.

Specifically, soldiers-in-training who reported greater depressive symptomatology in combination with prior history of treatment seeking reported a greater likelihood of help seeking, whereas soldiers-in-training who reported prior sexual trauma and PTSD in combination with large social networks reported a lower likelihood of seeking help. Finally, a greater percentage of soldiers-in-training with clinical levels of anxiety, depression, and PTSD indicated they would likely seek help in comparison to soldiers-in-training without clinical symptoms.


Findings suggest few soldiers-in-training are likely to seek help when experiencing a problem. General efforts to encourage help-seeking when needed are warranted with particular focus on subsets of soldiers-in-training (e.g., men, those with a history of some adverse childhood experiences).

Strengths of this study include the examination of a large sample of soldiers-in-training to identify possible leverage points for early intervention or prevention prior to entering stressful military operating environments.

Limitations of this study include the examination of only one military branch and exclusion of soldiers not “in-training.”

Future studies could consider replicating the current study using a sample of military personnel longitudinally to track behavioral trends as well as looking at military populations outside of basic combat training.


Duncan, J.M., Reed-Fitzke, K., Ferraro, A.J., Wojciak, A.S., Smith, K.M. & Sanchez, K. (2020) Identifying Risk and Resilience Factors Associated With the Likelihood of Seeking Mental Health Care Among U.S. Army Soldiers-in-Training. Military Medicine. doi: 10.1093/milmed/usz483. Online ahead of print.

Can a New Blood Test Help Identify Troops & Veterans with PTSD?

Medical professionals could potentially one day identify veterans with post-traumatic stress disorder (PTSD) through a quick blood test instead of complex psychological tests, thanks to new research from the
US Army and outside biometrics experts.

The study, which appeared in the journal Molecular Psychiatry, found a set of 27 blood markers which helped identify patients suffering from PTSD.

Researchers said the findings support past hypotheses that the disorder “affects not just the brain, but the entire body.”

In a statement, US Army Medical Research Systems Biology Chief Scientist Marti Jett said those markers “will continue to be refined and adapted for commercialisation” in coming years.

Researchers are hopeful blood tests can lead not only to more accurate diagnoses but also earlier ones, perhaps indicating signs of problems even before PTSD has fully manifested.

Senior study author Dr. Charles Marmar, chair of the Department of Psychiatry at the New York University School of Medicine, said a blood test could indicate signs of PTSD that veterans are unaware of or deliberately hiding out of fear surrounding the stigma of the diagnosis. It could also more quickly eliminate PTSD as a potential problem for patients with unclear medical issues.

“This is an attempt to take the field of psychiatry from the subjective to the objective,” he said. “It’s a way to start a new conversation about how to find the invisible wounds of war.”

But the study has limits. No women were among the veterans tracked for the research, and no civilians were included. Marmar said creating a simple, inexpensive blood test for widespread use to help diagnose PTSD is likely still years away. But he still lauded the findings as an important medical breakthrough for health experts looking for ways to more accurately track troops’ health.

Defence Department and Veterans Affairs researchers have estimated that as many as 25% of individuals who served in combat zones in Iraq or Afghanistan may suffer from PTSD, marked by uncontrolled anxiety, confusion or anger.

Officials have spent years trying to break down the stigma surrounding the diagnosis, which many service members fear could render them undeployable or otherwise unfit for duty because of the non-physical nature of the symptoms.

The study, the culmination of six years of work, tracked blood samples from 165 veterans, half of whom suffer from PTSD following deployments into war zones.

Scientists studied their medical histories and biochemistry, trimming down the list of potential identifying characteristics in their blood from more
than 1 million to less than 30.

In subsequent tests with other patients, the final set of blood markers showed a 77% accuracy rate in helping identify PTSD. Marmar said that is more than enough for a potential screening test, where medical professionals can follow up with more in-depth
examinations to diagnose the illness.

Past studies have hinted at blood markers as a potential indicator of PTSD, but researchers in the new study which included the Harvard John A. Paulson School of Engineering and Applied Sciences and the US Army Medical Research and Development Command said this is the first time a coherent set of measures has been developed.

Jett said that any screening tool that comes from the research would be used before and after deployments, and treatment for those issues would be provided based on military medical standards.

The full study is available on the journal’s website @