Original article Suicide ideation severity is associated with severe suicide attempts in a military setting Leah Shelef a , Anat Brunstein Klomek b , Eyal Fruchter c , Ron Kedem d , J. John Mann e , Gil Zalsman e,f,g, * a Psychology Branch, Israeli Air Forces, Israel Defense Force, Ramat Gan, Israel b School of Psychology, Interdisciplinary Center Herzliya (IDC), Herzliya, Israel c Psychiatry & Mental Health Division, Rambam Health Care Campus, Haifa, Israel d Medical Corps, Israel Defense Forces, Israel e Division of Molecular Imaging and Neuropathology, Department of Psychiatry, Columbia University and New York State Psychiatric Institute, New York City, USA f Geha Mental Health Center of the Clalit HMO, Petah Tiqwa, Israel g Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel A R T I C L E I N F O Article history: Received 30 December 2018 Received in revised form 12 June 2019 Accepted 17 June 2019 Available online 6 July 2019 Keywords: Suicidal ideation Suicide attempted Intent Military Risk assessment A B S T R A C T Background: There is an ongoing debate on the effectiveness of suicidal behavior prevention measures in the military. The association of three widely used tools with severe suicide attempts was assessed in this setting. Methods: Thirty-nine Israeli soldiers (59% males), mean age 19 yrs., who attempted suicide during military service were divided into two groups: severe (n = 14; 35.9%) and moderate suicide attempts, and were assessed using the Scale for Suicide Ideation (SSI), Suicide Intent Scale (SIS) and the Columbia Suicide Severity Rating Scale (C-SSRS). Results: Seven items from the SSI (p = 0.008), two items from SIS and one item from C-SSRS were associated with severe suicide attempts. Kendall’s tau-b correlation with bootstrap demonstrated stability of these correlations. Conclusion: Greater severity of suicidal ideation was associated with more severe suicide attempts. The combination of male gender, available firearms and current severe suicide ideation is high-risk danger sign in a military setting, even when reported intent to die is low. © 2019 Elsevier Masson SAS. All rights reserved. 1. Introduction The increase in suicide rates in U.S. military personnel since 2003 has been dramatic [1,2] even compared to the steady increase in suicide rates of the general U.S. population [3]. Much effort has been expended to identify risk factors for preventing suicide in the U.S. military [4], and many prevention strategies have been employed. Some of the programs were quite successful as for example, a program implemented in the air- force [5] and in other units [6]. However, the suicide rate in the US military as a whole is still fairly constant. In contrast, in the Israel Defense Forces (IDF) the suicide rate has declined for the last 6 years [7,8] by almost 50%. Understanding the reasons for these trends may help improve suicide prevention approaches in the military sector and may have implications for preventing civilian suicides. In the IDF suicides and suicide attempts occur mostly 6 to 12 months after induction into military service [9–11]. One explana- tion for this timing of suicide attempts is that adjustment to military service, which is very different from civilian life, is a major stressor [12]. One expects this effect to be most obvious during the first six months of service, thus it is clear that additional factors are at work. Studies indicate that untreated psychiatric disorders play a critical role in suicidal behavior [13], among both, Israeli [8, 11] and U.S. military personnel [14–17]. Suicide risk assessment in both civilians [18, 19] and soldiers [14] is one of the most challenging tasks in clinical practice. Suicide risk is dynamic [20], fluctuating in response to both external events and internal subjective emotions and thoughts as well as over time. That makes predicting imminent risk of suicidal behavior difficult [21]. Abbreviations: C-SSRS, Columbia Suicide Severity Rating Scale; IDF, Israel Defense Forces; IRS, intelligence rating score; PCP, primary care physician; SA, Scholastic Ability; SIS, Suicide Intent Scale; SSI, Scale for Suicide Ideation. * Corresponding author at: Geha Mental Health Center, P.O. Box 102, Petach Tiqwa 49100, Israel. E-mail address: zalsman@tauex.teu.ac.il (G. Zalsman). http://dx.doi.org/10.1016/j.eurpsy.2019.06.005 0924-9338/© 2019 Elsevier Masson SAS. All rights reserved. European Psychiatry 61 (2019) 49–55 Contents lists available at ScienceDirect European Psychiatry journal homepage: http://www.europsy- journal.com