Resilience In Servicemembers Research Articles

Lifetime prevalence of DSM-IV mental disorders among new soldiers in the U.S. Army: results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).

The prevalence of 30-day mental disorders with retrospectively reported early onsets is significantly higher in the U.S. Army than among socio-demographically matched civilians. This difference could reflect high prevalence of preenlistment disorders and/or high persistence of these disorders in the context of the stresses associated with military service. These alternatives can to some extent be distinguished by estimating lifetime disorder prevalence among new Army recruits. The New Soldier Study (NSS) in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) used fully structured measures to estimate lifetime prevalence of 10 DSM-IV disorders in new soldiers reporting for Basic Combat Training in 2011-2012 (n = 38,507). Prevalence was compared to estimates from a matched civilian sample. Multivariate regression models examined socio-demographic correlates of disorder prevalence and persistence among new soldiers. Lifetime prevalence of having at least one internalizing, externalizing, or either type of disorder did not differ significantly between new soldiers and civilians, although three specific disorders (generalized anxiety, posttraumatic stress, and conduct disorders) and multimorbidity were significantly more common among new soldiers than civilians. Although several socio-demographic characteristics were significantly associated with disorder prevalence and persistence, these associations were uniformly weak. New soldiers differ somewhat, but not consistently, from civilians in lifetime preenlistment mental disorders. This suggests that prior findings of higher prevalence of current disorders with preenlistment onsets among soldiers than civilians are likely due primarily to a more persistent course of early-onset disorders in the context of the special stresses experienced by Army personnel.

Prevalence and correlates of suicidal behavior among new soldiers in the U.S. Army: results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).

The prevalence of suicide among U.S. Army soldiers has risen dramatically in recent years. Prior studies suggest that most soldiers with suicidal behaviors (i.e., ideation, plans, and attempts) had first onsets prior to enlistment. However, those data are based on retrospective self-reports of soldiers later in their Army careers. Unbiased examination of this issue requires investigation of suicidality among new soldiers. The New Soldier Study (NSS) of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) used fully structured self-administered measures to estimate preenlistment histories of suicide ideation, plans, and attempts among new soldiers reporting for Basic Combat Training in 2011-2012. Survival models examined sociodemographic correlates of each suicidal outcome. Lifetime prevalence estimates of preenlistment suicide ideation, plans, and attempts were 14.1, 2.3, and 1.9%, respectively. Most reported onsets of suicide plans and attempts (73.3-81.5%) occurred within the first year after onset of ideation. Odds of these lifetime suicidal behaviors among new soldiers were positively, but weakly associated with being female, unmarried, religion other than Protestant or Catholic, and a race/ethnicity other than non-Hispanic White, non-Hispanic Black, or Hispanic. Lifetime prevalence estimates of suicidal behaviors among new soldiers are consistent with retrospective reports of preenlistment prevalence obtained from soldiers later in their Army careers. Given that prior suicidal behaviors are among the strongest predictors of later suicides, consideration should be given to developing methods of obtaining valid reports of preenlistment suicidality from new soldiers to facilitate targeting of preventive interventions.

Potential Biomarker for Suicide Vulnerability Identified

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessPotential Biomarker for Suicide Vulnerability IdentifiedNick ZagorskiNick ZagorskiSearch for more papers by this authorPublished Online:14 Aug 2014https://doi.org/10.1176/appi.pn.2014.8b23AbstractElevated methylation of a stress response gene is identified in the blood of people manifesting suicidal behaviors and could be involved in suicide etiology.Only a fraction of people who experience powerful emotional events such as trauma, depression, or extreme stress have thoughts of suicide, and fewer still end up going through with it. Scientists have long been trying to find biological traits that may explain what makes some people more prone than others to think about or carry out suicide.Zachary Kaminsky, Ph.D., notes that evidence of elevated SKA2 methylation prior to suicidal ideation suggests these changes are not an artifact that appears after suicidal behaviors start manifesting.Johns HopkinsA gene known as SKA2 may hold some answers. Zachary Kaminsky, Ph.D., an assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, and colleagues analyzed the brain tissue of several people who had died by suicide and found higher than average levels of methylation around SKA2 compared with people who died by other means. Methylation is a chemical modification to a gene—an epigenetic change—that turns down that gene’s expression; so the more methyl groups on the SKA2 gene, the less SKA2 protein gets made. There has been growing evidence that epigenetic patterns associated with suicide are different from those associated with other types of deaths (Psychiatric News, May 3, 2013), but cause and effect cannot be teased out postmortem. However, in this study, which appeared online in AJP in Advance July 30, the research group also identified heightened SKA2 methylation in blood samples of living people who were considered at risk for suicidal behaviors due to diagnoses of major depression or bipolar disorder. “Individually, each of the groups we analyzed was pretty small, and every one had its own caveats,” said Kaminsky. “But as the same results kept rolling in across six different cohorts and two types of tissues, we thought there really is something going on here. And we saw evidence of elevated methylation prior to suicidal ideation, suggesting these changes are not an artifact that appears after suicidal behaviors start manifesting.” SKA2 makes a protein known as a chaperone; it grabs on to glucocorticoid receptors inside a cell and escorts them to the nucleus, which helps regulate a cell’s response to the stress hormone cortisol. Inhibiting SKA2 via methylation could reduce this careful regulation and amplify the effects of a stressful or traumatic event.Finding elevated SKA2 methylation in blood samples also suggests that this altered cortisol response is a systemic phenomenon—suicidal thoughts are not just in a person’s head. On a more practical note, detectable methylation changes in the blood lead to the potential of developing a simple blood test that might help measure suicide risk. Kaminsky’s group assessed this possibility using the blood samples. They found that, by itself, SKA2 methylation was not predictive of any future suicidal thoughts or actions. However, when the researchers developed a model combining SKA2 methylation and anxiety status, they could predict suicidal behavior with about 80 percent accuracy.“This is an intriguing study that identified a very meaningful gene,” said Eric Caine, M.D., the John Romano Professor of Psychiatry at the University of Rochester Medical Center. “However, before we get ahead of ourselves, we need to test this methodology and see if it applies in a larger, more general population.”Kaminsky also acknowledges the need for replication of results, and to that end is collaborating with the U.S. Army STARRS (Study To Assess Risk and Resilience in Servicemembers) project to get such data.“One of the biggest challenges in conducting suicide research is getting prospective samples,” he said. “STARRS offers a large repository of blood taken both pre- and post-deployment, which can offer a wealth of information to help us more accurately identify at-risk people.”Kaminsky also hopes to better understand how the excess methylation develops. This current study did find that some of the subjects analyzed also had a variant sequence in the SKA2 gene region that might favor methylation, but while some genetic-epigenetic connection may exist, Kaminsky noted that the methylation changes were far more consistent among people who had thought about or completed suicide. “Epigenetics is the driving force,” he said.This study was supported by the National Institute of Mental Health, National Institute on Drug Abuse, Johns Hopkins Center for Mental Health Initiatives, and others. ■An abstract of “Identification and Replication of a Combined Epigenetic and Genetic Biomarker Predicting Suicide and Suicidal Behaviors” can be accessed here. ISSUES NewArchived

Classifying U.S. Army Military Occupational Specialties using the Occupational Information Network.

To derive job condition scales for future studies of the effects of job conditions on soldier health and job functioning across Army Military Occupation Specialties (MOSs) and Areas of Concentration (AOCs) using Department of Labor (DoL) Occupational Information Network (O*NET) ratings. A consolidated administrative dataset was created for the "Army Study to Assess Risk and Resilience in Servicemembers" (Army STARRS) containing all soldiers on active duty between 2004 and 2009. A crosswalk between civilian occupations and MOS/AOCs (created by DoL and the Defense Manpower Data Center) was augmented to assign scores on all 246 O*NET dimensions to each soldier in the dataset. Principal components analysis was used to summarize these dimensions. Three correlated components explained the majority of O*NET dimension variance: "physical demands" (20.9% of variance), "interpersonal complexity" (17.5%), and "substantive complexity" (15.0%). Although broadly consistent with civilian studies, several discrepancies were found with civilian results reflecting potentially important differences in the structure of job conditions in the Army versus the civilian labor force. Principal components scores for these scales provide a parsimonious characterization of key job conditions that can be used in future studies of the effects of MOS/AOC job conditions on diverse outcomes.

The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

Importance/Objective: Although the suicide rate in the U.S. Army has traditionally been below age-gender matched civilian rates, it has climbed steadily since the beginning of the Iraq and Afghanistan conflicts and since 2008 has exceeded the demographically matched civilian rate. The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multicomponent epidemiological and neurobiological study designed to generate actionable evidence-based recommendations to reduce Army suicides and increase knowledge about risk and resilience factors for suicidality and its psychopathological correlates. This paper presents an overview of the Army STARRS component study designs and of recent findings.Design/Setting/Participants/Intervention: Army STARRS includes six main component studies: (1) the Historical Administrative Data Study (HADS) of Army and Department of Defense (DoD) administrative data systems (including records of suicidal behaviors) for all soldiers on active duty 2004—2009 aimed at finding administrative record predictors of suicides; (2) retrospective case-control studies of fatal and nonfatal suicidal behaviors (each planned to have n = 150 cases and n = 300 controls); (3) a study of new soldiers (n = 50,765 completed surveys) assessed just before beginning basic combat training (BCT) with self-administered questionnaires (SAQ), neurocognitive tests, and blood samples; (4) a cross-sectional study of approximately 35,000 (completed SAQs) soldiers representative of all other (i.e., exclusive of BCT) active duty soldiers; (5) a pre-post deployment study (with blood samples) of soldiers in brigade combat teams about to deploy to Afghanistan (n = 9,421 completed baseline surveys), with sub-samples assessed again one, three, and nine months after returning from deployment; and (6) a pilot study to follow-up SAQ respondents transitioning to civilian life. Army/DoD administrative data are being linked prospectively to the large-scale survey samples to examine predictors of subsequent suicidality and related mental health outcomes.Main outcome measures: Measures (self-report and administratively recorded) of suicidal behaviors and their psychopathological correlates.Results: Component study cooperation rates are comparatively high. Sample biases are relatively small. Inefficiencies introduced into parameter estimates by using nonresponse adjustment weights and time-space clustering are small. Initial findings show that the suicide death rate, which rose over 2004—2009, increased for those deployed, those never deployed, and those previously deployed. Analyses of administrative records show that those deployed or previously deployed were at greater suicide risk. Receiving a waiver to enter the Army was not associated with increased risk. However, being demoted in the past two years was associated with increased risk. Time in current deployment, length of time since return from most recent deployment, total number of deployments, and time interval between most recent deployments (known as dwell time) were not associated with suicide risk. Initial analyses of survey data show that 13.9% of currently active non-deployed regular Army soldiers considered suicide at some point in their lifetime, while 5.3% had made a suicide plan, and 2.4% had attempted suicide. Importantly, 47—60% of these outcomes first occurred prior to enlistment. Prior mental disorders, in particular major depression and intermittent explosive disorder, were the strongest predictors of these self-reported suicidal behaviors. Most onsets of plans-attempts among ideators (58.3—63.3%) occurred within the year of onset of ideation. About 25.1% of non-deployed U.S. Army personnel met 30-day criteria for a DSM-IV anxiety, mood, disruptive behavior, or substance disorder (15.0% an internalizing disorder; 18.4% an externalizing disorder) and 11.1% for multiple disorders. Importantly, three-fourths of these disorders had pre-enlistment onsets.Conclusions: Integration across component studies creates strengths going well beyond those in conventional applications of the same individual study designs. These design features create a strong methodological foundation from which Army STARRS can pursue its substantive research goals. The early findings reported here illustrate the importance of the study and its approach as a model of studying rare events particularly of national security concern. Continuing analyses of the data will inform suicide prevention for the U.S. Army.

Commentary on “The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)”: Army STARRS: A Framingham-Like Study of Psychological Health Risk Factors in Soldiers

Although historically the Army suicide rate has been significantly lower than the civilian rate, in 2004, the suicide and accidental death rates began trending upward. By 2008, the Army suicide rate had risen above the national average (20.2 per 100,000). In 2009, 160 active duty Soldiers took their lives, making suicide the third leading cause of death among the Army population. If accidental death, frequently the result of high-risk behavior, is included, then more Soldiers died by their own actions than in combat in 2009. The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) was thus created in 2009 to begin to address these problems. The Army STARRS project is a large consortium of seven different studies to develop data-driven methods for mitigating or preventing suicide behaviors and improving the overall mental health and behavioral functioning of Army Soldiers during and after their Army service. The first research articles from the Army STARRS project were published in late 2013 and early 2014. This work has already begun to outline important facets of risk in the military, and it is helping to drive an empirically derived approach to improvements in understanding mental disorders and risk behavior and to improve prevention and support of mental health and resilience. The Framingham Heart Study, started in the 1940s, marked a watershed event in utilizing large cross-sectional and prospective longitudinal collaborative research to identify and understand risk factors for cardiovascular disease. The Army STARRS project, through its collaborative, prospective, and robust innovative design and implementation, may provide the beginning of a similar scientific cohort in mental disorders. The work of this project will help understand biological and psychological aspects of military service, including those leading to suicide. When coupled with timely feedback to Army leadership, it permits near real-time steps to diagnose, mitigate, and manage emerging mental health issues and the root causes of risk and resilience in Army Soldiers, with potential impact extending across many traumatized populations—not unlike a parallel process that has markedly improved survival and recovery from physical combat wounds.

Predictors of Suicide and Accident Death in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multicomponent study designed to generate actionable recommendations to reduce Army suicides and increase knowledge of risk and resilience factors for suicidality. To present data on prevalence, trends, and basic sociodemographic and Army experience correlates of suicides and accident deaths among active duty Regular Army soldiers between January 1, 2004, and December 31, 2009, and thereby establish a foundation for future Army STARRS investigations. Analysis of trends and predictors of suicide and accident deaths using Army and Department of Defense administrative data systems. Participants were all members of the US Regular Army serving at any time between 2004 and 2009. Death by suicide or accident during active Army service. The suicide rate rose between 2004 and 2009 among never deployed and currently and previously deployed Regular Army soldiers. The accident death rate fell sharply among currently deployed soldiers, remained constant among the previously deployed, and trended upward among the never deployed. Increased suicide risk was associated with being a man (or a woman during deployment), white race/ethnicity, junior enlisted rank, recent demotion, and current or previous deployment. Sociodemographic and Army experience predictors were generally similar for suicides and accident deaths. Time trends in these predictors and in the Army's increased use of accession waivers (which relaxed some qualifications for new soldiers) do not explain the rise in Army suicides. Predictors of Army suicides were largely similar to those reported elsewhere for civilians, although some predictors distinct to Army service emerged that deserve more in-depth analysis. The existence of a time trend in suicide risk among never-deployed soldiers argues indirectly against the view that exposure to combat-related trauma is the exclusive cause of the increase in Army suicides.

Suicide Risk Among Soldiers

Modeled after the FraminghamHeart Study, the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is designed to identify salient risk and protective factors regarding suicide, adverse mental health outcomes,andfunctionalimpairment. This groundbreaking initiative is investigating a wide range of domains, from large administrative data sets to behavioral, neurobiological, and genetic markers. It will certainly have a great impact on the field of psychiatry. The 3 articles1-3 published in this issue of JAMA Psychiatry are only the beginning. Schoenbaum et al1 report results from theHistorical AdministrativeData Study (HADS),which used the USArmy andDepartment of Defense administrative data systems to study deaths by suicides or accidents among approximately amillion Regular Army troopswho served between 2004 and 2009. Notably,members of themore vulnerableNationalGuardandArmyReservewerenot included.1Kessler et al2 and Nock et al3 report findings from the All Army Study (AAS), a cross-sectional survey of 5428 active duty soldiers who also provided consent for administrative data linkage. TheHADS suffers from the limitations of any administrative data set that can offer provocative findings and suggest intriguinghypothesis but cannot explore them ingreat depth. The AAS data were weighted because the data did not include informationondeployed soldiers or those inbasic training, andanother23.5%of soldiers couldnotcomplete thequestionnaire owing to conflictingduty assignments. For themost part, the weighted data compared very well with the target population of all US Army personnel. Rather than discuss each study separately, I will synthesize the information fromall 3 studies.1-3 Tome, themost striking findingsconcernsuicidesamongnondeployedsoldiers and the effect of a pre-enlistment psychiatric disorder on suicidal behavior, psychiatric morbidity, and functional impairment. These findings havemajor implications for screening, assessment, recruitment, and retention of volunteers seeking military enlistment.

Army Learning Complex FactorsAssociated With Soldier Suicides

Army Learning Complex FactorsAssociated With Soldier Suicides

Sociodemographic and career history predictors of suicide mortality in the United States Army 2004-2009.

The US Army suicide rate has increased sharply in recent years. Identifying significant predictors of Army suicides in Army and Department of Defense (DoD) administrative records might help focus prevention efforts and guide intervention content. Previous studies of administrative data, although documenting significant predictors, were based on limited samples and models. A career history perspective is used here to develop more textured models. The analysis was carried out as part of the Historical Administrative Data Study (HADS) of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). De-identified data were combined across numerous Army and DoD administrative data systems for all Regular Army soldiers on active duty in 2004-2009. Multivariate associations of sociodemographics and Army career variables with suicide were examined in subgroups defined by time in service, rank and deployment history. Several novel results were found that could have intervention implications. The most notable of these were significantly elevated suicide rates (69.6-80.0 suicides per 100000 person-years compared with 18.5 suicides per 100000 person-years in the total Army) among enlisted soldiers deployed either during their first year of service or with less than expected (based on time in service) junior enlisted rank; a substantially greater rise in suicide among women than men during deployment; and a protective effect of marriage against suicide only during deployment. A career history approach produces several actionable insights missed in less textured analyses of administrative data predictors. Expansion of analyses to a richer set of predictors might help refine understanding of intervention implications.

Clinical reappraisal of the Composite International Diagnostic Interview Screening Scales (CIDI-SC) in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).

A clinical reappraisal study was carried out in conjunction with the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) All-Army Study (AAS) to evaluate concordance of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses based on the Composite International Diagnostic Interview Screening Scales (CIDI-SC) and post-traumatic stress disorder (PTSD) checklist (PCL) with diagnoses based on independent clinical reappraisal interviews (Structured Clinical Interview for DSM-IV [SCID]). Diagnoses included: lifetime mania/hypomania, panic disorder, and intermittent explosive disorder; six-month adult attention-deficit/hyperactivity disorder; and 30-day major depressive episode, generalized anxiety disorder, PTSD, and substance (alcohol or drug) use disorder (abuse or dependence). The sample (n = 460) was weighted for over-sampling CIDI-SC/PCL screened positives. Diagnostic thresholds were set to equalize false positives and false negatives. Good individual-level concordance was found between CIDI-SC/PCL and SCID diagnoses at these thresholds (area under curve [AUC] = 0.69-0.79). AUC was considerably higher for continuous than dichotomous screening scale scores (AUC = 0.80-0.90), arguing for substantive analyses using not only dichotomous case designations but also continuous measures of predicted probabilities of clinical diagnoses.

Design of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).

The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multi-component epidemiological and neurobiological study designed to generate actionable evidence-based recommendations to reduce US Army suicides and increase basic knowledge about the determinants of suicidality. This report presents an overview of the designs of the six components of the Army STARRS. These include: an integrated analysis of the Historical Administrative Data Study (HADS) designed to provide data on significant administrative predictors of suicides among the more than 1.6 million soldiers on active duty in 2004-2009; retrospective case-control studies of suicide attempts and fatalities; separate large-scale cross-sectional studies of new soldiers (i.e. those just beginning Basic Combat Training [BCT], who completed self-administered questionnaires [SAQs] and neurocognitive tests and provided blood samples) and soldiers exclusive of those in BCT (who completed SAQs); a pre-post deployment study of soldiers in three Brigade Combat Teams about to deploy to Afghanistan (who completed SAQs and provided blood samples) followed multiple times after returning from deployment; and a platform for following up Army STARRS participants who have returned to civilian life. Department of Defense/Army administrative data records are linked with SAQ data to examine prospective associations between self-reports and subsequent suicidality. The presentation closes with a discussion of the methodological advantages of cross-component coordination.

Response bias, weighting adjustments, and design effects in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).

The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multi-component epidemiological and neurobiological study designed to generate actionable recommendations to reduce US Army suicides and increase knowledge about determinants of suicidality. Three Army STARRS component studies are large-scale surveys: one of new soldiers prior to beginning Basic Combat Training (BCT; n = 50,765 completed self-administered questionnaires); another of other soldiers exclusive of those in BCT (n = 35,372); and a third of three Brigade Combat Teams about to deploy to Afghanistan who are being followed multiple times after returning from deployment (n = 9421). Although the response rates in these surveys are quite good (72.0-90.8%), questions can be raised about sample biases in estimating prevalence of mental disorders and suicidality, the main outcomes of the surveys based on evidence that people in the general population with mental disorders are under-represented in community surveys. This paper presents the results of analyses designed to determine whether such bias exists in the Army STARRS surveys and, if so, to develop weights to correct for these biases. Data are also presented on sample inefficiencies introduced by weighting and sample clustering and on analyses of the trade-off between bias and efficiency in weight trimming.

Field procedures in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).

The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multi-component epidemiological and neurobiological study of unprecedented size and complexity designed to generate actionable evidence-based recommendations to reduce US Army suicides and increase basic knowledge about determinants of suicidality by carrying out coordinated component studies. A number of major logistical challenges were faced in implementing these studies. The current report presents an overview of the approaches taken to meet these challenges, with a special focus on the field procedures used to implement the component studies. As detailed in the paper, these challenges were addressed at the onset of the initiative by establishing an Executive Committee, a Data Coordination Center (the Survey Research Center [SRC] at the University of Michigan), and study-specific design and analysis teams that worked with staff on instrumentation and field procedures. SRC staff, in turn, worked with the Office of the Deputy Under Secretary of the Army (ODUSA) and local Army Points of Contact (POCs) to address logistical issues and facilitate data collection. These structures, coupled with careful fieldworker training, supervision, and piloting, contributed to the major Army STARRS data collection efforts having higher response rates than previous large-scale studies of comparable military samples.

Parallel psychometric and cognitive modeling analyses of the Penn Face Memory Test in the Army Study to Assess Risk and Resilience in Servicemembers

Objective: The psychometric properties of the Penn Face Memory Test (PFMT) were investigated in a large sample (4,236 participants) of U.S. Army Soldiers undergoing computerized neurocognitive testing. Data were drawn from the initial phase of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), a large-scale study directed towards identifying risk and resilience factors for suicidal behavior and other stress-related disorders in Army Soldiers. In this paper, we report parallel psychometric and cognitive modeling analyses of the PFMT to determine whether ability estimates derived from the measure are precise and valid indicators of memory in the Army STARRS sample. Method: Single-sample cross-validation methodology combined with exploratory factor and multidimensional item response theory techniques were used to explore the latent structure of the PFMT. To help resolve rotational indeterminacy of the exploratory solution, latent constructs were aligned with parameter estimates derived from an unequal-variance signal detection model. Results: Analyses suggest that the PFMT measures two distinct latent constructs, one associated with memory strength and one associated with response bias, and that test scores are generally precise indicators of ability for the majority of Army STARRS participants. Conclusions: These findings support the use of the PFMT as a measure of major constructs related to recognition memory and have implications for further cognitive–psychometric model development.

Introduction to the STAR*D Special Section

Introduction to the STAR*D Special Section