Suicidal Behavior in US Army Special Operations Forces.

Importance: Research on suicide risk among the US Army's elite special operations forces (SOF) has been extremely limited. Objective: To examine suicidal behaviors during the Iraq and Afghanistan war in the 2 major SOF elements: operators (ie, elite soldiers trained in unconventional warfare), and support personnel (ie, soldiers who assist operators and SOF missions). Design, Setting, and Participants: This retrospective cohort study of administrative data identified all operator, support, and other regular Army enlisted person-months from 2004 through 2012 with a first nonfatal suicide attempt and an equal-probability control sample. Separate case-control samples were drawn to examine suicide death and suicide ideation. Analyses were carried out from July 8, 2024, to May 27, 2025. Exposure: Serving as an SOF operator or support soldier. Main Outcomes and Measures: Suicide ideation and nonfatal suicide attempt were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes and Department of Defense Suicide Event Report records. Suicide death were identified using the Armed Forces Medical Examiner Tracking System. Sociodemographic, Army career, and mental health variables were constructed from administrative personnel and medical records. Results: The total weighted sample of regular Army enlisted soldiers was 48 103 189 person-months (41 717 105 male [86.7%]; mean [SD] age, 28.8 [8.6] years; 32 263 202 younger than aged 30 years [67.1%]). Operator suicide attempt crude rates were 70% lower than those of SOF support personnel (rate ratio [RR], 0.3; 95% CI, 0.2-0.3) and 90% lower than those of the total regular force (RR, 0.1; 95% CI, 0.1-0.2). Operator suicide ideation crude rates were 70% lower than rates for SOF support personnel (RR, 0.3; 95% CI, 0.2-0.3) and 80% lower than those of the total regular enlisted force (RR, 0.2; 95% CI, 0.1-0.2), whereas suicide death rates did not differ. The ratio of suicide attempts to suicide deaths was 2.1 (95% CI, 1.9-2.3) for operators, 7.6 (95% CI, 7.5-7.7) for support personnel, and 15.0 (95% CI, 15.0-15.0) for the total regular force. Adjusting for sociodemographic and Army career differences attenuated but did not eliminate operators' lower risk of suicide attempt and suicide ideation. In multivariable analyses, only 3 of 9 risk factors were associated with suicide attempt among both operators and support personnel: lower rank, past-year demotion, and mental health diagnosis during service. Odds were higher for female operators (OR, 7.4; 95% CI, 3.2-17.1). Sex was not associated with attempts among support personnel. Conclusions and Relevance: In this study of US regular Army enlisted soldiers during the Iraq and Afghanistan wars, SOF operators were less likely than other soldiers to engage in suicidal behavior, but it was more likely to be fatal when they did. Larger studies are needed to understand suicide risk among female operators.