MORBID THOUGHTS AND SUICIDAL IDEATION IN IRAQ WAR VETERANS: THE ROLE OF DIRECT AND INDIRECT KILLING IN COMBAT

Situational stress and suicide attempt behavior in Army soldiers and veterans: Insights from the Army Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study

INTRODUCTION

Prevention of suicide-related behaviors is considered a top clinical priority within the Departments of Veterans Affairs and Defense. Despite previous literature attesting to the likely importance of situational stress as a key correlate of acute changes in suicide risk, longitudinal research into associations between situational stress and suicide-related outcomes among military personnel has been relatively limited.

METHODS

The current study examined associations between situational stress, recent suicide attempt, and future suicide attempt using data from 14,508 Army soldiers and recently discharged veterans enrolled in the Army Study to Assess Risk and Resilience in Servicemembers-Longitudinal Studies (STARRS-LS).

RESULTS

Recent situational stress was more common among recently discharged veterans (vs. soldiers), those with a recent suicide attempt (vs. those without), and those with a subsequent suicide attempt (vs. those without). Job loss was more closely associated with suicide attempts among soldiers, whereas financial crisis, police contact, and death, illness, or injury of close others were more closely associated with suicide attempts among recently discharged veterans.

CONCLUSION

Findings further highlight situational stress as a salient risk factor for suicide-related outcomes among military personnel, particularly among recently discharged veterans. Implications for screening and treatment of at-risk military personnel are discussed.

Moral injury and peri- and post-military suicide attempts among post-9/11 veterans

BACKGROUND

Our goal was to examine the association between moral injury, mental health, and suicide attempts during military service and after separation by gender in post-9/11 veterans.

METHODS

A nationally representative sample of 14057 veterans completed a cross-sectional survey. To examine associations of exposure to potentially morally injurious events (PMIEs; witnessing, perpetrating, and betrayal) and suicidal self-directed violence, we estimated two series of multivariable logistic regressions stratified by gender, with peri- and post-military suicide attempt as the dependent variables.

RESULTS

PMIE exposure accounted for additional risk of suicide attempt during and after military service after controlling for demographic and military characteristics, current mental health status, and pre-military history of suicidal ideation and attempt. Men who endorsed PMIE exposure by perpetration were 50% more likely to attempt suicide during service and twice as likely to attempt suicide after separating from service. Men who endorsed betrayal were nearly twice as likely to attempt suicide during service; however, this association attenuated to non-significance after separation in the fully adjusted models. In contrast, women who endorsed betrayal were over 50% more likely to attempt suicide during service and after separation; PMIE exposure by perpetration did not significantly predict suicide attempts before or after service among women in the fully adjusted models.

CONCLUSIONS

Our findings indicate that suicide assessment and prevention programs should consider the impact of moral injury and attend to gender differences in this risk factor in order to provide the most comprehensive care.

Social Participation as a Predictor of Morbid Thoughts and Suicidal Ideation among the Elderly Population: A Cross-Sectional Study on Four Low-Middle-Income Countries

Social wellbeing constitutes a critical aspect of one’s health, quality of life, and overall psychosocial wellbeing. Social isolation and perceived loneliness are growing public health concerns as they are considered to be important risk factor for poor physical and mental health outcomes. Not much is known about how the level of one’s social participation is associated with morbid thought and suicidal ideation. In the present study, we aimed to investigate whether social participation shows any significant correlation with morbid thought and suicidal ideation among the elderly population. Methods: Cross-sectional data were collected from Wave 1 of the Study of Global AGEing and Adult Health (SAGE). The sample population consisted 2018 men and women aged 65 years and above from the following countries: China (n = 787), Ghana (n = 278), India (n = 560), and Russia (n = 396). Outcome variables of self-reported occurrence of morbid thoughts and suicide ideation during the past 12 months were reported. Results: A great majority of the participants reported not participating in activities such as public meetings (84.6%), club meeting (49.6%), neighborhood activities (46%), and religious activities (57.2%). Those who reported attending public meetings several times a year had a higher likelihood of reporting having morbid thoughts (predicted probability = 1.24, 95% CI = 1.02, 1.52). However, the association was no longer significant after stratifying by sex. Attending clubs (marginal effect = 0.61, 95% CI = 0.49, 0.76) and neighborhood activities (predicted probability = 0.71, 95% CI = 0.58, 0.88) several times a year showed protective effects against morbid thoughts. Being visited by friends several times a month (predicted probability = 0.52, 95% CI = 0.40, 0.67) and visiting friends (predicted probability = 0.61, 95% CI = 0.50, 0.75) several times a year also showed lower likelihood of morbid thoughts. Similar effects were observed for attending social gatherings with colleagues and social events as well. Conclusions: The present findings suggest that there exist significantly positive associations between participation in social activities and morbid thoughts and suicidal ideation among the elderly population in the sample countries. More in-depth studies are necessary to investigate the barriers to participation in social activities as well as the role of the quality of social relationships with experiencing suicidal thoughts.

Association of Combat Experiences With Suicide Attempts Among Active-Duty US Service Members

Importance

There is uncertainty about the role that military deployment experiences play in suicide-related outcomes. Most previous research has defined combat experiences broadly, and a limited number of cross-sectional studies have examined the association between specific combat exposure (eg, killing) and suicide-related outcomes.

Objective

To prospectively examine combat exposures associated with suicide attempts among active-duty US service members while accounting for demographic, military-specific, and mental health factors.

Design, Setting, and Participants

This cohort study analyzed data from the Millennium Cohort Study, an ongoing prospective longitudinal study of US service members from all military branches. Participants were enrolled in 4 phases from July 1, 2001, to April 4, 2013, and completed a self-administered survey at enrollment and every 3 to 5 years thereafter. The population for the present study was restricted to active-duty service members from the first 4 enrollment phases who deployed in support of the wars in Iraq and Afghanistan. Questionnaire data were linked with medical encounter data through September 30, 2015. Data analyses were conducted from January 10, 2017, to December 14, 2020.

Exposures

Combat exposure was examined in 3 ways (any combat experience, overall combat severity, and 13 individual combat experiences) using a 13-item self-reported combat measure.

Main Outcomes and Measures

Suicide attempts were identified from military electronic hospitalization and ambulatory medical encounter data using the International Classification of Diseases, Ninth Revision codes.

Results

Among 57 841 participants, 44 062 were men (76.2%) and 42 095 were non-Hispanic White individuals (72.8%), and the mean (SD) age was 26.9 (5.3) years. During a mean (SD) follow-up period of 5.6 (4.0) years, 235 participants had a suicide attempt (0.4%). Combat exposure, defined broadly, was not associated with suicide attempts in Cox proportional hazards time-to-event regression models after adjustments for demographic and military-specific factors; high combat severity and certain individual combat experiences were associated with an increased risk for suicide attempts. However, these associations were mostly accounted for by mental disorders, especially posttraumatic stress disorder. After adjustment for mental disorders, combat experiences with significant association with suicide attempts included being attacked or ambushed (hazard ratio [HR], 1.55; 95% CI, 1.16-2.06), seeing dead bodies or human remains (HR, 1.34; 95% CI, 1.01-1.78), and being directly responsible for the death of a noncombatant (HR, 1.81; 95% CI, 1.04-3.16).

Conclusions and Relevance

This study suggests that deployed service members who experience high levels of combat or are exposed to certain types of combat experiences (involving unexpected events or those that challenge moral or ethical norms) may be at an increased risk of a suicide attempt, either directly or mediated through a mental disorder.

Impact of specific combat experiences on suicidal ideation and suicide attempt in U.S. military veterans: Results from the National Health and Resilience in Veterans Study

BACKGROUND

A burgeoning body of research suggests that specific types of combat experiences may be a stronger predictor of suicidality among veterans than a history of combat exposure itself. To date, however, little population-based data exist about these associations in representative samples of veterans. This study examined the association between overall severity of combat exposure and specific combat experiences with suicidal ideation and suicide attempt(s) (SI/SA) in a nationally representative sample of combat veterans.

METHODS

Data were from the National Health and Resilience in Veterans Study, a nationally representative survey of U.S. combat veterans (n = 1100). Analyses (a) compared veterans with/without current SI and lifetime SA on sociodemographic, military, and clinical characteristics; and (b) examined associations between overall combat exposure and specific combat experiences, and SI/SA.

RESULTS

Hierarchical regression analyses revealed that overall combat exposure was positively, albeit weakly, associated with SI/SA, after adjusting for sociodemographic characteristics and lifetime trauma burden [odds ratios (ORs) = 1.02-1.03]. Combat experiences involving direct exposure to death, killing, or grave injury were independently associated with SI/SA (ORs = 1.46-1.70), whereas several general combat experiences (e.g., combat patrols) were negatively associated with SI/SA (ORs = 0.44-0.65).

DISCUSSION

Results indicate that U.S. combat veterans who have witnessed others be killed or wounded in combat are at substantially higher risk for SI/SA relative to those without such histories. Collectively, findings suggest that combat exposure, when examined as an aggregate severity measure, may yield a poor prognostication of suicide risk, as it may be insufficiently sensitive to detect the effects of specific combat-related experiences.

Defining and Measuring Moral Injury: Rationale, Design, and Preliminary Findings From the Moral Injury Outcome Scale Consortium

In the current paper, we first describe the rationale for and methodology employed by an international research consortium, the Moral Injury Outcome Scale (MIOS) Consortium, the aim of which is to develop and validate a content-valid measure of moral injury as a multidimensional outcome. The MIOS Consortium comprises researchers and clinicians who work with active duty military service members and veterans in the United States, the United Kingdom, the Netherlands, Australia, and Canada. We describe the multiphase psychometric development process being conducted by the Consortium, which will gather phenomenological data from service members, veterans, and clinicians to operationalize subdomains of impact and to generate content for a new measure of moral injury. Second, to illustrate the methodology being employed by the Consortium in the first phase of measure development, we present a small subset of preliminary results from semistructured interviews and questionnaires conducted with care providers (N = 26) at three of the 10 study sites. The themes derived from these initial preliminary clinician interviews suggest that exposure to potentially morally injurious events is associated with broad psychological/behavioral, social, and spiritual/existential impacts. The early findings also suggest that the outcomes associated with acts of commission or omission and events involving others' transgressions may overlap. These results will be combined with data derived from other clinicians, service members, and veterans to generate the MIOS.

Provider perspectives on a novel moral injury treatment for veterans: Initial assessment of acceptability and feasibility of the Impact of Killing treatment materials

OBJECTIVE

We assessed whether treatment providers specializing in evidence-based treatment for posttraumatic stress disorder found the Impact of Killing (IOK), a novel treatment for moral injury among combat veterans, acceptable, and feasible.

METHODS

Ten providers from a large veterans administration (VA) medical center were provided with materials from IOK. We audio-recorded a semistructured interview with each provider where we elicited open-ended feedback as well as asked five structured questions about the relative advantage, compatibility, complexity/simplicity, trialability, and observability of IOK.

RESULTS

All providers found IOK feasible, acceptable, and something they could incorporate into their existing practice. Providers reported that the spiritual and moral concerns addressed in IOK were novel, and that self-forgiveness and making amends were critical components promoting healing from moral injury not emphasized in other treatments.

CONCLUSIONS

Among trauma providers, IOK was found acceptable and feasible, offering a novel approach to addressing moral injury among combat veterans.

Alcohol use and suicidality in firefighters: Associations with depressive symptoms and posttraumatic stress

Both suicidality and alcohol use disorders are significant public health concerns among firefighters, and alcohol use is associated with increased suicide risk. In addition, firefighters endorse high rates of symptoms of depression and posttraumatic stress disorder (PTSD). Thus, the current investigation examined associations between alcohol dependence and suicide risk among a large sample of firefighters. Specifically, this study examined the indirect effects of alcohol dependence on suicidality outcomes via both depression and posttraumatic stress, using structural equation modeling. A total of 2883 male firefighters completed a self-report survey, containing measures of alcohol use, suicidality, PTSD, and depressive symptoms. Results indicated good model fit. The latent alcohol dependence variable was directly related to the latent suicide risk variable. However, when depression and posttraumatic stress latent variables were added into the model, alcohol dependence was no longer associated with suicide risk. Furthermore, alcohol dependence was indirectly related to suicide risk via latent depression and posttraumatic stress variables. Indirect effects were established after controlling for relevant covariates. Clinical implications are discussed.

The influence of gender on suicidal ideation following military sexual trauma among Veterans in the Veterans Health Administration

No studies have examined whether military sexual trauma, as measured and defined within the Veterans Health Administration (VHA), is associated with suicidal ideation among Veterans in VHA care, when taking prior suicide attempts into account. Research regarding the role of gender in this association is also limited. The present study examined: (1) whether military sexual trauma was associated with the presence of past-week suicidal ideation among 354 Veterans in VHA (310 men, 44 women); (2) whether gender moderated the association between military sexual trauma and suicidal ideation. Information regarding military sexual trauma, suicidal ideation, suicide attempt, and psychiatric diagnoses was obtained from self-report instruments and medical records. Adjusting for age, gender, combat, posttraumatic stress disorder, depressive disorders, negative affect, and lifetime suicide attempt, Veterans with military sexual trauma were significantly more likely to report suicidal ideation, compared to Veterans without military sexual trauma. Furthermore, the association between military sexual trauma and suicidal ideation was stronger for men compared to women. These results contribute to a growing literature identifying military sexual trauma as a risk factor for suicidal thoughts and behaviors among Veterans in VHA care and emphasize the importance of screening for suicidal ideation among survivors of military sexual trauma.