Differentiating U.S. military veterans who think about suicide from those who attempt suicide: A population-based study

Suicide-Specific Cognitions and Suicidal Behavior in U.S. Military Veterans

BACKGROUND

U.S. military veterans may be reluctant to disclose suicidal thoughts and behaviors. Suicide-specific cognitions, which generally avoid direct mention of suicide, may be reliable indicators of risk among those reluctant to disclose such thoughts and behaviors.

METHODS

Data from a population-based, cross-sectional study of 2,430 U.S. military veterans were analyzed to examine the associations between the Brief Suicide Cognitions Scale (B-SCS), suicidal ideation, and suicide planning.

RESULTS

After adjusting for age, sex, number of adverse childhood experiences, cumulative trauma burden, depressive symptom severity, and lifetime history of suicide attempt, total scores on the B-SCS (excluding the item mentioning suicide) were uniquely associated with suicidal ideation (odds ratio [OR] = 1.23, 95% confidence interval [CI] = 1.15-1.32) and suicide planning (OR = 1.27, 95%CI = 1.18-1.37). Exploratory post-hoc analyses revealed that difficulties with solving and coping with one's problems were uniquely linked to these outcomes.

CONCLUSIONS

Assessment of suicide-specific cognitions may help to enhance suicide detection and prevention in veterans, especially in those who may not directly disclose thoughts of suicide. Intervention efforts to bolster perceived deficits in coping and problem-solving may help mitigate suicide risk in this population.

Firearm storage practices among military veterans in the United States: Findings from a nationally representative survey

BACKGROUND

Unsafe storage of firearms is associated with increased risk of suicide.. However, contemporary population-based data on the prevalence and correlates of firearm storage practices among veterans are limited.

METHODS

Data were from the 2022 National Health and Resilience in Veterans Study, a nationally representative sample of 2441 veterans. Analyses examined: (1) the prevalence of firearm storage practices; (2) sociodemographic, psychiatric, and clinical characteristics associated with storing firearms loaded and/or in non-secure location; and (3) associations between types of potentially traumatic events and storage practices.

RESULTS

More than half of veterans reported owning one or more personal firearms (50.9%). Among firearm owners, 52.9% reported some form of unsafe firearm storage practice (i.e., loaded and/or non-secure location), with 39.9% reporting that they stored one or more firearms loaded. After adjusting for sociodemographic characteristics, major depressive, alcohol and drug use disorders, direct trauma exposures, future suicidal intent, and traumatic brain injury were associated with storing firearms loaded and/or in a non-secure location (ORs = 1.09-7.16). Veterans with a history of specific forms of direct trauma exposure (e.g., physical assault) were more likely to store firearms unsafely.

LIMITATIONS

Cross-sectional design precludes causal inference.

CONCLUSIONS

Half of U.S. veterans who own firearms store at least one personal firearm loaded and/or in a non-secure location, with approximately four-in-ten keeping a loaded firearm in the home. These high rates underscore the importance of nationwide training initiatives to promote safe firearm storage for all service members and veterans, regardless of risk status, as well as for healthcare professionals working with veterans.

Firearm Ownership Among a Nationally Representative Sample of U.S. Veterans

INTRODUCTION

This study aimed to identify the prevalence and correlates of firearm ownership in a large, contemporary, nationally representative sample of U.S. military veterans.

METHODS

Data were analyzed from the 2022 National Health and Resilience in Veterans Study (N=2,326; mean age=60.2 years). Weighted independent-sample t-tests and chi-square analyses were conducted to compare veterans who did with those who did not report firearm ownership on sociodemographic, military, and psychiatric variables. A multivariable logistic regression analysis using backward elimination was conducted to identify the characteristics independently associated with firearm ownership, and a relative importance analysis was conducted to quantify the relative variance in firearm ownership that was explained by each of the statistically significant main effects.

RESULTS

Of the total 2,326 veterans, 1,217 (weighted 50.9%, 95% CI=48.0%, 53.9%) reported owning any firearms. Male sex, conservative political ideology, living in rural area, home ownership, cumulative trauma burden, and lifetime history of alcohol use disorder were most strongly associated with firearm ownership.

CONCLUSIONS

This study provides an updated characterization of the prevalence and correlates of firearm ownership among the U.S. veterans. Results of this nationally representative study suggest that firearm ownership in this group may be higher than previously reported and underscore the importance of targeted suicide prevention efforts promoting firearm safety among vulnerable segments of this population.

Suicide Ideation, Plans, and Attempts Among Military Veterans vs Nonveterans With Disability

Importance

People with disability are at heightened risk for suicide ideation, planning, and attempt, with risk growing as the number of disabling limitations increases. Military veterans have higher rates of suicide deaths and disability relative to nonveterans.

Objective

To evaluate whether veteran status is associated with greater risk for suicide in those with disability.

Design, Setting, and Participants

This survey study used cross-sectional self-reported data from US adults who participated in the 2015-2020 National Survey on Drug Use and Health. Data were weighted to represent the population. Data analysis was conducted from July to August 2022.

Main Outcomes and Measures

Suicide ideation, planning, and attempt served as primary outcomes. Disability status (present or absent) and number of disabling limitations (1, 2, or ≥3) served as factors. Veteran status was determined based on self-report (veteran or nonveteran). Multivariable logistic regression examined suicide ideation, planning, and attempt as a function of veteran status and disability variables.

Results

Participants included 231 099 US veterans and nonveterans, representing 236 551 727 US adults, of whom 20.03% (weighted n = 47 397 876) reported a disabling limitation, 8.92% were veterans (weighted n = 21 111 727; 16.0% aged 35-49 years; 91.0% men; 6.7% Hispanic; 10.9% non-Hispanic Black; and 78.4% non-Hispanic White) and 91.08% were nonveterans (weighted n = 215 440 000; 25.4% aged 35-49 years; 44.0% male; 16.5% Hispanic; 11.7% non-Hispanic Black; and 63.3% non-Hispanic White). Overall, 4.39% reported suicide ideation, planning, or attempt (weighted n = 10 401 065). Among those with no disability, veteran status was associated with higher risk of suicide planning (adjusted odds ratio [AOR], 1.71; 95% CI, 1.17-2.49). Among those with 1 or 2 disabling limitations, being a veteran was associated with a lower risk of suicide planning (AOR, 0.57; 95% CI, 0.34-0.95) and history of attempt (AOR, 0.46; 95% CI, 0.24-0.88).

Conclusions and Relevance

In this study of how suicide risk differs as a function of disability and veteran status, risk for death by suicide was lower among veterans with disability relative to nonveterans with disability. Veteran status may mitigate risk for suicide given increased receipt of more disability-related care through the Department of Veterans Affairs. Further research would extend this line of inquiry by examining the cause and type of disability as well as perceptions of disability on self-worth. It is possible that physical wounds of war are protective because of the meaning and value of service to one's country.

Characterizing the Influence of Exposure to Military Sexual Trauma and Intimate Partner Violence on Mental Health Outcomes among Female Veterans

Military sexual trauma (MST) has deleterious long-term psychological consequences. Among female U.S. military members, MST is associated with increased risk for future interpersonal victimization, such as experiencing intimate partner violence (IPV). Few studies have investigated the implications of the cumulative effects of IPV and MST on psychological functioning. This study examined rates of co-exposure to MST, IPV, and their cumulative impact on psychological symptoms. Data were collected from 308 female Veterans (FVets; age: M = 42, SD = 10.4) enrolled in an inpatient trauma-focused treatment program in a Veterans Administration (VA) hospital. Data were collected at program admission on symptoms of posttraumatic stress disorder (PTSD), depression, and current suicidal ideation. Lifetime trauma exposure was assessed using semi-structured interviews that identified adverse childhood events (ACEs) and combat theater deployment as well as MST and IPV. Group differences on psychological symptoms were examined among those exposed to MST, IPV, MST + IPV, and compared to FVets with ACEs or combat exposure, but no other adulthood interpersonal trauma (NAIT). Half of the sample (51%) reported experiencing both MST and IPV, approximately 29% reported MST, 10% reported IPV, and 10% reported NAIT. FVets in the MST + IPV group had worse PTSD and depression symptoms than either the MST or IPV groups. The NAIT group had the lowest scores on these measures. There were no group differences in current suicidal ideation; however, 53.5% reported at least one previous suicide attempt. FVets in this sample reported significant lifetime exposure to MST and IPV, with the majority having experienced MST + IPV. Exposure to MST + IPV was associated with greater PTSD and depression symptom severity, yet an overwhelming proportion reported current and past suicidal ideation regardless of trauma exposure history. These results demonstrate the importance of assessing for lifetime interpersonal trauma history when developing and providing mental and medical health interventions for FVets.

Sex-specific risk and resilience correlates of suicidal ideation in U.S. military veterans

OBJECTIVES

To estimate the prevalence and identify gender-specific risk factors associated with suicidal ideation (SI) in a nationally representative sample of U.S. military veterans.

METHODS

Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 4069 veterans. Bivariate and multivariable analyses were conducted to identify factors associated with SI in male and female veterans.

RESULTS

The prevalence of SI was significantly higher in female than male veterans (18.1 % vs. 11.2 %). In female veterans, results of a relative importance analysis revealed that the majority of explained variance in SI (Nagelkerke R² = 0.54) was accounted for by lower psychological resilience (44.4 %), and history of non-suicidal self-injury (24.4 %) and alcohol use disorder (20.6 %). In male veterans, the majority of explained variance in SI (Nagelkerke R² = 0.32) was accounted for by higher loneliness (19.5 %) and hostility (19.1 %), and lower purpose in life (16.3 %).

CONCLUSIONS

Suicidal ideation is prevalent among U.S. veterans, particularly in female veterans. Different risk factors emerged as strong correlates of SI in female and male veterans, which may be used to inform gender-specific suicide prevention and treatment efforts in this population.

Subjective cognitive difficulties and posttraumatic stress disorder interact to increase suicide risk among middle-aged and older US military veterans

OBJECTIVES

To examine the role of subjective cognitive difficulties (SCD), posttraumatic stress disorder (PTSD), and their interaction in predicting suicidal ideation and current suicidal intent in middle-aged and older United States (US) military veterans.

DESIGN

Population-based cross-sectional study.

SETTING AND PARTICIPANTS

Data were analyzed from the 2019 to 2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 3602 US veterans aged 50 years and older (mean age = 69.0).

MEASUREMENTS

Questionnaires including the Medical Outcomes Study Cognitive Functioning Scale (SCD), PTSD Checklist for DSM-5 (PTSD), Patient Health Questionnaire-9 (suicidal ideation in the previous two weeks), and the Suicide Behaviors Questionnaire-Revised (current suicidal intent).

RESULTS

A total of 154 (4.4%) veterans screened positive for current PTSD, 239 (6.7%) reported past two-week suicidal ideation, and 37 (1.0%) reported current suicidal intent. The probability of suicidal ideation among veterans with both SCD and PTSD was more than six times higher than that observed in the full sample (44.5% vs. 6.7%) and more than 2.5 times higher than that observed in veterans with SCD and no PTSD (44.5% vs. 17.5%). Veterans with both subjective memory and concentration difficulties were more likely to report suicidal intent, though the interaction between SCD and PTSD was not significantly associated with suicidal intent.

CONCLUSION

Middle-aged and older U.S. veterans with subjective cognitive impairment and PTSD report higher rates of suicidal ideation than those with SCD alone. Interventions targeting SCD and PTSD may mitigate suicide risk among middle-aged and older veterans.

Identifying factors associated with elevated suicidal intent among U.S. military veterans

OBJECTIVE

Suicidal intent is a risk factor for engagement in suicidal behavior, use of violent means, and suicide mortality. Yet, scarce research has examined factors associated with suicidal intent among U.S. military veterans, a population at high risk for suicide. This study examined vulnerability factors associated with suicidal intent in a population-based sample of U.S. veterans.

METHODS

Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a representative sample of 4069 U.S. veterans. Analyses estimated the prevalence of current suicidal intent (i.e., veterans' report that they would likely attempt suicide in the future) and examined factors most strongly associated with suicidal intent.

RESULTS

Forty-nine veterans (1.4%; 95% confidence interval = 1.0-1.8%) reported suicidal intent. Recurrent past-year suicidal ideation (≥2 times), low dispositional gratitude, current depression, current insomnia, childhood sexual abuse, and a prior suicide attempt were most strongly associated with suicidal intent (7.1-50.1% of the total explained variance). Veterans with several of these co-occurring factors were at highest risk for suicidal intent; of veterans with 0, ≥1, ≥2, ≥3, and ≥4 of these factors, 0.1%, 4.4%, 10.8%, 19.5%, and 28.1% reported suicidal intent, respectively.

DISCUSSION

Specific vulnerability factors, particularly when co-occurring, may increase veterans' intention of attempting suicide. Findings underscore the importance for clinicians to continuously assess suicidal intent when working with this population, particularly as veterans' reports of suicidal thinking increases.

Military sexual trauma in the United States: Results from a population-based study

BACKGROUND

The reported prevalence of military sexual trauma (MST) has increased over the past decades in the United States, yet scarce population-based studies have examined the prevalence, correlates, and health burden of MST in the general veteran population.

METHODS

Data were from the 2019-2020 National Health and Resilience in Veterans Study, a population-based survey of veterans (n = 4069).

ANALYSES

(1) estimated the prevalence of MST; (2) identified sex-stratified sociodemographic, military, and trauma characteristics associated with MST; and (3) examined sex-stratified associations between MST and psychiatric comorbidities, functioning, disability, and treatment utilization.

RESULTS

Female veterans reported substantially higher rates of MST (44.2%) than male veterans (3.5%). Relative to male veterans without MST histories, male veterans with MST histories had nearly 3-fold increased odds of reporting future suicidal intent, 2-to-3-fold greater odds of screening positive for current posttraumatic stress disorder (PTSD), depression, and generalized anxiety disorder; and nearly 2-fold increased odds of being disabled. Male veterans with MST histories also scored lower on mental, physical, cognitive, and psychosocial functioning (d's = 0.16-0.29). Relative to female veterans without MST histories, female veterans with MST histories had 5-fold greater odds of current PTSD, 2-fold greater odds of engaging in mental health treatment, and scored lower on psychosocial functioning and higher on somatic symptoms (both d's = 0.25).

LIMITATIONS

Cross-sectional design precludes causal inference.

CONCLUSIONS

A substantial proportion of veterans in the U.S. experience sexual trauma during their military service, and these experiences are associated with an elevated health burden.

Risk factors for suicide attempts among U.S. military veterans: A 7-year population-based, longitudinal cohort study

BACKGROUND

Population-based data on risk factors for suicide attempts among veterans remains limited.

METHODS

A national probability sample of 2307 veterans was followed over the course of four timepoints spanning seven years to examine how a range of baseline risk factors predict incident suicide attempt. Suicide attempt data were aggregated into a single follow-up timepoint.

RESULTS

Sixty-two veterans (3.1%) reported attempting suicide during the 7-year period. The strongest risk factors for suicide attempts were higher baseline levels of loneliness, lower baseline levels of adaptive psychosocial traits (e.g., dispositional gratitude), baseline thoughts of self-harm, and greater post-baseline trauma exposures (12.3%-41.3% of explained variance). Veterans with multiple co-occurring risk factors were at greatest risk for attempts; of veterans with 0, 1, 2, 3, and all 4 of these factors, the predicted probability of suicide attempt was 2.0%, 5.3%, 13.5%, 30.4%, and 55.0%, respectively.

CONCLUSIONS

Baseline loneliness, dispositional gratitude, thoughts of self-harm, and new-onset traumas emerged as the strongest risk factors for suicide attempts among veterans, underscoring the potential importance of targeting these factors in prevention efforts. Veterans with multiple co-occurring risk factors have substantially greater risk for suicide attempts, suggesting that examination of multiple coinciding vulnerability factors may help improve suicide risk prediction models.