Means and capacity for suicidal behavior: a comparison of the ratio of suicide attempts and deaths by suicide in the US military and general population

The Purple Heart and suicide risk in Post-9/11 U.S. Army Combat Veterans with a traumatic brain injury: A mixed methods study

Active service members and Veterans with a combat-related traumatic brain injury (TBI) are four times more likely to attempt suicide than those without a TBI. TBIs are the signature injuries of the Post-9/11 conflicts and Combat Veterans (i.e., current and former service members who deployed in support of a combat mission) with these injuries are entitled to receive the Purple Heart medal. However, potentially tens of thousands of Combat Veterans did not receive, or were denied the Purple Heart during the first decade of the Global War on Terrorism because a TBI was not documented during the deployment. To our knowledge, this is the first study to explore the meaning of the Purple Heart and examine the impact of the Purple Heart on Army Combat Veterans with a combat-related TBI. Findings from this mixed methods study revealed that not receiving the Purple Heart is associated with increased suicide risk and lower quality of life after a brain injury. Additionally, thwarted belongingness, perceived burdensomeness, and perceived military institutional betrayal are associated with increased suicide risk in Army Combat Veterans with a TBI. This mixed methods study provides important insights into how Army culture is perceived and the power of the Purple Heart among this high-risk group of Combat Veterans.

Direct costs of hospital care of self-harm: A national register-based cohort study

OBJECTIVE

To estimate national direct hospital costs associated with treatment of self-harm and to analyse whether costs differ with respect to demographic and clinical characteristics.

METHODS

A cohort design was applied to register data on all people living in Denmark (5.8 million inhabitants) from Jan 1, 2012 to Dec 31, 2016. Self-harm presentations at all hospitals by persons aged 10 years and older were included. Total costs and costs related to somatic and psychiatric care and treatment setting (inpatient, emergency department and outpatient) were calculated (in US dollars). The association between specific characteristics and somatic inpatient costs was analysed adjusted using generalized linear models and expressed as Odds Ratios (OR).

RESULTS

In all, 42,634 (97.3%) self-harm presentations by 30,366 persons were included. Annual somatic and psychiatric costs amounted to $25,241,518 and $34,696,388, respectively, and the median cost per episode was $2248 (IQR: $1553-$4138). Predictors of high somatic inpatient costs were: admission to intensive care (OR = 15.6; 95% CI, 13.7-17.9), particularly dangerous methods of self-harm, such as being hit by moving objects (OR = 6.5; 95% CI, 2.7-15.7) and shooting (OR = 6.0; 95% CI, 3.4-10.7), and age ≥75 years (OR = 1.8; 95% CI, 1.5-2.2). A small group of persons (0.7%) with ≥10 presentations accounted for 8.2% of somatic and 15.3% of total hospital costs.

CONCLUSION

Substantial hospital costs were noted for inpatient treatment. Although one-time presenters accounted for the major share of costs, smaller patient groups accounted for considerable shares. Hospital costs of self-harm should be included in evaluation of initiatives for prevention and treatment.

The lethality of suicide methods: A systematic review and meta-analysis

BACKGROUND

The use of suicide methods largely determines the outcome of suicide acts. However, no existing meta-analysis has assessed the case fatality rates (CFRs) by different suicide methods. The current study aimed to fill this gap.

METHODS

We searched Scopus, Web of Science, PubMed, ProQuest and Embase for studies reporting method-specific CFRs in suicide, published from inception to 31 December 2020. A random-effect model meta-analysis was applied to compute pooled estimates.

RESULTS

Of 10,708 studies screened, 34 studies were included in the meta-analysis. Based on the suicide acts that resulted in death or hospitalization, firearms were found to be the most lethal method (CFR:89.7%), followed by hanging/suffocation (84.5%), drowning (80.4%), gas poisoning (56.6%), jumping (46.7%), drug/liquid poisoning (8.0%) and cutting (4.0%). The rank of the lethality for different methods remained relatively stable across study setting, sex and age group. Method-specific CFRs for males and females were similar for most suicide methods, while method-CFRs were specifically higher in older adults.

CONCLUSIONS

This study is the first meta-analysis that provides significant evidence for the wide variation of the lethality of suicide methods. Restricting highly lethal methods based on local context is vital in suicide prevention.

Development and Preliminary Evaluation of an Education Program for Primary Care Teams on Discussing Firearms Storage Safety with Veterans

BACKGROUND

Reducing access to lethal means is one of the few empirically supported approaches for lowering suicide rates, and safe firearms storage practices have been associated with reduced risk of death by suicide. Although there is substantial opportunity for primary care to assist in addressing lethal means with veterans, approaches to intervention and educating staff are not well documented. We sought to 1) describe development of an education program for primary care teams to help them discuss firearms storage safety (FSS) with veterans during primary care visits; and 2) conduct a preliminary evaluation of the pilot education program.

METHODS

We used an iterative process involving veterans and primary care staff stakeholders to develop program content, format, and supplemental materials. A grounded theory approach was used to analyze data from focus groups and individual interviews. Following piloting of the program with 71 staff members in two primary care clinics, we analyzed pre- and post-training participant surveys of program satisfaction and attitudes comfort related to firearms safety discussions.

RESULTS

During the development phase, 68 veterans and 107 staff members participated in four veteran focus groups and four primary care focus groups, respectively, and/or individual interviews. The program that was developed, "'Just in Case': Discussing means safety with veterans at elevated risk for suicide," addresses knowledge and skills learning objectives, and includes video demonstrations and skills practice. Survey data obtained just prior to the pilot training sessions showed low self-reported rates of discussing firearms safety with veterans who may be at elevated risk for suicide. Immediate post-training data showed generally high satisfaction with the program and significant improvements in participant self-reported ratings of the importance of, and comfort with FSS.

CONCLUSIONS

This interactive knowledge and skill-based means safety curriculum shows promise as a means for educating primary care staff to deliver messaging about firearms safety to veterans. Additional research is needed to refine and evaluate impacts of this or similar training programs on clinician and veteran behaviors over time.

Characteristics and Context of Veterans Experiencing Serious Suicidal Ideation or Suicide Attempt by Firearm which led to Hospitalization

OBJECTIVE

Suicide by former United States military service members is of great public health concern, and one area, veterans' suicide attempts involving firearms, is understudied. One group that has a unique perspective on this are veterans with a psychiatric admission following a firearm-related suicide crisis, such as making a suicide plan or a suicide rehearsal with a firearm within the preceding 72 hours. This study seeks to address this gap in the literature by describing the characteristics and context of non-fatal suicide events involving firearms among veterans.

METHOD

This convergent parallel mixed-methods design study collected both quantitative and qualitative data from male veterans (N = 15) who were hospitalized due to a suicide attempt or serious ideation using a firearm. Veterans admitted to a Veterans Affairs Medical Center (VAMC) were interviewed and asked to complete a survey. Qualitative data on characteristics and context were analyzed using a thematic analysis.

RESULTS

The fifteen male U.S. military veterans described their personal characteristics, such as their beliefs, family beliefs and structure, emotions, and employment status. Most participants were unemployed (n = 10; 67%), divorced (n = 7; 47%) or married (n = 5; 33%). Seven themes related to context emerged from qualitative interviews to include: combat trauma, non-combat trauma and negative life event(s), current and past suicide attempt(s), firearms, substance use, known deaths by suicide, and protective factors for suicide.

CONCLUSION

Results suggest that engaging support networks and communities is essential when developing programs to promote identification of early warning signs and implementation of interventions or programs for reducing veteran suicide.

Firearms storage safety discussions in VA primary care: Staff perspectives

OBJECTIVE

To describe VHA primary care clinician and staff perspectives on conducting firearms storage safety (FSS) discussions in primary care, and to identify key approaches for primary care teams to facilitate FSS conversations.

METHOD

Qualitative analysis of transcripts and notes from focus groups with VA primary care staff and individual semi-structured interviews with primary care clinicians. One hundred-seven VHA primary care team members participated in one of four focus groups or individual semi-structured interviews (n = 5).

RESULTS

FSS discussions are perceived as within the purview of primary care. Primary care staff also outlined five tools and processes needed to meaningfully implement FSS discussions in primary care: training on firearms and firearms culture; examining personal attitudes toward firearms; developing supplemental materials to normalize and support FSS discussions; increasing knowledge of firearms laws and regulations; and providing scripts to facilitate conversations.

CONCLUSIONS

Conducting FSS discussions in primary care settings is perceived as an acceptable practice, yet care teams identified barriers and suggestions for overcoming implementation challenges.

Strategies for Discussing Firearms Storage Safety in Primary Care: Veteran Perspectives

BACKGROUND

Two-thirds of veteran suicides are attributable to firearm injury. Although half of veterans who die by suicide are seen in primary care settings in the month prior to death, little is known about how to promote firearm safety within primary care.

OBJECTIVE

Describe veterans' perspectives on discussing firearms storage safety (FSS) during primary care visits, and identify key strategies for primary care teams to use in discussing FSS with veterans at elevated risk for suicide.

DESIGN

Qualitative analysis of transcripts and notes from four veteran focus groups and from individual semi-structured interviews with six veterans.

PARTICIPANTS

Altogether, 68 veterans participated. Three of the groups were associated with one Veterans Health Administration facility. Groups were diverse in age, service era, and gender.

APPROACH

The goals of the focus groups and interviews were to assess acceptance of FSS discussions during primary care visits, identify facilitators and barriers to conducting FSS discussions, and identify strategies for primary care teams to use to effectively conduct FSS discussions. Transcripts and meeting notes were analyzed using a grounded theory approach.

KEY RESULTS

There was general acceptance of having FSS discussions in primary care. Yet, most veterans did not support direct questioning about firearm ownership, which may trigger fears of having firearms taken away or limit access to firearms. Participants recommended primary care teams provide rationale for FSS discussions and be prepared to provide information on legal consequences of disclosing firearm ownership. Strategies suggested for primary care staff also included using a personalized, caring, and conversational approach rather than highly scripted or checklist approach, engaging veterans in a non-judgmental manner, and conveying respect for veterans' knowledge of firearms.

CONCLUSIONS

Discussing FSS with veterans in primary care settings is a promising upstream approach that can complement other suicide prevention efforts, but must be conducted in a veteran-centric manner.

No game, more pain - Examining possible long term effects and underlying mechanisms of habitual violent video gaming on the acquired capability for suicide

According to Joiner`s interpersonal-psychological theory of suicide repeated engagement in suicidal behavior or so-called painful and provocative events constitutes the acquired capability for suicide (ACS) comprising two facets: enhanced pain tolerance and fearlessness about death (FAD). Recent research showed that single bouts of violent-video-gaming (VVG) increase pain tolerance. It is unknown whether individuals who habitually play VVGs at a high frequency rate show higher signs of ACS in terms of low pain sensitivity, high tolerance and lowered FAD compared to non-gamers. In a cross-sectional case-control study, we compared pain sensitivity and tolerance during a 5-min Cold-Pressor-Test (CPT) besides FAD in young males, playing VVGs highly frequent (n = 18) vs. non-gamers (n = 17). Mood was rated before and after the CPT. We found higher CPT-pain tolerance, lower intensity ratings and higher FAD scores among gamers compared to non-gamers. A significant time x group interaction of pain ratings indicated a process of habituation in the gamers. An increase of positive mood in the gamers emphasizes the role of opponent processes. The results suggest that habitual VVG might reflect a repetitive behavior enhancing the ACS.

Demographic and Occupational Risk Factors Associated With Suicide-Related Aeromedical Evacuation Among Deployed U.S. Military Service Members

INTRODUCTION

Suicide is a significant problem in the U.S. military, with rates surpassing the U.S. general population as of 2008. Although there have been significant advances regarding suicide risk factors among U.S. military service members and veterans, there is little research about risk factors associated with suicide that could be potentially identified in theater. One salient study group consists of service members who receive a psychiatric aeromedical evacuation out of theater. The primary aims of this study were as follows: (1) determine the incidence of suicide-related aeromedical evacuation in deployed service members, (2) identify demographic and military characteristics associated with suicide-related aeromedical evacuation, and (3) evaluate the relationship between suicide-related aeromedical evacuation from a deployed setting and military separation.

MATERIALS AND METHODS

This was an archival analysis of U.S. Transportation Command Regulating and Command and Control Evacuation System and Defense Manpower Data Center electronic records of U.S. military service members (N = 7023) who were deployed to Iraq or Afghanistan and received a psychiatric aeromedical evacuation out of theater between 2001 and 2013. χ2 tests of independence and standardized residuals were used to identify cells with observed frequencies and proportions, respectively, that significantly differed from what would be expected by chance. In addition, odds ratios were calculated to provide context about the nature of any significant relationships.

RESULTS

For every 1000 psychiatric aeromedical evacuations that occurred between 2001 and 2013, 34.4 were suicide related. Gender, ethnicity, branch of service, occupation classification, and deployment theater were associated with suicide-related aeromedical evacuation (odds ratios ranged from 1.37 to 3.02). Overall, 53% of all service members who received an aeromedical evacuation for any psychiatric condition had been separated from the military for a variety of reasons (both voluntary and involuntary) upon record review in 2015. Suicide-related aeromedical evacuation was associated with a 37% increased risk of military separation compared to evacuation for another psychiatric condition (P < 0.02).

CONCLUSIONS

Findings provide novel information on risk factors associated with suicide-related aeromedical evacuation as well as military separation following a suicide-related aeromedical evacuation. In many cases, the psychiatric aeromedical evacuation of a service member for suicidal ideations and their subsequent separation from active duty is in the best interest of the individual and the military. However, the evacuation and eventual military separation can be costly for the military and the service member. Consequently, the military should focus on indicated prevention interventions for individuals who show sufficient early signs of crisis and functional problems so that specialized interventions can be used in theater to prevent evacuation. Indicated prevention interventions should start with leaders' awareness and mitigation of risk and, when feasible, evidence-based interventions for suicide risk provided by behavioral health (eg, brief cognitive behavioral therapy for suicide). Future research should evaluate the feasibility, safety, and efficacy of delivering suicide-related interventions in theater.

A test of the interpersonal theory of suicide in a large, representative, retrospective and prospective study: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

The interpersonal theory of suicide hypothesizes that perceived burdensomeness, thwarted belongingness, and hopelessness lead to active suicidal thoughts and individuals with active suicidal thoughts and elevated capability for suicide are most likely to attempt suicide. We retrospectively and prospectively tested this theory in a large sample of 7677 U.S. Army soldiers followed post-deployment for up to nine months. The interaction of perceived burdensomeness and hopelessness (OR = 2.59) was significantly associated with lifetime suicidal thoughts; however, the interactions of thwarted belongingness and perceived burdensomeness and of thwarted belongingness and hopelessness were not. Consistent with the theory, capability for suicide prospectively predicted suicide attempts during and following deployment (OR = 1.22); however, among soldiers reporting lifetime suicidal thoughts, capability did not predict attempts, only perceived burdensomeness did (OR = 1.36). Results supported some, but not all, theory hypotheses, suggesting that additional constructs may be needed to better identify the psychological factors that lead soldiers to attempt suicide.

Do Criminals Live Faster Than Soldiers and Firefighters? : A Comparison of Biodemographic and Psychosocial Dimensions of Life History Theory

A high risk of morbidity-mortality caused by a harsh and unpredictable environment is considered to be associated with a fast life history (LH) strategy, commonly linked with criminal behavior. However, offenders are not the only group with a high exposure to extrinsic morbidity-mortality. In the present study, we investigated the LH strategies employed by two groups of Polish men: incarcerated offenders (N = 84) as well as soldiers and firefighters (N = 117), whose professions involve an elevated risk of injury and premature death. The subjects were asked to complete the Mini-K (used as a psychosocial LH indicator) and a questionnaire which included a number of biodemographic LH variables. Although biodemographic and psychosocial LH indicators should be closely linked with each other, the actual connection between them is unclear. Thus, this study was driven by two aims: comparing LH strategies in two groups of men with a high risk of premature morbidity-mortality and investigating the relationship between the biodemographic and psychosocial LH dimensions. The study showed that incarcerated men employed faster LH strategies than soldiers and firefighters, but only in relation to biodemographic variables (e.g., number of siblings, age of sexual initiation, life expectancy). No intergroup differences emerged regarding psychosocial LH indicators. Moreover, the correlation analysis showed a weak association between biodemographic and psychosocial LH indicators. The results strengthen the legitimacy of incorporating biodemographic LH traits into research models and indicate the need for further research on the accuracy of the Mini-K. The possible explanations for the intergroup differences in LH strategies are discussed.

Evaluation of Prevention Efforts and Risk Factors Among Veteran Suicide Decedents Who Died by Firearm

OBJECTIVE

Veterans die by suicide at a higher rate than the U.S. population, and veterans more frequently use a firearm as the suicide method. Consequently, firearm accessibility and storage represent important prevention considerations. This project aimed to explore the implementation of suicide prevention efforts among veterans who went on to die by suicide, with and without the use of a firearm, and to identify factors that differentiated veteran suicide decedents to help inform suicide prevention efforts.

METHODS

Data from the Veteran Health Administration Behavior Health Autopsy Program was analyzed for 97 veteran suicide decedents.

RESULTS

Results demonstrated that veterans who used a firearm for suicide were less likely to have engaged in suicide prevention efforts overall and were less likely to have received lethal means safety counseling / safety planning. Veterans who died by firearm had lower levels of notable risk factors (e.g., prior suicide attempt, no-shows for appointments), however were more likely to have a documented unsecured firearm in their home.

CONCLUSION

These findings support the benefit of broadening the reach of suicide prevention efforts, especially for high-risk veterans with access to firearms.

A proposal for using the ratio of attempted to completed suicides across several countries worldwide

Completed suicide (CS) is a leading cause of death worldwide and its rates are available for most developed countries. On the other hand, attempted suicide (AS) is a risk factor for CS but there are limited data on its rates in various countries. In constructing a ratio for AS/CS rates, most would agree that for CS, the denominator should be the annual suicide rate (per 100 000). As for the ratio's numerator (AS) per 100 000, there are three possible calculations: (1) annual prevalence from population surveys, (2) annual prevalence from national clinical registers or (3) lifetime prevalence from population surveys. We think that the first possibility would probably be the best choice but, unfortunately, surveys providing the annual prevalence of AS are lacking for most countries. Annual prevalence from national registers is also lacking for most countries and is contaminated by under-reporting. Therefore, in this editorial, we are left with only the last option, a ratio for lifetime prevalence of AS (per 100 000) divided by annual rate of CS (per 100 000). This ratio for AS/CS rates appears to differ substantially across countries worldwide but presents no big regional differences other than two remarkable exceptions, one per continent. In Europe, Spain and France had greater ratios (174.4 and 152.5, respectively) than Italy (64.1). In Asia/Pacific, New Zealand has a higher ratio (345.9) compared with China (75.8) and Japan (76.9). The ratio for AS/CS rates could be a good index for implementing evidence-informed decision-making regarding suicidal behaviour (SB) among health service managers, and for helping them in the allocation of health resources for the prevention of SB.

Assessment and Management of Patients at Risk for Suicide: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines

DESCRIPTION

In May 2019, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved an update to the 2013 joint clinical practice guideline for assessing and managing patients who are at risk for suicide. This guideline provides health care providers with a framework by which to screen for, evaluate, treat, and manage the individual needs and preferences of VA and DoD patients who may be at risk for suicide.

METHODS

In January 2018, the VA/DoD Evidence-Based Practice Work Group convened to develop a joint VA/DoD guideline including clinical stakeholders and conforming to the National Academy of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel drafted key questions, systematically searched and evaluated the literature through April 2018, created algorithms, and advanced 22 recommendations in accordance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.

RECOMMENDATIONS

This synopsis, which includes 3 clinical practice algorithms, summarizes the key recommendations of the guideline related to screening and evaluation, risk management and treatment, and other management methods. Risk management and treatment recommendations address both pharmacologic and nonpharmacologic approaches for patients with suicidal ideation and behavior. Other management methods address lethal means safety (such as restricting access to firearms, poisons, and medications and installing barriers to prevent jumping from lethal heights) and population health strategies.

Detecting Potential Underreporting of Suicide Ideation Among U.S. Military Personnel

Using a military sample comprised largely of National Guard personnel, zero-inflation negative binomial regression was applied to estimate the effects of indirect, nonface valid indicators of suicide ideation [Thwarted Belongingness (TB), Perceived Burdensomeness (PB), and Hopelessness], in predicting suicide ideation. Data from a sample of 497 military personnel (82.1% male; m_age  = 27.24; range = 18-59) were analyzed. TB and the interaction of TB with Hopelessness were significant predictors in the logistic regression, and in the negative binomial regression, the main effects of TB and hopelessness, and the interactions of TB with hopelessness and PB with hopelessness were significant. The findings further indicated that approximately 10% of those not reporting ideation would be predicted to be ideators. Clinically, these results indicate that, in samples reluctant to report ideation, the assessment of suicide risk may improve through the use of relevant measures that do not explicitly reference suicide thoughts.

Psychopathic personality traits as a form of dispositional capability for suicide

The capability to enact lethal self-harm has recently been highlighted as a critical risk factor for suicidal behavior. Klonsky and May's (2015) three step theory of suicide (3ST) expanded upon the construct of the capability for suicide by dividing it into categories: dispositional, acquired, and practical. The current study examined constructs of Patrick and colleagues' (2009) triarchic model of psychopathy as indicators of dispositional capability in gun owners, a sample at heightened risk for death by suicide (Anestis and Houtsma, 2017). We anticipated that specific psychopathic traits would exhibit robust associations with other components of the capability for suicide. In a sample of 300 gun-owning adults, Boldness was uniquely related to all indicators of practical capability in both male and female gun owners, and a Boldness*Meanness interaction predicted the highest levels of some capability components. These results are consistent with theoretical conceptualizations of the triarchic model. Our findings indicate that, among US gun owners, dispositional factors may impact comfort with and aptitude with guns, which may enhance our understanding of which gun owners are at the greatest risk of gun suicide should they develop suicidal thoughts.

Suicide among emergency and protective service workers: A retrospective mortality study in Australia, 2001 to 2012

BACKGROUND

Emergency and protective services personnel (e.g., police, ambulance, fire-fighters, defence, prison and security officers) report elevated levels of job stress and health problems. While population-level research is lacking, there has been some research suggesting suicide rates may be elevated in emergency and protective services.

OBJECTIVES

This paper compares suicide rates between emergency and protective services occupational groups over a 12-year period (2001-2012) in Australia.

METHOD

Labour force data was obtained from the 2006 Australian Census. Suicide data was obtained from the National Coroners Information System (NCIS). Negative binomial regression was used to estimate the association between suicide and employment as an emergency or protective service worker (including prison and security officers) over the period 2001-2012, as compared to all other occupations. Information on suicide method was extracted from the NCIS.

RESULTS

The age-adjusted suicide rate across all emergency and protective service workers was 22.4 (95% CI 19.5 to 25.2) per 100,000 in males and 7.8 in females (95% CI 4.6 to 11.00), compared to 15.5 per 100,000 (95% CI 15.2 to 15.9) for males and 3.4 (95% CI 3.2 to 3.6) for females in other occupations. The highest risk by subgroup was observed among those employed in the defence force, prison officers, and ambulance personnel. The major method of death for all occupational groups was hanging.

CONCLUSIONS

Our results clearly highlight the need for suicide prevention among emergency and protective service occupations.

Military personnel compared to multiple suicide attempters: Interpersonal theory of suicide constructs

The current study aimed to address the discrepancy between suicide rates in the military and general population by comparing facets of the interpersonal theory of suicide between civilians with multiple suicide attempts and U.S. military personnel. Military personnel exhibited higher levels of capability for suicide but lower levels of perceived burdensomeness and thwarted belongingness than civilian multiple attempters. When comparing only personnel endorsing ideation and civilian multiple attempters, the significant difference for capability remained, but the differences for perceived burdensomeness and thwarted belongingness became nonsignificant. Results suggest the emergence of ideation places personnel at a greater risk for suicide than many civilian multiple attempters.

Traumatization, Loneliness, and Suicidal Ideation among Former Prisoners of War: A Longitudinally Assessed Sequential Mediation Model

Although highly researched among veterans, the underlying mechanisms of suicidal ideation (SI) among former prisoners of war (ex-POWs), especially in the long-term, have rarely been investigated. Furthermore, while posttraumatic stress symptoms (PTSS) and loneliness have been individually associated with veteran SI, and both may be differentially implicated by captivity versus war traumas, the interplay between them has yet to be examined. Filling this gap, the current longitudinal study examined a hypothetical sequential model wherein war captivity, compared with combat-induced trauma, is implicated in worse PTSS, which is then implicated in worse loneliness and PTSS, which together may explain subsequent SI. Two groups of Israeli veterans of the 1973 Yom Kippur War, 163 ex-POWs and 185 matched non-captive veterans were assessed 18 (T1) and 30 (T2) years after the war. Analyses indicated that compared with war, captivity was implicated in worse PTSS, which was implicated in worse loneliness, and these worked in tandem to implicate SI. Loneliness, however, was not directly affected by the type of trauma, nor was its relation to SI linked to its implication in subsequent PTSS. These results may inform future research and clinical practice as the study underscores the importance of both PTSS and loneliness in ex-POWs' long-term SI.

Treating the Capability for Suicide: A Vital and Understudied Frontier in Suicide Prevention

Current efforts at suicide prevention center largely on reducing suicidal desire among individuals hospitalized for suicidality or being treated for related psychopathology. Such efforts have yielded evidence-based treatments, and yet the national suicide rate has continued to climb. We propose that this disconnect is heavily influenced by an unmet need to consider population-level interventions aimed at reducing the capability for suicide. Drawing on lessons learned from other public health phenomena that have seen drastic declines in frequency in recent decades (HIV, lung cancer, motor vehicle accidents), we propose that current suicidality treatment efforts trail current suicidality theories in their lack of focus on the extent to which individuals thinking about suicide are capable of transitioning from ideation to attempt. We summarize extant evidence for specific capability-centered approaches (e.g., means safety) and propose other options for improving our ability to address this largely overlooked variable. We also note that population-level approaches in this regard would represent an important opportunity to decrease risk in individuals who either lack access to evidence-based care or underreport suicidal ideation, as a reduced capability for suicide would theoretically diminish the potency of suicidal desire and, in this sense, lower the odds of a transition from ideation to attempt.

Access to means of suicide, occupation and the risk of suicide: a national study over 12 years of coronial data

BACKGROUND

Availability of lethal means is a significant risk factor for suicide. This study investigated whether occupations with greater access to lethal means had higher suicide rates than those without access, and further, whether this relationship differed for females versus males.

METHODS

A retrospective mortality study was conducted across the Australian population over the period 2001 to 2012. Data from the Australian Bureau of Statistics, which collects Census information on occupation for the Australian population, and the National Coroners Information System, which records information on suicide deaths, were combined. Employed suicide records were coded by occupation and work-related access to lethal means. Descriptive analysis and negative binomial regression were used to assess the relationship between access to means and suicide.

RESULTS

Persons in occupations with access to firearms, medicines or drugs, and carbon monoxide more frequently used these methods to end their lives than those without access to means. Females employed in occupations with access to means had suicide rates that were 3.02 times greater (95% CI 2.60 to 3.50, p < 0.001) than those employed in occupations without access. Males in occupations with access had suicide rates that were 1.24 times greater than those without access (95% CI 1.16 to 1.33, p < 0.001).

CONCLUSION

Work-related access to means is a risk factor for suicide in the employed population, but is associated with a greater risk for females than males. The findings of this study suggest the importance of controlling access to lethal methods in occupations where these are readily available.

Risk Factors, Methods, and Timing of Suicide Attempts Among US Army Soldiers

IMPORTANCE

Suicide attempts in the US Army have risen in the past decade. Understanding the association between suicide attempts and deployment, as well as method and timing of suicide attempts, can assist in developing interventions.

OBJECTIVE

To examine suicide attempt risk factors, methods, and timing among soldiers currently deployed, previously deployed, and never deployed at the time this study was conducted.

DESIGN, SETTING, AND PARTICIPANTS

This longitudinal, retrospective cohort study of Regular Army-enlisted soldiers on active duty from 2004 through 2009 used individual-level person-month records to examine risk factors (sociodemographic, service related, and mental health), method, and time of suicide attempt by deployment status (never, currently, and previously deployed). Administrative data for the month before each of 9650 incident suicide attempts and an equal-probability sample of 153 528 control person-months for other soldiers were analyzed using a discrete-time survival framework.

MAIN OUTCOMES AND MEASURES

Suicide attempts and career, mental health, and demographic predictors were obtained from administrative and medical records.

RESULTS

Of the 9650 enlisted soldiers who attempted suicide, 86.3% were male, 68.4% were younger than 30 years, 59.8% were non-Hispanic white, 76.5% were high school educated, and 54.7% were currently married. The 40.4% of enlisted soldiers who had never been deployed (n = 12 421 294 person-months) accounted for 61.1% of enlisted soldiers who attempted suicide (n = 5894 cases). Risk among those never deployed was highest in the second month of service (103 per 100 000 person-months). Risk among soldiers on their first deployment was highest in the sixth month of deployment (25 per 100 000 person-months). For those previously deployed, risk was highest at 5 months after return (40 per 100 000 person-months). Currently and previously deployed soldiers were more likely to attempt suicide with a firearm than those never deployed (currently deployed: OR, 4.0; 95% CI, 2.9-5.6; previously deployed: OR, 2.7; 95% CI, 1.8-3.9). Across deployment status, suicide attempts were more likely among soldiers who were women (currently deployed: OR, 3.4; 95% CI, 3.0-4.0; previously deployed: OR, 1.5; 95% CI, 1.4-1.7; and never deployed: OR, 2.4; 95% CI, 2.3-2.6), in their first 2 years of service (currently deployed: OR, 1.9; 95% CI, 1.5-2.3; previously deployed: OR, 2.2; 95% CI, 1.9-2.7; and never deployed: OR, 3.1; 95% CI, 2.7-3.6), and had a recently received a mental health diagnosis in the previous month (currently deployed: OR, 29.8; 95% CI, 25.0-35.5; previously deployed: OR, 22.2; 95% CI, 20.1-24.4; and never deployed: OR, 15.0; 95% CI, 14.2-16.0). Among soldiers with 1 previous deployment, odds of a suicide attempt were higher for those who screened positive for depression or posttraumatic stress disorder after return from deployment and particularly at follow-up screening, about 4 to 6 months after deployment (depression: OR, 1.4; 95% CI, 1.1-1.9; posttraumatic stress disorder: OR, 2.4; 95% CI, 2.1-2.8).

CONCLUSIONS AND RELEVANCE

Identifying the timing and risk factors for suicide attempt in soldiers requires consideration of environmental context, individual characteristics, and mental health. These factors can inform prevention efforts.

Correlates of Attempted Suicide from the Emergency Room of 2 General Hospitals in Montreal, Canada

Introduction:

The epidemiology of attempted suicide has not been well characterized because of lack of national data or an International Classification of Diseases (ICD) code for suicide attempts. We conducted a retrospective chart review in 2 adult general hospitals (tertiary and community) in Montreal, Canada, in 2009-2010 to 1) describe the characteristics of men and women who presented to the emergency department (ED) and/or were hospitalized following a suicide attempt, 2) identify factors associated with attempts requiring hospitalizations, and 3) validate the use of International Classification of Diseases, 10th Revision (ICD-10) codes for “intentional self-harm” as a method to detect suicide attempts from hospital abstract summary records.

Method:

All potential suicide attempts were identified from hospital abstract summary records and ED nursing triage file using ICD-10 codes and keywords suggestive of suicide attempts. All identified charts were examined, and those with confirmed suicide attempts were fully reviewed.

Results:

Of the 5746 identified charts, 369 were fully reviewed. Of these, 176 were for suicide attempters treated in the ED and 193 for hospitalized attempters, of whom 46% had an ICD-10 code for intentional self-harm. Poisoning (46%) was the most frequent method of suicide used. Half of attempters were younger than 34 years, 53% were female, and 75% had a history of mental disorders.

Conclusion:

About half of individuals who seek medical care for attempted suicide are admitted to hospital. About half of attempters use poisoning as a method of suicide, and a quarter do not have a history of mental disorders. Intentional self-harm codes capture only about half of hospitalized attempters.

From impulse to action among military personnel hospitalized for suicide risk: alcohol consumption and the reported transition from suicidal thought to behavior

OBJECTIVE

Alcohol use is associated with unplanned or impulsive suicide attempts. Although unplanned suicide attempts assume a rapid transition for suicidal impulse to action, many studies do not quantify the time elapsed from suicidal impulse to action. The current study was designed to clarify how alcohol use facilitates the transition from suicidal impulse to action among U.S. Army personnel. We hypothesized that alcohol consumption during the 24 h preceding a suicide attempt would be associated with significantly faster transition from suicidal impulse to action but would be unrelated to medical lethality.

METHOD

A total of 119 active duty U.S. Army Soldiers who made a total of 175 suicide attempts during military service, 121 of which occurred during the preceding year, completed clinician-administered structured interviews focused on psychiatric diagnosis and the contextual characteristics of their suicide attempts.

RESULTS

Alcohol use during the 24 h prior to a suicide attempt was associated with significantly faster transition from suicidal impulse to action. Among suicide attempts in the past year, lethality significantly increased as the length of time since the last alcoholic drink increased. Drug use during the 24 h prior to a suicide attempt was unrelated to speed of transition or attempt lethality.

CONCLUSIONS

Soldiers acted upon their suicidal impulses more quickly when they had been drinking on the day of their suicide attempts. This rapid transition may contribute to the selection of less lethal suicide methods during periods of active drinking as compared to methods selected after the discontinuation of alcohol consumption.

The associations between state veteran population rates, handgun legislation, and statewide suicide rates

BACKGROUND

Within the US, veterans exhibit an elevated suicide rate, with firearms serving as the most common method. Research has demonstrated that several state laws regulating handgun ownership are associated with lower suicide rates.

METHOD

Publically available databases were utilized to extract relevant data.

RESULTS

Statewide veteran population rates (per 100,000) predicted overall suicide rates, firearm suicide rates, and the proportion of suicides by firearms. Furthermore, the association between veteran population and overall suicide rate was largely explained by the elevated proportion of suicides by firearms in states with higher veteran populations. Lastly, results demonstrated states without handgun legislation in place exhibited higher veteran populations.

CONCLUSIONS

Findings indicate veterans may impact statewide suicide rates through their propensity to use firearms as their method and that the tendency for veterans to live in states without handgun legislation may exacerbate this phenomenon.

Testing the main hypotheses of the interpersonal-psychological theory of suicidal behavior in a large diverse sample of United States military personnel

BACKGROUND

Preliminary data indicate the suicide rate in the United States military decreased in 2013, but the National Guard saw a continued increase.

METHOD

We examined the utility of the interpersonal-psychological theory of suicidal behavior (IPTS) in a sample of US military personnel drawn largely from the National Guard (n=934; 77.7% male; 59.5% white).

RESULTS

Results indicated the interaction of thwarted belongingness and perceived burdensomeness predicted suicidal ideation and resolved plans and preparations for suicide. In each case, risk was greatest at higher levels of both predictors. Furthermore, results indicated the interaction of thwarted belongingness, perceived burdensomeness, and acquired capability for suicide predicted prior suicide attempts. In this interaction term, the relationship between suicidal desire (thwarted belongingness and perceived burdensomeness) and suicide attempts was significant and positive only at high levels of acquired capability. All analyses were cross-sectional.

CONCLUSIONS

Results indicate the IPTS may be useful for conceptualizing suicide risk in the National Guard.

The US framework for understanding, preventing, and caring for the mental health needs of service members who served in combat in Afghanistan and Iraq: a brief review of the issues and the research

This paper reviews the psychological health research conducted in the United States in support of combat veterans from Iraq and Afghanistan, using the Military Psychological Health Research Continuum, which includes foundational science, epidemiology, etiology, prevention and screening, treatment, follow-up care, and services research. The review is limited to those studies involving combat veterans and military families. This review discusses perplexing issues regarding the impact of combat on the mental health of service members such as risk and resilience factors of mental health, biomarkers of posttraumatic stress syndrome (PTSD), mental health training, psychological screening, psychological debriefing, third location decompression, combat and suicide, the usefulness of psychotherapy and drug therapy for treating PTSD, role of advanced technology, telemedicine and virtual reality, methods to reduce stigma and barriers to care, and best approaches to the dissemination of evidence-based interventions. The mental health research of special populations such as women, National Guardsmen and reservists, and military families is also presented. The review concludes by identifying future areas of research.

Reconsidering the link between impulsivity and suicidal behavior

It is widely accepted that suicidal behavior often occurs with little planning. We propose, however, that suicidal behavior is rarely if ever impulsive-that it is too frightening and physically distressing to engage in without forethought-and that suicidal behavior in impulsive individuals is accounted for by painful and fearsome behaviors capable of enhancing their capacity for suicide. We conducted a meta-analysis of the association between trait impulsivity and suicidal behavior and a critical review of research considering the impulsiveness of specific suicide attempts. Meta-analytic results suggest the relationship between trait impulsivity and suicidal behavior is small. Furthermore, studies examining a mediating role of painful and provocative behaviors have uniformly supported our model. Results from our review suggest that researchers have been unable to adequately measure impulsivity of attempts and that measures sensitive to episodic planning must be developed to further our understanding of this phenomenon.

Fatal school shootings and the epidemiological context of firearm mortality in the United States

Background The December 14, 2012 mass shooting at Sandy Hook Elementary School in Newtown, Connecticut, USA, vaulted concerns regarding gun violence to the forefront of public attention. This high-visibility incident occurred within the epidemiological context of U.S. firearm mortality that claims more than 88 lives daily. Methods National epidemiologic data on firearm deaths over two decades were analyzed along with data registries on school shootings in order to place the tragedy at Sandy Hook in perspective. School shootings were classified as random or targeted. Results The U.S. has the highest rates of firearm deaths, suicides, and homicides among the world's 34 "advanced economies." Seventy percent of U.S. homicides and more than 50% of U.S. suicides are committed using a firearm. U.S. firearm homicide rates first declined, and then stabilized, during the past 23 years, 1990-2012. "Shooting massacres" in school settings, a new phenomenon within the past 50 years, are extremely rare events. Over 23 years, 1990-2012, 215 fatal school shooting incidents resulted in 363 deaths, equivalent to 0.12% of national firearm homicides during that time period. Most episodes were "targeted" shootings in which the perpetrator intentionally killed a specific individual in a school setting. Only 25 of these 215 events (11.6%) were "random" or "rampage" shootings, resulting in 135 deaths (0.04% of national firearm homicides). Among these, just three shooting rampages - Columbine High School, Virginia Tech University, and Sandy hook Elementary School - accounted for 72 (53.3%) of these 135 deaths. The frequency of random/rampage shooting incidents in schools has remained within the narrow range of 0 to 3 episodes per year. Conclusions Each year, more than 32,000 Americans die by firearms and more than 70,000 are wounded, representing a volume of preventable deaths and injuries that the U.S. government describes as a "public health crisis." School massacres, such as Sandy Hook, occur periodically, galvanizing public reaction and bringing forth a collective call for intervention. Epidemiological analyses position these rare, but uniquely compelling, incidents within the broader national patterns of gun violence. The intention is to inform the selection of a balanced, comprehensive set of effective remedies to address the daily death toll from firearm suicides and "targeted" firearm homicides that account for more than 99% of firearm fatalities; as well as the rare, random, and sporadic rampage shootings in school or community settings.