PTSD symptoms and suicide risk in veterans: Serial indirect effects via depression and anger

Patterns of comorbid PTSD, depression, alcohol use disorder, and insomnia symptoms in firefighters: A latent profile analysis

BACKGROUND

Firefighters are an at-risk population for multiple psychiatric conditions, including posttraumatic stress disorder (PTSD), depression, alcohol use disorders (AUDs), and insomnia. These disorders are likely to co-occur; however, patterns of comorbidity have scarcely been investigated in firefighters. We aimed to identify subgroups of comorbidity of PTSD, depression, AUDs, and insomnia in a nationwide population of firefighters in South Korea.

METHODS

A total of 54,054 firefighters responded to an online survey. Latent classes of comorbidity were categorized using latent profile analysis (LPA) based on the symptom scores of PTSD, depression, AUDs, and insomnia. Analysis of variance was performed to compare the characteristics of the identified classes, and multinomial logistic regression was conducted to examine whether anger reactions, resilience, and number of traumatic events predicted class membership.

RESULTS

The LPA identified four subgroups: minimal symptoms (n = 42,948, 79.5 %), predominant PTSD (n = 2858, 5.3 %), subthreshold symptoms and comorbidity (n = 7003, 13.0 %), and high symptoms and comorbidity (n = 1245, 2.3 %). Three comorbidity classes were defined based on severity and one class showed predominant PTSD symptoms. Number of traumatic exposures predicted predominant PTSD, while resilience and anger reactions predicted severity of comorbidities.

LIMITATIONS

The cross-sectional design and usage of self-reported questionnaires are limitations of this study.

CONCLUSIONS

The severity of PTSD, depression, AUDs and insomnia tend to correlate and co-occur in firefighters. Our findings highlight the need to assess comorbid symptoms in firefighters and need to reduce anger reactions and enhance resilience in those with multiple comorbidities.

Developing emotional preparedness and mental resilience through high-fidelity simulation: a 'bridge too far' for institutions teaching major trauma management and mass-casualty medicine?

BACKGROUND

Clinical acumen represents only part of being adequately equipped to attend a major incident. The emotive sights, sounds and smells of these dynamic environments are all-encompassing experiences, and responders must also be armed with the emotional preparedness to perform their clinical or managerial duties effectively, as well as the mental resilience to facilitate professional continuance. Despite this, limited training and a sparsity of evidence exists to guide developments within this domain. Historically, major incident training has focused on clinical theory acquisition, but irrespective of how comprehensive the learning materials, they are of little consequence if tandem steps to cultivate mental resilience and emotional preparedness are absent. High-Fidelity Simulation (HFS) has a growing reputation as an effective means of bridging important gaps between theory and practice. This pilot study aimed to measure student's self-reported perception of their readiness to respond to a major incident following a large-scale HFS.

METHODS

Quantitative data was obtained from a sample of 108 students undertaking paramedic science, physician associate studies and adult nursing degree programmes. A bespoke questionnaire was developed to measure self-reported clinical acumen, mental and emotional preparedness.

RESULTS

91% of students agreed the combination of theoretical training and HFS provided made them feel clinically prepared to attend a real major incident; 86% agreed this experience had developed their mental resilience and 90% agreed that they felt emotionally prepared to attend a major incident.

CONCLUSION

Within this pilot study, the blend of theoretical training and HFS contributed to self-reported clinical acumen, mental and emotional preparation, in learners training to work in disaster environments or emergency medicine settings.

Posttraumatic growth-oriented peer-based training among U.S. veterans: evaluation of post-intervention and long-term follow-up outcomes

Introduction

Exposure to trauma among U.S. military veterans occurs at a high rate, often resulting in continued difficulty with emotional adjustment and a diagnosis of posttraumatic stress disorder (PTSD). The present study provides data from 184 U.S. military veterans who completed a manualized posttraumatic-growth oriented training program during an integrative seven-day retreat.

Methods

Data was collected at baseline, after program completion, and at 18-month follow-up.

Results

Results on primary outcomes indicated significant increases, with medium to large effect sizes, in growth related outcomes. Specifically, there was a significant increase in scores by 54% on the posttraumatic growth outcome measure (PTGI-X) from baseline (M = 50.2, SD = 31.1) to endpoint (M = 77.4, SD = 29.6), t(183) = -8.78, p < 0.001. Also, results indicate that immediately following training (Day 7), participants reported a significant decrease of 49% on the PCL-5 from baseline (M = 39.7, SD = 17.6) to endpoint (M = 20.1, SD = 13.2), t(183) = 11.75, p < 0.001. Depression subscale scores decreased by 60% from baseline (M = 8.0, SD = 5.2) to endpoint (M = 3.2, SD = 3.0), t(183) = 10.68, p < 0.001; Anxiety scores decreased by 28% from baseline (M = 5.8, SD = 4.3) to endpoint (M = 4.2, SD = 3.5), t(183) = 4.08, p < 0.001; and Stress scores decreased by 50% from baseline (M = 10.0, SD = 4.4) to endpoint (M = 5.0, SD = 3.3), t(183) = 12.21, p < 0.001. Eighteen-month follow-up data was available for 74 participants and indicated that all significant changes in growth-related outcomes were maintained. Further, all significant changes in symptomatology-related outcomes were also maintained at follow-up.

Discussion

These findings demonstrate both the immediate and the long-lasting impact of an integrative posttraumatic growth-oriented training program on psychological growth and PTSD symptom reduction among U.S. military veterans.

Prison Adjustment Among Military Veterans: The Impact of Traumatic Events, Service History, and PTSD

Military veterans have been shown to differ demographically from non-veterans in the criminal justice system. However, relatively little is known about their psychological adjustment, institutional misbehavior, and the efficacy of programing received while incarcerated. Using data taken from a national sample of prison inmates, this study investigates how traumatic events experienced during military service can impact the intensity of negative affect among veterans. Additionally, we examine whether prison misconduct is influenced by military service history and the receipt of substance abuse treatment. Controlling for a host of relevant variables, our results indicate that traumatic events show a significant effect on psychological adjustment only indirectly through veterans who developed post-traumatic stress disorder and that misconduct is lower among those who received an honorable discharge. Overall, these findings suggest that the ability of veterans to resist adverse outcomes may depend on a variety of factors both within and outside the prison environment.

Time doesn't heal all: PTSD symptoms exacerbate the relationship between age and pain intensity

Objective

Posttraumatic stress disorder (PTSD) symptoms and pain interfere with daily functioning and quality of life for many combat Veterans. As individuals age, pain symptoms tend to increase whereas PTSD symptoms tend to decrease. PTSD symptoms exacerbate pain, but the nature of this relationship across the aging process is unclear. The purpose of this study was to determine how PTSD symptoms affect the association between age and pain intensity.

Methods

Participants in this cross-sectional study included 450 Veterans (80% male) who served after September 11, 2001. PTSD and pain intensity ratings were assessed by the PTSD Checklist for DSM-5 (PCL-5) and the Brief Pain Inventory (BPI), respectively. Hierarchical multiple linear regression evaluated main and interaction effects between age, PTSD symptoms, and pain intensity.

Results

Age (B = 0.04, p < 0.001) and PTSD symptoms (B = 0.05, p < 0.001) were positively associated with pain intensity. Age and PTSD symptoms were inversely correlated (r = -0.16, p < 0.001). PTSD symptoms exacerbated the relationship between age and pain intensity (ΔR2 = 0.01, p = 0.036). Specifically, when greater PTSD symptoms were reported at older ages, pain intensity was significantly higher.

Conclusion

Results of these analyses suggests that age is important when considering the effects of PTSD symptoms on pain intensity ratings. Specifically, pain intensity ratings are higher in older Veterans with PTSD symptoms. These findings underscore the importance for clinical providers to evaluate trauma history and PTSD symptoms in older Veterans reporting pain symptoms.

Dynamic suicide topic modelling: Deriving population-specific, psychosocial and time-sensitive suicide risk variables from Electronic Health Record psychotherapy notes

In the machine learning subfield of natural language processing, a topic model is a type of unsupervised method that is used to uncover abstract topics within a corpus of text. Dynamic topic modelling (DTM) is used for capturing change in these topics over time. The study deploys DTM on corpus of electronic health record psychotherapy notes. This retrospective study examines whether DTM helps distinguish closely matched patients that did and did not die by suicide. Cohort consists of United States Department of Veterans Affairs (VA) patients diagnosed with Posttraumatic Stress Disorder (PTSD) between 2004 and 2013. Each case (those who died by suicide during the year following diagnosis) was matched with five controls (those who remained alive) that shared psychotherapists and had similar suicide risk based on VA's suicide prediction algorithm. Cohort was restricted to patients who received psychotherapy for 9+ months after initial PTSD diagnoses (cases = 77; controls = 362). For cases, psychotherapy notes from diagnosis until death were examined. For controls, psychotherapy notes from diagnosis until matched case's death date were examined. A Python-based DTM algorithm was utilized. Derived topics identified population-specific themes, including PTSD, psychotherapy, medication, communication and relationships. Control topics changed significantly more over time than case topics. Topic differences highlighted engagement, expressivity and therapeutic alliance. This study strengthens groundwork for deriving population-specific, psychosocial and time-sensitive suicide risk variables.

Characterizing Moral Injury and Distress in US Military Surgeons Deployed to Far-Forward Combat Environments in Afghanistan and Iraq

IMPORTANCE

Moral injury and distress (MID), which occurs when individuals have significant dissonance with their belief system and overwhelming feelings of being powerless to do what is believed to be right, has not been explored in the unique population of military surgeons deployed far forward in active combat settings. Deployed military surgeons provide care to both injured soldiers and civilians under command-driven medical rules of engagement (MROE) in variably resourced settings. This practice setting has no civilian corollary for comparison or current specific tool for measurement.

OBJECTIVE

To characterize MID among military surgeons deployed during periods of high casualty volumes through a mixed-methods approach.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study using convergent mixed methods was performed from May 2020 to October 2020. Participants included US military surgeons who had combat deployments to a far-forward role 2 treatment facility during predefined peak casualty periods in Iraq (2003-2008) and Afghanistan (2009-2012), as identified by purposeful snowball sampling. Data analysis was performed from October 2020 to May 2021.

MAIN OUTCOMES AND MEASURES

Measure of Moral Distress for Healthcare Professionals (MMD-HP) survey and individual, semistructured interviews were conducted to thematic saturation.

RESULTS

The total cohort included 20 surgeons (mean [SD] age, 38.1 [5.2] years); 16 (80%) were male, and 16 (80%) had 0 or 1 prior deployment. Deployment locations were Afghanistan (11 surgeons [55%]), Iraq (9 surgeons [45%]), or both locations (3 surgeons [15%]). The mean (SD) MMD-HP score for the surgeons was 104.1 (39.3). The primary thematic domains for MID were distressing outcomes (DO) and MROE. The major subdomains of DO were guilt related to witnessing horrific injuries; treating pregnant women, children, and US soldiers; and second-guessing decisions. The major subdomains for MROE were forced transfer of civilian patients, limited capabilities and resources, inexperience in specialty surgical procedures, and communication with command. Postdeployment manifestations of MID were common and affected sleep, medical practice, and interpersonal relationships.

CONCLUSIONS AND RELEVANCE

In this qualitative study, MID was ubiquitous in deployed military surgeons. Thematic observations about MID, specifically concerning the domains of DO and MROE, may represent targets for further study to develop an evaluation tool of MID in this population and inform possible programs for identification and mitigation of MID.

Social and Psychological Rehabilitation of War Veterans

The subject of the study is determined by the need for effective rehabilitation of war veterans and the presence of many problems of sociopsychological recovery after being in the zone of active combat operations, and the need to develop an effective rehabilitation programme for this category of people. The purpose of the study is to conduct a comprehensive analysis of the features of socio-psychological rehabilitation, identify the relationship of physiological states with individual psychological components of the individual’s functioning in specific conditions of life, determine which measures are most effective for the establishment of areas of work in the aspect of socio-psychological rehabilitation of war veterans. The basis of the methodological approach in this study is the analysis and generalisation based on the results of the examination of scientific and theoretical material, which determines the establishment of conclusions and recommendations in the field under study. The following methods of scientific knowledge are used: dialectical, logical-semantic, system-structural, functional, and logicalnormative. The study proves the direct connection between the presence of a person in a war zone and their psychoemotional state. It is considered which psychophysiological disorders can be caused by involvement in armed conflicts. The conclusion is formulated that participants in military operations need social and psychological rehabilitation, and problematic issues and prospects for rehabilitation are outlined. Specific medical and socio-psychological aspects are highlighted, the avoidance or generation of which will help in the process of rehabilitation of military personnel and their families. It was identified that although psychological rehabilitation is generally conducted, it requires more government support, popularisation, and wider involvement of both war veterans and experts. Ways to improve approaches to providing psychological assistance to military personnel and their families in Ukraine are proposed. The conclusions of the study are of substantial importance for psychologists and social workers, psychology students and teaching staff of psychology faculties as a doctrinal basis for the educational process

Who improves in trauma-focused treatment: A cluster analysis of treatment response in VA patients undergoing PE and CPT

BACKGROUND

Although most veterans with posttraumatic stress disorder (PTSD) benefit from evidence-based treatments, questions persist concerning the profiles of those at risk for poor outcomes. To help address these gaps, this study analyzed a large clinical cohort of veterans receiving prolonged exposure (PE) or cognitive processing therapy (CPT).

METHODS

Cluster analysis using Ward's method with Euclidian distances identified clinically meaningful subgroups of veterans in a national cohort (n = 20,848) using variables maintained in the electronic medical record. The clusters were then compared via one-way analysis of variance and Tukey's HSD on indicators of treatment progress including PTSD symptom change, clinical recovery, clinically significant change, remission, and treatment completion.

RESULTS

Effect size differences on clinical outcome measures for PE and CPT were negligible. Less than half of veterans achieved at least a 15-point reduction in PCL-5 score and half completed treatment. We identified 10 distinct clusters. Higher rates of PTSD service-connected disability were linked to poorer outcomes across multiple clusters, especially when combined with Post-Vietnam service era. Non-White race was also linked with poorer clinical outcomes. Factors associated with better outcomes included a greater proportion of female veterans, especially when combined with recent service era, and longer PTSD diagnosis duration.

CONCLUSIONS

This study suggests the need to improve PTSD treatment outcomes for non-White and male veterans, examine treatment response in Post-Vietnam era veterans, and consider ways in which the service connection process could hinder treatment response. The results from this study also indicate the benefits of integrating elements of clinical complexity into an analytic approach.

Parental post-traumatic stress disorder and increased risk of chronic pain conditions and major psychiatric disorders in their offspring

BACKGROUND

Previous research suggests that individuals with post-traumatic stress disorder (PTSD) have higher risk of chronic pain symptoms. It remains unknown whether risk of chronic pain symptoms occurs in the offspring of parents with PTSD. This study aimed to explore the risk of chronic pain conditions and depression in the offspring of parents with PTSD.

METHODS

Between 1996 and 2011, we included subjects whose parents had PTSD and controls with parents without PTSD or any major psychiatric disorders (MPDs) from the Taiwan National Health Research Database. The controls (1:10) were matched for age, sex, time of birth, income, and residence. Poisson regression was applied to estimate the risk of chronic pain conditions and MPDs between case and control cohorts during the study period. The chronic pain conditions assessed were migraine, tension headache, fibromyalgia, peripheral neuropathy, dorsopathies, dysmenorrhea, irritable bowel syndrome (IBS), and dyspepsia.

RESULTS

We included 1139 cases and 11,390 matched controls. After adjusting for demographics and family history of psychiatric comorbidities, offspring of parents with PTSD had higher risk for depressive disorder [reported as odds ratio (OR) with 95% confidence interval (CI): 2.59, 1.71-3.92] than controls. For chronic pain conditions, offspring of parents with PTSD had higher risk for migraine (2.01, 1.01-3.98) and IBS (1.55, 1.02-2.34) than controls.

CONCLUSIONS

Healthcare workers should be aware that offspring of parents with PTSD have a higher risk of chronic pain conditions and depressive disorder. Further intervention to mitigate the risk is warranted.

Longitudinal relationships between guilt and suicide risk among adolescents in a postdisaster context: Mediating roles of rumination and posttraumatic stress disorder

OBJECTIVE

To analyze the pathways and mechanisms underlying the impact of guilt on suicide risk using a well-controlled longitudinal study, we examined the mediating roles of intrusive rumination, deliberate rumination, and posttraumatic stress disorder (PTSD) in this association.

METHOD

Four hundred and eight adolescent survivors (M_age  = 14.05 years) were assessed using self-report questionnaires three and a half years and four and a half years after the Ya'an earthquake. The self-report questionnaires included the Trauma Exposures Questionnaire, the Interpersonal Guilt Questionnaire, the Event-Related Rumination Inventory, the PTSD Checklist for the DSM-5, and the Child Behavior Problems Questionnaire.

RESULTS

The results indicated that guilt had a direct and positive effect on suicide risk. Intrusive rumination and PTSD mediated the relationship between guilt and suicide risk. Guilt could increase deliberate rumination, but deliberate rumination did not significantly predict PTSD and suicide risk.

CONCLUSION

Negative postdisaster emotions, such as guilt, can enhance the combined effects of cognition and psychological disorders on suicide risk. Guilt affects suicide risk indirectly through intrusive rumination and PTSD but not through deliberate rumination.

Suicidal Depression in Ancient Egypt

OBJECTIVE

To evaluate the oldest record of a depressed individual contemplating suicide.

METHOD

A directed review of ancient Egyptology literature of translations and discussion regarding a papyrus that is approximately 4,000 years old.

RESULTS

The content of the document is consistent with a man going through a severe depression and is contemplating suicide. However, this does not appear to be a suicide note, but more of an ancient example of 'journaling' or working through the thoughts of suicide and its possible consequences to the man's eternal life in the afterworld.

CONCLUSIONS

Presentation of depression, the reasons for considering suicide, and the process by which an individual works through those thoughts have not varied significantly over the past 4,000 years.

Posttraumatic stress disorder hyperarousal event detection using smartwatch physiological and activity data

Posttraumatic Stress Disorder (PTSD) is a psychiatric condition affecting nearly a quarter of the United States war veterans who return from war zones. Treatment for PTSD typically consists of a combination of in-session therapy and medication. However; patients often experience their most severe PTSD symptoms outside of therapy sessions. Mobile health applications may address this gap, but their effectiveness is limited by the current gap in continuous monitoring and detection capabilities enabling timely intervention. The goal of this article is to develop a novel method to detect hyperarousal events using physiological and activity-based machine learning algorithms. Physiological data including heart rate and body acceleration as well as self-reported hyperarousal events were collected using a tool developed for commercial off-the-shelf wearable devices from 99 United States veterans diagnosed with PTSD over several days. The data were used to develop four machine learning algorithms: Random Forest, Support Vector Machine, Logistic Regression and XGBoost. The XGBoost model had the best performance in detecting onset of PTSD symptoms with over 83% accuracy and an AUC of 0.70. Post-hoc SHapley Additive exPlanations (SHAP) additive explanation analysis showed that algorithm predictions were correlated with average heart rate, minimum heart rate and average body acceleration. Findings show promise in detecting onset of PTSD symptoms which could be the basis for developing remote and continuous monitoring systems for PTSD. Such systems may address a vital gap in just-in-time interventions for PTSD self-management outside of scheduled clinical appointments.

The relationship between anger and suicidal ideation: Investigations in two samples

OBJECTIVES

Suicidal ideation (SI) nearly always precedes lethal suicide attempts. Anger may play a role in SI, but this appears to vary by gender and nuances in this relationship are unclear.

METHOD

We investigated whether levels of (a) anger and (b) SI vary by gender, (c) the cross-sectional relationship between anger and SI, and (d) if gender moderates that relationship in two samples: adults seeking care for excessive anger (Study 1) and undergraduates endorsing previous suicide attempt (Study 2).

RESULTS

In Study 1, anger was more commonly endorsed in women; however, in Study 2, anger did not vary by gender. In both studies, SI did not vary by gender. Further, in both studies, anger and SI were positively related. The relationship between anger and SI did not vary by gender in either study.

CONCLUSIONS

The strength of the relationship between anger and SI did not vary by gender.

Association of Traumatic Brain Injury With Mortality Among Military Veterans Serving After September 11, 2001

IMPORTANCE

Emerging evidence suggests that harmful exposures during military service, such as traumatic brain injury (TBI), may contribute to mental health, chronic disease, and mortality risks.

OBJECTIVE

To assess the mortality rates and estimate the number of all-cause and cause-specific excess deaths among veterans serving after the September 11, 2001, terrorist attacks (9/11) with and without exposure to TBI.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed administrative and mortality data from January 1, 2002, through December 31, 2018, for a cohort of US military veterans who served during the Global War on Terrorism after the 9/11 terrorist attacks. Veterans who served active duty after 9/11 with 3 or more years of care in the Military Health System or had 3 or more years of care in the Military Health System and 2 or more years of care in the Veterans Health Administration were included for analysis. The study used data from the Veterans Affairs/Department of Defense Identity Repository database, matching health records data from the Military Health Service Management Analysis and Reporting tool, the Veterans Health Administration Veterans Informatics and Computing Infrastructure, and the National Death Index. For comparison with the total US population, the study used the Centers for Disease Control and Prevention WONDER database. Data analysis was performed from June 16 to September 8, 2021.

EXPOSURE

Traumatic brain injury.

MAIN OUTCOMES AND MEASURES

Multivariable, negative binomial regression models were used to estimate adjusted all-cause and cause-specific mortality rates for the post-9/11 military veteran cohort, stratified by TBI severity level, and the total US population. Differences in mortality rates between post-9/11 military veterans and the total US population were used to estimate excess deaths from each cause of death.

RESULTS

Among 2 516 189 post-9/11 military veterans (2 167 736 [86.2%] male; and 45 324 [1.8%] American Indian/Alaska Native, 160 178 [6.4%], Asian/Pacific Islander, 259 737 [10.3%] Hispanic, 387 926 [15.4%] non-Hispanic Black, 1 619 834 [64.4%] non-Hispanic White, and 43 190 [1.7%] unknown), 17.5% had mild TBI and 3.0% had moderate to severe TBI; there were 30 564 deaths. Adjusted, age-specific mortality rates were higher for post-9/11 military veterans than for the total US population and increased with TBI severity. There were an estimated 3858 (95% CI, 1225-6490) excess deaths among all post-9/11 military veterans. Of these, an estimated 275 (95% CI, -1435 to 1985) were not exposed to TBI, 2285 (95% CI, 1637 to 2933) had mild TBI, and 1298 (95% CI, 1023 to 1572) had moderate to severe TBI. Estimated excess deaths were predominantly from suicides (4218; 95% CI, 3621 to 4816) and accidents (2631; 95% CI, 1929 to 3333). Veterans with moderate to severe TBI accounted for 33.6% of total excess deaths, 11-fold higher than would otherwise be expected.

CONCLUSIONS AND RELEVANCE

This military veteran cohort experienced more excess mortality compared with the total US population than all combat deaths from 9/11/01 through 9/11/21, concentrated among individuals exposed to TBI. These results suggest that a focus on what puts veterans at risk for accelerated aging and increased mortality is warranted.

Prevalence of post-traumatic stress disorder in the United States: a systematic literature review

OBJECTIVE

This study synthesized evidence regarding the prevalence of post-traumatic stress disorder (PTSD) in the United States (US).

METHODS

A systematic literature review (SLR) identified recently published (2015-2019) observational studies of PTSD prevalence in the US via the MEDLINE, EMBASE, and PsycINFO databases. Eligible studies' most recent data were collected no earlier than 2013. Data elements extracted included study design, sample size, location, data source/year(s), study population(s), traumatic event type, prevalance estimates with corresponding look-back periods, and clinical metrics.

RESULTS

Data from 38 identified articles were categorized by population, diagnostic criteria, and lookback period. Among civilians, point prevalence ranged from 8.0% to 56.7%, 1-year prevalence from 2.3% to 9.1%, and lifetime prevalence from 3.4% to 26.9%. In military populations, point prevalence ranged from 1.2% to 87.5%, 1-year prevalence from 6.7% to 50.2%, and lifetime prevalence from 7.7% to 17.0%. Within these ranges, several estimates were derived from relatively high quality data; these articles are highlighted in the review. Prevalence was elevated in subpopulations including emergency responders, refugees, American Indian/Alaska Natives, individuals with heavy substance use, individuals with a past suicide attempt, trans-masculine individuals, and women with prior military sexual trauma. Female sex, lower income, younger age, and behavioral health conditions were identified as risk factors for PTSD.

CONCLUSIONS

PTSD prevalence estimates varied widely, partly due to different study designs, populations, and methodologies, and recent nationally representative estimates were lacking. Efforts to increase PTSD screening and improve disease awareness may allow for a better detection and management of PTSD.

Fluid vulnerability theory as a framework for understanding the association between posttraumatic stress disorder and suicide: A narrative review

Suicide is a persistent issue in the United States and across the globe. A large body of published research shows that posttraumatic stress disorder (PTSD) increases the risk of suicidal ideation, suicidal behaviors, and death by suicide. However, the existing literature examining why that association might pertain is widely dispersed across disciplines (e.g., psychology, nursing) and lacks an integrative theoretical framework, making it difficult to conceptualize the current state of science in this area. Therefore, the primary aims of this narrative review were to (a) provide a comprehensive and interdisciplinary critique of the current state of knowledge regarding mechanisms that underlie the association between PTSD and suicide and (b) organize that knowledge according to a specified theoretical framework. The framework guiding this review is "fluid vulnerability theory," a diathesis-stress model of suicide that emphasizes the dynamic nature of suicide risk across cognitive, emotional, behavioral, and physiological domains. A summary of the findings, including patterns that emerged, gaps that remain, and recommendations for the advancement of science and practice in this area are addressed in this narrative review.

Suicidality in childhood abuse survivors - the contribution of identification with the aggressor

OBJECTIVE

Childhood abuse survivors are at risk for suicidal ideation and suicide attempts. Research has indicated that posttraumatic stress disorder (PTSD) symptoms and dissociation are related to elevated suicidal ideation and behavior (SIB) among this population. At the same time, although the theoretical and clinical literature in the trauma field have suggested that survivors' pathological attachment to their perpetrators, known as identification with the aggressor, might explain SIB, this supposition has not been investigated to date.

METHOD

Filling this gap, this study explored the associations between identification with the aggressor, PTSD symptoms, dissociation, and SIB among 589 adult survivors of childhood abuse.

RESULTS

Identification with the aggressor, PTSD symptoms, and dissociation were related to elevated levels in suicidal ideation and behavior. Furthermore, profile type (namely, having high versus medium or low levels of identification with the aggressor, PTSD symptoms, and dissociation) was implicated in participants' SIB: Participants who adhered to a profile characterized by high levels of identification with the aggressor, PTSD symptoms, and dissociation had higher levels of suicide risk and suicidal ideation, as well as higher odds of reporting a history of suicide attempts, compared to participants who adhered to the other two profiles (i.e., characterized by medium or low levels of identification with the aggressor, PTSD symptoms, and dissociation).

LIMITATIONS

This study relied on convenience sampling and a cross-sectional design.

CONCLUSIONS

Identification with the aggressor might serve, alongside PTSD symptoms and dissociation, as a risk factor for suicidal ideation and behavior among childhood abuse survivors.

A review and conceptual model of the association of Type D personality with suicide risk

The role of personality as distal risk factor for suicidal thoughts and behavior is still unclear. This review aims to propose two conceptual models that explain the psychological plausibility of Type D personality as distal risk factor and contributor to the transition from general to suicide distress. To support this aim, we performed a systematic review of existing studies on the association between Type D personality and suicidal distress. A systematic search yielded eight studies that reported on Type D personality and suicidal distress. Type D personality was robustly associated with suicidal thoughts and behaviors, across populations and countries. Type D was related to the level/frequency of suicidal ideation in seven studies, and suicide attempt in two studies. Our first theoretical model identifies intra-psychic (depression, alcohol misuse, posttraumatic stress) and interpersonal (low belonging, social isolation, lack of support) vulnerabilities of individuals with Type D that may fuel the development of suicidal thoughts and behaviors. Type D by itself will not account for why people become suicidal, but our second theoretical model suggests that the avoidant-passive tendencies of Type D individuals may result in persistent problem-solving deficits, and, eventually, feelings of entrapment that may contribute to the desire to escape from pain. We conclude that empirical evidence supports the hypothesized link between Type D personality, and suicidal thoughts and behaviors. Our conceptual models - albeit often supported by indirect evidence - further substantiate the plausibility of this link, and offer concrete guidance for future studies. Primarily, more longitudinal research is necessary.

Natural language processing of clinical mental health notes may add predictive value to existing suicide risk models

BACKGROUND

This study evaluated whether natural language processing (NLP) of psychotherapy note text provides additional accuracy over and above currently used suicide prediction models.

METHODS

We used a cohort of Veterans Health Administration (VHA) users diagnosed with post-traumatic stress disorder (PTSD) between 2004-2013. Using a case-control design, cases (those that died by suicide during the year following diagnosis) were matched to controls (those that remained alive). After selecting conditional matches based on having shared mental health providers, we chose controls using a 5:1 nearest-neighbor propensity match based on the VHA's structured Electronic Medical Records (EMR)-based suicide prediction model. For cases, psychotherapist notes were collected from diagnosis until death. For controls, psychotherapist notes were collected from diagnosis until matched case's date of death. After ensuring similar numbers of notes, the final sample included 246 cases and 986 controls. Notes were analyzed using Sentiment Analysis and Cognition Engine, a Python-based NLP package. The output was evaluated using machine-learning algorithms. The area under the curve (AUC) was calculated to determine models' predictive accuracy.

RESULTS

NLP derived variables offered small but significant predictive improvement (AUC = 0.58) for patients that had longer treatment duration. A small sample size limited predictive accuracy.

CONCLUSIONS

Study identifies a novel method for measuring suicide risk over time and potentially categorizing patient subgroups with distinct risk sensitivities. Findings suggest leveraging NLP derived variables from psychotherapy notes offers an additional predictive value over and above the VHA's state-of-the-art structured EMR-based suicide prediction model. Replication with a larger non-PTSD specific sample is required.

A network analysis of risk factors for suicide in Iraq/Afghanistan-era veterans

Suicidal ideation (SI) is a prevalent issue in the veteran population. A number of factors have been identified as risk factors for suicidal ideation (SI) in veterans, including suicide attempts, depression, posttraumatic stress disorder (PTSD), and drug use. However, clinicians' ability to predict suicide is poor, particularly given the interplay between various factors such as previous suicide attempts. As such, there is a gap in our knowledge of which factors most saliently predict suicide risk and which should be targets for interventions designed to lower SI. Network analysis, a method allowing for an examination of how variables relate within the context of a network of factors, may bridge this gap by simultaneously evaluating the interrelationships between risk factors for suicide in veterans. Current study used network analysis and data from 2268 Iraq/Afghanistan-era military veterans to examine the relationships between suicidal ideation and several factors related to suicide risk, such as past suicide attempts, PTSD symptoms, depression, drug use, trauma exposure. Partial correlation network results showed suicidal ideation to be strongly related to depression, with smaller connections to past suicide attempts and anger. Additionally, past suicide attempts was strongly related to history of childhood trauma and weakly related to problematic drug use and PTSD symptoms. These results offer valuable information for both predicting suicide risk and differentiating targets for interventions lowering suicide risk in veterans.

Nonsuicidal Self-Injury Disorder, Borderline Personality Disorder, and Lifetime History of Suicide Attempts among Male and Female Veterans with Mental Health Disorders

BACKGROUND

Expanding on research that has identified nonsuicidal self-injury (NSSI) as a strong predictor of suicide risk, the present study examined NSSI disorder (NSSID) and borderline personality disorder (BPD) as unique contributors to lifetime suicide attempts. To our knowledge, the present study represents the first exploration of these associations among veterans.

METHODS

Participants included 124 male (74%) and female (26%) veterans diagnosed with at least one mental health disorder. Posttraumatic stress disorder (93%) and major depression (86%) were the most common mental health diagnoses. Large proportions of the sample met criteria for NSSID (48%) and BPD (40%). Suicide attempts were reported by 28% of the sample. Chi-square tests determined the bivariate associations among NSSID, BPD, history of suicide attempts, and other variables. Significant diagnostic (i.e., MDD, BPD, and NSSID) and demographic (i.e., age) characteristics were included as covariates in a logistic regression model examining the associations of BPD and NSSID with suicide attempts.

RESULTS

BPD, Χ²=11.1, p<0.001, and NSSID, Χ²=13.9, p<0.001, were uniquely associated with suicide attempts. When all significant predictors were included in the final model, only NSSID emerged as a significant contributor to suicide attempts, OR = 4.9, p < 0.001.

LIMITATIONS

Causality cannot be determined from cross-sectional analyses.

CONCLUSION

These findings highlight NSSID as a powerful and unique correlate of suicide attempts among veterans, beyond the associations of established diagnostic risk factors. Improving our understanding of the relationship between NSSID and suicide risk has the potential to inform suicide prevention efforts and improve clinical outcomes among veterans.

Pregnancy and Binge Drinking: An Intersectionality Theory Perspective Using Veteran Status and Racial/Ethnic Identity

OBJECTIVES

Alcohol use during pregnancy is a critical public health issue that results in several adverse outcomes for both mother and child. While the prevalence of and consequences of binge drinking among pregnant women is well-documented in the literature, little is known about the intersectional effect of racial/ethnic identity and veteran status. The purpose of this study was to examine the prevalence of binge drinking among pregnant women using the intersectionality of racial/ethnic identity and veteran status.

METHODS

This study utilized combined data from the 2016, 2017 and 2018 Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS is a telephone survey that collects health-related risk behaviors, chronic health conditions and use of preventative services among U.S residents. Generalized linear mixed models were used to examine the prevalence of binge drinking using the interaction between race/ethnicity and veteran status.

RESULTS

Overall binge drinking prevalence was 3.60% among the sample of 6101 pregnant women. Binge drinking prevalence was the highest among racial/ethnic minority veterans at 17.42%, compared to 5.34% among white veterans, 4.05% among non-veteran racial/ethnic minorities and 3% among non-veteran whites, supporting the theory of intersectionality.

CONCLUSIONS

Intersectionality Theory suggests that the stressors from membership in two vulnerable groups may lead to increased disparities. The results of this study highlight the unique experience of being a veteran and identifying as a member of a racial/ethnic minority group. This calls for a need to customize preventative measures that address the combined impact of both racial/ethnic minority group status and veteran status.

Factors Related to Suicide Attempts: The Roles of Childhood Abuse and Spirituality

Objectives: The purpose of this article was to identify independent factors associated with suicide attempts in patients with depression and/or anxiety. Background and Aims: This study was conducted in order to examine whether risk and protective psychological factors influence the risk of suicide attempts among outpatients with anxiety and/or depressive disorders. In this regard, explanatory models have been reported to detect high-risk groups for suicide attempt. We also examined whether identified factors serve as mediators on suicide attempts. Materials and Methods: Patients from 18 to 65 years old from an outpatient clinic at Seoul St. Mary's Hospital were invited to join clinical studies. From September 2010 to November 2017, a total of 737 participants were included in the final sample. The Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), Childhood Trauma Questionnaire (CTQ), Functional Assessment of Chronic Illness Therapy-Spiritual Well-being Scale (FACIT-Sp-12), and Functional Social Support Questionnaire (FSSQ) were used to assess psychiatric symptoms. An independent samples t-test, a chi-square test, hierarchical multiple regression analyses, and the Baron and Kenny's procedures were performed in order to analyze data. Results: Young age, childhood history of emotional and sexual abuse, depression, and a low level of spirituality were significant independent factors for increased suicide attempts. Depression was reported to mediate the relationship between childhood emotional and sexual abuse, spirituality, and suicide attempts. Conclusions: Identifying the factors that significantly affect suicidality may be important for establishing effective plans of suicide prevention. Strategic assessments and interventions aimed at decreasing depression and supporting spirituality may be valuable for suicide prevention.

Posttraumatic Stress Disorder, Suicidal Ideation, and Suicidal Self-Directed Violence Among U.S. Military Personnel and Veterans: A Systematic Review of the Literature From 2010 to 2018

Rates of suicide and posttraumatic stress disorder remain high among United States military personnel and veterans. Building upon prior work, we conducted a systematic review of research published from 2010 to 2018 regarding: (1) the prevalence of suicidal ideation, suicide attempt, and suicide among United States military personnel and veterans diagnosed with posttraumatic stress disorder; (2) whether posttraumatic stress disorder was associated with suicidal ideation, suicide attempt, and suicide among United States military personnel and veterans. 2,106 titles and abstracts were screened, with 48 articles included. Overall risk of bias was generally high for studies on suicidal ideation or suicide attempt and low for studies on suicide. Across studies, rates of suicidal ideation, suicide attempt, and suicide widely varied based on study methodology and assessment approaches. Findings regarding the association between posttraumatic stress disorder diagnosis with suicidal ideation and suicide were generally mixed, and some studies reported that posttraumatic stress disorder was associated with lower risk for suicide. In contrast, most studies reported significant associations between posttraumatic stress disorder and suicide attempt. These findings suggest complex associations between posttraumatic stress disorder and suicidal ideation, suicide attempt, and suicide, which are likely influenced by other factors (e.g., psychiatric comorbidity). In addition, most samples were comprised of veterans, rather than military personnel. Further research is warranted to elucidate associations between posttraumatic stress disorder and suicidal ideation, suicide attempt, and suicide, including identification of moderators and mediators of this relationship. Addressing this among United States military personnel, by gender, and in relation to different trauma types is also necessary.

Unintentional injury fatalities in the context of rising U.S. suicide rates: A five-year review of the web-based injury statistics query and reporting system

This archival study focuses specifically on suicide fatalities in relation to unintentional and undetermined injury fatalities in an effort to determine whether or not these rates are rising consistently. This question may serve to inform whether or not suicides are being accurately reported and documented. Data from all 50 states from the years 2012-2016 were obtained from the Web-based Injury Statistics Query and Reporting System (WISQARS) developed by the Centers for Disease Control and Prevention. A total of 213,726 suicide fatalities, 702,176 unintentional injury fatalities, and 24,533 undetermined injury fatalities comprised the dataset. Injury fatality rates depicted annual increases in both suicide and unintentional injury fatalities but variability in undetermined injury fatalities. Bivariate analyses discovered a statistically significant association between annual suicide fatality rates and unintentional (nonsuicidal) injury fatality rates. It would be suspected, ceteris paribus, that calculated rate changes over these years would follow suit. However, this was not observed. Given the trends and increasing stigma surrounding suicide, it is worth considering the degree to which suicides may be underreported or -documented and the epidemiological and translational ramifications of these trends as they pertain to future suicide research.

Suicidal attempts, insomnia, and major depressive disorder among family members of suicide victims in South Korea

BACKGROUND

Suicide survivors are defined as victims who experienced suicide of siblings or parents, spouses, or lineal relatives within the fourth degree who had lived with them. We compared the effects of major depressive disorder (MDD), symptoms of posttraumatic stress disorder (PTSD), and impulsivity on lifetime suicide attempts among suicide survivors.

METHODS

Participants included 272 suicide survivors. We compared them to 5,200 members from the general population who were matched by age, sex, and years of education. We evaluated participants using the Patient Health Questionnaire-9 (PHQ-9), the EuroQuality of Life (EuroQol) scale, the Impact of Events Scale-Revised (IES-R), the Barratt Impulsiveness Scale-11 (BIS-11), and the Composite International Diagnostic Interview (K-CIDI).

RESULTS

Among the 272 suicide survivors, MDD was nine times higher (47.1% vs. 5.3%), and suicidal attempts were six times higher (20.5% vs. 3.3%) than reported among the general population. The suicide survivors showed more severe depression, greater impulsivity, and poorer quality of life than did the general population. In multivariate logistic regression analyses performed to evaluate each IES-R item, "trouble staying asleep" was the only PTSD symptom item that was significantly associated with suicide attempts among suicide survivors. Suicide survivors who had both MDD with insomnia and high impulsivity were at four times higher risk for suicide attempts than the general population with no MDD (AOR = 4.04, 95% CI: 1.25-13.09).

CONCLUSIONS

Surviving suicide by family members is an important risk factor for suicide attempts. In particular, MDD with insomnia and impulsivity are associated with suicide attempts among suicide survivors.

Anger mediates the relationship between posttraumatic stress disorder and suicidal ideation in veterans

BACKGROUND

Theoretical models and cross-sectional empirical studies of suicide indicate that anger is a factor that may help explain the association between posttraumatic stress disorder (PTSD) and suicide, but to date no longitudinal studies have examined this relationship. The current study used longitudinal data to examine whether changes in anger mediated the association between changes in PTSD symptomatology and suicidal ideation (SI).

METHODS

Post 9/11-era veterans (N = 298) were assessed at baseline, 6-months, and 12-month time points on PTSD symptoms, anger, and SI. Analyses covaried for age, sex, and depressive symptoms. Multilevel structural equation modeling was used to examine the three waves of data.

RESULTS

The effect of change in PTSD symptoms on SI was reduced from B = 0.02 (p = .008) to B = -0.01 (p = .67) when change in anger was added to the model. Moreover, the indirect effect of changes in PTSD symptoms on suicidal ideation via changes in anger was significant, B = 0.02, p = .034. The model explained 31.1% of the within-person variance in SI.

LIMITATIONS

Focus on predicting SI rather than suicidal behavior. Sample was primarily male.

CONCLUSIONS

Findings suggest that the association between PTSD and SI is accounted for, in part, by anger. This study further highlights the importance of anger as a risk factor for veteran suicide. Additional research on clinical interventions to reduce anger among veterans with PTSD may be useful in reducing suicide risk.

Sex differences in type of lifetime trauma and suicidal ideation mediated by post-traumatic stress and anxio-depressive disorders in older adults

OBJECTIVES

Examine the association between trauma and daily stressors, post-traumatic stress syndrome (PTSS), anxio-depressive disorders, and suicidal ideation in older adults.

DESIGN

A cross-sectional study.

SETTING AND PARTICIPANTS

This study included 1446 older adults recruited in primary care practices (2011-2013) and participating in Quebec's longitudinal study on health services in the elderly.

MEASUREMENTS

Lifetime trauma and PTSS was assessed using the validated PTSS scale for older adults based on scores from the Impact of Events Scale-Revised, number of lifetime traumatic events and interference with daily activities. The presence of an anxio-depressive disorder was based on physician diagnoses. Path analyses were conducted to determine the pathways between trauma, daily stressors, PTSS and anxio-depressive disorders and SI. Analyses were conducted on the overall sample and by sex.

RESULTS

Seven percent and 12% reported SI and PTSS. In males, traumas of sexual assault, violence/stalked, war/combat/imprisonment and daily hassles were directly associated with SI. In females, daily hassles were directly associated with SI. In males, a number of traumas were associated with SI through the mediating effect of PTSS and anxio-depressive disorders. In females, PTSS but not anxio-depressive disorders mediated the relationship between traumas and daily stressors, and suicidal ideation.

CONCLUSIONS

The effects of lifetime traumas persist well into older age. Traumas leading to SI differ between males and females as do the pathways and comorbidity with PTSS and anxio-depressive disorders. This highlights differences in etiologic patterns, which may be used in primary care practice to identify symptom profiles of older persons at risk of suicidal ideation.

Increasing nurse practitioner students' comfort levels in caring for veterans with post-traumatic stress disorder

ABSTRACT

Few nurse practitioner programs integrate education on care of veterans into their curriculum. Because more veterans are seeking health care outside of the Veteran Affairs system, all advanced practice nurses need to be prepared to meet the unique needs of veterans with post-traumatic stress disorder (PTSD). The authors developed an education session on military-to-civilian transition and screening and treatment of veterans with PTSD. The session was provided to a convenience sample of students. Case studies were included to allow student participation and active learning. Students completed pre-education and post-education surveys to measure their comfort level in caring for this specific population and their understanding of PTSD. The participant scores on comfort level with identifying and managing PTSD after the education session were significantly increased. Placing veteran-specific education into nurse practitioner programs enhances the comfort level with identifying and managing PTSD. Adding this veteran-specific education could enhance the overall care for veterans in the civilian sector.

Military hazing and suicidal ideation among active duty military personnel: Serial mediation effects of anger and depressive symptoms

BACKGROUND

Military hazing is one of most serious problems affecting suicidal ideation (SI) among active duty personnel, but has received limited research attention. Studies on hazing and SI indicate anger and depressive symptoms as mediators for SI.

METHODS

A sample of active duty military personnel (N = 944) completed an offline survey, consisting of the revised Conflict Tactics Scale-2, Composite International Diagnostic Interview Screening Scale, and revised Columbia Suicide Severity Rating Scale. Frequency, bivariate correlation, and serial mediation analyses were conducted to assess the serial effects of military hazing on SI, mediated via anger and depressive symptoms.

RESULTS

Military hazing, anger, depressive symptoms, and SI were positively related to each other in bivariate analyses. In serial mediation analyses, hazing was found to be a significant predictor of higher levels of anger, consequently triggering depressive symptoms, which, in turn, were associated with greater SI.

LIMITATIONS

Study limitations included the use of cross-sectional data with the use of retrospective self-report.

CONCLUSION

Hazing in the military is prevalent (17.6%), and SI is associated with serial effects of hazing, anger, and depressive symptoms with full mediation path. Findings suggest that policies that address reducing hazing and implementing clinical interventions specifically focused on symptoms of anger and depression may be important for decreasing SI in military personnel.

Developing Predictive Models to Enhance Clinician Prediction of Suicide Attempts Among Veterans With and Without PTSD

The limitations of self-report confine clinicians' ability to accurately predict suicides and suicide attempts (SAs). Behavioral assessments (e.g., Death Implicit Association Test [IAT]) may be a means of supplementing self-report and clinician prediction.

OBJECTIVE

The authors aimed to build and test a predictive model of SAs that included established risk factors and measures of suicide risk, and Death IAT scores. The authors also sought to test the predictive validity of the SA model among subgroups of Veterans with and without PTSD.

METHOD

Participants included 166 psychiatrically hospitalized Veterans.

RESULTS

A model that included patient prediction, age, and Death IAT scores improved upon clinician prediction of SAs during the six-month follow-up (C-statistic for clinician prediction = 73.6, 95% CI [62.9, 84.4] and C-statistic for model = 82.8, 95% CI [74.6, 91.0]). The model was tested in subgroups of Veterans with and without PTSD. Among Veterans without PTSD, the Death IAT and patient prediction predicted SAs above and beyond clinician prediction, while these variables did not significantly improve prediction among Veterans with PTSD (C-statistic for no-PTSD = 91.3, 95% CI [80.6, 1.00]; C-statistic for PTSD = 86.8, 95% CI [76.8, 96.8]). Building a separate model for Veterans with PTSD did not improve upon clinician prediction.

CONCLUSIONS

Findings indicate that predictive models may bolster clinician prediction of SAs and that predictors may differ for Veterans with PTSD.

The protective effects of grit on suicidal ideation in individuals with trauma and symptoms of posttraumatic stress

OBJECTIVE

It is important to understand factors that moderate the likelihood of developing suicidal thoughts following traumatic exposure and posttraumatic stress symptoms.

METHOD

In this cross-sectional study, a moderated atemporal mediation analysis was conducted in a sample of 709 college students (71% female, M _age  = 19.90 years, 67% Caucasian) to test the associations between trauma, posttraumatic stress disorder (PTSD) symptoms, and suicidal ideation, with grit entered as a moderator of all paths in the equation.

RESULTS

PTSD symptoms mediated the association between trauma and suicidal ideation. Grit moderated the direct pathway from PTSD symptoms to suicidal ideation.

CONCLUSIONS

Grit and other constructs of resiliency may inform strength-focused interventions to remediate the impact of trauma and posttraumatic stress symptoms and potentially reduce suicidal thoughts and risk for suicide.

Insomnia and risk for suicidal behavior: A test of a mechanistic transdiagnostic model in veterans

BACKGROUND

Insomnia has been shown to have direct and indirect associations with suicidal ideation, attempts, and death in U.S. military and veteran populations. However, transdiagnostic models of insomnia and psychopathology have not been used to examine the contribution of psychopathology.

METHOD

The present study is a secondary analysis examining the associations among insomnia symptoms, posttraumatic stress disorder (PTSD) and depressive symptoms, interpersonal theory of suicide variables, and risk for suicidal behavior in community veterans (n = 392). Serial mediation was used to test sequential associations, allowing for examination of direct and indirect associations.

RESULTS

The model with insomnia, PTSD, and depressive symptoms, and thwarted belongingness, accounted for 29% of the variance in risk. Insomnia symptoms had an indirect association through PTSD and depressive symptoms, and thwarted belongingness. The model with insomnia, PTSD, and depressive symptoms, and perceived burdensomeness accounted for 35% of the variance in risk. Insomnia symptoms had an indirect association through PTSD and depressive symptoms, and perceived burdensomeness.

LIMITATIONS

Data are cross-sectional, precluding the testing of causal associations.

CONCLUSIONS

In veterans, insomnia symptoms may be associated with increased PTSD and depressive symptoms, which may be associated with increased risk for suicidal behavior directly and indirectly through relationship disruptions.

Angry and Fearful Face Conflict Effects in Post-traumatic Stress Disorder

In the presence of threatening stimuli, post-traumatic stress disorder (PTSD) can manifest as hypervigilance for threat and disrupted attentional control. PTSD patients have shown exaggerated interference effects on tasks using trauma-related or threat stimuli. In studies of PTSD, faces with negative expressions are often used as threat stimuli, yet angry and fearful facial expressions may elicit different responses. The modified Eriksen flanker task, or the emotional face flanker, has been used to examine response interference. We compared 23 PTSD patients and 23 military controls on an emotional face flanker task using angry, fearful and neutral expressions. Participants identified the emotion of a central target face flanked by faces with either congruent or incongruent emotions. As expected, both groups showed slower reaction times (RTs) and decreased accuracy on emotional target faces, relative to neutral. Unexpectedly, both groups showed nearly identical interference effects on fearful and neutral target trials. However, post hoc testing suggested that PTSD patients showed faster RTs than controls on congruent angry faces (target and flanker faces both angry) relative to incongruent, although this finding should be interpreted with caution. This possible RT facilitation effect with angry, but not fearful faces, also correlated positively with self-report measures of PTSD symptoms. These results suggest that PTSD patients may be more vigilant for, or primed to respond to, the appearance of angry faces, relative to fearful, but further study is needed.

Posttraumatic Mental Contamination and the Interpersonal Psychological Theory of Suicide: Effects via DSM-5 PTSD Symptom Clusters

Research has yet to establish a relationship between posttraumatic mental contamination and suicide risk, despite theoretical overlap. The present study examined relationships between posttraumatic mental contamination and suicide risk via posttraumatic stress symptom clusters and appraisals of perceived burdensomeness and thwarted belongingness. Trauma-exposed participants (N=183) completed measures of posttraumatic mental contamination, posttraumatic stress symptoms, thwarted belongingness, perceived burdensomeness, and suicide risk. Findings revealed significant indirect effects of posttraumatic mental contamination on suicide risk via all posttraumatic stress symptom clusters. Significant serial indirect effects of posttraumatic mental contamination on suicide risk were observed via posttraumatic avoidance and arousal/reactivity and, subsequently, via thwarted belongingness and perceived burdensomeness. Serial models via posttraumatic re-experiencing and negative cognitions/mood symptoms were nonsignificant. Results suggest that posttraumatic mental contamination may increase suicide risk via posttraumatic stress symptom severity, and maladaptive interpersonal appraisals may explain these links through distinct symptom pathways. Implications for posttraumatic suicide risk are discussed.

Posttraumatic stress disorder: from diagnosis to prevention

Posttraumatic stress disorder (PTSD) is a chronic impairment disorder that occurs after exposure to traumatic events. This disorder can result in a disturbance to individual and family functioning, causing significant medical, financial, and social problems. This study is a selective review of literature aiming to provide a general outlook of the current understanding of PTSD. There are several diagnostic guidelines for PTSD, with the most recent editions of the DSM-5 and ICD-11 being best accepted. Generally, PTSD is diagnosed according to several clusters of symptoms occurring after exposure to extreme stressors. Its pathogenesis is multifactorial, including the activation of the hypothalamic-pituitary-adrenal (HPA) axis, immune response, or even genetic discrepancy. The morphological alternation of subcortical brain structures may also correlate with PTSD symptoms. Prevention and treatment methods for PTSD vary from psychological interventions to pharmacological medications. Overall, the findings of pertinent studies are difficult to generalize because of heterogeneous patient groups, different traumatic events, diagnostic criteria, and study designs. Future investigations are needed to determine which guideline or inspection method is the best for early diagnosis and which strategies might prevent the development of PTSD.

Depressive symptoms, post-traumatic stress symptoms and suicide risk among graduate students: The mediating influence of emotional regulatory self-efficacy

The current study was to examine the relationship among depressive symptoms, post-traumatic stress symptoms, emotion regulatory self-efficacy and suicide risk. A cross-sectional survey was conducted among 3257 graduate students from a medical college of China. Lifetime prevalence of suicidal ideation, plan and attempt were 25.7%, 1.6%, 1.1%, respectively, with one-year suicidal ideation showing at 6.3%. Structural equation modeling was employed to examine the relative contribution of depressive symptoms, post-traumatic stress symptoms and emotion regulatory self-efficacy on suicide risk. Structural equation model had a highly satisfactory fit [χ² = 7.782, df = 4, p = 0.096; RMSEA = 0.021; CFI = 0.992; GFI = 0.997]. Post-traumatic stress symptoms had a direct effect and an indirect effect on suicide risk via emotion regulatory self-efficacy. Depressive symptoms also had a direct effect and an indirect effect on suicide risk via emotion regulatory self-efficacy. The depressive and post-traumatic stress symptoms increased the risk of suicide risk, but the variable of emotion regulatory self-efficacy would be served as a buffering factor, decreasing the risk of suicide. The interaction term of depressive symptoms and post-traumatic stress symptoms had a direct effect on suicide risk. A significant interactive effect of depressive and post-traumatic stress symptoms on suicide risk was found.

Increased risk of attempted suicide in Australian veterans is associated with total and permanent incapacitation, unemployment and posttraumatic stress disorder severity

BACKGROUND

Military veterans have higher rates of suicidality and completed suicides compared to the general population. Previous research has demonstrated suicidal behaviour is higher in US combat veterans who are younger, suffer from posttraumatic stress disorder, depression and anxiety and score lower on measures of health. However, research on predictors of suicide for Australian veterans is limited. The aim of this study was to identify significant demographic and psychological differences between veterans with posttraumatic stress disorder who had attempted suicide and those with posttraumatic stress disorder who had not, as well as determine predictors of suicide attempts within an Australian cohort.

METHODS

A retrospective analysis was conducted on 229 ex-service personnel diagnosed with posttraumatic stress disorder who had attended a Military Service Trauma Recovery Day Program as outpatients at Toowong Private Hospital from 2007 to 2014. Patients completed a battery of mental health self-report questionnaires assessing symptoms of posttraumatic stress disorder, alcohol use, anger, depression, anxiety and quality of life. Demographic information and self-reported history of suicide attempts were also recorded.

RESULTS

Results indicated the average age was significantly lower, and the rates of posttraumatic stress disorder, anger, anxiety and depression symptoms were significantly higher in those veterans with history of a suicide attempt. Multivariate logistic regression analyses indicated posttraumatic stress disorder symptom severity, unemployment or total and permanent incapacity pension status significantly predicted suicide attempt history.

CONCLUSION

Among a cohort of Australian veterans with posttraumatic stress disorder, psychopathology severity, unemployment and total and permanent incapacity status are significantly associated with suicidality. This study highlights the importance of early identification of posttraumatic stress disorder and psychopathology, therapeutic and social engagement, and prioritisation of tangible employment options or meaningful and goal-directed activities for veterans deemed unable to work.

Post-traumatic psychiatric disorders: PTSD is not the only diagnosis

Traumatic events and their consequences are often hidden or minimised by patients for reasons linked to the post-traumatic stress disorder itself (inexpressibility, shame, depressive thoughts, fear of stigmatisation, etc.). Although post-traumatic stress disorder (PTSD) remains the most widely known disorder, chronic post-traumatic psychiatric disorders are many and varied. After a trauma, the practitioner has to check for the different clinical forms of post-traumatic psychological consequences: PTSD is not the only diagnosis. Based on our own clinical experience compared to the international literature, we think necessary to build a didactic classification describing chronic post-traumatic symptoms and syndromes. Post traumatic depressions and bereavement lead to high risk of suicidal crisis and self-harm behaviours. Re-experiencing are felt with anxiety, hyper arousal increases anxious reactivity, and avoidance strategies increase anticipatory anxiety, indicating post-traumatic anxiety disorders (agoraphobia, specific phobia, obsessive compulsive disorder, separation anxiety, social phobia). Characterising an often-severe clinical picture, the co-occurrence of post-traumatic and chronic psychotic symptoms is not unusual (post-traumatic schizophrenia, post-traumatic depression with mood-congruent psychotic features, non-schizophrenic post-traumatic psychotic disorder, and bipolar reaction to trauma). A physical injury occurring at the same time as a traumatic exposure increases the risk of developing post-traumatic stress disorder later which, in turn, afflicts the subjective perception of the physical health (development of somatoform and psychosomatic disorders, comorbidity with a post-concussion syndrome). The trauma may cause a rupture in the biography of a person, also in his/her internal physiological functioning as in his/her social activities (impacts of instinctive functions and behaviours, personality changes, and adjustment difficulties on professional and personal life). Although a nomenclature is necessary for semiological descriptions, a thorough analysis of the patient's general psychological functioning must also be conducted.

The Moral Injury Symptom Scale-Military Version

The purpose of this study was to develop a multi-dimensional measure of moral injury symptoms that can be used as a primary outcome measure in intervention studies that target moral injury (MI) in Veterans and Active Duty Military with PTSD. This was a multi-center study of 427 Veterans and Active Duty Military with PTSD symptoms recruited from VA Medical Centers in Augusta, Los Angeles, Durham, Houston, and San Antonio, and from Liberty University in Lynchburg. Internal reliability of the Moral Injury Symptom Scale-Military Version (MISS-M) was examined along with factor analytic, discriminant, and convergent validity. Participants were randomly split into two equal samples, with exploratory factor analysis conducted in the first sample and confirmatory factor analysis in the second. Test-retest reliability was assessed in a subsample of 64 Veterans. The 45-item MISS-M consists of 10 theoretically grounded subscales assessing guilt, shame, moral concerns, religious struggles, loss of religious faith/hope, loss of meaning/purpose, difficulty forgiving, loss of trust, and self-condemnation. The Cronbach's alpha of the overall scale was .92 and of individual subscales ranged from .56 to .91. The test-retest reliability was .91 for the total scale and ranged from .78 to .90 for subscales. Discriminant validity was demonstrated by relatively weak correlations with other psychosocial, religious, and physical health constructs, and convergent validity was indicated by strong correlations with PTSD, depression, and anxiety symptoms. The MISS-M is a reliable and valid multi-dimensional symptom measure of moral injury that can be used in studies targeting MI in Veterans and Active Duty Military with PTSD symptoms and may also be used by clinicians to identify those at risk.