The role of depression and suicidal cognitions as contributors to suicide risk among active duty soldiers reporting symptoms of posttraumatic stress disorder

Key Improvements to the Army's Suicide Prevention and Intervention Training: An Interagency Collaboration to Develop the New "ACE Base +1" Curriculum

INTRODUCTION

Suicide is a prevalent problem impacting the military community. The U.S. Army recognized the need to address this complex issue; one line of effort has been to provide suicide prevention and intervention education and training that is informed by current research, doctrine, and implementation best practices. The purpose of this article is to outline and present the genesis of the Army's new suicide prevention and intervention training-"Ask, Care, Escort (ACE) Base +1"-that aligns with the DoD newly published regulation-driven initiatives.

MATERIALS AND METHODS

The development of the "ACE Base +1" curriculum was a collaborative effort between two organizations within the Defense Health Agency: The Defense Centers for Public Health-Aberdeen and the WRAIR. A multidisciplinary team was formed by selecting specific operational and subject-matter experts from each organization based on educational qualifications and practical experiences expected to aid the development of curriculum content (e.g., subject-matter experts) and/or the training design. Revisions to the curriculum were informed by the Army's existing suicide prevention training module, current research in suicide prevention and public health, updated and relevant Army regulations, and current public health policy guidance from the CDC and the Department of Suicide Prevention Office. A detailed account of the systematic and iterative curriculum development process is provided.

RESULTS AND CONCLUSIONS

The interagency collaborative efforts resulted in a suite of training products, "ACE Base +1" version 1.3 that is modernized in training content, delivery methods, and design. Four primary elements shaped the final products: (1) A modular framework allowing a tailored approach to mandatory training, (2) a public-health approach that focuses on earlier intervention opportunities while building trust and cohesion, (3) a training design centered on peer discussions and behavioral rehearsal, and (4) an expansion of the curriculum to be inclusive of the entire Army community. Practical implications for each element are discussed.As the program of record, "ACE Base +1" training satisfies the annual requirement for all Active Army, Army National Guard, U.S. Army Reserve, and Department of the Army (DA) civilians. Both the training content (e.g., public-health concepts) and design of "ACE Base +1" reflect a comprehensive approach, focused on developing concrete, applicable skills that support the shared responsibility to suicide prevention and intervention. Limitations, such as delayed interagency collaboration and time constraints, are discussed. Future directions include recommendations for future curriculum projects, specifically within military populations, such as interprofessional, interagency collaboration, and selecting a multidisciplinary team of subject-matter experts. Additionally, WRAIR plans to continue their support to Directorate of Prevention, Resilience and Readiness with the expansion of the +1 menu of trainings, ongoing program evaluation, and longitudinal analysis to inform future revisions and ensure the content and delivery methods remain modernized, relevant, and effective.

First- and Second-Generation Psychological Theories of Suicidal Behaviour

Suicidal behaviour is defined as taking actions with the intention of killing oneself and thinking of performing these actions. Suicide is a serious public health problem with complex biological, social and psychological risk factors and a multidimensional clinical appearance, occurring all over the world and ranking among the leading causes of death. In this study, psychological approaches explaining suicide were evaluated under the headings of first-generation and second-generation suicide theories, the different aspects of these theories were put forward, and previously published studies and recent evidence were reviewed. A literature review on the theoretical foundations of suicide is presented. First-generation suicide theories were developed before the 2000s and second-generation suicide theories were developed after the 2000s. While Psychodynamic Theory, Social Learning Theory, Hopelessness Theory, Shneidman's Suicide Theory and Escape Theory are included under the title of first-generation suicide theories, Interpersonal Psychological Suicide Theory, Three Stage Suicide Theory, Complementary Motivational-Demotivational Theory and Variable Predisposition Theory are examined as second-generation suicide theories. The approaches of the theories provide important evidence in understanding suicidal behaviour and recognising various risk factors in the transition from suicidal ideation to suicidal action. Controlling the risk factors may contribute both in terms of preventive community mental health and in the development of health policies.

The role of alexithymia in suicide ideation among Taiwanese army military personnel: A serial mediation model investigating the effects of perceived stress and depression

Maintaining the good mental health of Taiwanese military personnel is crucial, especially in light of incidents such as the Taiwan Strait crisis. Suicide is a leading cause of death among military personnel and alexithymia is a significant risk factor for suicidal ideation. However, the mechanisms linking alexithymia and suicidal ideation in this psychologically burdened population remain poorly understood. In total, 863 voluntary army military personnel from Taiwanese reserve brigades and combined-arms brigades were enroled between May 2020 and February 2021. Structured questionnaires about alexithymia, perceived stress, depression, suicidal ideation, and background characteristics were used. Mediation analyses were conducted to examine the serial mediation roles of perceived stress and depression in the relationship between alexithymia and suicidal ideation. Significant positive correlations were observed between alexithymia, perceived stress, depression, and suicidal ideation in bivariate analyses. Serial mediation analyses revealed that alexithymia significantly predicted higher levels of perceived stress, subsequently leading to depressive symptoms, which were associated with suicidal ideation. Depression served as a significant mediator between alexithymia and suicidal ideation. The strongest mediating effect (71.4%) was observed in the pathway from alexithymia through perceived stress and depression to suicidal ideation. Limitations included the utilization of cross-sectional data and a reliance on retrospective self-report measures. Perceived stress and depression were identified as serial mediators in the association between alexithymia and suicidal ideation. Clinically, it is crucial to prioritise interventions that target emotional regulation skills and assess the presence of alexithymia to effectively reduce suicidal ideation in military personnel.

Male sex and hazardous alcohol use following military sexual assault increase suicide risk among US service members and veterans

Background: Higher alcohol use and military sexual assault (MSA) are associated with increased risk of death by suicide. Risk for death by suicide is rapidly increasing among females, who report higher rates of MSA, yet actual death by suicide and alcohol use are higher among males. It is not well understood whether higher alcohol use confers greater suicide risk in male or female service members and veterans who have experienced MSA.Objective: To determine whether the association between alcohol misuse and suicide risk was moderated by biological sex in a sample of male and female service members (N = 400, 50% female) who reported MSA.Method: Participants completed surveys of alcohol use and suicide risk as well as a demographic inventory. Linear regression with an interaction term was used to determine if suicide risk differed by sex and alcohol use severity after accounting for discharge status, sexual orientation, and age.Results: Average scores on the suicide risk measure were consistent with an inpatient psychiatric sample and scores on the AUDIT-C were indicative of a probable positive screen for alcohol misuse. Suicide risk was most pronounced among males who reported higher levels of hazardous alcohol use. A sensitivity analysis examining suicide risk by sex and screening results for alcohol misuse (positive/negative) showed that men with a probable positive screen had higher suicide risk.Discussion: The current study provides novel findings on suicide risk among survivors of military sexual violence by including both male and female survivors. Interventions to decrease suicide risk following MSA may consider alcohol reduction strategies, and optimizing these interventions in males. Engaging military culture at both the US Departments of Defense and Veterans Affairs to encourage more healthy alcohol consumption may mitigate this public health concern. Future research may consider how country of origin relates to these associations.

Anshen Dingzhi prescription in the treatment of PTSD in mice: Investigation of the underlying mechanism from the perspective of hippocampal synaptic function

BACKGROUND

Anshen Dingzhi prescription (ADP) is an important prescription for the treatment of mental diseases in traditional Chinese medicine and is widely used to treat neuropsychiatric disorders.

PURPOSE

To explore the ameliorative effect of ADP on post-traumatic stress disorder (PTSD)-like behaviors in mice and determine the underlying mechanism.

METHODS

The constituents of ADP were analyzed by UPLC-Q-TOF/MS. The PTSD-like behaviors of mice subjected to single prolonged stress (SPS) were evaluated using behavioral tests. Potential pathological changes in the hippocampus were assessed by hematoxylin and eosin (H&E) staining. Western blotting and immunohistochemistry (IHC) were employed to detect the expression of proteins involved in relevant signaling pathways.

RESULTS

Five quality control markers (ginsenoside Rg1, ginsenoside Rb1, tenuifolin, poricoic acid B, and α-asarone) were detected in the ADP solution. The ginsenoside Rg1 content in ADP was found to be 0.114 mg/g. Mice subjected to SPS showed obvious fear generalization and anxiety-like behaviors. ADP treatment prevented the behavioral changes caused by exposure to SPS. Compared with control animals, the number of normal pyramidal cells in the hippocampal CA1 region of mice exposed to SPS was decreased and the number of degenerating pyramidal cells was increased; however, ADP administration could counteract these effects. Furthermore, the protein expression of BDNF, p-TrkB, μ-calpain, PSD95, GluN2A, GluA1, p-AKT, p-mTOR, and ARC was decreased, while that of PTEN and GluN2B was increased in the hippocampus of mice subjected to SPS compared with that in control animals; however, these changes in protein expression were reversed following ADP treatment. Importantly, the ameliorative effect of ADP on PTSD-like behaviors and synaptic protein expression were inhibited by rapamycin administration.

CONCLUSIONS

ADP administration improves PTSD-like behaviors in mice and this effect may be mediated through an mTOR-dependent improvement in synaptic function in the hippocampus.

Predictive Model of Suicide Risk in Young People: The Mediating Role of Alcohol Consumption

Suicidal behavior is one of the public health problems that cause most deaths in young people and has been associated with emotional and affective problems, so predictive models are required to account for the relationship between depression, anxiety, hopelessness, and alcohol consumption to propose actions for its prevention. The Plutchik Suicide Risk Scale, the CAGE Questionnaire, the Hopelessness Scale, the Depression Inventory and the Beck Anxiety Scale were applied. A total of 1.379 young people (M = 20.45; SD = 3.23) from the cities of Manizales (n = 739; 53.6%) and Medellín (n = 640; 46.5%) in Colombia were evaluated. The variables of anxiety, hopelessness and depression explained 51% (R² = 0.509; 95% CI = 0.467-0.552; p = 0.001) of the variation in suicidal risk. Likewise, alcohol consumption is a mediating variable between depression and anxiety in the prediction of suicidal risk, whose total, direct and indirect effects are statistically significant. The findings support the role of alcohol consumption as a mediating variable between anxiety, depression, hopelessness and suicidal risk in young people, given the difficulties it causes in information processing, regulation of emotions and therefore in having an adequate coping with the demands of the environment. This justifies the importance of directing suicide prevention actions through strategies for the reduction of alcohol consumption and the management of emotions in young people. HIGHLIGHTSAlcohol modulates the effect of depression and anxiety on suicide riskThis is a study on the risk of suicide in young people in ColombiaThe findings have implications for timely clinical interventions.

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.

The global prevalence of depression, suicide ideation, and attempts in the military forces: a systematic review and Meta-analysis of cross sectional studies

BACKGROUND

Given the wide range of depressive disorders, suicidal ideation and suicide attempts in various military studies around the world, determining the exact prevalence of these disorders in line with health planning as well as care and treatment service designing for military forces can be useful. The aim of the present meta-analysis was to determine the pooled prevalence of depressive disorders, suicide thoughts, and attempts in the military.

METHODS

The present systematic review and meta-analysis study was performed based on PRISMA criteria in 5 steps of the search strategy, screening and selection of articles, data extraction, evaluation of article quality and meta-analysis. International databases (PubMed (Medline), Scopus, Web of science, Embase (Elsevier), PsycInfo (Ovid), Cochrane CENTRAL (Ovid)) were searched using related keywords extracted from Mesh and Emtree. After screening and final selection of articles, data were extracted and qualitative evaluation was performed using the NOS checklist.

RESULTS

The results of meta-analysis showed that the prevalence of depression in active military forces and veterans was 23% (%95 CI: 20-26%) and 20% (%95 CI: 18-22%), respectively. In addition, the prevalence of suicidal ideation and attempts in the military was 11% (%95 CI: 10-13%) and 11% (%95 CI: 9-13%), respectively. The prevalence of suicide ideation and attempts in drug-using military was 18% (%95 CI: 7-33%) and 30% (%95 CI: 23-36%), respectively. The prevalence of suicidal ideation and attempts in military consuming alcohol were 9% (%95 CI: 4-13%) and 8% (%95 CI: 7-10%), respectively. In militaries with AIDS / HIV, the prevalence of suicide attempts was 5% (%95 CI: 4-8%).

CONCLUSION

Therefore, it is necessary to develop and design training and intervention programs in order to increase the awareness of the military, especially veterans, to prevent the occurrence of suicide and depression.

Delayed reward discounting and increased risk for suicide attempts among U.S. adults with probable PTSD

BACKGROUND

PTSD is an established risk factor for suicide attempts and suicide death, but the mechanisms underlying this association remain unknown. The present study examined associations among delayed reward discounting-the balance between smaller immediate available rewards versus larger delayed rewards-self-reported PTSD symptoms, and recent suicide attempts among individuals reporting suicide ideation within the past year.

METHODS

A cross-sectional survey of U.S. adults completed the Primary Care PTSD Screen for DSM-5, the 21-item Monetary Choice Questionnaire, and the Self-Injurious Thoughts and Behaviors Interview-Revised. Analyses of variance and multinomial regression models were used to test associations among variables.

RESULTS

Among participants reporting suicide ideation within the past year, discount rates were significantly higher among those reporting more PTSD symptoms and a past-year suicide attempt, suggesting these participants expressed a preference for immediately available rewards.

CONCLUSIONS

Choice behavior among individuals reporting many PTSD symptoms and a recent suicide attempt is influenced to a greater degree by immediately available rewards. Sensitivity to immediate rewards at the expense of larger delayed rewards may reflect a vulnerability for suicidal behavior among individuals screening positive for PTSD.

The association of childhood trauma with sleep disturbances and risk of suicide in US veterans

BACKGROUND

Sleep dysregulation is prevalent among veterans and is associated with increased risk of suicidal ideation and behaviors. A confluence of risk factors have been identified to date that contribute to increase risk for suicidal behavior. How these risk factors including childhood trauma, comorbid psychopathology, impulsivity, and hostility together with sleep disturbance contribute to suicide risk remains an open question. These factors have never been examined simultaneously in a unified mediation model, as investigated in the present study, to determine their relative contribution to suicide risk.

METHODS

Veterans (N = 105) were recruited across 3-groups, including Major Depressive Disorder (MDD) with/without a history of a suicide attempt (n = 35 and n = 37, respectively), and non-psychiatric controls, who had no history of mental illness or suicidal behavior (n = 33). The participants were assessed using validated self-report assessments with in-depth phenotyping for relevant risk factors associated with suicidal behavior including childhood adversity, depression severity, impulsivity, hostility, and sleep quality. These factors were included in mediation models using path analysis.

RESULTS

Across all subjects including those with MDD and non-psychiatric controls, mediation analysis showed that higher levels of childhood trauma had an indirect effect on poor sleep quality (p = 0.001). This effect was orthogonal, being independently mediated by both MDD psychopathology (p = 0.003), and higher traits of impulsivity (p = 0.001) and hostility (p = 0.015). Amongst MDD veterans, childhood trauma was directly associated with increased suicide risk (p = 0.034), irrespective of their severity of depression, or their degree of hostility and impulsivity.

LIMITATIONS

include use of self-report data, and the inability to establish causal inferences with cross-sectional design.

CONCLUSION

Childhood adversity as a significant pre-deployment risk factor for disturbed sleep and elevated suicide risk, potentially important for incorporation in clinical practice for suicide.