Suicide risk among combatants: The longitudinal contributions of pre-enlistment characteristics, pre-deployment personality factors and moral injury

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.

Longitudinal associations between exposure to potentially morally injurious events and suicidal ideation among recently discharged veterans - The mediating roles of depression and loneliness

BACKGROUND

Exposure to potentially morally injurious events (PMIEs) during military service is associated with heightened suicidal ideation (SI). However, no longitudinal study has established temporal associations between these variables and examined the possible mediating roles of depression and loneliness in this effect.

METHODS

Participants were 374 active-duty Israeli combatants who participated in a five-year longitudinal study with four measurement points: T1- one year before enlistment, T2- one month before discharge from army service, and then again six months and twelve months following their discharge (T3 and T4, respectively). Data were assessed through semi-structured interviews and validated self-report questionnaires.

RESULTS

Above and beyond pre-enlistment personal characteristics (T1) and combat exposure (T2), PMIEs-'betrayal' (T2) predicted more frequent SI over the past twelve months (T4) through the mediation of depression. Moreover, both PMIEs-'betrayal' and 'self' (T2) predicted more frequent SI over the past twelve months (T4) through the mediation of loneliness.

LIMITATIONS

We used self-report measures to assess PMIEs and SI, which may suffer from various biases.

CONCLUSIONS

Our findings are the first to provide evidence of longitudinal, temporal associations between exposure to PMIEs and SI. Notably, potential interventions might consider addressing the loneliness experienced following exposure to PMIEs during military service, among recently discharged traumatized veterans.

The impact of moral injury on trajectories of depression: a five-year longitudinal study among recently discharged Israeli veterans

BACKGROUND

Perpetrating or witnessing acts that violate one's moral code are frequent among military personnel and active combatants. These events, termed potentially morally injurious events (PMIEs), were found to be associated with an increased risk of depression, in cross-sectional studies. However, the longitudinal contribution of PMIEs to depression among combatants remains unclear.

METHOD

Participants were 374 active-duty combatants who participated in a longitudinal study with four measurement points: T1-one year before enlistment, T2-at discharge from army service, and then again 6- and 12-months following discharge (T3 and T4, respectively). At T1, personal characteristics assessed through semi-structured interviews. At T2-T4, PMIEs and depressive symptoms were assessed.

RESULTS

At discharge (T2), a total of 48.7% of combatants reported experiencing PMIEs incident, compared with 42.4% at T3 and 30.7% at T4. We found a significant interaction effect in which combatants endorsing PMIEs at discharge reported higher severity of depression symptoms at discharge (T2) than combatants who reported no PMIEs. This effect decreased over time as depression levels were lower at T3 and T4.

CONCLUSIONS

PMIE experiences, and especially PMIE-Betrayal experiences, were found to be valid predictors of higher severity of depression symptoms after the first year following discharge.

Moral injury and its mental health consequences among protesters: findings from Israel's civil protest against the government's judicial reform

Background: Government actions and participating in protracted-duration protests against it affect protesters' mental health, leading to high distress levels, such as posttraumatic and depressive symptoms. Aside from exposure to violence and other issues, protest participation can pose unique challenges to the protesters as they may be exposed to potentially morally injurious events (PMIEs), such as the betrayal of leaders they once trusted. This study's primary objective was to examine the extent of psychological difficulties among civilians participating in long-duration protests in Israel. More specifically, the study aimed to understand the contribution of exposure to protest-related PMIEs to psychological difficulties such as posttraumatic and depressive symptoms.Method: Participants comprised 4036 Israelis who were actively involved in the unfolding civil protest movement against the government-led judicial overhaul between January 2023 and August 2023. The protesters completed validated self-report questionnaires that included measures of PMIE exposure, PTSD and depressive symptoms.Results: About half (44.3%) of the sample met the criteria for self-report diagnosis of major depression and 10.6% for PTSD. Most of the protesters indicated their exposure to at least one moral injury event, with 63.9% reporting exposure to PMIE-Betrayal. Protesters exposed to PMIEs reported significantly higher levels of both PTSD and depression than non-PMIE-exposed protesters. Hierarchical regression analyses revealed that, beyond demographics and protest-related characteristics such as exposure to violence, PMIE dimensions significantly contributed to both PTSD and depression levels.Conclusions: The findings highlight the mental burden of protesters during the civil protests against the judicial overhaul in Israel. More central to the present research, the findings highlight the critical contribution of PMIEs exposure to this burden. Clinicians treating protesters coping with depression and PTSD following the civil actions should attend to their exposure to PMIEs, which may relate to the deleterious psychological effects among protesters.

Longitudinal associations between transgressions of moral beliefs and suicidal ideation among recently discharged veterans

We evaluated longitudinal associations between subjective appraisals of transgressions of moral beliefs, values, and expectations (potential morally injurious events; PMIEs) and suicidal ideation (SI) among recently discharged combat veterans. Participants were 374 active-duty Israeli combatants who participated in a five-year longitudinal study with four measurement points: T1- one year before enlistment, T2- one month before discharge from army service, and then again six months and twelve months following discharge (T3 and T4, respectively). A history of lifetime suicidal ideation and behavior was associated with higher levels of subjective appraisals of PMIEs, as compared to no history of suicidal ideation and behavior. Above and beyond pre-enlistment personal characteristics, cross-lagged pathway analyses indicated significant bi-directional pathways between subjective appraisals of PMIEs and SI. For all PMIEs dimensions, SI was associated with greater subjective appraisals of PMIEs, on subsequent measurement. However, cross-lagged effects of PMIEs-'other' (T2) predicting SI (T3) and PMIEs-'betrayal' (T3) predicting SI (T4) were also found. Our findings are the first to provide evidence of longitudinal, temporal associations between subjective appraisals of PMIEs and SI, which might serve as potential intervention targets among recently discharged traumatized veterans.

FEATURES OF AFFECTIVE SYMPTOMS IN COMBATANTS WITH NON-PSYCHOTIC MENTAL DISORDERS THAT HAVE SUFFERED FROM COVID-19

OBJECTIVE

The aim: To establish the level of anxiety and depressive disorders and the impact of covid-19 on affective pathology in combatants with non-psychotic mental disorders who have suffered from COVID-19 in a comparative aspect.

PATIENTS AND METHODS

Materials and methods: 252 male combatants with non-psychotic mental disorders who suffered from COVID-19 were clinically examined using HRDS and HARS scales.

RESULTS

Results: A lower prevalence of anxiety or fear was found in combatants who did not have COVID-19: 70.5% vs. 80.8%; low mood - 55.3% vs. 66.7%; emotional lability - 44.7% vs. 58.3%; irritability - 40.9% vs. 55.0%; emotional sensitivity - 53.0% vs. 71.7%; dulling of emotions - 6.8% vs. 6.7%; anhedonia - 77.3% vs. 83.3% of patients, rapid fatigue - 51.5% vs. 65.8%, feelings of guilt, futility, anxiety or fear - 78.0% vs. 87.5%, dissomnia - 47.0% vs. 61.7%; inability to concentrate and make decisions - 25.8% vs. 43.3%; thoughts of death or suicide - 25.0% vs. 35.8% pessimism - 21.2% vs. 31.7%, low self-esteem - 21.2% vs. 31.7%, unstable appetite and weight loss-17.4% vs. 24.2%. The overall HDRS depression score in combatants with non-psychotic mental disorders who did not have COVID-19 was also significantly lower: 15.29±4.16 points vs. 18.05±4.29 points. Similar patterns were found for indicators of anxiety on the HARS scale: 20.52±7.14 points vs. 24.53±6.69 points.

CONCLUSION

Conclusions: Combatants with non-psychotic mental disorders are characterized by high levels of depressive and anxiety disorders. COVID-19 disease aggravates the course of affective pathology in combatants with non-psychotic mental disorders and increases the incidence of their depressive and anxiety symptoms.