Life stressors, emotional distress, and trauma-related thoughts occurring in the 24 h preceding active duty U.S. soldiers' suicide attempts

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.

Situational stress and suicide attempt behavior in Army soldiers and veterans: Insights from the Army Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study

INTRODUCTION

Prevention of suicide-related behaviors is considered a top clinical priority within the Departments of Veterans Affairs and Defense. Despite previous literature attesting to the likely importance of situational stress as a key correlate of acute changes in suicide risk, longitudinal research into associations between situational stress and suicide-related outcomes among military personnel has been relatively limited.

METHODS

The current study examined associations between situational stress, recent suicide attempt, and future suicide attempt using data from 14,508 Army soldiers and recently discharged veterans enrolled in the Army Study to Assess Risk and Resilience in Servicemembers-Longitudinal Studies (STARRS-LS).

RESULTS

Recent situational stress was more common among recently discharged veterans (vs. soldiers), those with a recent suicide attempt (vs. those without), and those with a subsequent suicide attempt (vs. those without). Job loss was more closely associated with suicide attempts among soldiers, whereas financial crisis, police contact, and death, illness, or injury of close others were more closely associated with suicide attempts among recently discharged veterans.

CONCLUSION

Findings further highlight situational stress as a salient risk factor for suicide-related outcomes among military personnel, particularly among recently discharged veterans. Implications for screening and treatment of at-risk military personnel are discussed.

A controlled examination of acute warning signs for suicide attempts among hospitalized patients

BACKGROUND

Near-term risk factors for suicidal behavior, referred to as 'warning signs' (WS), distinguish periods of acute heightened risk from periods of lower risk within an individual. No prior published study has examined, using a controlled study design, a broad set of hypothesized WS for suicide attempt. This study addressed this gap through examination of hypothesized behavioral/experiential, cognitive, and affective WS among patients recently hospitalized following a suicide attempt.

METHODS

Participants were recruited during hospitalization from five medical centers across the USA including two civilian hospitals and three Veterans Health Administration facilities (n = 349). A within-person case-crossover study design was used, where each patient served as her/his own control. WS were measured by the Timeline Follow-back for Suicide Attempts Interview and were operationalized as factors that were present (v. absent) or that increased in frequency/intensity within an individual during the 6 h preceding the suicide attempt (case period) compared to the corresponding 6 h on the day before (control period).

RESULTS

Select WS were associated with near-term risk for suicide attempt including suicide-related communications, preparing personal affairs, drinking alcohol, experiencing a negative interpersonal event, and increases in key affective (e.g. emptiness) and cognitive (e.g. burdensomeness) responses.

CONCLUSIONS

The identification of WS for suicidal behavior can enhance risk recognition efforts by medical providers, patients, their families, and other stakeholders that can serve to inform acute risk management decisions.

Instability of emotional relationships and suicide among youth: a qualitative study

BACKGROUND

Interpersonal problems are one of the factors for understanding the complex issues that result in suicide attempts and self-injury by poisoning. The quality of familial relationships is a predictor of the occurrence and outcome of suicide attempts. This study aimed to explore motives for self-poisoning suicide attempts amongst young adults.

METHOD

This research was a qualitative study conducted using semi-structured interviews in 2019 in Kermanshah Province, Iran. Eighteen participants who had attempted suicide by self-poisoning were interviewed, and information was collected until data saturation was achieved. The interviews were recorded and transcribed, and the data were analyzed through content analysis.

RESULTS

The results included the category of instability in emotional relationships with the three sub-categories of 1- Emotional failure, 2- Emotional trauma, and 3- Loss of emotional resilience (caused by emotional failure and emotional trauma within the previous few months). Instability in emotional relationships creates feelings of disgrace, humiliation, burdensomeness, worthlessness, and insignificance, which increases the chances of attempting suicide.

CONCLUSION

The study results provided an in-depth understanding of romantic, and unstable familial relationships as a significant factor in suicide attempts, demonstrating the role of emotional stress in attempting suicide. The present study provided information on the risk factors and warning signs for psychiatrists and nurses dealing with suicidal patients to take effective measures to prevent suicide through social support.

Recent Stressful Experiences and Suicide Risk: Implications for Suicide Prevention and Intervention in U.S. Army Soldiers

Objectives

To identify the extent to which the presence of recent stressful events are risk factors for suicide among active-duty soldiers as reported by informants.

Methods

Next-of-kin (NOK) and supervisors (SUP) of active duty soldiers (n = 135) who died by suicide and two groups of living controls: propensity-matched (n = 128) and soldiers who reported suicidal ideation in the past year, but did not die (SI) (n = 108) provided data via structured interviews from the Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Multivariate logistic regression analyses were used to create a risk score for suicide.

Results

The odds of suicide increased significantly for soldiers experiencing relationship problems, military punishment, and perceived failure or humiliation in the month prior to death. Suicide risk models with these risk factors predicted suicide death among those who reported SI in the past year (OR = 5.9, [95% CI = 1.5, 24.0] χ 2 = 6.24, p = 0.0125, AUC, 0.73 (0.7, 0.8) NOK) and (OR = 8.6, [95% CI = 1.4, 51.5] χ 2 = 5.49, p = 0.0191, AUC, 0.78 (0.7, 0.8); SUP) suggesting the combination of these recent stressors may contribute to the transition from ideation to action.

Conclusions

Our findings suggest for the first time recent stressors distinguished suicide ideating controls from suicide decedents in the month prior to death as reported by informants. Implications for preventive intervention efforts for clinicians, supervisors and family members in identifying the transition from ideation to action are discussed.

Qualitative analysis of hospital patient narratives of warning signs on the day of their suicide attempt

OBJECTIVE

Research on warning signs, defined as acute risk factors for suicide or suicide attempt, has been slow due to the difficulty of examining the hours and minutes preceding suicidal behavior. This study sought to identify new warning signs and to re-examine warning signs that have been proposed.

METHOD

Narrative stories of adult patients with substance use problems hospitalized following a suicide attempt were transcribed. The narrative segments describing the 24-h period prior to suicide attempt were examined with directed qualitative content analysis using codes based on prior literature and new codes developed inductively.

RESULTS

The sample (N = 35) was mean age = 40, 51% female, and 49% White non-Hispanic. Analysis of the transcripts of the 24-h periods (M word count = 637) yielded a broad range of cognitive (e.g., cognitive disturbance such as rumination), behavioral (e.g., alcohol use), emotional (e.g., dramatic mood changes), and social (e.g., social withdrawal) warning signs, along with a small number of cognitions and behaviors that appeared to mark a dangerous shift to acute preparation and intent for attempt, for example 'self-persuasion to attempt suicide.'

CONCLUSION

We posit that a broad range of cognitive, behavioral, emotional, and social warning signs increase acute risk for suicidal behavior by creating the conditions for a shift to acute preparation and intent, a highly potent category of warning signs.

Financial Status and Well-being in Recently Separated Military Veterans

INTRODUCTION

Veterans transitioning from military service to civilian life manage numerous changes simultaneously, in health, employment, social relationships, and finances. Financial problems may impact financial well-being as well as adjustment to civilian life in general; yet, research on Veterans' financial challenges remains limited. This study examined six indicators of perceived financial status among newly transitioned Veterans over a period of 3 years and then examined perceived financial well-being measured in two domains-satisfaction and functioning-and difficulty adjusting to civilian life as functions of financial status.

MATERIALS AND METHODS

A sample representing 48,965 Veterans who separated from active duty/activated status in fall 2016 provided informed consent and survey data over their first 33 post-military months; data were analyzed in weighted regression models that included demographics, military characteristics, social support, resilience, life stress, and indicators of financial status.

RESULTS

Financial status immediately post-separation included having stable housing (88%), being able to pay for necessities (83%), keeping up with creditors (88%), having insurance for catastrophic events such as disability (79%), saving for retirement (62%), and setting aside 3 months of salary (50%). Thirteen percent of Veterans disclosed troubled financial status, having achieved no more than two of these financial goals; 38% had moderate and 49% excellent financial status. Troubled or moderate financial status, Black race, enlisted, and higher levels of stress predicted lower financial functioning. Older age, college degree at baseline, employment, and social support predicted better financial satisfaction. Veterans with troubled financial status reported greater difficulty adjusting to civilian life (odds ratio 1.34); women were less likely to report difficulty adjusting to civilian life (odds ratio 0.85).

CONCLUSIONS

Findings indicate that financial satisfaction and functioning may be sensitive to psychosocial factors (social support and stress). Findings also underscore the value of assessing Veterans' financial status (poor debt management and lack of future planning), providing encouragement and assistance to pursue a college degree, and improving household financial management, thus increasing the likelihood that Veterans will have the necessary tools to manage their finances after separation and achieve whole health well-being.

Using Machine Learning to Predict Suicide Attempts in Military Personnel

Identifying predictors of suicide attempts is critical in intervention and prevention efforts, yet finding predictors has proven difficult due to the low base rate and underpowered statistical approaches. The objective of the current study was to use machine learning to examine predictors of suicidal behaviors among high-risk suicidal Soldiers who received outpatient mental health services in a randomized controlled trial of Brief Cognitive Behavioral Therapy for Suicide Prevention (BCBT) compared to treatment as usual (TAU). Self-report measures of clinical and demographic variables, administered prior to the start of outpatient treatment to 152 participants with recent suicidal thoughts and/or behaviors were analyzed using machine learning software to identify the best combination of variables for predicting suicide attempts during or after treatment. Worst-point suicidal ideation, history of multiple suicide attempts, treatment group (i.e., BCBT or TAU), suicidogenic cognitions, and male sex were found, in combination, correctly classified 30.8% of patients who attempted suicide during the two-year follow-up period. This combination has higher sensitivity than many models that have previously been used to predict suicidal behavior. Overall, this study provides a combination of variables that can be assessed clinical to help identify high-risk suicidal individuals.

Suicide ideation severity is associated with severe suicide attempts in a military setting

BACKGROUND

There is an ongoing debate on the effectiveness of suicidal behavior prevention measures in the military. The association of three widely used tools with severe suicide attempts was assessed in this setting.

METHODS

Thirty-nine Israeli soldiers (59% males), mean age 19 yrs., who attempted suicide during military service were divided into two groups: severe (n = 14; 35.9%) and moderate suicide attempts, and were assessed using the Scale for Suicide Ideation (SSI), Suicide Intent Scale (SIS) and the Columbia Suicide Severity Rating Scale (C-SSRS).

RESULTS

Seven items from the SSI (p = 0.008), two items from SIS and one item from C-SSRS were associated with severe suicide attempts. Kendall's tau-b correlation with bootstrap demonstrated stability of these correlations.

CONCLUSION

Greater severity of suicidal ideation was associated with more severe suicide attempts. The combination of male gender, available firearms and current severe suicide ideation is high-risk danger sign in a military setting, even when reported intent to die is low.

Studying the predictive factors of suicide attempts in patients with type 1 bipolar disorder

Bipolar disorder has the highest suicide attempt rate among psychiatric disorders. Many factors are associated with the risk of suicide attempt in patients with type 1 bipolar disorder, but the relation between them has still not been explicitly stated. This study aimed to examine the predictability of suicide attempt risk in BID patients based on quality of life, stressful life events, comorbidity of axis I disorders and medication compliance. We selected 140 inpatients with type 1 bipolar disorder by convenient sampling. Then they completed the WHOQOL-BREF questionnaire, Paykel's stressful life events scale and the medication adherence report scale (MARS). Logistic regression analysis showed that bipolar patients with axis I comorbidity are 40 times more likely to attempt suicide than those without axis I comorbidity. The higher the patients' quality of life, the lower the chance of attempt of suicide. Higher medication compliance reduces the likelihood of suicidal attempt in these patients. And, the increase of stressful life events would raise the risk of suicide attempts, but the relationship wasn't significant. So it can be concluded that quality of life, stressful life events and axis I comorbidity can predict the risk of suicide attempts in patients with type 1 bipolar disorder.

Moral injury and suicidality among combat-wounded veterans: The moderating effects of social connectedness and self-compassion

OBJECTIVE

Among combat veterans, moral injury (i.e., the guilt, shame, inability to forgive one's self and others, and social withdrawal associated with one's involvement in events that occurred during war or other missions) is associated with a host of negative mental health symptoms, including suicide. To better inform and tailor prevention and treatment efforts among veterans, the present study examined several potential risk (i.e., overidentification and self-judgment) and protective (i.e., self-kindness, mindfulness, common humanity, and social connectedness) variables that may moderate the association between moral injury and suicidality.

METHOD

Participants were 189 combat wounded veterans (96.8% male; mean age = 43.14 years) who had experienced one or more deployments (defined as 90 days or more). Nearly all participants reported a service-connected disability (n = 176, 93.1%) and many had received a Purple Heart (n = 163, 86.2%).

RESULTS

Within a series of moderation models, we found 3 statistically significant moderation effects. Specifically, the association between self-directed moral injury and suicidality strengthened at higher levels of overidentification, that is, a tendency to overidentify with one's failings and shortcomings. In addition, the association between other-directed moral injury and suicidality weakened at higher levels of mindfulness and social connectedness.

CONCLUSIONS

These findings provide insight on risk and protective factors that strengthen (risk factor) or weaken (protective factor) the association between moral injury and suicidality in combat-wounded veterans. Taken together, mindfulness, social connectedness, and overidentification are relevant to understand the increased/decreased vulnerability of veterans to exhibit suicidality when experiencing moral injury. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Individuate and separate: Values and identity re-development during rehabilitation and transition in the Australian Army

Many health behaviours and outcomes in veterans can be attributed to issues of identity. Identity is informed by core values, which are critical to service organisations that demand unity, including the military, but the intersection between values, identity, and adaptation to serious wounds, injuries, and illnesses remains relatively unexplored. This article elucidates the relationship between values, identity, and adaptation during rehabilitation in high-risk military personnel through examination of the experiences of 13 Australian combat soldiers undergoing rehabilitation for serious wounds, injuries, and mental health conditions. Each participated in two semi-structured, in-depth interviews which were conducted between March and December 2014. Data were thematically analysed using a qualitative approach dialectically positioned between social constructionism and critical realism. Results demonstrate those primarily with physical limitations sequentially drew on five sets of values that underscored four sequential stages of adaptation that collectively reflect the psychosocial task of adolescence, namely identity development. Those primarily with mental health conditions did not share such a clear trajectory. This insight may inform overarching primary healthcare strategies in clinical and community settings, as well as a transition research agenda.

Depression and impulsiveness among soldiers who died by suicide: A psychological autopsy study

INTRODUCTION

Despite the accumulated knowledge about suicide, suicidal acts remain difficult to predict, and many suicides are acted out impulsively.

METHODS

We performed a psychological autopsy study based on inquiries about the deaths of all male soldiers aged 18-21 years who served in the Israeli army and died by suicide between 2009 and 2013 (n = 69). The study population was first divided into two groups: those who had depressive disorder (n = 31); and those who did not (n = 38). Socio-demographic characteristics of the subjects and the characteristics of the suicidal act were compared. Afterwards, the study population was re-divided by the presence or absence of impulsive personality traits (n = 22, and n = 47, respectively), and investigated for distinct suicidal behavior features.

RESULTS

No significant socio-demographic differences were found between the depressed and non-depressed suicide victims. The depressed group had showed more signs of planning the act (47% vs. 23%), and had expressed suicidal ideation in the days preceding the suicide (51.6% vs. 21%). One third of the subjects were found to have an impulsive personality trait, with significantly more histories of disciplinary issues, violence and cluster B personality disorders. Alcohol use during the act was significantly more prevalent among impulsive than non-impulsive subjects (45.4% vs. 14.9%).

CONCLUSION

Identification of distinct clinical groups of suicide victims among young males might help clinicians evaluate high risk cases, and may provide valuable opportunities to alleviate and prevent these events in the future.

Intimate partner relationship stress and suicidality in a psychiatrically hospitalized military sample

OBJECTIVE

Suicide among United States service members is a significant public health concern. Intimate partner relationship stress may contribute to suicide risk, as a failed or failing relationship is the most commonly documented stressor preceding military suicide attempts and deaths. However, little is known about the manner by which relationship stressors are associated with the experience of military suicidality.

METHODS

A sample of 190 psychiatrically hospitalized military personnel and adult dependents enrolled in an ongoing randomized controlled trial evaluating the efficacy of an inpatient cognitive behavioral treatment for suicidality were included in this study. Analyses examined depression, hopelessness, and suicidality among participants with (n = 105) and without (n = 85) self-reported romantic relationship stress.

RESULTS

Over half (55%) of the sample reported current romantic relationship stress. Compared to participants without current romantic relationship stress, results indicated that individuals reporting current romantic relationship stress were more hopeless (AOR = 1.07 (95% CI: 1.01-1.12), p = 0.020), more likely to endorse multiple suicide attempts (AOR = 1.96 (95% CI: 1.01-3.79), p = 0.046), had higher overall suicide risk (AOR = 2.49, (95% CI: 1.03-6.06), p = 0.044), and were more likely to report that the reason for their suicidality was at least in part to get a reaction from others.

CONCLUSIONS

Findings suggest romantic relationship stress is associated with greater suicide risk, and have clinical implications for suicide prevention and intervention. Future research may examine mechanisms and pathways between romantic relationship stress, suicidality, and prevention and intervention strategies.

What's Changed? A Comparison of Army Suicide Surveillance Data to Cases from 1975 to 1982

US Army suicide rates increased significantly in the last decade and have remained high. To inform future research hypotheses, Army suicide surveillance data (2012-2014) were compared to similar Army data for suicides from 1975 to 1982. Preliminary data suggest that suicide rates increased across most demographic groups, but may have decreased among divorced soldiers. Mental health utilization increased over time. Legal problems and physical health problems were identified in a higher percentage of cases in the recent data relative to the 1975-1982 era. Potential implications for suicide prevention are discussed.

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

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

The role of stressful life events preceding death by suicide: Evidence from two samples of suicide decedents

Stressful life events (SLEs) are associated with increased risk for suicidal behavior. Less is known regarding the intensity of SLEs and how this may vary as a function of suicide attempt history. As a large percentage of suicide decedents do not have a history of suicidal behavior, SLEs precipitating suicide may help characterize suicidality in this understudied population. This paper examines the intensity, number, and accumulation of SLEs preceding death by suicide among decedents with varying suicide attempt histories. Suicide attempts, SLEs, and suicide methods were examined in two samples: 62 prison-based and 117 community-based suicide decedents. Regression was used to compare the level of stressor precipitating death by suicide in decedents who died on a first attempt versus multiple previous attempts. A non-significant trend was observed in the prison population which was supported by significant findings in the community-based sample. Decedents who died on a first attempt experienced a stressor of a lower magnitude when compared to decedents with multiple previous suicide attempts. We discuss the implications of these findings in relation to the stress-diathesis model for suicide.

Interpersonal-Psychological Theory, Alexithymia, and Personality Predict Suicide Ideation among Maladjusted Soldiers in Taiwan

This case-control study enrolled 226 maladjusted soldiers and 229 controls to investigate the impact of the interpersonal-psychological theory of suicide, alexithymia, personality, and childhood trauma on suicide risk among Taiwanese soldiers. Assessments included the Toronto Alexithymia Scale, Eysenck Personality Inventory, Mini-International Neuropsychiatric Interview, and Brief Symptom Rating Scale. In addition to thwarted belongingness and perceived burdensomeness, other risks included less extraversion with higher neuroticism, higher alexithymia, poor academic performance, domestic violence, and life-threatening events. Our study demonstrates the interaction of the interpersonal-psychological theory and other suicide risk factors in Taiwanese soldiers.

Can Religious Beliefs be a Protective Factor for Suicidal Behavior? A Decision Tree Analysis in a Mid-Sized City in Iran, 2013

This study aimed to assess using tree-based models the impact of different dimensions of religion and other risk factors on suicide attempts in the Islamic Republic of Iran. Three hundred patients who attempted suicide and 300 age- and sex-matched patient attendants with other types of disease who referred to Kerman Afzalipour Hospital were recruited for this study following a convenience sampling. Religiosity was assessed by the Duke University Religion Index. A tree-based model was constructed using the Gini Index as the homogeneity criterion. A complementary discrimination analysis was also applied. Variables contributing to the construction of the tree were stressful life events, mental disorder, family support, and religious belief. Strong religious belief was a protective factor for those with a low number of stressful life events and those with a high mental disorder score; 72 % of those who formed these two groups had not attempted suicide. Moreover, 63 % of those with a high number of stressful life events, strong family support, strong problem-solving skills, and a low mental disorder score were less likely to attempt suicide. The significance of four other variables, GHQ, problem-coping skills, friend support, and neuroticism, was revealed in the discrimination analysis. Religious beliefs seem to be an independent factor that can predict risk for suicidal behavior. Based on the decision tree, religious beliefs among people with a high number of stressful life events might not be a dissuading factor. Such subjects need more family support and problem-solving skills.

The Promise and the Challenge of Technology-Facilitated Methods for Assessing Behavioral and Cognitive Markers of Risk for Suicide among U.S. Army National Guard Personnel

Suicide was the 10th leading cause of death for Americans in 2015 and rates have been steadily climbing over the last 25 years. Rates are particularly high amongst U.S. military personnel. Suicide prevention efforts in the military are significantly hampered by the lack of: (1) assessment tools for measuring baseline risk and (2) methods to detect periods of particularly heightened risk. Two specific barriers to assessing suicide risk in military personnel that call for innovation are: (1) the geographic dispersion of military personnel from healthcare settings, particularly amongst components like the Reserves; and (2) professional and social disincentives to acknowledging psychological distress. The primary aim of this paper is to describe recent technological developments that could contribute to risk assessment tools that are not subject to the limitations mentioned above. More specifically, Behavioral Signal Processing can be used to assess behaviors during interaction and conversation that likely indicate increased risk for suicide, and computer-administered, cognitive performance tasks can be used to assess activation of the suicidal mode. These novel methods can be used remotely and do not require direct disclosure or endorsement of psychological distress, solving two challenges to suicide risk assessment in military and other sensitive settings. We present an introduction to these technologies, describe how they can specifically be applied to assessing behavioral and cognitive risk for suicide, and close with recommendations for future research.

A Review of Psychometrically Tested Instruments Assessing Suicide Risk in Adults

OBJECTIVE

Identify suicidal ideation and behavior screening instruments with the strongest psychometric properties, using the Interpersonal-Psychological Theory of Suicidal Behavior.

METHODS

Information databases PsycINFO and PubMed were systematically searched, and articles evaluating the psychometric properties of instruments assessing suicidal ideation and behavior ( n = 2,238) were reviewed. International populations and articles with diverse methodologies were integrated.

RESULTS

Review of records resulted in the inclusion of 51 articles that assessed 16 instruments. The majority of studies used the English language version (68.6%) and included U.S. populations (65.7%). However, global populations and non-English language versions were also represented.

CONCLUSION

More diverse population representation, and non-English versions of instruments, is required to improve generalizability of assessment measures. Including underrepresented groups and non-English instruments will promote culturally and linguistically sensitive instruments that may better assess suicide risk in diverse populations.

Individual and environmental contingencies associated with multiple suicide attempts among U.S. military personnel

Suicidal behavior among U.S. military personnel persists as a significant public health issue. Previous research indicates the primary motive for suicide attempts among military personnel is the desire to reduce or alleviate emotional distress, a finding that converges with studies in nonmilitary samples. Much less is understood about the consequences of a first suicide attempt that could influence the occurrence of additional suicide attempts. In order to identify these contingencies, 134 active duty Soldiers who had attempted suicide (n=69 first-time attempters, n=65 multiple attempters) participated in structured interviews focused on their experiences immediately following their first attempt. Soldiers were more likely to have made multiple suicide attempts if they were younger at the time of their first attempt, were not admitted to a hospital or treatment program after their first attempt, or experienced emotional and psychological relief immediately afterwards. Results suggest that Soldiers who experience emotional and/or psychological relief immediately after their first suicide attempt or do not receive treatment are more likely to make additional suicide attempts.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Combat Exposure and Risk for Suicidal Thoughts and Behaviors Among Military Personnel and Veterans: A Systematic Review and Meta-Analysis

Due to seemingly mixed empirical results, questions persist about the possible role of deployments and combat exposure. We conducted a narrative review and meta-analysis of 22 published studies to integrate findings regarding the relationship of deployment-related predictors (i.e., deployment, deployment to a combat zone, combat experience, and exposure to specific combat events) with suicide-related outcomes (i.e., suicide ideation, attempt, and death). Across all predictors and outcomes, the combined effect was small and positive, r = .08 [0.04, 0.13], and marked by significant heterogeneity, I²  = 99.9%, Q(21)=4880.16, p < .0001, corresponding to a 25% increased risk for suicide-related outcomes among those who have deployed. Studies examining the relationship between exposure to killing and atrocities (k = 5) showed the largest combined effect, r = .12 [0.08, 0.17], and less heterogeneity, I²  = 84.4%, Q(4)=34.96, p < .0001, corresponding to a 43% increased risk for suicide-related outcomes among those exposed to killing or atrocity. Implications for theory, research, and clinical practice are discussed.

Acute vs. chronic stressors, multiple suicide attempts, and persistent suicide ideation in US soldiers

This study examined recent-onset (i.e., acute) and persistent (i.e., chronic) life stressors among 54 acutely suicidal US Army Soldiers and examined their relationship to persistence of suicidal crises over time. Soldiers with a history of multiple suicide attempts reported the most severe suicide ideation (F(2,51) = 4.18, p = 0.021) and the greatest number of chronic stressors (F(2,51) = 5.11, p = 0.009). Chronic but not acute stressors were correlated with severity of suicide ideation (r = 0.24, p = 0.026). Participants reporting low-to-average levels of chronic stress resolved suicide ideation during the 6-month follow-up, but participants reporting high levels of chronic stress did not (Wald χ(1) = 4.57, p = 0.032). Soldiers who are multiple attempters report a greater number of chronic stressors. Chronic, but not acute-onset, stressors are associated with more severe and longer-lasting suicidal crises.

Mediating effects of stress, weight-related issues, and depression on suicidality in college students

OBJECTIVE

Through a holistic health lens, the current study examines the effects of weight-related issues and stress on suicidality while controlling for depressive symptoms in college students.

PARTICIPANTS

In total, 872 undergraduate and graduate students at DePaul University completed the American College Health Association-National College Health Assessment II Web-based survey in Spring 2010.

METHODS

Measures of suicidality, depression, weight-related issues, and life stressors were assessed, along with gender differences.

RESULTS

Females reported experiencing more weight loss attempts and total stressors than males. Weight-related issues and stress both significantly predicted depressive symptoms in a path analysis; depressive symptoms, in turn, significantly predicted suicidality. Gender differences were found; depressive symptoms mediate the relation between stress and suicidal behavior for females but not for males.

IMPLICATIONS

This investigation furthers previous research on suicidality in college students and suggests that all-inclusive interventions that address weight-related issues and stress may help reduce depressive symptoms, which then may reduce suicidal behavior.

Reasons for desiring death: examining causative factors of suicide attempters treated in emergency rooms in Korea

BACKGROUND

Suicide attempters treated in emergency rooms were studied in order to understand the motives behind this behavior. Disparities between the etiological contributions to suicidal ideation, intention, and action were examined in order to characterize motives in these categories.

METHODS

Suicide attempters who visited the emergency departments of seven university hospitals were analyzed. Attempts leading to mortality were excluded from the analysis. Participants were assessed using semi-structured questionnaires, the results of which were noted on their medical records. These were analyzed retrospectively.

RESULTS

Attempter self-report assessment revealed that participants chose external sources of stress (75.4%) and psychiatric symptoms (19.1%) as their main reasons for attempting suicide. However, assessments by interviewers indicated that stressors contributed to suicide attempts to a lesser degree (52.8%) while psychiatric symptoms were more etiologically relevant (36.6%). Compared to those with stressors that was identified as causal in both self-report and clinician assessed evaluation, the participants-regardless of their self-report evaluation-who identified with causal psychiatric symptoms by psychiatrist had more severe and intense suicidal ideation and more determined suicidal intention.

LIMITATIONS

We collected samples from only university hospitals, resulting in selection bias. In addition, we did not use psychiatric scales to evaluate the participants׳ symptoms.

CONCLUSIONS

Stress was the greatest motive for attempting suicide, affirmed in both self-report and clinician assessed evaluation. A fair proportion of people were objectively identified as being motivated by psychiatric symptoms, yet were unaware of what they suffered from. Furthermore, suicide severity, intensity, and suicidal intention were stronger in psychiatrically driven cases.

Prevalence and correlates of suicidal behavior among soldiers: results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

IMPORTANCE

The suicide rate among US Army soldiers has increased substantially in recent years.

OBJECTIVES

To estimate the lifetime prevalence and sociodemographic, Army career, and psychiatric predictors of suicidal behaviors among nondeployed US Army soldiers.

DESIGN, SETTING, AND PARTICIPANTS

A representative cross-sectional survey of 5428 nondeployed soldiers participating in a group self-administered survey.

MAIN OUTCOMES AND MEASURES

Lifetime suicidal ideation, suicide plans, and suicide attempts.

RESULTS

The lifetime prevalence estimates of suicidal ideation, suicide plans, and suicide attempts are 13.9%, 5.3%, and 2.4%. Most reported cases (47.0%-58.2%) had pre-enlistment onsets. Pre-enlistment onset rates were lower than in a prior national civilian survey (with imputed/simulated age at enlistment), whereas post-enlistment onsets of ideation and plans were higher, and post-enlistment first attempts were equivalent to civilian rates. Most reported onsets of plans and attempts among ideators (58.3%-63.3%) occur within the year of onset of ideation. Post-enlistment attempts are positively related to being a woman (with an odds ratio [OR] of 3.3 [95% CI, 1.5-7.5]), lower rank (OR = 5.8 [95% CI, 1.8-18.1]), and previously deployed (OR = 2.4-3.7) and are negatively related to being unmarried (OR = 0.1-0.8) and assigned to Special Operations Command (OR = 0.0 [95% CI, 0.0-0.0]). Five mental disorders predict post-enlistment first suicide attempts in multivariate analysis: pre-enlistment panic disorder (OR = 0.1 [95% CI, 0.0-0.8]), pre-enlistment posttraumatic stress disorder (OR = 0.1 [95% CI, 0.0-0.7]), post-enlistment depression (OR = 3.8 [95% CI, 1.2-11.6]), and both pre- and post-enlistment intermittent explosive disorder (OR = 3.7-3.8). Four of these 5 ORs (posttraumatic stress disorder is the exception) predict ideation, whereas only post-enlistment intermittent explosive disorder predicts attempts among ideators. The population-attributable risk proportions of lifetime mental disorders predicting post-enlistment suicide attempts are 31.3% for pre-enlistment onset disorders, 41.2% for post-enlistment onset disorders, and 59.9% for all disorders.

CONCLUSIONS AND RELEVANCE

The fact that approximately one-third of post-enlistment suicide attempts are associated with pre-enlistment mental disorders suggests that pre-enlistment mental disorders might be targets for early screening and intervention. The possibility of higher fatality rates among Army suicide attempts than among civilian suicide attempts highlights the potential importance of means control (ie, restricting access to lethal means [such as firearms]) as a suicide prevention strategy.

Suicide attempts before joining the military increase risk for suicide attempts and severity of suicidal ideation among military personnel and veterans

OBJECTIVE

Past self-injurious thoughts and behaviors (SITB) are robust predictors of future suicide risk, but no studies have explored the prevalence of SITB occurring prior to military service among military personnel and veterans, or the association of premilitary SITB with suicidal ideation and suicide attempts during or after military service. The current study explores these issues in two separate samples.

METHOD

Self-report data were collected from 374 college student veterans via anonymous only survey (Study 1) and from 151 military personnel receiving outpatient mental health treatment (Study 2).

RESULTS

Across both studies, premilitary suicide attempts were among the most prominent predictor of subsequent suicide attempts that occurred after joining the military, even when controlling for demographics and more recent emotional distress. Among military personnel who made a suicide attempt during or after military service, approximately 50% across both samples experienced suicidal ideation and up to 25% made a suicide attempt prior to joining the military. Military personnel and veterans who made suicide attempts prior to joining the military were over six times more likely to make a later suicide attempt after joining the military. In Study 2, significantly more severe current suicidal ideation was reported by participants with histories of premilitary suicide risk, even when controlling for SITB occurring while in the military.

CONCLUSIONS

Military personnel and veterans who experienced SITB, especially suicide attempts, prior to joining the military are more likely to attempt suicide while in the military and/or as a veteran, and experience more severe suicidal crises.

Agency is associated with decreased emotional distress and suicidal ideation in military personnel

Suicides in the U.S. military continue to rise at a rapid rate. Identification of protective factors that reduce risk for suicidal thoughts and behaviors among military personnel are therefore needed. Agency--the sense that one is competent, effective, and in control of one's life--has shown to reduce the effects of hopelessness and emotional distress on suicidal thoughts and attempts in non-military populations. The current study explores the association of agency with suicidal ideation in a sample (n = 273) of active duty Air Force Security Forces personnel. Results of generalized regression modeling suggest that agency is directly associated with decreased emotional distress and severity of suicidal ideation, but does not moderate the effect of emotional distress on suicidal ideation.

The functions of social support as protective factors for suicidal ideation in a sample of air force personnel

This study examined various functions of social support (i.e., tangible, esteem, belonging, and appraisal) were examined as protective factors for suicidal ideation in a sample of 273 active duty Air Force Security Forces personnel. Generalized linear regression analyses were conducted to determine if various social support functions were differentially associated with the presence and severity of suicidal ideation, both as main effects and as moderators of emotional distress. None of the four social support functions differentiated suicidal from nonsuicidal Airmen, but esteem support (i.e., feeling respected, encouraged, and valued by others) was associated with significantly less severe suicidal ideation (B = -.074, SE = .025, p = .003). A significant interaction of tangible support (i.e., access to material resources) with emotional distress indicated that emotional distress was associated with more severe suicidal ideation only among Airmen reporting low levels of tangible support (B = .006, SE = .003, p = .018). When considered concurrently, both tangible and self-esteem functions of social support are differentially associated with decreased suicidal ideation among Airmen, but belonging (i.e., having someone to do things with) and appraisal (i.e., having someone to talk to about problems) functions were not. Findings suggest that different aspects of social support affect suicidal ideation in different ways.

Shame, pride, and suicidal ideation in a military clinical sample

BACKGROUND

Suicide risk among U.S. military personnel has been increasing over the past decade. Fluid vulnerability theory (FVT; Rudd, 2006) posits that acute suicidal episodes increase in severity when trait-based (e.g., shame) and state-based (e.g., hopelessness) risk factors interact, especially among individuals who have been previously suicidal. In contrast, trait-based protective factors (e.g., pride) should buffer the deleterious effects of risk factors.

METHODS

77 active duty military personnel (95% Air Force; 58.4% male, 39.0% female; 67.5% Caucasian, 19.5% African-American, 1.3% Native American, 1.3% Native Hawaiian/Pacific Islander, 1.3% Asian, and 5.2% other) engaged in outpatient mental health treatment completed self-report surveys of shame, hopelessness, pride, and suicidal ideation. Multiple generalized regression was utilized to test the associations and interactive effects of shame, hopelessness, and worst-point past suicidal ideation on severity of current suicidal ideation.

RESULTS

Shame significantly interacted with hopelessness (B=-0.013, SE=0.004, p<0.001) and worst-point suicidal ideation (B=0.027, SE=0.010, p=0.010), augmenting each variable's effect on severity of current suicidal ideation. A significant three-way interaction among shame, worst-point suicidal ideation, and pride was also observed (B=-0.010, SE=0.0043, p=0.021), indicating that pride buffered the interactive effects of shame with worst-point suicidal ideation.

LIMITATIONS

Small sample size, cross-sectional design, and primarily Air Force sample.

CONCLUSIONS

Among military outpatients with histories of severe suicidal episodes, pride buffers the effects of hopelessness on current suicidal ideation. Results are consistent with FVT.

Intent in Manner Determination

Manner of death determination is a basic and traditional task for medical examiners. Though it has a history spanning centuries, many facets of manner determination continue to be problematic. Few issues are more vexing than the difficulties in determining intent. A survey of members of the National Association of Medical Examiners was performed to determine current practice and attitudes about the use of intent in manner determination. There were 168 completed responses, representing an approximately 20% response rate. The results reveal significant variation. While the concept of “volition” as distinct from “intent” has been common for over a decade, less than 60% of respondents made the distinction in their practice. There was also wide variation in the degree of certainty practitioners noted they used when determining manner with peaks at between 51-60% and 95-99%. Some of this represents real uncertainty in manner determination and some represents cultural and regional differences in practice. The variation and uncertainty in these determinations has led some to suggest that this role be abandoned. However, the statistical, policy, and cultural need for these determinations dictate that the function will be performed even if abandoned by the medical examiner community. Medical examiners are uniquely positioned and trained to fill this need, and should continue to do so.