Comparative associations of problematic alcohol and cannabis use with suicidal behavior in U.S. military veterans: A population-based study

Sensitivity, specificity, and discordance with self-report of nail sample testing for alcohol and cannabis

BACKGROUND

Nails accumulate the alcohol metabolite, ethyl glucuronide (ETG), and the cannabis metabolite, carboxy- delta-9-THC over 3-6 months. Few studies have examined nail toxicology testing's sensitivity and specificity and the agreement between nail testing and self-reported alcohol and marijuana use.

METHODS

In an ongoing clinical trial, 1101 veterans completed initial telephone questionnaires and were then asked to mail nail clippings for substance use analysis. We examined sensitivity and specificity of ETG and carboxy- delta-9-THC in nails compared to self-report of alcohol use patterns (the AUDIT-C) and substance-related harms (alcohol and THC subscales of the ASSIST). We then examined factors associated with discordance between nails and self-report.

RESULTS

Almost two-thirds (707/1101) of respondents mailed in nail clippings. Those with returned nails were disproportionately married, white race, older, and less depressed. At a threshold of 8pg/mg, sensitivity was only.50 to detect risky alcohol use and.49 to detect alcohol-related issues. Sensitivity for marijuana issues was only.61. Specificity was greater than.77 for all measures. Factors associated with positive nails/negative self-report (i.e. false positives) for risky alcohol use on the Audit-C included more pain and being unmarried; false positive nails for alcohol-related issues on the ASSIST were associated with being unmarried and non-Hispanic ethnicity. False positive nails for THC-related issues on the ASSIST were associated with being African American, Hispanic, and having had legal issues.

CONCLUSIONS

At standard cut-offs, nail measures had low sensitivity and higher specificity. The groups who disproportionately submit positive nails/negative self-report could have substance use patterns not adequately captured by self-report, inaccurate self-report due to social pressures, or distinct drug metabolism.

Alcohol use disorder as a moderator of the relationship between posttraumatic stress disorder and suicidality among military personnel

BACKGROUND

Alcohol use disorder (AUD), posttraumatic stress disorder (PTSD), and suicide are substantial public health concerns among military service members, yet the nature of their relationships is not well understood. Here, we tested the hypothesis that AUD moderates the relationship between PTSD symptom severity and suicidal ideation.

METHODS

This secondary analysis uses data collected at baseline for a randomized clinical trial. The sample consists of 160 active-duty service members from three service branches (Army, Air Force, and Navy). All participants met diagnostic criteria for PTSD and were not engaged in evidence-based PTSD treatment at the time of enrollment. Zero-inflated Poisson generalized linear regression models were used to test the associations of PTSD and AUD symptom severity with the presence and severity of suicidal ideation.

RESULTS

Findings suggest that AUD symptom severity moderates (i.e., amplifies) the relationship between PTSD symptoms and severity of suicidal ideation among military personnel with untreated PTSD. Among service members with mild or absent AUD, we found no significant association between PTSD symptoms and the severity of suicidal ideation. However, when AUD severity was average (i.e., sample mean) or high (mean + 1SD), PTSD symptoms were significantly positively associated with the severity of suicidal ideation.

CONCLUSIONS

This study highlights the importance of assessing AUD and PTSD as a part of suicide risk evaluations of veterans. The results also provide strong support for the maintenance and further development in the military health system of treatment programs that simultaneously address AUD and PTSD comorbidity.

Prevalence and Correlates of Cannabis Use among U.S. Veterans during the Second Wave of the COVID-19 Pandemic

INTRODUCTION

Military veterans are at increased risk of substance use disorders. Limited research is available about veterans' cannabis use (CU) during the coronavirus disease 2019 (COVID-19) pandemic. This study estimated the prevalence of past 30-day CU, investigated individual-level correlates of past 30-day CU, and evaluated the reasons (medical, recreational, or both) of past 30-day CU among U.S. Veterans during the second wave of the COVID-19 pandemic.

MATERIALS AND METHODS

We used population-based, cross-sectional data from the 2021 Behavioral Risk Factor Surveillance System Survey Marijuana Use model. The sample included nationally representative military veterans aged 18+ years (n = 11,167). The outcome was past 30-day CU. Individual-level demographic, socioeconomic, behavioral, and clinical correlates were examined. Analyses were weighted to account for the survey's complex design with results generalizable to nearly 2.9 million veterans. We conducted weighted descriptive statistics, prevalence estimates, and multivariable logistic regression analyses.

RESULTS

Out of 2.9 million veterans, 11.1% self-reported as non-Hispanic Black, 3.7% Hispanic, and 79.1% non-Hispanic White; 88.5% were men, and 72.8% were aged 50+ years. About 14.6% were current tobacco smokers, 4.7% were current e-cigarette users, 12.5% were binge alcohol drinkers, and 43.4% had three or more comorbid conditions. Overall, 8.5% reported CU in the past 30 days, of which 30.4% used it for medical reasons and 25.8% used it for nonmedical reasons. The prevalence of past 30-day CU decreased with age, education, and income level. Compared to their counterparts, the odds of past 30-day CU were greater among men, those living in urban areas, those with frequent mental distress, infrequent physical distress, and those who had at least one comorbid condition. Non-Hispanic Black veterans had 89% increased odds of past 30-day CU (adjusted odds ratio [AOR] =1.89, 95% confidence interval [CI], 1.19-3.0) compared with non-Hispanic White veterans. Current tobacco smokers had 3.54 (95% CI, 2.40-5.24) and former smokers had 1.78 (95% CI, 1.28-2.47) times higher odds of reporting past 30-day CU than never smokers. Current e-cigarette use (AOR = 3.37, 95% CI, 2.20-5.16) and binge drinking (AOR = 3.18, 95% CI, 2.29-4.41) were also statistically significantly associated with increased odds of past 30-day CU compared to no e-cigarette use and no binge drinking.

CONCLUSIONS

CU is prevalent among veterans, and certain subgroups are at higher risk of CU. Thus, identifying high-risk subgroups of veterans and adequately educating them about CU's benefits, risks, and safety is crucial.

Firearm storage practices among military veterans in the United States: Findings from a nationally representative survey

BACKGROUND

Unsafe storage of firearms is associated with increased risk of suicide.. However, contemporary population-based data on the prevalence and correlates of firearm storage practices among veterans are limited.

METHODS

Data were from the 2022 National Health and Resilience in Veterans Study, a nationally representative sample of 2441 veterans. Analyses examined: (1) the prevalence of firearm storage practices; (2) sociodemographic, psychiatric, and clinical characteristics associated with storing firearms loaded and/or in non-secure location; and (3) associations between types of potentially traumatic events and storage practices.

RESULTS

More than half of veterans reported owning one or more personal firearms (50.9%). Among firearm owners, 52.9% reported some form of unsafe firearm storage practice (i.e., loaded and/or non-secure location), with 39.9% reporting that they stored one or more firearms loaded. After adjusting for sociodemographic characteristics, major depressive, alcohol and drug use disorders, direct trauma exposures, future suicidal intent, and traumatic brain injury were associated with storing firearms loaded and/or in a non-secure location (ORs = 1.09-7.16). Veterans with a history of specific forms of direct trauma exposure (e.g., physical assault) were more likely to store firearms unsafely.

LIMITATIONS

Cross-sectional design precludes causal inference.

CONCLUSIONS

Half of U.S. veterans who own firearms store at least one personal firearm loaded and/or in a non-secure location, with approximately four-in-ten keeping a loaded firearm in the home. These high rates underscore the importance of nationwide training initiatives to promote safe firearm storage for all service members and veterans, regardless of risk status, as well as for healthcare professionals working with veterans.

Differences in the phenotypic expression of posttraumatic stress disorder symptoms in US military veterans with and without clinical insomnia

STUDY OBJECTIVES

The goal of this study was to examine the phenotypic expression of posttraumatic stress disorder (PTSD) symptoms in veterans with probable PTSD and clinical insomnia relative to those with probable PTSD alone.

METHODS

Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 4,069 US military veterans.

RESULTS

A total of 3.9% of the full sample screened positive for probable PTSD and clinical insomnia and 3.2% for probable PTSD alone. Relative to veterans with probable PTSD alone, those with probable PTSD and clinical insomnia reported significantly greater severity of intrusions, avoidance, and anxious and dysphoric arousal symptoms. Post hoc analyses of individual symptoms revealed that trauma-related nightmares; flashbacks; trauma-related emotional and physiological reactivity; avoidance of trauma-related thoughts, feelings, and external reminders; exaggerated startle response; concentration difficulties; and trauma-related sleep difficulties differed between groups. A multivariable logistic regression analysis further revealed that trauma-related sleep difficulties, trauma-related physiological reactivity, and exaggerated startle response independently predicted probable PTSD and clinical insomnia relative to PTSD alone.

CONCLUSIONS

Results of this study suggest that trauma-related reactivity and arousal symptoms differentiate veterans with probable PTSD and clinical insomnia from those with probable PTSD alone. They further underscore the importance of utilizing nuanced models of PTSD symptom expression as part of assessment and treatment planning efforts in this population.

CITATION

DeViva JC, McCarthy E, Fischer I, Pietrzak RH. Differences in the phenotypic expression of posttraumatic stress disorder symptoms in US military veterans with and without clinical insomnia. J Clin Sleep Med. 2024;20(3):345-351.

Suicide Attempts in an Italian Population with Cannabis Use Disorders: Results of a Follow-Up Study

The relationship between cannabis use and suicidal behavior is complex, with no consensus in the literature. We used electronic health records of national health services to identify individuals who received a diagnosis of Cannabis Use Disorder in the Metropolitan area of Bologna from 2009 to 2019. In this cohort we identified accesses to Emergency Departments for suicide attempts from 2009 to 2019. The Crude Suicide Rate for 1,000 Person Years was 2.5, higher in females, in patients with Alcohol Use Disorders, with any psychiatric diagnosis, within one year from the first visit, and during the COVID-19 period. The risk was over 22 times higher than in the general population. Considering the high prevalence of cannabis use in the general population and the consequent risk of Cannabis Use Disorders, these data suggest the importance of a clinical evaluation for suicidal risk.

John J, Noel NE. Drug use and suicidal ideation in the daily lives of individuals in a dialectical behavior therapy program

OBJECTIVES

Substance use disorders and borderline personality disorders (BPD) often co-occur and may be concurrently treated by Dialectical Behavior Therapy (DBT). However, there is limited information on how drug use and suicidal ideation may interact in the daily lives of individuals receiving DBT treatment.

METHODS

This study examined the DBT diary cards of 47 individuals in a community mental health center's partial hospital and intensive outpatient program. Multilevel modeling techniques were used to examine the moderating effects of BPD symptom severity on the relationship between same day, 1-, 2-, and 3-day lagged drug use and suicidal ideation.

RESULTS

Results indicated a significant relationship between same-day, 1-day lagged, 2-day lagged drug use and suicidal ideation. BPD was a moderator for the relationship between 1-day lagged drug use and suicidal ideation.

CONCLUSION

Limitations of the study include the measure for BPD symptom severity was only collected pretreatment and the results are likely limited to the effects of cannabis use on suicidal ideation. Clinicians may need to consider the prolonged effects of drug use on suicidal ideation when conducting chain analyses on suicidal behaviors.

Telephone monitoring and 15-month outcomes for patients with co-occurring substance use and mental health disorders: Moderating effects of high-risk patient characteristics

INTRODUCTION

Telephone monitoring interventions for substance use disorders are an important component of continuing care to reduce relapse and connect patients to services. However, a knowledge gap still exists as to which patient groups benefit most from them. This secondary analysis of a randomized controlled trial examined moderators of associations between telephone monitoring and 15-month substance use outcomes among patients with co-occurring substance use and mental health disorders. High-risk patient characteristics at baseline were examined as potential moderators of the effectivness of telephone monitoring, including history of incarceration, severity of depression symptoms, and suicide risk.

METHODS

Participants were 406 psychiatry inpatients with documented substance use and mental health disorders who were randomized to treatment as usual (TAU; n = 199) or TAU plus telephone monitoring (TM; n = 207). Outcomes included abstinence self-efficacy (Brief Situational Confidence Questionnaire) and alcohol and drug use severity (Addiction Severity Index composites) at 15-month follow-up. Analyses examined main effects of treatment condition and moderators, and interactions between treatment condition and moderators.

RESULTS

The study found five significant main effects, three of which were qualified by significant interactions. Incarceration history was associated with higher drug use severity; higher suicide risk was associated with higher abstinence self-efficacy. Regarding interaction effects, among participants with an incarceration history, TM compared to TAU was associated with significantly lower alcohol use severity at 15-month follow-up; this finding did not hold for never-incarcerated participants. For participants with less severe depression symptoms, TM compared to TAU was associated with significantly lower alcohol use severity and higher abstinence self-efficacy at follow-up; this did not hold for participants with more severe depression symptoms. Suicide risk was not a significant moderator of any outcome.

CONCLUSIONS

Results indicate that TM is effective in improving alcohol use severity and abstinence self-efficacy for some subgroups of patients, including patients with an incarceration history or less severe depression. Results inform the clinical provision of substance use disorder care by means of telehealth, which increased due to the COVID-19 pandemic.

Mental and Physical Health Conditions Among U.S. Veterans with Cannabis Use and Cannabis Use Disorders

Purpose of Review

Veterans are a large population that is disproportionately affected by various physical and mental health conditions. The primary aim of this review is to provide a concise overview of recent literature on the prevalence of cannabis use and cannabis use disorder (CUD) among US Veterans, and associations with mental and physical health conditions. We also addressed gaps in the literature by investigating associations between CUD and mental and physical health conditions in 2019 data from the Veterans Health Administration (VHA; N=5,657,277).

Recent Findings

In total, 25 studies were reviewed. In 2019, the prevalence of Veteran cannabis use ranged from 11.9%-18.7%. Cannabis use and CUD were associated with bipolar disorders, psychotic disorders, suicidality, pain conditions, and other substance use, but less consistently associated with depressive disorders, anxiety disorders, and posttraumatic stress disorder. Analyses of 2019 VHA data indicated that CUD was strongly associated with a broad array of physical and mental health conditions and mortality.

Summary

Cannabis use and CUD are prevalent and highly comorbid with other conditions among US Veterans. Harm reduction methods tailored to these populations are needed.

Exacerbated PTSD symptoms among older U.S. military veterans during the COVID-19 pandemic: Results from the national health and resilience in veterans study

Research has demonstrated that the impact of the coronavirus 2019 (COVID-19) pandemic on the mental health of United States (U.S.) veterans was less negative than originally anticipated. However, U.S. veterans are susceptible to exacerbation of post-traumatic stress disorder (PTSD) symptomology in late life. The aims of this study were to examine the extent to which older U.S. veterans experienced an exacerbation of PTSD symptoms during the COVID-19 pandemic, and to identify pre- and peri-pandemic factors that conferred risk for symptom exacerbation. Participants were U.S. military veterans aged 60 and older who completed three waves of the 2019-2022 National Health and Resilience in Veterans Study (NHRVS) (n=1858). PTSD symptoms were measured at all waves using the PTSD Checklist for DSM-5, and a latent growth mixture model was conducted to compute latent slopes of change of PTSD symptoms over the 3-year period. 159 (8.3%) participants experienced a worsening of PTSD symptomology over the pandemic period. Factors related to PTSD exacerbation were incident trauma exposure between Waves 1 and 2, more medical conditions with onset prior to the pandemic, and peri-pandemic social restriction stress. Number of incident traumas moderated the relationship between both number of pre-pandemic medical conditions and pre-pandemic social connectedness, and exacerbated PTSD symptoms. These results suggest that the pandemic did not confer additional risk for PTSD exacerbation than would be expected over a 3-year period for older veterans. Those who experience incident trauma exposure should be monitored for symptom exacerbation.

Mental health impact of the COVID-19 pandemic in U.S. military veterans: a population-based, prospective cohort study

BACKGROUND

The coronavirus disease-2019 (COVID-19) pandemic has caused myriad health, social, and economic stressors. To date, however, no known study has examined changes in mental health during the pandemic in the U.S. military veteran population.

METHODS

Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, a nationally representative, prospective cohort survey of 3078 veterans. Pre-to-peri-pandemic changes in psychiatric symptoms were evaluated, as well as pre-pandemic risk and protective factors and pandemic-related correlates of increased psychiatric distress.

RESULTS

The prevalence of generalized anxiety disorder (GAD) positive screens increased from pre- to peri-pandemic (7.1% to 9.4%; p < 0.001) and was driven by an increase among veterans aged 45-64 years (8.2% to 13.5%; p < 0.001), but the prevalence of major depressive disorder and posttraumatic stress disorder positive screens remained stable. Using a continuous measure of psychiatric distress, an estimated 13.2% of veterans reported a clinically meaningful pre-to-peri-pandemic increase in distress (mean = 1.1 standard deviation). Veterans with a larger pre-pandemic social network size and secure attachment style were less likely to experience increased distress, whereas veterans reporting more pre-pandemic loneliness were more likely to experience increased distress. Concerns about pandemic-related social losses, mental health COVID-19 effects, and housing stability during the pandemic were associated with increased distress, over-and-above pre-pandemic factors.

CONCLUSIONS

Although most U.S. veterans showed resilience to mental health problems nearly 1 year into the pandemic, the prevalence of GAD positive screens increased, particularly among middle-aged veterans, and one of seven veterans experienced increased distress. Clinical implications of these findings are discussed.

Cannabis smoking increases the risk of suicide ideation and suicide attempt in young individuals of 11-21 years: A systematic review and meta-analysis

BACKGROUND

Cannabis is the most frequently consumed drug around the world. Its use has been associated with increased suicide behaviors; nonetheless, the association of cannabis smoking and suicide behaviors in adolescents has not yet been established. The aim of this systematic review and meta-analysis was to evaluate the risk of suicide attempt, suicidal ideation or suicide planning in individuals of 11-21 years of age who smoke cannabis.

METHODS

We performed an online searched using PubMed, EBSCO and Science Direct databases, up to July 2021. We calculated odds ratio with 95% confidence intervals to evaluate the association between suicide attempt, suicidal ideation or suicide planning and cannabis smoking in individuals of 11-21 years of age.

RESULTS

Twenty studies reported suicide attempts in 34,859 young individuals, suicidal ideation in 26, 937 individuals, and suicide planning in 9054 young individuals. We found an increased risk of suicide attempt in cannabis smokers than in non-cannabis users (OR: 2.33; 95% CI: 1.78-3.05; Z p value; <0.0001; I² = 97.12%), as well as a significant association between cannabis smoking and suicidal ideation (OR: 2.04; 95%CI: 1.64-2.53; Z p value: <0.001; I²: 94.88) and suicide planning (OR: 1.674; 95% CI: 1.554-1.804; Z p value: 0.000; I²: 92.609). Subgroup analyses showed that American teens have an increased risk of suicidal ideation; the meta-regression analysis revealed that age was negatively associated with the risk of suicide attempt.

CONCLUSIONS

This meta-analysis shows that cannabis smoking increased the risk of suicide attempt, suicidal ideation and suicide planning in young individuals of 11-21 years of age. The high risk of suicide behaviors could vary depending on the population studied; therefore, more studies are necessary to corroborate the risk of presenting suicide behaviors in individuals of 11-21 years of age who smoke cannabis.

Cannabis use and suicide risk among Gulf War veterans

Cannabis use has been indicated as a risk factor for suicide in veterans. This study of Gulf War veterans tested the relationship between self-report past year cannabis use and (a) past year suicidal ideation and (b) risk for suicidal behavior. Data were from a national sample (N = 1126) of Gulf War veterans. Logistic regression models indicated cannabis use was associated with past year suicidal ideation and elevated risk for suicidal behavior, independent of key covariates. In corroboration with research on other military populations, this study indicates a potentially concerning association between cannabis use and suicide risk in Gulf War veterans.

Cannabis use among U.S. military veterans with subthreshold or threshold posttraumatic stress disorder: Psychiatric comorbidities, functioning, and strategies for coping with posttraumatic stress symptoms

Cannabis use is common among individuals with posttraumatic stress disorder (PTSD) symptoms, but its impact on psychiatric symptoms and functioning in this population is unclear. To clarify the clinical and functional correlates of cannabis use in individuals with PTSD symptoms, we analyzed data from the 2019-2020 National Health and Resilience in Veterans Study, a nationally representative survey of U.S. military veterans. Participants with current subthreshold or full PTSD (N = 608) reported on their past-6-month cannabis use and current psychiatric symptoms, functioning, treatment utilization, and PTSD symptom management strategies. Veterans with subthreshold/full PTSD who used cannabis more than weekly were more likely to screen positive for co-occurring depression, anxiety, and suicidal ideation than those who did not use cannabis, ORs = 3.4-3.8, or used cannabis less than weekly, ORs = 2.7-3.7. Veterans who used cannabis more than weekly also scored lower in cognitive functioning than veterans with no use, d = 0.25, or infrequent use, d = 0.71, and were substantially more likely to endorse avoidance coping strategies, ORs = 8.2-12.2, including substance use, OR = 4.4, and behavioral disengagement, ORs = 2.7-9.1, to manage PTSD symptoms. Despite more psychiatric and functional problems, veterans with frequent cannabis use were not more likely to engage in mental health treatment, ORs = 0.87-0.99. The results suggest enhanced cannabis use screening, interventions targeting risky use, and strategies promoting treatment engagement may help ameliorate more severe clinical presentations associated with frequent cannabis use among veterans with subthreshold/full PTSD.

Epidemiology of DSM-5 alcohol use disorder in U.S. military veterans: Results from the National Health and Resilience in Veterans Study

BACKGROUND

Alcohol use disorder (AUD) is a prevalent public health concern in the U.S. that disproportionately affects veterans relative to civilians. Given changes to the demographic composition of the veteran population and AUD diagnostic criteria in the DSM-5, updated knowledge regarding the epidemiology of DSM-5 AUD in a national sample of veterans is critical to informing the population-based burden of this disorder.

METHODS

Data were analyzed from the National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 4069 U.S. veterans. Lifetime DSM-5 AUD (mild, moderate, severe) and past-year DSM-5 AUD were assessed using validated self-report measures, and sociodemographic, military, and psychiatric characteristics associated with lifetime and past-year AUD were evaluated.

RESULTS

Prevalences of lifetime and past-year DSM-5 AUD were 40.8% (95% confidence interval [CI]=39.2-42.3%) and 10.5% (95%CI=9.6-11.5%), respectively. Lifetime prevalences of mild, moderate, and severe AUD were 20.5%, 8.3%, and 12.0%, respectively. Veterans with lifetime AUD had elevated rates of psychiatric disorders and suicidal behavior, which generally increased as a function of AUD severity. Lifetime AUD was also associated with being younger, male, white, unmarried, retired and experiencing more adverse childhood experiences and traumas. For past-year AUD, being younger, male, white, having more adverse childhood experiences, and experiencing lifetime PTSD were significant correlates.

CONCLUSIONS

AUD is highly prevalent among U.S. veterans and associated with substantial psychopathology, including elevated odds of suicidal behaviors. Results underscore the importance of comprehensive screening and preventive efforts for AUD, and interventions that concurrently target overlapping alcohol use and psychiatric difficulties.

Severity of substance use as an indicator of suicide risk among U.S. military veterans

BACKGROUND

Substance use is a strong risk factor for suicidal behavior. To date, however, no known study has evaluated optimal cut-off scores on substance use severity measures to identify individuals who may be at elevated risk for suicide.

METHODS

Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 4069 U.S. veterans. Receiver operating characteristic curve analyses were conducted to identify cut-off scores on the Alcohol Use Disorders Identification Test (AUDIT) and Screen of Drug Use (SDU) that optimally differentiated veterans with and without past-year suicidal ideation (SI) in the full sample, as well a high-risk subsample with histories of major depressive disorder (MDD) and/or posttraumatic stress disorder (PTSD).

RESULTS

The prevalence of past-year SI was 11.7% (n = 387); A total of 10.5% (n = 360) of the sample screened positive for past-year alcohol use disorder, 9.1% (n = 314) for past-year drug use disorder, and 22.4% (n = 833) for lifetime MDD/PTSD. The optimal AUDIT cut-off score that differentiated suicide ideators and non-ideators was ≥14 in the full sample, and ≥18 in the high-risk subsample; these scores are indicative of moderate-to-severe alcohol use disorder. The optimal SDU cut-off score was ≥1 for both the full sample and high-risk subsample, which is lower than the recommend cut-off score for probable drug use disorder (≥7).

CONCLUSIONS

Results identify high-specificity thresholds on the AUDIT and SDU that may have clinical utility in suicide risk assessment in veterans. Veterans with moderate-to-severe alcohol use disorder or who use non-prescription drugs may warrant further suicide risk assessment.

Prevalence of cannabis use, disorder, and medical card possession in U.S. military veterans: Results from the 2019-2020 National Health and Resilience in Veterans Study

More than half of U.S. states legalized medical or recreational sale and possession of cannabis since the prevalence of cannabis use was last estimated among U.S. military veterans in 2014. To provide updated estimates of the prevalence and correlates of cannabis use, cannabis use disorder (CUD), and medical cannabis card possession in this population, data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, a nationally representative survey of 4,069 veterans ages 22-99 years who reported on their past-6-month cannabis use, CUD symptoms, and possession of a medical cannabis card. An estimated 11.9% [95% confidence interval (CI) = 10.9-12.9%)] of veterans reported using cannabis, 2.7% (95% CI = 2.3-3.3%) screened positive for CUD, and 1.5% (95% CI = 1.2-2.0%) reported possessing a medical card. Prevalence of cannabis use, CUD, and card possession were higher among younger veterans (use: 20.2%, CUD: 5.6%, card: 2.1%) and those with psychiatric conditions (use: 24.0%-30.0%, CUD: 8.9%-13.0%, card: 3.1%-4.0%). Younger age, alcohol use disorder, and childhood adversity explained a large proportion of variance in cannabis use and CUD, and depression was independently associated with CUD (odds ratio [OR] = 2.76). Physical disability (OR = 3.59), combat veteran status (OR = 2.84), and non-Hispanic black (OR = 0.23) relative to white race/ethnicity most strongly predicted using cannabis with a medical card. The estimated prevalence of cannabis use in veterans-nearly 12%-is higher than the most recently reported estimate (9% in 2014). Veteran cannabis use may be increasing and is particularly prevalent among veterans with psychiatric conditions.

Differentiating U.S. military veterans who think about suicide from those who attempt suicide: A population-based study

OBJECTIVE

Several vulnerability factors for suicidal behavior in U.S. veterans have been identified. However, little is known about factors that differentiate veterans who contemplate suicide from those who attempt suicide. This study examined sociodemographic and clinical characteristics that distinguish veterans who think about suicide from those who attempt suicide.

METHOD

Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a population-based sample of 4069 veterans. Analyses estimated the lifetime prevalence of suicide ideation (SI) and suicide attempts (SA); and examined differences between veterans with a history of attempt(s), and SI without a history of attempt(s).

RESULTS

A total 25.9% of U.S. veterans reported lifetime SI and 3.9% reported a SA. Several factors distinguished veterans with a history of SA from those with SI only: the strongest were younger age (odds ratio [OR] = 0.97, 95% CI = 0.95-0.98), nonsuicidal self-injury (OR = 1.81, 95% CI = 1.11-3.03), adverse childhood experiences (OR = 1.14; 95% CI = 1.06-1.23), alcohol use disorder (OR = 1.99; 95% CI = 1.28-3.12), lower household income (OR = 0.62; 95% CI = 0.40-0.95), and physical disability (OR = 1.69; 95% CI = 1.07-2.70).

CONCLUSIONS

Although a quarter of U.S. veterans contemplate suicide in their lifetimes, the majority do not attempt suicide. Specific sociodemographic and clinical features may differentiate veterans who contemplate versus attempt suicide.

New-onset and exacerbated insomnia symptoms during the COVID-19 pandemic in US military veterans: A nationally representative, prospective cohort study

The COVID‐19 pandemic has had a negative impact on physical and mental health worldwide. While pandemic‐related stress has also been linked to increased insomnia, scarce research has examined this association in nationally representative samples of high‐risk populations, such as military veterans. We evaluated pre‐ and pandemic‐related factors associated with new‐onset and exacerbated insomnia symptoms in a nationally representative sample of 3,078 US military veterans who participated in the National Health and Resilience in Veterans Study. Veterans were surveyed in the USA in 11/2019 (pre‐pandemic) and again in 11/2020 (peri‐pandemic). The Insomnia Severity Index was used to assess severity of insomnia symptoms at the pre‐ and peri‐pandemic assessments. Among veterans without clinical or subthreshold insomnia symptoms pre‐pandemic (n = 2,548), 11.5% developed subthreshold (10.9%) or clinical insomnia symptoms (0.6%) during the pandemic; among those with subthreshold insomnia symptoms pre‐pandemic (n = 1,058; 26.0%), 8.0% developed clinical insomnia symptoms. Pre‐pandemic social support (21.9% relative variance explained), pandemic‐related stress related to changes in family relationships (20.5% relative variance explained), pre‐pandemic chest pain (18.5% relative variance explained) and weakness (11.1% relative variance explained), and posttraumatic stress disorder (8.2% relative variance explained) explained the majority of the variance in new‐onset subthreshold or clinical insomnia symptoms during the pandemic. Among veterans with pre‐pandemic subthreshold insomnia, pandemic‐related home isolation restrictions (59.1% relative variance explained) and financial difficulties (25.1% relative variance explained) explained the majority of variance in incident clinical insomnia symptoms. Taken together, the results of this study suggest that nearly one in five US veterans developed new‐onset or exacerbated insomnia symptoms during the pandemic, and identify potential targets for prevention and treatment efforts.

Moral injury and suicidal behavior among US combat veterans: Results from the 2019-2020 National Health and Resilience in Veterans Study

BACKGROUND

Recent research suggests that exposure to potentially morally injurious experiences (PMIEs) may be associated with increased risk for suicidal behavior among US combat veterans, but population-based data on these associations are scarce. This study examined the association between PMIEs with current suicidal ideation (SI), lifetime suicide plans (SP), and suicide attempts (SA) in a contemporary, nationally representative sample of combat veterans.

METHODS

Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of US combat veterans (n = 1321). PMIEs were assessed using the Moral Injury Events Scale (MIES). Multivariable logistic regression analyses were conducted to examine associations between MIES total scores and specific types of PMIEs with suicidal behavior.

RESULTS

Thirty-six point three percent of veterans reported at least one PMIE. Perceived transgressions by self, others, and betrayal were associated with SI, SP, and SA (odds ratios [ORs] = 1.21-1.27, all p s < .05), after adjusting for sociodemographic, trauma, and psychiatric characteristics. MIES total scores were significantly, albeit weakly, associated with SP (OR = 1.03, p < .01), but not SI/SA. Depression, posttraumatic stress disorder (PTSD), and age emerged as the strongest correlates of SI/SP/SA (14.9%-38.1% of explained variance), while PMIEs accounted for a comparatively modest amount of variance (3.3%-8.9%).

CONCLUSIONS

Reports of potentially morally injurious experiences are prevalent among US combat veterans, and associated with increased risk for suicidal behavior, above and beyond severity of combat exposure, PTSD, and depression. Implications for clinical practice and future research are discussed, including the need for methodological advancements in the measurement of moral injury.