The influence of gender on suicidal ideation following military sexual trauma among Veterans in the Veterans Health Administration

A Literature Review of Mental Health Symptom Outcomes in U.S. Veterans and Servicemembers Following Combat Exposure and Military Sexual Trauma

Combat exposure (CE) and military sexual trauma (MST) are among the most common types of traumatic experiences faced by veterans and active duty servicemembers and, as such, have both garnered increased research focus over the past decades. However, there has not yet been a critical review of the literature to examine the distinct clinical presentations associated with different trauma types. This is particularly important, as understanding distinct clinical profiles could help researchers and clinicians refine treatment approaches based on trauma type. To address this question, we conducted a search of the available literature in PsycINFO and PubMed prior to October 2022. We identified 43 articles evaluating the distinct and overlapping clinical symptoms of CE and MST. Study findings were conceptually organized by psychiatric condition. In general, there was substantial variability in study methodology including sample size, composition, and operationalizations of CE and MST. Despite this variability, notable patterns emerged across studies. Specifically, MST and CE uniquely predicted posttraumatic stress disorder symptoms, MST was more related to depressive symptoms and suicidality than CE, and CE appeared to be more related to alcohol use and other externalizing behaviors. Gender also played a significant role in the relationship between CE, MST, and clinical variables across studies. This review suggests that individuals with a history of MST and CE likely have distinct clinical presentations and more research into these presentations could better inform assessment and treatment. Important methodological gaps in the literature are also discussed.

The Association of Military Sexual Harassment/Assault With Suicide Ideation, Plans, Attempts, and Mortality Among US Service Members/Veterans: A Meta-Analysis

Suicide rates continue to increase among service members/veterans. Military sexual harassment/assault (MSH/A) may increase risk of suicide, but little is known about the collective magnitude of associations between MSH/A and suicide outcomes, including ideation, plan, attempt, and mortality. The current meta-analysis addressed this literature gap while testing potential moderators of gender, marital status, discharge status, and military branch. PsycINFO, PubMed, Dissertations/Theses, relevant citation lists, and conference brochures were reviewed for papers that included quantitative analyses in English, U.S. military samples, and measures of MSH/A and suicide ideation/plan/attempt/mortality. The search resulted in 22 studies (N = 10,898,875) measuring the association of MSH/A with suicide ideation (k = 15), plans (k = 1), attempts (k = 14), and mortality (k = 2), with papers published from 2007-2021. MSH/A was associated with suicide ideation (r   ¯ = .14) and attempts (r   ¯ = .11, ps < .05). The association of MSH/A and suicide ideation and attempts was higher among women relative to men, those identifying as married versus not married, those actively serving compared to discharged, and those reporting service in the Air Force relative to all other branches. The association of MSH/A with suicide plans and mortality was not calculated due to the small number of studies reporting those effect sizes (ks = 1-2). The effect sizes observed suggest MSH/A is part of a larger network of risk factors for suicide. Moderators indicate that suicide risk is higher among specific groups, and prevention strategies would be most effective if they targeted these individuals. This research area would be strengthened by additional studies of plans and mortality.

Perspectives of VA healthcare from rural women veterans not enrolled in or using VA healthcare

PURPOSE

Women Veterans have unique healthcare needs and often experience comorbid health conditions. Despite this, many women Veterans are not enrolled in the Veterans Health Administration (VHA) and do not use VHA services. Underutilization of VHA services may be particularly prevalent among rural women Veterans, who may experience unique barriers to using VHA care. Nonetheless, knowledge of rural women Veterans and their experiences remains limited. We sought to understand rural women Veterans' perceptions and needs related to VHA healthcare, including barriers to enrolling in and using VHA services, and perspectives on how to communicate with rural women Veterans about VHA services.

METHODS

Rural women Veterans were recruited through community engagement with established partners and a mass mailing to rural women Veterans not enrolled in or using VHA healthcare. Ten virtual focus groups were conducted with a total of twenty-nine rural women Veterans (27 not enrolled in VHA care and 2 who had not used VHA care in the past 5 years) in 2021. A thematic inductive analytic approach was used to analyze focus group transcripts.

FINDINGS

Primary themes regarding rural women Veterans' perceptions of barriers to enrollment and use of VHA healthcare included: (1) poor communication about eligibility and the process of enrollment; (2) belief that VHA does not offer sufficient women's healthcare services; and (3) inconvenience of accessing VHA facilities.

CONCLUSION

Although VHA has substantially expanded healthcare services for women Veterans, awareness of such services and the nuances of eligibility and enrollment remains an impediment to enrolling in and using VHA healthcare among rural women Veterans. Recommended strategies include targeted communication with rural women Veterans not enrolled in VHA care to increase their awareness of the enrollment process, eligibility, and expansion of women's healthcare services. Creative strategies to address access and transportation barriers in rural locations are also needed.

Moral injury and peri- and post-military suicide attempts among post-9/11 veterans

BACKGROUND

Our goal was to examine the association between moral injury, mental health, and suicide attempts during military service and after separation by gender in post-9/11 veterans.

METHODS

A nationally representative sample of 14057 veterans completed a cross-sectional survey. To examine associations of exposure to potentially morally injurious events (PMIEs; witnessing, perpetrating, and betrayal) and suicidal self-directed violence, we estimated two series of multivariable logistic regressions stratified by gender, with peri- and post-military suicide attempt as the dependent variables.

RESULTS

PMIE exposure accounted for additional risk of suicide attempt during and after military service after controlling for demographic and military characteristics, current mental health status, and pre-military history of suicidal ideation and attempt. Men who endorsed PMIE exposure by perpetration were 50% more likely to attempt suicide during service and twice as likely to attempt suicide after separating from service. Men who endorsed betrayal were nearly twice as likely to attempt suicide during service; however, this association attenuated to non-significance after separation in the fully adjusted models. In contrast, women who endorsed betrayal were over 50% more likely to attempt suicide during service and after separation; PMIE exposure by perpetration did not significantly predict suicide attempts before or after service among women in the fully adjusted models.

CONCLUSIONS

Our findings indicate that suicide assessment and prevention programs should consider the impact of moral injury and attend to gender differences in this risk factor in order to provide the most comprehensive care.

Sex-specific risk and resilience correlates of suicidal ideation in U.S. military veterans

OBJECTIVES

To estimate the prevalence and identify gender-specific risk factors associated with suicidal ideation (SI) in a nationally representative sample of U.S. military veterans.

METHODS

Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 4069 veterans. Bivariate and multivariable analyses were conducted to identify factors associated with SI in male and female veterans.

RESULTS

The prevalence of SI was significantly higher in female than male veterans (18.1 % vs. 11.2 %). In female veterans, results of a relative importance analysis revealed that the majority of explained variance in SI (Nagelkerke R² = 0.54) was accounted for by lower psychological resilience (44.4 %), and history of non-suicidal self-injury (24.4 %) and alcohol use disorder (20.6 %). In male veterans, the majority of explained variance in SI (Nagelkerke R² = 0.32) was accounted for by higher loneliness (19.5 %) and hostility (19.1 %), and lower purpose in life (16.3 %).

CONCLUSIONS

Suicidal ideation is prevalent among U.S. veterans, particularly in female veterans. Different risk factors emerged as strong correlates of SI in female and male veterans, which may be used to inform gender-specific suicide prevention and treatment efforts in this population.

Informing measurement of gender differences in suicide risk and resilience: A national study of United States military veterans

OBJECTIVE

To inform measure selection when examining gender differences in suicide risk, this paper evaluates measure performance for a set of gender-relevant constructs and examines gender differences in mean scores.

METHODS

A national sample of veterans (n = 968) who had recently attempted suicide (past 6 months) completed measures assessing life experience-, psychosocial-, and health-related constructs. A multigroup latent variable model was used to assess similarity of measurement properties between women and men.

RESULTS

Metric and scalar invariance indicated that the latent variables functioned similarly between women and men. Women had higher scores on negative coping, institutional betrayal, and social rejection; men had higher scores on self-compassion, autonomy, and suicide ideation.

CONCLUSIONS

Measurement properties and gender differences in mean values support the use of these measures for research on gender differences. Findings also suggest further investigation of social rejection, institutional betrayal, and negative coping among women veterans at risk for suicide.

Sexual compulsivity, erectile dysfunction, and suicidality among male survivors of military sexual violence

Although military sexual trauma (MST) is associated with an increased risk of suicide, suicide attempts, and suicidal ideation among service members and veterans, there is limited knowledge regarding the mechanisms of MST and suicidality among men. The current study examined whether MST was associated with sexual compulsivity and/or erectile dysfunction and if these, in turn, explained elevated suicidal thoughts and the likelihood of engaging in future suicidal behavior after accounting for mental health, military, and demographic characteristics. Service members and veterans who reported their gender as male (N = 508) were recruited via social media and completed online self-report measures assessing MST, erectile dysfunction, sexual compulsivity, suicidal ideation frequency, and the likelihood of engaging in future suicidal behavior. Path analysis was used to examine the study hypotheses. In total, 67 participants (13.2%) reported a history of MST; of these individuals, 27 (40.3%) reported suicidal ideation in the past 12 months, and 29 (43.9%) reported an increased likelihood of engaging in future suicidal behavior. MST was associated with increased sexual compulsivity, which, in turn, predicted more frequent suicidal ideation as well as a higher self-reported likelihood of engaging in future suicidal behavior. MST was associated with higher levels of erectile dysfunction, but erectile dysfunction was not associated with suicidal ideation in the adjusted model. Although the data were cross-sectional, precluding determinations of causality, the results support assessing and intervening with regard to sexual compulsivity to mitigate the risk for suicide-related outcomes among men who experience MST.

Trajectories of suicidal ideation following separation from military service: Overall trends and group differences

BACKGROUND

Although the transition out of military service is a high-risk time for suicidal ideation (SI), a paucity of research examines the development of SI during this transition process and veteran subgroups at risk for SI as they readjust to civilian life.

METHODS

A population-based, longitudinal post-9/11 veteran cohort reported SI frequency at 3, 9, 15, 21, and 27 months post-separation using the Patient Health Questionnaire-9. We identified distinct trajectories of SI over time (i.e., classes) using latent class growth analysis and examined demographic and military service predictors of class membership overall and by gender using multinomial logistic regression.

RESULTS

Four SI trajectories that were similar across genders were identified: resilient (90.1%), delayed onset (5.0%), remitting (2.7%), and chronic (2.2%). Younger age, minority race/ethnicity, medical and other (vs. honorable) separation types, and Veterans Health Administration service utilization were associated with increased odds of assignment to a higher-risk trajectory (delayed onset, remitting, and/or chronic vs. resilient), whereas continued service in the National Guard/Reserves and officer rank was associated with lower odds of assignment to a higher-risk trajectory.

CONCLUSIONS

Findings regarding veterans at greatest risk for SI following military separation can inform targeted assessment and early intervention efforts.

Military sexual trauma in the United States: Results from a population-based study

BACKGROUND

The reported prevalence of military sexual trauma (MST) has increased over the past decades in the United States, yet scarce population-based studies have examined the prevalence, correlates, and health burden of MST in the general veteran population.

METHODS

Data were from the 2019-2020 National Health and Resilience in Veterans Study, a population-based survey of veterans (n = 4069).

ANALYSES

(1) estimated the prevalence of MST; (2) identified sex-stratified sociodemographic, military, and trauma characteristics associated with MST; and (3) examined sex-stratified associations between MST and psychiatric comorbidities, functioning, disability, and treatment utilization.

RESULTS

Female veterans reported substantially higher rates of MST (44.2%) than male veterans (3.5%). Relative to male veterans without MST histories, male veterans with MST histories had nearly 3-fold increased odds of reporting future suicidal intent, 2-to-3-fold greater odds of screening positive for current posttraumatic stress disorder (PTSD), depression, and generalized anxiety disorder; and nearly 2-fold increased odds of being disabled. Male veterans with MST histories also scored lower on mental, physical, cognitive, and psychosocial functioning (d's = 0.16-0.29). Relative to female veterans without MST histories, female veterans with MST histories had 5-fold greater odds of current PTSD, 2-fold greater odds of engaging in mental health treatment, and scored lower on psychosocial functioning and higher on somatic symptoms (both d's = 0.25).

LIMITATIONS

Cross-sectional design precludes causal inference.

CONCLUSIONS

A substantial proportion of veterans in the U.S. experience sexual trauma during their military service, and these experiences are associated with an elevated health burden.

Moral Injury as a Mediator of the Associations Between Sexual Harassment and Mental Health Symptoms and Substance Use Among Women Veterans

Moral injury is an array of symptoms theorized to develop in response to morally injurious events, defined as events that challenge one's core moral beliefs and expectations about the self, others, and world. Recent measures of moral injury have distinguished self-directed moral injury (e.g., moral injury symptoms that emerge following the perpetration of morally injurious events) from other-directed moral injury, the symptoms of which are believed to stem from one's response to actions that others have committed (e.g., within-rank violence, failures of leadership, and acts of betrayal committed by trusted others or institutions). Using a convenience sample of 154 primarily former military women, the present study examined if other-directed moral injury symptoms (e.g., anger, betrayal, and mistrust) associated with military experience would mediate the association between military sexual harassment and mental health and substance abuse symptoms. Results demonstrated that 85.8% (n = 127) of the of this sample of women veterans reported experiencing sexual harassment during their military service. Using a single mediation model, we further demonstrated that other-directed moral injury mediated the association between sexual harassment experience and mental health symptoms. Given the percentage of women veterans who reported sexual harassment, these results suggest that additional training for military members, and particularly, military leaders, is necessary to begin to reduce sexual harassment. In addition, mental health providers who work with current and former military members should consider how other-directed moral injury may be associated with mental health symptoms among women veterans who have experienced sexual harassment while in the military.

Associations Among Military Sexual Trauma, Opioid Use Disorder, and Gender

INTRODUCTION

Opioid use disorder and high-risk opioid prescription increase the risks for overdose and death. In Veterans, military sexual trauma is associated with increased risk for assorted health conditions. This study evaluates the association of military sexual trauma with opioid use disorder and high-risk opioid prescription and potential moderation by gender.

METHODS

In a national sample of Veterans Health Administration outpatients receiving care from October 1, 2009 to August 1, 2017, logistic regression models were fit to evaluate the associations between military sexual trauma and opioid use disorder and high-risk opioid prescription, adjusting for demographic and clinical covariates. A second set of models included a gender X military sexual trauma interaction. Analyses were conducted in 2020-2021.

RESULTS

Patients with history of military sexual trauma (n=327,193) had 50% higher odds of opioid use disorder diagnosis (AOR=1.50, 95% CI=1.45, 1.54, p<0.001) and 5% higher odds of high-risk opioid prescription (AOR=1.05, 95% CI=1.04, 1.07, p<0.001) than those without history of military sexual trauma (n=7,738,665). The effect of military sexual trauma on opioid use disorder was stronger in men than in women . The predicted probability of opioid use disorder among men with history of military sexual trauma (1.5%) was nearly double that of women with history of military sexual trauma (0.8%).

CONCLUSIONS

Military sexual trauma was a significant risk factor for opioid use disorder and high-risk opioid prescription, with the former association particularly strong in men. Clinical care for Veterans with military sexual trauma should consider elevated risk of opioid use disorder and high-risk opioid prescription.

A sex-stratified analysis of suicidal ideation correlates among deployed post-9/11 veterans: Results from the survey of experiences of returning veterans

BACKGROUND

Suicide rates are higher among veterans than non-veterans; this difference is particularly salient for females. Knowledge is sparse regarding correlates of suicidal ideation (SI) among female veterans, particularly in non-VHA samples. As such, and given that SI confers a strong risk for subsequent suicidal behavior, this study aimed to: (1) compare prevalence of recent SI by sex; and (2) determine whether deployment stressors, mental health symptoms, and recent psychosocial stressors are associated with recent SI, by sex, among post-9/11 veterans.

METHODS

A sex-stratified analysis of cross-sectional data from 809 post-9/11, deployed veterans was conducted using the Survey of Experiences of Returning Veterans (SERV); statistical interactions between sex and correlates of interest were assessed.

RESULTS

Self-reported prevalence of recent SI did not differ by sex. A statistically significant interaction between sex and combat was observed; greater combat experience was associated with increased SI for females only. While significant interactions were not observed for other correlates, differences in significant predictors and predictor effect sizes were noted across sex-stratified models. Recent housing and financial concerns were only associated with increased SI prevalence among females, whereas concern about other recent stressful life events was associated with increased SI prevalence only among males.

LIMITATIONS

This is a cross-sectional analysis of a national survey with limited power to detect statistical sex interactions.

CONCLUSIONS

While correlates of SI are relatively consistent for males and females notable differences suggest that tailored assessment and intervention based on sex may hold merit in mitigating SI among post-9/11 era Veterans.

Military Sexual Trauma and Adverse Mental and Physical Health and Clinical Comorbidity in Women Veterans

INTRODUCTION

Military sexual trauma (MST)-exposure to sexual harassment or assault during military service-is a major health priority for the Veterans Health Administration (VHA). We examined the health correlates of MST in the largest sample of U.S. women veterans studied to date.

METHODS

Using national VHA electronic medical record data, we identified 502,199 women veterans who enrolled in the VHA between January 1, 2000, and December 31, 2017, had at least one VHA visit, and were screened for MST (exclusive of those who declined to answer the screening). We conducted logistic regression analyses to examine associations of a positive MST screen with various mental and physical health conditions-defined by administrative diagnostic codes-and comorbidity of mental and/or physical health conditions. Models were adjusted for demographic and military service characteristics, along with duration in the VHA.

RESULTS

Approximately 26% (n = 130,738) of women veterans screened positive for MST. In fully adjusted models, a positive MST screen was associated with greater risk of having all mental and physical health conditions examined, except cancer-related conditions, ranging from 9% greater odds of rheumatic disease to 5.4 times greater odds of post-traumatic stress disorder. MST was also associated with greater comorbidity, including greater odds of having ≥2 mental health conditions (odds ratio [OR], 3.28; 99% confidence interval [CI], 3.20-3.37), having ≥2 physical health conditions (OR, 1.26; 99% CI, 1.22-1.29), and having ≥1 mental health condition and ≥1 physical health condition (OR, 2.05; 99% CI, 2.00-2.11).

CONCLUSIONS

Findings suggest that MST is common in women veterans and may play a role in the clinical complexity arising from comorbid conditions.

Military sexual trauma and suicidal ideation in VHA-care-seeking OEF/OIF/OND veterans without mental health diagnosis or treatment

Sexual trauma is a suicide risk factor. While military sexual trauma (MST) is frequently associated with suicidal ideation (SI) in women and men veterans who served in recent conflicts, less is known about MST's relationship to SI in veterans who have no documented mental health concerns. Of the 1.1 million post-9/11 veterans enrolled in the Veterans Healthcare Administration (VHA) we examined 41,658 (12.3% women, 87.7% men) without evidence of mental health diagnosis or treatment and who were screened for MST and SI using the standard VHA clinical reminders between 2008 and 2013. Relative risk estimates were generated using separate models for women and men. MST was reported by 27.9% of women and 2.9% of men; SI by 14.7% and 16.5%, respectively. The adjusted relative risk of MST on SI was 1.65 (95% CI 1.35, 2.00) in women, and 1.49 (95% CI 1.26, 1.75) in men. In this sample of veterans without evidence of mental health diagnosis or treatment, MST was associated with a high risk of SI in both genders. Positive MST screening should prompt SI screening and risk management if indicated, and further study of barriers to mental healthcare among MST survivors at risk for suicide is warranted.

Racial/Ethnic Disparities in Sexual Harassment in the United States, 2018

This study was designed to assess racial/ethnic disparities in victimization from sexual harassment and assault by sex in the United States, and to assess racial/ethnic differences in depression/anxiety as a consequence of sexual harassment or assault, among those victimized. In January 2018, the organization Stop Street Harassment led a nationally representative online survey regarding lifetime experiences of sexual harassment and assault with women and men aged 18+ (N = 2,009). We used sex-stratified multinomial logistic regression models to assess racial/ethnic differences in (a) self-reported victimization from these sexual abuses and (b) depression/anxiety due to these abuses among those reporting victimization. Eighty-one percent (81%) of women and 43% of men reported victimization from sexual harassment (27% and 6% indicating sexual assault, for women and men, respectively). Among those reporting harassment or assault, 30.8% of women and 19.8% of men reported depression or anxiety as a consequence. We found no significant racial/ethnic disparities in victimization from sexual harassment or assault among women, although an insignificant trend of increased risk for harassment was seen for Hispanic relative to White women (adjusted odds ratio [AOR] = 1.95, 95% confidence interval (CI) = 0.95, 3.99). Black relative to White men had lower odds of reporting sexual harassment (AOR = 0.53, 95% CI = 0.30, 0.93), and Hispanic relative to White men had higher odds of reporting sexual assault (AOR = 2.17, 95% CI = 1.06, 4.45). No racial/ethnic differences were observed for women or men in likelihood of depression or anxiety as a consequence of this abuse. These findings highlight the ubiquity of sexual harassment and assault, especially for women, with increased risk for Hispanics relative to Whites. In addition, findings demonstrate mental health effects of these types of abuses regardless of sex and race/ethnicity. Broad social change is needed to support prevention and intervention efforts with intersectional and trauma-informed approaches.

A Factor Analysis of the Suicide Cognitions Scale in Veterans with Military Sexual Trauma-Related Posttraumatic Stress Disorder

The Suicide Cognitions Scale (SCS) assesses suicide-specific cognitions which may drive suicide risk. Nonetheless, prior work has been mixed regarding optimal factor structure. Additionally, this measure has not been validated for use with veterans with military sexual trauma-related posttraumatic stress disorder (MST-related PTSD), a population that is at elevated risk for suicidal self-directed violence (SDV). This study sought to determine the optimal factor structure of the SCS for use with veterans with MST-related PTSD as well as its psychometric properties. An exploratory factor analysis revealed a four-factor structure, including unlovability, unbearability, unsolvability, and negative urgency. The SCS also demonstrated excellent internal consistency and good convergent validity. This study identified a novel factor, negative urgency, which may explain some of the predictive power of the SCS found in previous research. This paper provides initial support for a four-factor structure of the SCS among those with MST-related PTSD. Additional work remains necessary in evaluating the SCS as a tool for detecting risk for future suicidal SDV among veterans with MST-related PTSD.

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

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

Sex Differences in Military Sexual Trauma and Severe Self-Directed Violence

INTRODUCTION

Previous research has demonstrated an association between military sexual trauma and risk for suicide; however, risk for self-directed violence such as suicide attempt or nonsuicidal self-injury following military sexual trauma is understudied. This study examines the relationship between military sexual trauma and serious self-directed violence resulting in hospitalization, as well as whether this relationship differs by sex.

METHODS

Participants were 750,176 Operations Enduring Freedom/Iraqi Freedom/New Dawn veterans who were enrolled in Veterans Health Administration care during the period of October 1, 2001-September 30, 2014 and who were screened for military sexual trauma. Data were analyzed in 2019. Bivariate analyses and Cox proportional hazards regression models were employed.

RESULTS

Women veterans were more likely to screen positive for military sexual trauma (21.33% vs 1.63%), and women and men were equally likely to experience serious self-directed violence (1.19% women vs 1.18% men). Controlling for demographic variables and psychiatric morbidity, military sexual trauma predicted serious self-directed violence for both men and women. Further, men with military sexual trauma were 15% less likely to experience self-directed violence compared with women with military sexual trauma (hazard ratio=0.85, 95% CI=0.74, 0.98).

CONCLUSIONS

Military sexual trauma is associated with risk for serious self-directed violence for both men and women veterans, and the relationship may be pronounced among women. Results underscore the importance of incorporating military sexual trauma into treatment and preventative efforts for self-directed violence.

The Relationship between Trauma Exposure and Psychiatric Hospitalization for Suicide Ideation or Suicide Attempt among Patients Admitted to a Military Treatment Setting

Suicide attempts and psychiatric hospitalization represent the final outcomes of a complex dynamical system of interacting factors that influence a particular individual's likelihood of engaging in suicidal behavior, as well as their ability to seek help prior to acting upon suicidal impulses. This study examined the association between different types of lifetime trauma exposure and the likelihood of psychiatric hospitalization following a suicide attempt (SA) rather than suicidal ideation (SI) alone. Electronic medical records for 1100 U.S. military service members and their dependents admitted to a military psychiatric inpatient setting for SA or SI were reviewed for documented lifetime trauma exposure history. Findings indicated that exposure to at least one childhood trauma of any type, and childhood neglect in particular, increased the likelihood that an individual would be hospitalized for SA rather than SI. Exploratory gender-stratified analyses demonstrated that childhood neglect, childhood sexual abuse, and adulthood traumatic loss may be linked with the likelihood of being hospitalized for SA. These findings demonstrate the importance of developing more detailed and nuanced conception of factors known to be associated with suicide as their effects may depend on details of their timing and nature, as well as their interactions with other systems.

Self- and Other-Directed Violence as Outcomes of Deployment-Based Military Sexual Assault in Iraq/Afghanistan-era Veteran Men and Women

Although military sexual assault (MSA) has been well-established as a risk factor for psychopathology (e.g., PTSD, depression), little research has examined the association between MSA and self- and other-directed violence. Furthermore, there has been a growing empirical focus on potential gender differences in the effects of MSA, but few of these studies have examined gender differences in self- and other-directed violence. In a sample of 1571 Iraq/Afghanistan-era veterans (21.0% women), we examined the effect of MSA on difficulty controlling violent behavior and attempting suicide among veteran men and women, above and beyond the influence of childhood sexual abuse, combat trauma, PTSD, and major depressive disorder. Results of a logistic regression revealed that MSA increased risk of attempting suicide and difficulty controlling violence among women but not men. Thus, the results suggest that MSA may be a risk factor for both types of violence in women. Furthermore, because PTSD was associated with both types of violence in both men and women, MSA may also confer risk of violence via PTSD.

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

OBJECTIVES

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

DESIGN

A cross-sectional study.

SETTING AND PARTICIPANTS

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

MEASUREMENTS

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

RESULTS

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

CONCLUSIONS

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

Military Sexual Trauma in Older Women Veterans: Prevalence and Comorbidities

BACKGROUND

Recent attention has highlighted the common occurrence and health consequences of military sexual trauma (MST) in younger women veterans. However, almost nothing is known about MST in older veterans.

OBJECTIVE

To describe MST among older women veterans, including prevalence and common comorbidities.

DESIGN

Cross-sectional observational study, using data from national Department of Veterans Affairs medical records.

PARTICIPANTS

Population-based sample of women Veterans aged 55+ with at least one documented MST screen response and at least one clinical encounter in fiscal years 2005-2015.

MAIN MEASURES

MST screen: medical diagnoses (diabetes, hypertension, hyperlipidemia, myocardial infarction, cerebrovascular disease, congestive heart failure, obesity, chronic pain conditions, back pain, dementia, insomnia, sleep apnea, menopause symptoms) and mental health diagnoses (anxiety, depression, posttraumatic stress disorder, tobacco use, alcohol use disorder, substance use disorder, opioid use disorder, suicidal ideation) from International Classification of Diseases, Ninth Revision Clinical Modification codes in the medical record.

KEY RESULTS

In this cohort of older women veterans (n = 70,864, mean age 65.8 ± 10.4 years), 13% had a positive MST screen. In multivariable regression analyses adjusted for age, race/ethnicity, and marital status, MST was strongly associated with most mental health diagnoses, particularly posttraumatic stress disorder (OR 7.25, 95% CI 6.84-7.68), depression (OR 2.39, 95% CI 2.28-2.50), and suicidal ideation (OR 2.42, 95% CI 2.08-2.82). MST was also associated with multiple medical conditions, particularly sleep disorders (insomnia OR 1.61, 95% CI 1.43-1.82; sleep apnea OR 1.48, 95% CI 1.37-1.61) and pain (chronic pain OR 1.58, 95% CI 1.50-1.67; back pain OR 1.40, 95% CI 1.34-1.47).

CONCLUSIONS

A history of MST is common among older women veterans and associated with a range of medical and mental health diagnoses. These findings call attention to the need for additional research in this understudied population, and the importance of trauma-informed care approaches for women across the lifespan.

Gender differences among medical students, house staff, and faculty physicians at high risk for suicide: A HEAR report

BACKGROUND

In comparison with the general population, physicians, and physicians-in-training are at greater risk for suicide. Although key gender differences in suicide risk factors and behaviors have been identified in the general population, the extent to which these differences apply to physicians and physicians-in-training is unclear. Here, we aimed to identify gender differences in risk factors, clinical presentation, and help-seeking behaviors of medical students, house staff, and physician faculty at high risk for suicide.

METHODS

We explored gender differences among 450 physicians and trainees meeting criteria for high suicide risk on anonymous online questionnaires completed between 2009 and 2017.

RESULTS

High-risk female trainees and physicians had higher mean Patient Health Questionnaire-9 (PHQ-9) scores compared with the males (11.1, standard deviation [SD] 5.1 vs. 9.8, SD 4.7) and were more likely to endorse feeling worried (73.8% vs. 61.2%), irritable (60.4% vs. 49.4%), and stressed (79.6% vs. 70%). High-risk male trainees and physicians were more likely than females to endorse suicidal thoughts (31.2% vs. 22.1%), intense anger (24.3% vs. 16.1%), drinking too much (31.2% vs. 22.3%), and recreational drug or prescription medication use without clinically appropriate follow-up (9.4% vs. 4.3%). There were no gender differences in help-seeking behaviors.

CONCLUSIONS

This is the first study to report gender differences among risk factors, presentation, and help-seeking behaviors of physicians, and trainees at high risk for suicide. Our findings are mostly consistent with those of the general population and show that only a minority of at-risk men and women in healthcare sought treatment, highlighting the importance of intervention and suicide prevention in this population.

Depression and PTSD-related anhedonia mediate the association of military sexual trauma and suicidal ideation in female service members/veterans

Previous research shows a direct link between military sexual trauma and suicide risk. Little is known about mediators of this association, including posttraumatic stress disorder (PTSD) or depression severity, mental health conditions that are correlated with both suicide risk and military sexual trauma. Moreover, existing studies of military sexual trauma do not distinguish between harassment and assault, resulting in a gap in our knowledge regarding suicide risk as a function of sexual trauma type. We explored whether PTSD symptom clusters and depression mediated the association of military sexual trauma type (none, harassment-only, assault) and suicidal ideation (SI). Female service members/Veterans (n = 1190) completed a demographic inventory, military sexual trauma history and type screening, and PTSD symptom cluster severity, depression severity, and SI measures. Structural equation modeling revealed that the association of military sexual trauma, particularly assault, with SI was mediated by depression severity and PTSD-related anhedonia. Screening for SI among those endorsing a history of military sexual trauma, PTSD-related anhedonia, and depression may help identify those at risk for SI. Therapeutic interventions aimed at reducing PTSD-related anhedonia and depression symptoms may be the most efficient way to mitigate suicide risk in those with histories of assault military sexual trauma.

Meaning in life following deployment sexual trauma: Prediction of posttraumatic stress symptoms, depressive symptoms, and suicidal ideation

Deployment sexual trauma (DST; i.e., sexual harassment or assault during deployment in the military) is associated with physical and mental health consequences, including posttraumatic stress disorder (PTSD), depression, and suicidal ideation (SI). Less attention has been placed on factors that may offer protection from deleterious mental health outcomes following DST. Global meaning in life (i.e., purpose, beliefs, goals, and subjective feelings) has been shown to be a protective factor against PTSD, depression, and SI following combat trauma; however, the extent to which meaning in life may affect outcomes following DST has not been investigated. Cross-sectional associations and Hayes mediation models were examined using baseline interview data from the Survey of Experiences of Returning Veterans sample (SERV; 850 recently returned veterans, 352 women). DST was associated with post-deployment posttraumatic stress symptoms (PTSS), depressive symptoms, and SI severity, and with decreased sense of meaning in life. Further, meaning in life was a significant mediator between DST and each of the three outcomes, even after controlling for demographic variables and combat experiences. The mediation models did not differ by gender. Findings suggest meaning in life may be an important clinical factor, both for the identification of risk and as a point of intervention.

Identifying factors associated with suicidal ideation and suicide attempts following military sexual trauma

BACKGROUND

As increasing research demonstrates that military sexual trauma (MST) is associated with suicidal ideation and attempts, discerning factors that place MST survivors at risk for these outcomes is critical. The present study aimed to: (1) characterize suicidal ideation and attempts among MST survivors; (2) identify factors associated with post-MST suicide attempts, post-MST suicidal ideation, and past-week suicidal ideation.

METHODS

A convenience sample of 108 veterans (66 women, 42 men) who reported a history of MST participated in this cross-sectional study. Pre-MST suicidal ideation and attempt, childhood physical and sexual abuse, military sexual assault, institutional betrayal, and posttraumatic cognitions about self, world, and self-blame were examined, with age and gender as covariates.

RESULTS

Seventy-five percent of participants reported experiencing post-MST suicidal ideation, and 40.7% reported attempting suicide following MST. Pre-MST suicide attempt and posttraumatic cognitions about self were associated with post-MST suicide attempt. Pre-MST suicidal ideation, military sexual assault, childhood physical abuse, and posttraumatic cognitions about self were associated with post-MST suicidal ideation. Lastly, pre-MST suicidal ideation and posttraumatic cognitions about self were associated with past-week suicidal ideation; results were unchanged when accounting for recent PTSD or depressive symptoms.

LIMITATIONS

The cross-sectional design, retrospective self-report, and small sample are limitations.

CONCLUSIONS

Addressing negative posttraumatic beliefs about self may be important for managing suicide risk among MST survivors. Assessing for pre-MST suicidal ideation and attempt is likely also warranted. Further understanding of the longitudinal impact of posttraumatic beliefs about self on subsequent risk for suicidal ideation and attempt is warranted.

Seeking help for the health sequelae of military sexual trauma: a theory-driven model of the role of institutional betrayal

Although rates vary, approximately 38.4% of women and 3.9% of men report experiencing military sexual trauma (MST). MST is associated with numerous psychosocial consequences, increased propensity for physical and mental health diagnoses, suicide, and an elevated likelihood of revictimization. Consequently, medical and mental health care for MST-related health sequelae is often warranted for individuals who have experienced MST; however, many MST survivors forgo or delay MST-related care, despite the fact that the Veterans Health Administration (VHA) provides free healthcare for MST-related health conditions. One potential explanation for this phenomenon is that survivors of MST feel betrayed by the military institution that they served when the MST occurred due to the institutional response to MST or perceptions that the institution failed to prevent MST from occurring. Perceptions of institutional betrayal may, in turn, decrease survivors' likelihood of disclosing MST and utilizing necessary treatment through VHA or affiliated institutions. A theoretical model of the role of institutional betrayal on help-seeking is proposed in which institutional betrayal serves as a potential barrier to utilizing MST-related healthcare. Potential mediators of this association (e.g., distrust, beliefs about safety) are also posited. This model offers utility in conceptualizing institutional factors that may influence helping-seeking following MST. By testing and refining such models, institutions and providers may be better-equipped to support MST survivors in obtaining necessary healthcare.

Psychosocial Factors that Shape Substance Abuse and Related Mental Health of Women Military Veterans who Use Community-Based Services

BACKGROUND

Women Veterans who use the Veterans Health Administration (VA) have high rates of substance abuse and poorer health than non-Veteran women. Less is known about the psychosocial needs of women Veterans who seek care in non-VA settings.

OBJECTIVES

We provide a grounded description of factors that impact substance abuse, mental health, and related quality of life of women Veterans who use non-VA community-based health and social services.

METHODS

Utilizing a mixed methods design, we conducted semi-structured in-person interviews with 22 women Veterans in Los Angeles in 2013-2015.

RESULTS

The current health of these women Veterans was shaped by substance abuse and several other factors, including: histories of trauma (in childhood, during military service) and discrimination, and associated mental health conditions; post-military socio-economic stressors; shifting social roles and adverse social support; and lost personal identity after military service. Psychosocial factors collectively underscore areas in which delivery of health and social services to women Veterans being treated in non-VA settings could be improved: (1) diffuse, implement, and sustain evidence-based gender-sensitive substance abuse treatment; (2) address traumas contributing to poor health; (3) recognize stress proliferation processes erode women's capacity to access healthcare or cope with stressors in healthy ways; (4) champion women Veterans who embody resilience and thereby can help others to form empowered personal identities of health and wellness.

CONCLUSION

Findings can inform interventions and services that ameliorate vulnerability to substance abuse and other health risks among women Veterans.

Workplace victimization risk and protective factors for suicidal behavior among active duty military personnel

BACKGROUND

Workplace victimization is a potential risk factor for suicidal behaviors (SB) among military personnel that has been largely overlooked. This paper examines both the impact of workplace victimization on reported SB and several potential protective factors associated with such suicidal behaviors in a large sample of active duty soldiers.

METHODS

A case-control study was conducted with 71 soldiers who reported SB in the past 12 months, each matched on sociodemographic characteristics to two others without reported suicidal behaviors. A multiple regression model was estimated to assess the effects of risk and protective factors while controlling for other variables.

RESULTS

SB was associated with several aspects of victimization, mental health and substance abuse conditions, pain, impulsivity, stressors, negative life events, work-family conflict, active coping behaviors and positive military-related factors. Controlling for other variables, those with SB were more likely to have sought mental health or substance abuse services, to be depressed, anxious, impulsive, and less resilient than non-SB personnel.

LIMITATIONS

Study limitations included the use of retrospective self-report data, absence of some known SB predictors, and a population restricted to active duty Army personnel.

CONCLUSIONS

SB among active duty personnel is associated with victimization since joining the military and is protected by resiliency. These findings suggest that in addition to the usual mental health factors, these additional predictors should be accounted for in SB intervention and prevention planning for active duty personnel.

Decreases in Suicide Cognitions After Cognitive Processing Therapy Among Veterans With Posttraumatic Stress Disorder Due to Military Sexual Trauma: A Preliminary Examination

Posttraumatic stress disorder (PTSD) is associated with suicidal ideation (SI) and suicidal self-directed violence (SDV). Military sexual trauma (MST) is a common precursor to PTSD among veterans. Survivors of MST are more likely to be diagnosed with PTSD and are at greater risk for SI than survivors of other forms of trauma. Suicide-specific beliefs (e.g., unlovability, unbearability, unsolvability) have been shown to be strong predictors of SI and future suicidal SDV. Suicide-specific beliefs were examined over the course of treatment and follow-up in 32 veterans (23 women, 9 men) who received cognitive processing therapy (CPT) for MST-related PTSD. Hierarchical linear models revealed that veterans who received CPT had significant reductions in suicide-specific cognitions regarding unbearability, unlovability, and unsolvability. These preliminary findings warrant replication in a randomized controlled trial with a larger sample that includes participants with more acute suicidal intent.

Sexual vs. Non-sexual trauma, sexual satisfaction and function, and mental health in female veterans

Trauma in general, and sexual assault in particular, is associated with serious mental health and functional problems. The quality of sexual satisfaction/function may be particularly impacted by sexual assault, and such sexual problems may account for some of the broader mental health and functioning impairments in sexual assault survivors. Accordingly, we examined self-reports of sexual health and mental health in a sample of 255 female veterans in committed, monogamous relationships who provided data regarding sexual assault (n = 153) or nonsexual trauma (n = 102). Trauma type was not associated with differences in sexual function, but sexual trauma was associated with significantly lower sexual satisfaction, greater posttraumatic stress disorder (PTSD) and depressive symptoms, and higher suicidal ideation. Furthermore, the indirect effect of trauma type on all mental health outcomes was significant via sexual satisfaction but not via sexual function. Finally, trauma type moderated the association of sexual function with suicidality, such that the association was significantly positive in those with a history of sexual assault but nonsignificant in those with nonsexual trauma. These results suggest that (1) female veterans' experience of sexual assault is related to sexual satisfaction, which in turn is related to mental health outcomes, and (2) a history of sexual assault may increase the importance of sexual functioning with regard to suicidality.

Sexual dysfunction is associated with suicidal ideation in female service members and veterans

BACKGROUND

Suicide is a leading cause of premature death among military service members/veterans (SM/Vs). The Interpersonal Theory of Suicide (Joiner, 2007) proposes that higher thwarted belonging, perceived burdensomeness, and acquired capability confer increased risk for suicide. However, no studies have examined the association of sexual dysfunction, a possible component of thwarted belonging and perceived burdensomeness, with suicidal ideation. The present study explored whether sexual dysfunction was associated with suicidal ideation when accounting for mental health, demographic, and military characteristics among female SM/Vs.

METHOD

Female SM/Vs (n = 710) completed an anonymous online survey assessing demographics, mental health, military characteristics, sexual dysfunction, and suicidal ideation.

RESULTS

One hundred fifty-nine participants (22.39%) reported suicidal ideation during the preceding two weeks. A multivariable ordinal regression adjusted for age, marital status, probable posttraumatic stress disorder (PTSD), probable depression, race/ethnicity, Army service, and deployment history. Lower sexual functioning (adjusted odds ratio [AOR] = 0.98, 95% confidence interval[CI] = 0.95-0.99), probable PTSD (AOR = 2.54, 95% CI = 1.61-4.01), and probable depression (AOR = 5.28, 95% CI = 3.34-8.34) were associated with suicidal ideation. Post-hoc analyses examined the association of suicidal ideation with specific components of sexual functioning: difficulties with sexual arousal (AOR = 0.87, 95% CI = 0.79-0.97) and sexual satisfaction (AOR = 0.85, 95% CI = 0.75-0.96) were associated with suicidal ideation.

LIMITATIONS

Data were cross-sectional and limited to self-report.

DISCUSSION

Sexual dysfunction is associated with suicidal ideation, accounting for established mental health, military, and demographic characteristics among female SM/Vs. Efforts to prevent suicidal ideation in female SM/Vs may be enhanced by screening for and treating sexual dysfunction, particularly sexual arousal and satisfaction.

Psychiatric and Interpersonal Correlates of Suicide Ideation in Military Sexual Trauma Survivors: The National Health and Resilience in Veterans Study

BACKGROUND

Veterans who experience military sexual trauma are at increased risk for experiencing suicidal ideation, suicide attempt, and suicide. Yet few studies have attempted to discern factors that relate to suicidal ideation and suicide attempts among survivors of military sexual trauma. The present study aimed to identify psychiatric and interpersonal correlates of suicidal ideation (primary aim) and suicide attempt (secondary aim) among survivors of military sexual trauma.

METHODS

This cross-sectional analysis included 115 veterans (56 females; mean age = 53.24) who participated in the National Health and Resilience in Veterans Study and reported experiencing military sexual trauma. Self-report measures assessed psychological distress, hazardous alcohol use, social support, loneliness, social acknowledgment following one's worst trauma, suicidal ideation, and suicide attempts.

RESULTS

Military sexual trauma survivors who reported more severe psychological distress (OR = 2.88), hazardous alcohol use (OR = 1.14), and perceived general disapproval from others (OR = 1.14) were significantly more likely to report experiencing suicidal ideation in the past two weeks. Hazardous alcohol use (OR = 1.19) and perceived general disapproval from others (OR = 1.36) were associated with being more likely to report attempting suicide in adulthood.

CONCLUSIONS

Addressing alcohol misuse, psychological distress, and perceived general disapproval from others in relation to one's worst traumatic event is recommended when assessing and managing suicide risk among veterans who have experienced military sexual trauma. Findings also contribute to a growing literature highlighting the importance of understanding perceptions of the interpersonal response to trauma. Considering the cross-sectional design, longitudinal research is needed to further elucidate the roles of these constructs in predicting suicidal ideation and suicide attempt following military sexual trauma.