Suicide Risk among Women Veterans in Distress: Perspectives of Responders on the Veterans Crisis Line

The Social Determinants of Suicide among Female Service Members and Veterans : Running Title: Social Determinants of Suicide

AIMS

Evaluate the social determinants of health (SDOH) associated with suicidality among female Service Members and Veterans (SMV) in Arizona.

METHODS

Used data from a statewide Arizona Veteran Survey (n = 1,134) to analyze SDOH associated with suicidality (any self-report of suicidal ideation, suicide attempt, or calling a crisis line). Response data were cross-tabulated and analyzed for statistical significance using a chi-square test with a p-value of p < 0.05.

RESULTS

Depression, disability, barriers to treatment, housing instability, feelings of loneliness, and more were associated with increased suicidality among respondents. Substance use within the last 30 days, social support, and Veteran social support were not found to be significantly associated with suicidality.

CONCLUSIONS

Female SMV populations experiencing social, economic, and health disparities appear to be at higher risk for suicide. These findings suggest that future suicide prevention efforts may be more effective if tailored towards populations in need of additional support and social services.

"Something Has to Be Done to Make Women Feel Safe": Women Veterans' Recommendations for Strengthening the Veterans Crisis Line for Women Veterans

OBJECTIVE

Women represent 15% of veteran callers to the Veterans Crisis Line (VCL); there has been little research identifying the experiences and needs of women veterans who use the VCL. The objective of this study was to identify women veterans' experiences with and recommendations for strengthening VCL services for women.

METHOD

We conducted qualitative interviews with 26 women veterans across the United States who had contacted the VCL in the preceding year. Interviews were conducted by telephone in 2022 and were audio recorded and transcribed. A team-based content analysis approach was used to identify participants' concerns around contacting the VCL and recommendations for strengthening the service.

RESULTS

Interviews revealed women veterans' concerns with regard to contacting the VCL related to responder gender, appropriateness of VCL services for veterans not at imminent risk for suicide, and potential consequences of contacting the VCL. Key recommendations included letting veterans select the gender of the responder who takes their call, providing more information to potential callers about what to expect from VCL calls, and raising awareness about and maintaining options for caller anonymity.

CONCLUSIONS

This study uniquely focused on women veterans' experiences and perspectives, in their own voices. Findings point to trauma-informed approaches supporting women veteran callers to the VCL and may also hold implications for other similar crisis hotline services.

Relationship between Veterans Crisis Line risk rating and subsequent suicidal self-directed violence among veteran callers: A gender comparison

BACKGROUND

Disparities in suicide rates by veteran status are particularly striking for women. Veterans Crisis Line (VCL) is a preventive strategy.

OBJECTIVES

Examine the relationships and gender differences between VCL risk rating, and subsequent suicidal self-directed violence (SSDV) in the 12-months following VCL index call.

METHODS

Cohort study of VCL callers in 2018.

OUTCOMES

Dichotomized composite SSDV (non-fatal suicide event and/or suicide) in the 12 months following VCL call.

RESULTS

Veterans with high/moderate VCL risk had significantly higher odds of SSDV (OR = 4.02, 95% CI: 3.75, 4.30). There were no gender/VCL risk interaction (p = 0.3605). We also examined the association of gender, combination of VCL risk and suicide attempt (SA) history, on SSDV. Differential odds of SSDV for gender and combined VCL risk and SA history combinations were observed (p = 0.0005). Compared to those with lower VCL risk without SA history, those with high/moderate VCL risk with SA history showed higher odds of SSDV. Magnitude was higher for men, than for women veterans.

CONCLUSIONS AND RELEVANCE

Veterans Crisis Line risk assessment performs relatively stable across the gender binary and highlights potential gender differences when factoring in SA history. Combining risk assessment and attempt history may lead to effective suicide prevention strategies.

Characteristics associated with non-suicidal self-injury among veterans seeking military sexual trauma-related mental healthcare

Military sexual trauma (MST) is a serious issue among Veterans; it is associated with increased rates of posttraumatic stress disorder (PTSD) and nonsuicidal self-injury (NSSI), both of which are correlated with poorer mental health outcomes, including increased suicide risk. Additional insight into the characteristics associated with NSSI among Veterans with MST can help identify individuals at increased risk for suicide and other negative outcomes and improve care for Veterans with a history of MST. The current study was comprised of 327 Veterans referred for MST-related mental health services at a VHA hospital. Participants completed a semi-structured interview for clinical symptoms, including NSSI behaviors. Results of a retrospective chart review revealed a high endorsement of lifetime NSSI (26.9%) with cutting behaviors identified as the most frequently endorsed method. Logistic regression showed personality features, history of cumulative sexual trauma, and younger age were uniquely related to lifetime NSSI. These results corroborate previous findings that show elevated rates of NSSI among Veterans with exposure to trauma. This study expands upon previous findings by examining risk factors specific to treatment-seeking Veterans with a history of MST, which can aid clinical care and risk management procedures in Veteran healthcare.

Recent and Frequent Mental Distress Among Women with a History of Military Service, 2003–2019

Examining women veterans' self-reported mental health is critical to understanding their unique mental and physical health needs. This study describes self-reported mental distress over a 17-year period among cross-sectional nationally representative samples of women in the USA using data from the Behavioral Risk Factor Surveillance System (BRFSS) core national surveys from 2003 to 2019. Nationally representative prevalence estimates of self-reported mental distress were compared between women veterans and their (1) men veteran and (2) women civilian counterparts. In each year examined, women veterans report significantly more days of recent mental distress and significantly higher prevalence of frequent mental distress than their men veteran counterparts. In several years, women veterans also report greater levels of recent and frequent mental distress than women civilians. These findings highlight the long-standing high prevalence of self-reported poor mental health among women veterans and suggest that specific efforts to address mental health among women veterans as a unique population may be warranted.

Potential paths to suicidal ideation and suicide attempts among high-risk women

Although men are more likely to die by suicide, women experience a greater and more rapidly increasing rate of suicidal ideation (SI) and are 3 times more likely to attempt suicide than men. Despite this increased risk, little is known about factors that contribute to SI or suicide attempts (SA) among women. We examined factors associated with SI and SA among women and identified mood-related symptoms that differentiate women who reported attempting suicide from those who did not. Women at elevated risk for depression from across the U.S. (N = 3372; age 18 to 90) completed a survey regarding depression, anxiety, sociodemographic and reproductive status, behavioral/mental health history, and exposure to adversity. Structural equation modeling and logistic regression were used to analyze the data. Variables with the most significant relationships to SI were severity of depression (OR = 5.2, p = 0.000) and perceived stress (OR = 1.18, p = 0.000) while frequency of suicidal thoughts (OR = 3.3, p = 0.000), family history of a depression diagnosis (OR = 1.6, p = 0.000) and exposure to violence (OR = 1.9, p = 0.000) had the strongest association with SA. Childhood abuse/trauma was associated with SA (OR = 1.13, p = 0.000) but not SI. 'Feeling bad about themselves, a failure, or having let themselves or their family down' was the symptom that most clearly differentiated women who attempted suicide from women who reported suicidal ideation but no SA. The salience of childhood abuse and domestic/community violence to women's risk for a suicide attempt reinforces previous findings that these adversities may differentiate suicide risk for women versus men. Continued research is essential to understand varied paths that may lead to suicidal behavior among women, some which appear unrelated to the frequency or intensity of their suicidal thoughts.

Mental Health Emergency Hotlines in the United States: A Scoping Review (2012-2021)

OBJECTIVE

Mental health emergency hotlines provide clinical supports and connection to services. This scoping review describes the current literature on hotlines in the United States, including which populations they do and do not reach, typical call volumes and engagement levels, barriers to and facilitators of implementation, and common call outcomes. The review also identifies gaps in the literature and presents recommendations.

METHODS

A systematic search of peer-reviewed articles on U.S.-based telephone, text, and chat hotlines published between January 2012 and December 2021 retrieved 1,049 articles. In total, 96 articles met criteria for full-text review, of which 53 met full inclusion criteria.

RESULTS

Approximately half of the included studies (N=25) focused on descriptive information of callers, most of whom were females, younger adults, and White; veteran hotlines typically reached older men. Common reasons for calling were suicidality, depression, and interpersonal problems. Of studies examining intervention effects (N=20), few assessed hotlines as interventions (N=6), and few evaluated caller behavioral outcomes (N=4), reporting reduced distress and suicidality among callers after hotline engagement. However, these studies also suggested areas for improvement, including reaching underrepresented high-risk populations. Six studies reported implementation needs, such as investments in data collection and evaluation, staff training, and sustainable funding.

CONCLUSIONS

Hotlines appear to be more effective at reaching some populations than others, indicating that more intensive outreach efforts may be necessary to engage underrepresented high-risk populations. The findings also indicated limited evidence on the relationship between use of hotlines-particularly local text and chat hotlines-and caller outcomes, highlighting an area for further investigation.

Preventing Suicide Among Women Veterans: Gender-Sensitive, Trauma-Informed Conceptualization

Purpose of Review

There is growing concern regarding suicide among women veterans, who have experienced an increase in suicide rates that has exceeded that reported for other US adult populations. Recent research has bolstered understanding of correlates of suicide risk specific to women veterans. Yet most existing suicide prevention initiatives take a gender-neutral, rather than gender-sensitive, approach. We offer clinical considerations and suggestions for suicide prevention tailored to the needs, preferences, and experiences of women veterans. Discussion is framed around the White House strategy for preventing suicide among military service members and veterans.

Recent Findings

Considering high rates of trauma exposure among women veterans, we propose that a trauma-informed lens is essential for taking a gender-sensitive approach to suicide prevention with this population. Nonetheless, research to inform evidence-based assessment and intervention remains largely focused on veteran men or gender-neutral. Integral next steps for research are posited.

Summary

Extant research provides an initial foundation for beginning to understand and address suicide among women veterans in a gender-sensitive, trauma-informed manner. Additional research that is specific to women veterans or that examines gender differences is critical to ensure women veterans receive optimal, evidence-based care to prevent suicide.

Gender differences in use of suicide crisis hotlines: a scoping review of current literature

Purpose

Little is known about the gender profile of callers to crisis hotlines, despite distinct gender differences in suicide risk and behavior. The authors assessed current knowledge of the role of caller gender in the use of crisis hotlines for suicide, specifically whether there are differences in frequency, reason for call and caller outcomes by gender.

Design/methodology/approach

The authors conducted a scoping literature review of peer-reviewed studies published since 2000 in Medline, PubMed and PsychInfo, examining a total of 18 articles based on 16 studies.

Findings

Overall, women represent a higher percentage of calls to crisis hotlines worldwide, despite men having higher rates of suicide. Primary reasons for calling hotlines were the same for men and women, regardless of geography or culture. When gender differences in reason for call were reported, they were consistent with literature documenting gender differences in the prevalence of risk factors for suicide, including higher rates of substance use among men and higher instances of domestic violence/abuse among women.

Research limitations/implications

There was variability in the studies the authors examined. This review was limited to research on crisis telephone hotlines and did not include text or chat services. Due to data reporting, the findings are constrained to reporting on a male/female gender binary.

Originality/value

Findings on gender differences in crisis line use suggest a need for continued research in this area to determine how to best meet the needs of callers of all genders.

Gender differences in veterans' use of the Veterans Crisis Line (VCL): Findings from VCL call data

OBJECTIVE

To compare characteristics of calls to the Veterans Crisis Line (VCL) by caller gender and identify potentially unique needs of women callers.

METHOD

Retrospective review of clinical data collected during VCL calls, comparing call characteristics between women and men veteran callers.

RESULTS

The data included 116,029 calls by women veterans and 651,239 calls by men veterans between January 1, 2018-December 31, 2019. Timing (hour/day/season) of VCL calls was similar between women and men callers. We observed gender differences in reason for call, with the most salient differences in reasons related to interpersonal violence, including sexual trauma (e.g., military sexual trauma as reason for call - prevalence ratio (PR) for women vs. men = 9.13, 95% CI = 8.83, 9.46). Women callers were also more likely than men callers to screen positive for suicide risk (PR = 1.28, 95% CI = 1.26, 1.29), receive a higher suicide risk assessment rating (PR = 1.05, 95% CI = 1.02, 1.07), and be referred to a VA Suicide Prevention Coordinator for follow-up (PR = 1.09, 95% CI = 1.09, 1.11).

CONCLUSIONS

Analysis of VCL call data indicated both similarities and differences across genders in call characteristics, including interpersonal relationships and experiences of abuse and assault as particularly salient factors prompting women veterans' calls to VCL. This study also suggests the presence of increased suicide risk among women versus men veteran VCL callers.

Female Veterans' Willingness to Seek Veterans Health Administration and Non-Veterans Health Administration Services for Suicidal Thoughts and Mental Health Concerns

BACKGROUND

The extent to which female veterans are willing to seek Veterans Health Administration (VHA) and non-VHA care when they are suicidal or experiencing mental health (MH) concerns is unknown.

OBJECTIVES

The objectives of this study were to: (1) examine whether current, past, and never VHA using female veterans' willingness to seek VHA care differs from their willingness to seek non-VHA care if suicidal or experiencing MH symptoms; (2) examine if VHA use, military sexual trauma, and suicidal ideation and attempt are associated with female veterans' willingness to use VHA and non-VHA care when experiencing suicidal thoughts or MH symptoms.

RESEARCH DESIGN

A cross-sectional anonymous survey.

SUBJECTS

Four hundred thirty nine female veterans, including current, past, and never VHA users were included.

MEASURES

General Help-Seeking Questionnaire, Self-Injurious Thoughts and Behaviors Interview, and the VA Military Sexual Trauma Screening Questions.

RESULTS

Current VHA users reported more willingness to use VHA than non-VHA care; conversely, past and never VHA users reported less willingness to use VHA care relative to non-VHA care. Military sexual assault and none or past VHA use were associated with lower willingness to use VHA care if suicidal or experiencing MH symptoms. In contrast, those with none or past VHA use reported greater willingness to use non-VHA care if suicidal or experiencing MH symptoms, while prior suicide attempt was associated with lower willingness.

CONCLUSIONS

Ensuring that acceptable and effective suicide prevention services are available to female veterans in both VHA and community settings is critical. Increasing help-seeking intentions among female veterans who have attempted suicide or experienced military sexual assault is also essential.

Suicidal ideation, suicide attempt, and non-suicidal self-injury among female veterans: Prevalence, timing, and onset

BACKGROUND

Suicide rates among female veterans have continued to increase, particularly among those not using Veterans Health Administration (VHA) care. Nonetheless, suicide research has rarely focused on female veterans, particularly non-VHA users. The present study examined the prevalence and onset of suicidal ideation (SI), suicide attempt (SA), and non-suicidal self-injury (NSSI) in relation to military service among female veterans. Additionally, current, past, and never VHA users were compared in regard to SI, SA, and NSSI prevalence.

METHODS

Female veterans (n = 439) participated in a national, cross-sectional survey.

RESULTS

Lifetime prevalence of SI (47.9%), SA (17.7%), and NSSI (13.2%) were high. Participants were more likely to report experiencing SI and SA following separation, compared to preceding (SI, SA) or during (SI only) military service, controlling for time at risk. However, onset was more likely to occur prior to military service, compared to after separation, for SI, SA, and NSSI. In age-adjusted analyses, current and past users of VHA care were more likely to report experiencing lifetime SI, compared to those who never used VHA care. However, when adjusting for service era, past and never VHA users did not significantly differ.

LIMITATIONS

Cross-sectional design, retrospective recall, and convenience sample.

CONCLUSIONS

For female veterans, onset of SI, SA, and NSSI appears to most commonly occur before military service. However, SI and SA prevalence are highest following separation, suggesting a period warranting additional support and intervention. Results underscore the need for continued suicide surveillance, prevention, and intervention efforts for female veterans, especially current VHA users.

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.

Mental Health Service Preferences and Utilization Among Women Veterans in Crisis: Perspectives of Veterans Crisis Line Responders

Women military veterans are at increased risk of suicide compared to non-veterans, but little is known about the mental health service preferences and needs of women veterans in crisis. This study used qualitative, secondary source key informant interviews to ascertain the experiences of women veterans in crisis from 54 responders working at the Veterans Crisis Line. Responders indicated that women veterans reported different experiences with Veterans Administration (VA) and non-VA care, though drivers of satisfaction or dissatisfaction were similar. Availability of specialty care, sensitivity to veterans' issues or Military Sexual Trauma, strong provider relationships, and continuity of care contributed to satisfaction; lengthy appointment wait times, limited service options, and insensitivity to veterans' issues contributed to dissatisfaction. Responders suggested that barriers limiting VA access for women veterans are perceived as similar to non-VA care. Findings suggest that caller experiences with providers drive satisfaction with VA and non-VA mental health services.

Life course well-being framework for suicide prevention in Canadian Armed Forces Veterans

Introduction: The risks of suicidality (suicidal ideation or behaviour) are higher in Canadian Armed Forces (CAF) Veterans (former members) than in the Canadian general population (CGP). Suicide prevention is everyone’s responsibility, but it can be difficult for many to see how they can help. This article proposes an evidence-based theoretical framework for discussing suicide prevention. The framework informed the 2017 joint CAF – Veterans Affairs Canada (VAC) suicide prevention strategy. Methods: Evidence for the framework was derived from participation in expert panels conducted by the CAF in 2009 and 2016, a review of findings from epidemiological studies of suicidality in CAF Veterans released since 1976, suicide prevention literature reviews conducted at VAC since 2009, and published theories of suicide. Results: Common to all suicide theories is the understanding that suicide causation is multifactorial, complex, and varies individually such that factors interact rather than lie along linear causal chains. Discussion: The proposed framework has three core concepts: a composite well-being framework, the life course view, and opportunities for prevention along the suicide pathway from ideation to behaviour. Evidence indicates that Veterans are influenced onto, along, and off the pathway by variable combinations of mental illness, stressful well-being problems and life events, individual factors including suicidal diathesis vulnerability, barriers to well-being supports, acquired lethal capability, imitation, impulsivity, and access to lethal means. The proposed framework can inform discussions about both whole-community participation in prevention, intervention and postvention activities at the individual and population levels, and the development of hypotheses for the increased risk of suicidality in CAF Veterans.

An initial investigation of nonsuicidal self-injury among male and female survivors of military sexual trauma

Nonsuicidal self-injury (NSSI) has been understudied among survivors of military sexual trauma (MST). The aims of the current study were to: (1) describe characteristics of NSSI among survivors of MST and (2) determine if MST survivors who have engaged in NSSI differ from those who have never engaged in NSSI in terms of the severity of posttraumatic stress disorder (PTSD) and depressive symptoms, trauma-related cognitions, and recent suicidal ideation. Participants were 107 veterans (65 females, 42 males) with a history of MST who completed measures of NSSI, PTSD and depressive symptoms, recent suicidal ideation, and trauma-related cognitions. Approximately one-fourth of participants (n = 27; 25.23%) endorsed a history of NSSI. The majority of participants who engaged in NSSI reported that they first engaged in NSSI following MST (n = 18; 66.67%). MST survivors with a history of NSSI reported more severe PTSD symptoms, recent suicidal ideation, and trauma-related cognitions. NSSI was relatively common in the sample and was associated with a more severe clinical presentation. Longitudinal research is needed to understand the development, maintenance, and function of NSSI in MST survivors, especially as it pertains to risk for suicidal self-directed violence.

Expanding Suicide Crisis Services to Text and Chat

Abstract. Background: Crisis support services have historically been offered by phone-based suicide prevention hotlines, but are increasingly becoming available through alternative modalities, including Internet chat and text messaging. Aims: To better understand differences in the use of phone and chat/text services. Method: We conducted semistructured interviews with call responders at the Veterans Crisis Line who utilize multimodal methods to respond to veterans in crisis. Results: Responders indicated that veterans may access the chat/text service primarily for reasons that included a desire for anonymity and possible inability to use the phone. Responders were divided on whether callers and chatters presented with different issues or risk of suicide; however, they suggested that veterans frequently use chat/text to make their first contact with mental health services. Limitations: We spoke with call responders, not the veterans themselves. Additionally, as this is qualitative research, applicability to other settings may be limited. Conclusion: While new platforms offer promise, participants also indicated that chat services can supplement phone lines, but not replace them.