Suicide Risk by Unit Component among Veterans Who Served in Iraq or Afghanistan

The Purple Heart and suicide risk in Post-9/11 U.S. Army Combat Veterans with a traumatic brain injury: A mixed methods study

Active service members and Veterans with a combat-related traumatic brain injury (TBI) are four times more likely to attempt suicide than those without a TBI. TBIs are the signature injuries of the Post-9/11 conflicts and Combat Veterans (i.e., current and former service members who deployed in support of a combat mission) with these injuries are entitled to receive the Purple Heart medal. However, potentially tens of thousands of Combat Veterans did not receive, or were denied the Purple Heart during the first decade of the Global War on Terrorism because a TBI was not documented during the deployment. To our knowledge, this is the first study to explore the meaning of the Purple Heart and examine the impact of the Purple Heart on Army Combat Veterans with a combat-related TBI. Findings from this mixed methods study revealed that not receiving the Purple Heart is associated with increased suicide risk and lower quality of life after a brain injury. Additionally, thwarted belongingness, perceived burdensomeness, and perceived military institutional betrayal are associated with increased suicide risk in Army Combat Veterans with a TBI. This mixed methods study provides important insights into how Army culture is perceived and the power of the Purple Heart among this high-risk group of Combat Veterans.

Mechanisms through which executive dysfunction influences suicidal ideation in combat-exposed Iraq and Afghanistan veterans

OBJECTIVE

Executive dysfunction has previously been associated with suicidality, but it remains unclear how deficits in executive functioning contribute to increased suicidal thoughts and behaviors. Although it has been proposed that poorer executive functioning leads to difficulty generating and implementing appropriate coping strategies to regulate distress and inhibit suicidal thoughts and behaviors, studies have not systematically examined these relationships. Therefore, the present study examined various hypotheses to elucidate the mechanisms through which executive dysfunction influences suicidal ideation (SI) in combat-exposed Iraq/Afghanistan veterans.

METHOD

Veterans who endorsed SI were compared to those who denied SI on demographic and diagnostic variables and measures of neuropsychological functioning, psychological symptoms, coping styles, and combat experiences. Serial mediation models were tested to examine mechanistic relationships among executive functioning, psychological distress, coping, and SI.

RESULTS

Those who endorsed SI had worse executive functioning, greater psychological distress, and greater avoidant coping relative to those who denied SI. Serial mediation model testing indicated a significant indirect path, such that executive dysfunction increased psychological distress, which in turn increased avoidant coping, leading to SI.

CONCLUSIONS

Findings support and extend previous hypotheses regarding how executive functioning contributes to increased risk of suicidality via increased distress and avoidant coping. Intervention efforts focused on reducing suicidality may benefit from techniques that enhance executive functioning (e.g. computerized training, cognitive rehabilitation) and in turn reduce distress prior to targeting coping strategies.

Suicidal Depression in Ancient Egypt

OBJECTIVE

To evaluate the oldest record of a depressed individual contemplating suicide.

METHOD

A directed review of ancient Egyptology literature of translations and discussion regarding a papyrus that is approximately 4,000 years old.

RESULTS

The content of the document is consistent with a man going through a severe depression and is contemplating suicide. However, this does not appear to be a suicide note, but more of an ancient example of 'journaling' or working through the thoughts of suicide and its possible consequences to the man's eternal life in the afterworld.

CONCLUSIONS

Presentation of depression, the reasons for considering suicide, and the process by which an individual works through those thoughts have not varied significantly over the past 4,000 years.

White matter integrity, suicidal ideation, and cognitive dysfunction in combat-exposed Iraq and Afghanistan Veterans

White matter alterations in frontolimbic circuits and poorer cognitive functioning have been observed in individuals endorsing suicidality across numerous psychiatric conditions. However, relationships between white matter integrity, cognition, and suicidality in Veterans are poorly understood, particularly for those at increased risk for suicide due to mental health conditions (e.g., posttraumatic stress disorder, depression) and traumatic brain injury history. We (1) examined white matter alterations in combat-exposed Iraq/Afghanistan Veterans with and without suicidal ideation (SI) and (2) investigated relationships between white matter integrity and neuropsychological functioning in regions that differed between SI groups. No group differences were found regarding psychiatric diagnoses. Participants with SI had lower fractional anisotropy (FA) in the posterior corona radiata, superior corona radiata, and superior longitudinal fasciculus relative to those without SI. Worse processing speed/attention performance was associated with lower FA in the superior longitudinal fasciculus, while worse executive functioning performance was associated with lower FA in the superior corona radiata and superior longitudinal fasciculus. Memory performance was not associated with FA. These findings suggest that white matter integrity may be involved in cognitive dysfunction and increased risk for SI. Interventions that target cognitive dysfunction may ameliorate SI, and in turn, reduce risk for suicide among Veterans.

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 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.

Mortality Among Male U.S. Army Soldiers Within 18 Months of Separation

INTRODUCTION

Understanding how soldiers die after separation from military service, particularly those who die shortly after separating from service, may help to identify opportunities to ease transitions to civilian life.

MATERIALS AND METHODS

Mortality data were analyzed for male U.S. Army soldiers who died within 18 months of their separation from service (from 1999 to 2011). Descriptive statistics were calculated for natural, accidental, suicidal, homicidal, undetermined, and legal/operation of war deaths and were stratified by age, component, time in service, and type of discharge. Crude and age-adjusted mortality rates, standardized for all years using the 2004 Regular Army population, were also calculated. The Public Health Review Board of the U.S. Army Public Health Center approved this study as Public Health Practice.

RESULTS

Of the 1,884,653 male soldiers who separated from service during the study period, 3,819 died within 18 months of separation. A majority of all separations were Reserve or National Guard (58%), and 62% of decedents were in the Reserve or National Guard. Deaths from natural causes (38%) were the most common, followed by accident deaths (34%), suicides (20%), homicides (6%), undetermined deaths (2%), and legal/operation of war deaths (<1%). For overall mortality, age-adjusted rates were higher among the male U.S. population when compared to male soldiers who had separated from the Army.

CONCLUSIONS

The time period immediately following separation from the Army presents a unique challenge for many soldiers. Developing more effective pre-separation prevention programs that target specific risks requires knowing the causes of death for natural deaths, suicides, and accidents. Over half of all deaths occurring shortly after separation from service are preventable. Continued surveillance of specific causes of preventable deaths following separation can improve pre-separation prevention programs and transitions to post-service care.

Risk of suicide among U.S. veterans who deployed as part of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn

Background

There has been concern about the risk of suicide among veterans returning from deployment to Afghanistan and Iraq as part of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND). This study assessed suicide risk among OEF/OIF/OND veterans by gender and unit component. Firearm related suicide was also briefly examined.

Findings

The study cohort was identified from records of the US Department of Defense. Vital status and cause of death through 2016 was obtained from the Mortality Data Repository, which obtains data from the National Death Index. Suicide risk was first assessed using standardized mortality ratios (SMR)s, comparing the rate of suicide among all veterans, both collectively and separately by gender and unit component (active vs. reserve/National Guard) to the expected based on the US population adjusted for age, race, sex, and calendar year. Risk of suicide among active duty compared to reserve/National Guard veterans and male compared to female veterans was assessed with hazard ratios (HR) s, generated by Cox proportional hazards models, that included the covariates race, age, marital status, rank, and branch of service. There was an increased risk of suicide when all OEF/OIF/OND Veterans were compared to the US population, (SMR = 1.42; 95%, C.I., 1.38,1.46). Both male and female veterans had an increased risk of suicide when compared to their gender specific non-veteran counterparts, (SMR = 1.40; 95%, C.I., 1.36,1.45 and SMR = 1.85; 95%, C.I., 1.60,2.13), respectively. Active duty veterans had an increased risk of suicide compared to reserve/National Guard veterans, (HR = 1.22; 95%, C.I., 1.14,1.30). Male veterans had an almost 3-fold increased risk compared to female veterans, (HR = 2.85; 95%, C.I., 2.47,3.29). Among all veteran suicides 68.3% involved a firearm, including 68.7% among males and 59.5% among females.

Conclusions

All OEF/OIF/OND veterans have an increased risk of suicide compared to non-veterans. Veterans will benefit from enhanced access to mental health services and initiatives to promote suicide prevention. Strategies that emphasize lethal means safety, an evidence based suicide prevention strategy which includes increasing safe storage practices (i.e., storing firearms unloaded and locked) can help address this increased risk of veteran suicide.

Repetitive Transcranial Magnetic Stimulation for Treatment-Resistant Depression in Active-Duty Service Members Improves Depressive Symptoms

OBJECTIVES

Current research on the efficacy of repetitive transcranial magnetic stimulation (rTMS) over left dorsolateral prefrontal cortex as a noninvasive therapy for treatment-resistant depression is largely settled science. However, little is known about its efficacy with active-duty service members (ADSMs) with major depressive disorder. In a retrospective chart review, we examined depressive symptom ratings in ADSMs seeking treatment at the US Army Outpatient Behavioral Health Service Clinic at Eisenhower Army Medical Center, Fort Gordon, Ga.

METHODS

We reviewed 121 consecutive outpatient charts, which yielded 61 ADSMs who completed a minimum of 20 rTMS sessions for refractory depression, and for whom both pretreatment and posttreatment depressive symptom ratings were available. Pre- and post-Patient Health Questionnaire 9 (PHQ-9) scores were subjected to a paired t test, and Reliable Change Indices were calculated to determine both reliable and clinical significance.

RESULTS

Average (SD) pretreatment and posttreatment PHQ-9 scores were 15.8 (6.2) and 12.6 (7.6), respectively. Statistically significant reduction in post-PHQ-9 was demonstrated (P < 0.001), with 69% of patients lowering their ratings and 31% demonstrating reliable change (improvement >5.64). Additionally, 20% demonstrated a reliable change that placed them in the nondysfunctional range (post-PHQ-9 <9.6), demonstrating clinical significance.

CONCLUSIONS

These data confirm a course of standard rTMS to ADSMs with major depression is promising in reducing depressive symptoms. Given that success and completion rates from this clinic are similar to those reported in civilian populations (80%), rTMS may be an adequate additional treatment or augmentation strategy for refractory depression in ADSMs.

Mortality among U.S. military participants at eight aboveground nuclear weapons test series

BACKGROUND

Approximately 235,000 military personnel participated at one of 230 U.S. atmospheric nuclear weapons tests from 1945 through 1962. At the Nevada Test Site (NTS), the atomic veterans participated in military maneuvers, observed nuclear weapons tests, or provided technical support. At the Pacific Proving Ground (PPG), they served aboard ships or were stationed on islands during or after nuclear weapons tests.

MATERIAL AND METHODS

Participants at seven test series, previously studied with high-quality dosimetry and personnel records, and the first test at TRINITY formed the cohort of 114,270 male military participants traced for vital status from 1945 through 2010. Dose reconstructions were based on Nuclear Test Personnel Review records, Department of Defense. Standardized mortality ratios (SMR) and Cox and Poisson regression models were used in the analysis.

RESULTS

Most atomic veterans were enlisted men, served in the Navy at the PPG, and were born before 1930. Vital status was determined for 96.8% of the veterans; 60% had died. Enlisted men had significantly high all-causes mortality SMR (1.06); officers had significantly low all-causes mortality SMR (0.71). The pattern of risk over time showed a diminution of the 'healthy soldier effect': the all-causes mortality SMR after 50 years of follow-up was 1.00. The healthy soldier effect for all cancers also diminished over time. The all-cancer SMR was significantly high after 50 years (SMR 1.10) primarily from smoking-related cancers, attributed in part to the availability of cigarettes in military rations. The highest SMR was for mesothelioma (SMR 1.56) which was correlated with asbestos exposure in naval ships. Prostate cancer was significantly high (SMR 1.13). Ischemic heart disease was significantly low (SMR 0.84). Estimated mean doses varied by organ were low; e.g., the mean red bone marrow dose was 6 mGy (maximum 108 mGy). Internal cohort dose-response analyses provided no evidence for increasing trends with radiation dose for leukemia (excluding chronic lymphocytic leukemia (CLL)) [ERR (95% CI) per 100 mGy -0.37 (-1.08, 0.33); n = 710], CLL, myelodysplastic syndrome, multiple myeloma, ischemic heart disease, or cancers of the lung, prostate, breast, and brain.

CONCLUSION

No statistically significant radiation associations were observed among 114,270 nuclear weapons test participants followed for up to 65 years. The 95% confidence limits were narrow and excluded mortality risks per unit dose that are two to four times higher than those reported in other investigations. Significantly elevated SMRs were seen for mesothelioma and asbestosis, attributed to asbestos exposure aboard ships.

Mental Health and Suicidality in Separating U.S. Reserve and National Guard Personnel

OBJECTIVE

We examined the association of U.S. Reserve Component (RC) personnel separating from military service with the risk of mental health problems at three time periods.

METHODS

Structured interviews were conducted with a nationally representative sample of 1,582 RC personnel at baseline and three follow-up waves from 2010 to 2013. Multivariate logistic regression analyses examined posttraumatic stress disorder (PTSD), major depressive disorder (MDD), binge drinking, suicide ideation, and mental health diagnosis by a health provider.

RESULTS

Approximately 10%, 20%, and 28% of RC personnel reported separating from military service at waves 2-4. At an estimated 6 months since leaving military service, there were no differences between those who left and those who remained in service. However, at 1 year after leaving service, those who had left had a higher risk of MDD, suicidal ideation, and reporting having mental health diagnosis by a health provider. At 1.6 years after leaving military service, those who had left had a higher risk of reporting having mental health diagnosis by a health provider. The results were essentially unchanged after adjusting for baseline mental disorder for each outcome.

CONCLUSION

Results suggest a higher risk of mental health problems in RC veterans separating, compared to those who remained in the military. This risk may not occur immediately following separation but may occur within the first year or two after separation. Transition from military to civilian life may be a critical period for interventions to address the unique needs of the RC's citizen-soldiers and reduce their risk of adverse mental health outcomes.

Identifying Suicide Typologies Among Trauma-Exposed Veterans

Background: Suicide among veterans has increased in recent years, making the identification of those at greatest risk for self-injurious behavior a high research priority. Aims: We investigated whether affective impulsivity and risky behaviors distinguished typologies of self-injurious thoughts and behaviors in a sample of trauma-exposed veterans. Method: A total of 95 trauma-exposed veterans (ages 21-55; 87% men) completed self-report measures of self-injurious thoughts and behaviors, impulsivity, and clinical symptoms. Results: A latent profile analysis produced three classes that differed in suicidal ideation, suicide attempts and nonsuicidal self-injury (NSSI): A low class that reported little to no self-injurious thoughts or behaviors; a self-injurious thoughts (ST) class that endorsed high levels of ideation but no self-harm behaviors; and a self-injurious thoughts and behaviors (STaB) class that reported ideation, suicide attempts and NSSI. Membership in the STaB class was associated with greater affective impulsivity, disinhibition, and distress/arousal than the other two classes. Limitations: Limitations include an overrepresentation of males in our sample, the cross-sectional nature of the data, and reliance on self-report measures. Conclusion: Findings point to affective impulsivity and risky behaviors as important characteristics of veterans who engage in self-injurious behaviors.