Nexus of despair: A network analysis of suicidal ideation among veterans

Child Maltreatment, Adult Trauma, and Mental Health Symptoms Among Women Veterans: A Scoping Review of Published Quantitative Research

The objective of this scoping review was to describe and synthesize the measures, methods, and key findings of published quantitative research examining the influence of child maltreatment (i.e., abuse and/or neglect) and adult trauma exposure on mental health symptoms among women Veterans. A systematic search from database inception to June 2023 generated 18,861 unique articles retrieved and independently screened for eligibility. A total of 21 articles met pre-established inclusion criteria: (a) quantitative data and results within a sample or subsample of U.S. women veterans, (b) published in a peer-reviewed journal, and (c) examining variables of interest simultaneously (i.e., child maltreatment, adult trauma exposure, mental health symptom) in quantitative analyses. Reviewed literature showed a lack of uniformity in measurement and methodologies to evaluate women veterans' lifetime trauma exposure in relation to mental health. Studies most frequently used self-report survey data to evaluate exposure to child maltreatment and/or adult trauma with convenience samples of women veterans (52.4%, n = 11) and examined depressive and/or posttraumatic stress symptomatology. Findings demonstrate the need for additional research attending to the interplay between child maltreatment and adult trauma exposures in relation to women veterans' mental health using comprehensive assessment, longitudinal methods, and understudied as well as more representative samples.

Suicidal behaviour in adolescents: A network analysis

OBJECTIVE

Suicidal behaviour has not yet been analysed from a network approach in adolescent samples. It is imperative to incorporate new psychological models to understand suicidal behaviour from a different perspective. The main objective of this work was twofold: (a) to examine suicidal behaviour through network analysis and (b) to estimate the psychological network between suicidal behaviour and protective and risk factors in school-age adolescents.

METHOD

Participants were 443 students (M=14.3 years; SD=0.53; 51.2% female) selected incidentally from different schools. Different instruments were administered to assess suicidal behaviour, emotional and behavioural difficulties, prosocial behaviour, subjective well-being, emotional intelligence, self-esteem, depressive symptomatology, empathy, positive and negative affect, and emotional regulation.

RESULTS

The resulting network of suicidal behaviour was strongly interconnected. The most central node in terms of strength and expected influence was "Consider taking your own life". In the estimated psychological network of suicidal behaviour and risk and protective factors, the nodes with the highest strength were depressive symptomatology, positive affect, and empathic concern. The most influential nodes were those related to emotional intelligence abilities. Suicidal behaviour was positively connected to depression symptoms and negative affect, and negatively connected to self-esteem and positive affect. The results of the stability analysis indicated that the networks were accurately estimated.

CONCLUSIONS

Suicidal behaviour can be conceptualized as a dynamic, complex system of cognitive, emotional, and affective characteristics. The new psychopathological and psychometric models allow us to analyse and understand human behaviour and mental health problems from a new perspective, suggesting new forms of conceptualization, evaluation, intervention, and prevention.

The relationships between anxiety and suicidal ideation and between depression and suicidal ideation among Chinese college students: A network analysis

Background

Suicide is a worldwide public health problem. Evidence from previous studies has confirmed the relationship among anxiety, depression and suicidal ideation. However, the complex psychopathological pathways between anxiety and suicidal ideation and between depression and suicidal ideation require further study.

Methods

A total of 505 college students from Shanghai during COVID-19 pandemic were investigated in an online study. Anxiety, depression and suicidal ideation of the participants were investigated. R software was used to construct the anxiety-suicidal ideation and depression-suicidal ideation networks and to evaluate the bridge expected influences.

Results

The anxiety-suicidal ideation network had 28 cross-community edges, the strongest one was A7 "Afraid something will happen"-S7 "Unable to solve personal problem"; A5 "Restlessness" and S3 "Hopelessness and suicide thoughts" had the highest bridge expected influences. The depression-suicidal ideation network had 36 cross-community edges, and the strongest one was D9 "Thoughts of death"-S5 "Unable to accomplish something important"; D9 "Thoughts of death" and S3 "Hopelessness and suicide thoughts" had the highest bridge expected influences.

Conclusion

Intricate psychopathological pathways exist between anxiety and suicidal ideation and between depression and suicidal ideation. "Restlessness", "Thoughts of death" and "Hopelessness and suicide thoughts" are considered targets for suicidal ideation interventions. The present study enriches the theory of symptoms and mental disorders and provides a reliable reference for the intervention practice of suicidal ideation.

Reporting Ethical Procedures in Suicide Prevention Research: Current Status and Recommendations

OBJECTIVE

Ethical concerns frequently arise in suicide prevention research regarding participant safety and confidentiality. Despite a substantial literature on managing and navigating ethical concerns in suicide research, little attention has been paid to the reporting of ethical procedures. Furthermore, standard procedures for reporting ethical risk management procedures have not been developed.

METHOD

A review of the current literature was performed to examine the current state of reporting of ethical procedures within suicide research. Articles published in 2020 (N = 263) from three suicide-focused publications were screened and then coded (n = 131) to identify reporting of procedures for the ethical conduct of research and suicide risk management steps taken by the research teams.

RESULTS

The majority of articles reported ethical review or approval (84.7%) and reported the use of an informed consent process (77.9%). Only 28.2% included risk mitigation procedures. Of those 29.7% of those articles reported conducting risk evaluation, 66.7% reported resource dissemination, and 51.4% reported an intervention.

CONCLUSION

As empirical support for brief interventions accrues, suicide prevention researchers should consider establishing standards for the reporting of procedures to ensure the safety of participants with suicidal risk.HighlightsReporting suicide safety protocols helps ensure high ethical standards in research.Fewer than 1/3 of articles reviewed reported risk mitigation procedures in 2020.Standard procedures for reporting safety protocols in suicide research are needed.

Association between modifiable social determinants and mental health among post-9/11 Veterans: A systematic review

Introduction

As U.S. Veterans reintegrate from active duty to civilian life, many are at risk for negative modifiable social determinants of health. The prevalence of mental health conditions among Veterans is also high. Awareness of the associations between these two factors is growing. This systematic review provides a comprehensive analysis of the current state of knowledge of the associations between modifiable social determinants and mental health among U.S. Veterans.

Methods

The authors systematically searched four databases and identified 28 articles representing 25 unique studies that met inclusion criteria. Findings from the studies were extracted and synthesized on the basis of modifiable social determinants. Study quality and risk of bias were assessed using the Methodological Quality Questionnaire.

Results

The studies identified in the systematic review examined three modifiable social determinants of health: 1) housing stability, 2) employment and finances, and 3) social support. Although the lack of validity for measures of housing stability, employment, and finances compromised study quality, the overall evidence suggests that Veterans with access to supportive social determinants had better mental health status. Evidence was particularly robust for the association between strong social support and lower symptoms of posttraumatic stress disorder.

Discussion

Current evidence suggests the need to consider modifiable social determinants of health when designing mental health interventions. However, more research encompassing a wider range of modifiable social determinants such as food security, education, and transportation and using comprehensive methods and validated instruments is needed. Future research also needs to intentionally include Veterans from diverse racial-ethnic groups.

Exploring psychological and psychosocial correlates of non-suicidal self-injury and suicide in college students using network analysis

BACKGROUND

Non-suicidal self-injury (NSSI) and suicide are a serious health concern in young people. Remarkable progress has been made in understanding the correlates and risk factors for suicidality. However, it remains unclear the complex interplay between different factors and which factors are most saliently associated with NSSI and suicide risk and should be targeted for interventions.

METHODS

This study utilized network analysis to examine the interrelationship between NSSI, suicide and a variety of psychological (e.g., depression, psychotic-like experiences) and psychosocial (e.g., childhood maltreatment, family dysfunction, being bullied and social support) correlates in a sample of Chinese first year college students (n = 2328).

RESULTS

The severity of depressive symptoms was the only factor connected to both NSSI and suicide. Other psychiatric factors like psychotic experiences could only act in an indirect way via the bridging effect of depression. Emotional abuse, compared with other forms of childhood adversities, was found to be the most influential maltreatment form associated with suicidal ideation and attempts. Finally, social support showed the potential to lower the risk of self-injury and suicide in young people.

LIMITATIONS

Only a subset of risk and resilience factors of NSSI and suicide were included. Causal inference was impossible due to the cross-sectional design.

CONCLUSIONS

Our findings highlighted the importance of identifying risk groups with mental illnesses or negative childhood events, and providing additional support during the key time of transitioning into higher education.

Exploring Risk Factors in Suicidal Ideation and Attempt Concept Cooccurrence Networks

Suicide is a significant and rising threat to public health. In the United States, 47,500 people died from suicide in 2019, a 10-year increase of 30%. Many researchers are interested in studying the risk factors associated with suicidal ideation and suicide attempt to help inform clinical screening, intervention, and prevention efforts. Many suicide risk factor analyses draw from clinical subdomains and quantify risk factors independently. While traditional modeling approaches might assume independence between risk factors, current suicide research suggests that the development of suicidal intent is a complex, multifactorial process. Thus, it may be beneficial to how suicide risk-factors interact with one another. In this study, we used network analysis to generate visual suicidality risk relationship diagrams. We extract medical concepts from free-text clinical notes and generate cooccurrence-based risk networks for suicidal ideation and suicide attempt. In addition, we generate a network of risk factors for suicidal ideation which evolves into a suicide attempt. Our networks were able to replicate existing risk factor findings and provide additional insight into the degree to which risk factors behave as independent morbidities or as interacting comorbidities with other risk factors. These results highlight potential avenues for risk factor analyses of complex outcomes using network analysis.

Risk factors of suicidal behaviors in a high-risk longitudinal veteran sample: A network analysis

INTRODUCTION

Suicide is a substantial public health burden, particularly among veterans. Risk factors have been delineated for suicide; however, the dynamic interrelations between risk factors have not been fully examined. Such research has the potential to elucidate processes that contribute to suicide risk between individuals with a past suicide attempt (attempters) and those without a past suicide attempt (nonattempters).

METHODS

In the current study, network analysis was used to compare networks between attempters and nonattempters in a high-risk veteran sample (N = 770; M_age  = 32.3 years, SD = 6.8; 326 with a past suicide attempt) who were followed over 1 year. Networks were estimated to examine (1) concurrent relations of suicide risk factors at baseline and (2) predictability of prospective suicidal behavior (SB).

RESULTS

There were no differences in the overall connectivity of attempter and nonattempter networks. Perceived burdensomeness and posttraumatic stress disorder (PTSD) symptoms were most central in the attempters' network, whereas PTSD symptoms and insomnia were most central in the nonattempters' network. The risk factors prospective SB in either network. However, attempters were more likely to engage in SB over the course of the study.

CONCLUSION

These findings highlight the difficulty in predicting who will attempt suicide.

Network analysis of distress, suicidality, and resilience in a treatment seeking sample of first responders

INTRODUCTION

First responders are routinely and regularly exposed to traumatic events that can clinically manifest with a symptom constellation of posttraumatic stress disorder (PTSD), generalized anxiety, depression, and suicidality.

METHODS

We used network analysis to examine baseline data from treatment seeking first responders (n = 308) to examine the interrelatedness of those constructs, including a measure of resilience. We estimated two models: a regularized partial correlation network and a Bayesian Directed Acyclic Graph (DAG).

RESULTS

The models reveal converging evidence highlighting the central role of negative alterations in cognitions and mood PTSD cluster along with affective depression. These nodes did not significantly differ, though they were among the strongest in the partial correlation network and shared the most variance with the other nodes. The DAG results suggested that the negative alterations in cognitions and mood PTSD cluster predicted downstream constructs of affective depression; intrusion, hyperarousal, and avoidance PTSD clusters; and resilience. Only resilience and affective depression exhibited direct effects on suicidality. Both somatic depression and suicidality were endogenous endpoints in the DAG. Resilience exhibited an inverse path to suicide. However, resilience was relatively independent of the other constructs in the models and the DAG suggested that it was a consequence of PTSD related distress.

LIMITATIONS

The data is cross-sectional in nature that should be followed up in longitudinal studies.

CONCLUSION

Findings are discussed in respect to the role of distress and emotional dysregulation as common factors underlying a broad range of internalizing problems.

Toward an integrative model of transdiagnostic risk factors and suicide: A network comparison of psychiatric outpatients

Predictive models using traditional statistical methods have largely failed to describe suicide etiology. Network theory, which conceptualizes factors as mutually interacting, reinforcing elements of a complex outcome, can model relationships between transdiagnostic and neurocognitive vulnerability factors. The present study used a network approach to produce an atheoretical model of psychological factors and their interrelationships within a population of ideators and non-ideators. We developed two network models (i.e., suicidal ideators and psychiatric controls) describing the relationships between a diverse set of risk factors and symptom measures for a population of psychiatric outpatients. We compared networks using three measures of network structure (i.e., network structure invariance, global strength invariance, edge invariance) and described the differences. Network structures for ideators (N = 229) and non-ideators (N = 454) were stable and accurate. In non-ideators, cognitive-affective depression symptoms (Expected Influence [EI]: 2.06), trauma avoidance (EI: 1.08), and negative affect (EI: 0.81) were most influential to the psychological network. In ideators, cognitive-affective depression symptoms (EI: 1.77), intolerance of uncertainty-negative self-referent implications (EI: 1.29), and negative affect (EI: 1.19) were most influential. Invariance testing did not indicate significant differences in overall network structure between ideators and non-ideators (p = .111), but did indicate significant differences in node strength (p = .013). Significant differences in node EI were detected for intolerance of uncertainty-negative self-referent implications, anxiety sensitivity physical concerns, thwarted belongingness, worry, and negative affect. These findings indicated differences in network structures for suicidal psychiatric outpatients and provide crucial directions for future research on therapeutic targets for suicidal thoughts and behaviors.

Coexisting service-related factors preceding suicide: a network analysis

OBJECTIVES

The overall objective was to analyse service-related factors involved in the complex processes that precede suicide in order to identify potential targets for intervention.

DESIGN AND SETTING

Explorative network analysis study of post-suicide root cause analysis data from Swedish primary and secondary healthcare.

PARTICIPANTS

217 suicide cases reported to the Swedish national root cause analysis database between 2012 and 2017.

PRIMARY AND SECONDARY OUTCOME MEASURES

A total of 961 reported incidents were included. Demographic data and frequencies of reported deficiencies were registered. Topology, centrality indices and communities were explored for three networks. All networks have been tested for robustness and accuracy.

RESULTS

Lack of follow-up, evaluations and insufficient documentation issues emerged as central in the network of major themes, as did the contributing factors representing organisational problems, failing procedures and miscommunication. When analysing the subthemes of deficiencies more closely, disrupted treatments and staffing issues emerged as prominent features. The network covering the subthemes of contributing factors also highlighted discontinuity, fragile work structures, inadequate routines, and lack of resources and relevant competence as potential triggers. However, as the correlation stability coefficients for this network were low, the results need further investigation. Four communities were detected covering nodes for follow-up, evaluation, cooperation, and procedures; communication, documentation and organisation; assessments of suicide risk and psychiatric status; and staffing, missed appointments and declined treatment.

CONCLUSION

The results of this study suggest that healthcare providers may improve patient safety in suicide preventive pathways by taking active measures to provide regular follow-ups to patients with elevated suicide risk. In some cases, declined or cancelled appointments could be a warning sign. Tentative results show organisational instability, in terms of work structure, resources and staffing, as a potential target for intervention, although this must be more extensively explored in the future.

Examining unique and prospective relationships among self-injurious thoughts and behaviors and posttraumatic stress disorder: a network analysis in two trauma-exposed samples

BACKGROUND

As self-injurious thoughts and behaviors (SITB) remain a pressing public health concern, research continues to focus on risk factors, such as posttraumatic stress disorder (PTSD). Network analysis provides a novel approach to examining the PTSD-SITB relationship. This study utilized the network approach to elucidate how individual PTSD symptoms may drive and maintain SITB.

METHODS

We estimated cross-sectional networks in two samples of trauma-exposed adults (Sample 1: N = 349 adults; Sample 2: N = 1307 Veterans) to identify PTSD symptoms that may act as bridges to SITB. Additionally, we conducted a cross-lagged panel network in Sample 2 to further clarify the temporal relationship between PTSD symptoms and SITB during a 2-year follow-up. Finally, in both samples, we conducted logistic regressions to examine the utility of PTSD symptoms in prospectively predicting SITB, over a 15-day period (Sample 1) and over a 2-year period (Sample 2), allowing us to examine both short- and long-term prediction.

RESULTS

Two PTSD symptoms (i.e. negative beliefs and risky behaviors) emerged as highly influential on SITB in both cross-sectional networks. In the cross-lagged panel network, distorted blame emerged as highly influential on SITB over time. Finally, risky behaviors, unwanted memories, and psychological distress served as the strongest predictors of SITB across the two samples.

CONCLUSIONS

Overall, our results suggest that treatments targeting negative beliefs and risky behaviors may prevent SITB in community and Veteran populations, whereas treatments targeting distorted blame and unwanted memories may help reduce SITB for individuals with a history of combat trauma.

Suicide Risk and Protective Factors: A Network Approach

OBJECTIVE

Suicide is a complex phenomenon, with numerous factors contributing to an individual's risk of suicide. The aim of the present study was to explore how risk and protective factors for suicide interact with one another in a network sense and to determine which factors were most central to a network of these factors.

METHOD

Using an online survey, cross-sectional data were collected from a sample of 515 individuals who lived in New Zealand, Australia, the United Kingdom, and the United States of America. Participants were recruited through either social media or Prolific Academic. A network of 18 risk and protective factors for suicide was estimated using network analysis. Analyses were preregistered on the Open Science Framework.

RESULTS

Factors that had the highest strength centrality were feeling depressed, feeling hopeless, perceived burdensomeness, self-esteem, and social support. Factors that were directly associated with suicidal ideation included feeling depressed, perceived burdensomeness, feeling hopeless, self-esteem, resilience, access to mental health services and a positive attitude toward these services.

CONCLUSION

This research demonstrates the importance of examining protective factors as well as risk factors when estimating an individual's suicide risk. The results suggest that interventions targeting depression may be particularly beneficial in reducing suicide risk, but further longitudinal research is required.HIGHLIGHTSThe network analyses estimated depression to be the most central risk factor.Depression and perceived burdensomeness were risk factors for suicidal ideation.Self-esteem and resilience were protective against suicidal ideation.

Identifying Central Symptoms and Bridge Pathways Between Autism Spectrum Disorder Traits and Suicidality Within an Active Duty Sample

OBJECTIVE

This study employed network analysis to characterize central autism spectrum disorder (ASD) traits and suicide symptoms within an active duty military sample as well as to identify symptoms that may bridge between ASD traits and suicidality (i.e., suicidal ideation and behaviors).

METHOD

Participants were active duty U.S. military service members (N = 287). Autism spectrum traits, suicidality, depression, and suicide related constructs were assessed online via self-report.

RESULTS

Within the combined ASD trait-suicidality network, suicide rumination, suicide behaviors, and depression had the highest strength centrality. The most central bridge symptoms between ASD and suicidality were thwarted belongingness, social skills deficits, and depressive symptoms.

CONCLUSIONS

Social skills deficits and thwarted belongingness may function as a meaningful bridge between ASD symptoms and suicidality within active duty members. Individuals with ASD symptoms who additionally present with high levels of thwarted belongingness and/or considerable social skills deficits may be at increased risk for suicidality.HIGHLIGHTSWithin an ASD-suicidality network, social skills deficits, low belonging, and depression had the greatest bridge strength.Although low belonging emerged as a bridge symptom, perceived burdensomeness did not.Suicide rumination, suicide behaviors, and depression were the most central symptom in an ASD-suicidality network.Symptoms related to social skills deficits may connect ASD traits and suicidality.

A network analysis of risk factors for suicide in Iraq/Afghanistan-era veterans

Suicidal ideation (SI) is a prevalent issue in the veteran population. A number of factors have been identified as risk factors for suicidal ideation (SI) in veterans, including suicide attempts, depression, posttraumatic stress disorder (PTSD), and drug use. However, clinicians' ability to predict suicide is poor, particularly given the interplay between various factors such as previous suicide attempts. As such, there is a gap in our knowledge of which factors most saliently predict suicide risk and which should be targets for interventions designed to lower SI. Network analysis, a method allowing for an examination of how variables relate within the context of a network of factors, may bridge this gap by simultaneously evaluating the interrelationships between risk factors for suicide in veterans. Current study used network analysis and data from 2268 Iraq/Afghanistan-era military veterans to examine the relationships between suicidal ideation and several factors related to suicide risk, such as past suicide attempts, PTSD symptoms, depression, drug use, trauma exposure. Partial correlation network results showed suicidal ideation to be strongly related to depression, with smaller connections to past suicide attempts and anger. Additionally, past suicide attempts was strongly related to history of childhood trauma and weakly related to problematic drug use and PTSD symptoms. These results offer valuable information for both predicting suicide risk and differentiating targets for interventions lowering suicide risk in veterans.

Affective dynamics among veterans: Associations with distress tolerance and posttraumatic stress symptoms

We tested a dynamic structural equation model (DSEM; Asparouhov, Hamaker, & Muthén, 2018) of positive and negative affect in 254 veterans with approximately 1.5 years of experience sampling data. The analysis provided estimates of several aspects of veteran's emotional experience including "trait" positive and negative affect (i.e., mean levels), inertia (i.e., tendency for emotions to self-perpetuate), innovation variance (conceptualized as lability, reactivity, or exposure to stressors), and cross-lagged associations between positive and negative affect. Veterans with higher trait negative affect had more negative affect inertia and innovation variance. This suggests a pattern whereby the veteran has more negative reactions, and negative emotions, in turn, tend to maintain themselves, contributing to higher trait negative affect. In contrast, veterans with higher trait positive affect exhibited more positive affect innovation variance (e.g., positive reactivity). Although veterans showed some consistency in dynamics across emotions (e.g., positive and negative reactivity were positively correlated), trait positive and negative affect were not significantly associated. Veterans with higher posttraumatic stress symptoms (PTSS) at baseline exhibited higher reactivity to negative events, less positive affect, and more negative affect during the follow-up. Veterans with higher distress tolerance reported not only lower PTSS but also a more adaptive pattern of affective experience characterized by lower inertia and reactivity in negative affect and more positive lagged associations between negative affect and subsequent positive affect. The results demonstrated that distress tolerance and PTSS in veterans were associated with dynamics of positive and negative emotion over time, suggesting specific differences in affect regulation processes. (PsycInfo Database Record (c) 2021 APA, all rights reserved).