Suicidal ideation among National Guard troops deployed to Iraq: the association with postdeployment readjustment problems

Longitudinal associations between exposure to potentially morally injurious events and suicidal ideation among recently discharged veterans - The mediating roles of depression and loneliness

BACKGROUND

Exposure to potentially morally injurious events (PMIEs) during military service is associated with heightened suicidal ideation (SI). However, no longitudinal study has established temporal associations between these variables and examined the possible mediating roles of depression and loneliness in this effect.

METHODS

Participants were 374 active-duty Israeli combatants who participated in a five-year longitudinal study with four measurement points: T1- one year before enlistment, T2- one month before discharge from army service, and then again six months and twelve months following their discharge (T3 and T4, respectively). Data were assessed through semi-structured interviews and validated self-report questionnaires.

RESULTS

Above and beyond pre-enlistment personal characteristics (T1) and combat exposure (T2), PMIEs-'betrayal' (T2) predicted more frequent SI over the past twelve months (T4) through the mediation of depression. Moreover, both PMIEs-'betrayal' and 'self' (T2) predicted more frequent SI over the past twelve months (T4) through the mediation of loneliness.

LIMITATIONS

We used self-report measures to assess PMIEs and SI, which may suffer from various biases.

CONCLUSIONS

Our findings are the first to provide evidence of longitudinal, temporal associations between exposure to PMIEs and SI. Notably, potential interventions might consider addressing the loneliness experienced following exposure to PMIEs during military service, among recently discharged traumatized veterans.

How well can U.S. military veterans' suicidal ideation be predicted from static and change-based indicators of their psychosocial well-being as they adapt to civilian life?

BACKGROUND

Identifying predictors of suicidal ideation (SI) is important to inform suicide prevention efforts, particularly among high-risk populations like military veterans. Although many studies have examined the contribution of psychopathology to veterans' SI, fewer studies have examined whether experiencing good psychosocial well-being with regard to multiple aspects of life can protect veterans from SI or evaluated whether SI risk prediction can be enhanced by considering change in life circumstances along with static factors.

METHODS

The study drew from a longitudinal population-based sample of 7141 U.S. veterans assessed throughout the first three years after leaving military service. Machine learning methods (cross-validated random forests) were applied to examine the predictive utility of static and change-based well-being indicators to veterans' SI, as compared to psychopathology predictors.

RESULTS

Although psychopathology models performed better, the full set of well-being predictors demonstrated acceptable discrimination in predicting new-onset SI and accounted for approximately two-thirds of cases of SI in the top strata (quintile) of predicted risk. Greater engagement in health promoting behavior and social well-being were most important in predicting reduced SI risk, with several change-based predictors of SI identified but stronger associations observed for static as compared to change-based indicator sets as a whole.

CONCLUSIONS

Findings support the value of considering veterans' broader well-being in identifying individuals at risk for suicidal ideation and suggest the possibility that well-being promotion efforts may be useful in reducing suicide risk. Findings also highlight the need for additional attention to change-based predictors to better understand their potential value in identifying individuals at risk for SI.

Situational stress and suicide attempt behavior in Army soldiers and veterans: Insights from the Army Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study

INTRODUCTION

Prevention of suicide-related behaviors is considered a top clinical priority within the Departments of Veterans Affairs and Defense. Despite previous literature attesting to the likely importance of situational stress as a key correlate of acute changes in suicide risk, longitudinal research into associations between situational stress and suicide-related outcomes among military personnel has been relatively limited.

METHODS

The current study examined associations between situational stress, recent suicide attempt, and future suicide attempt using data from 14,508 Army soldiers and recently discharged veterans enrolled in the Army Study to Assess Risk and Resilience in Servicemembers-Longitudinal Studies (STARRS-LS).

RESULTS

Recent situational stress was more common among recently discharged veterans (vs. soldiers), those with a recent suicide attempt (vs. those without), and those with a subsequent suicide attempt (vs. those without). Job loss was more closely associated with suicide attempts among soldiers, whereas financial crisis, police contact, and death, illness, or injury of close others were more closely associated with suicide attempts among recently discharged veterans.

CONCLUSION

Findings further highlight situational stress as a salient risk factor for suicide-related outcomes among military personnel, particularly among recently discharged veterans. Implications for screening and treatment of at-risk military personnel are discussed.

Associations of vulnerability to stressful life events with suicide attempts after active duty among high-risk soldiers: results from the Study to Assess Risk and Resilience in Servicemembers-longitudinal study (STARRS-LS)

BACKGROUND

The transition from military service to civilian life is a high-risk period for suicide attempts (SAs). Although stressful life events (SLEs) faced by transitioning soldiers are thought to be implicated, systematic prospective evidence is lacking.

METHODS

Participants in the Army Study to Assess Risk and Resilience in Servicemembers (STARRS) completed baseline self-report surveys while on active duty in 2011-2014. Two self-report follow-up Longitudinal Surveys (LS1: 2016-2018; LS2: 2018-2019) were subsequently administered to probability subsamples of these baseline respondents. As detailed in a previous report, a SA risk index based on survey, administrative, and geospatial data collected before separation/deactivation identified 15% of the LS respondents who had separated/deactivated as being high-risk for self-reported post-separation/deactivation SAs. The current report presents an investigation of the extent to which self-reported SLEs occurring in the 12 months before each LS survey might have mediated/modified the association between this SA risk index and post-separation/deactivation SAs.

RESULTS

The 15% of respondents identified as high-risk had a significantly elevated prevalence of some post-separation/deactivation SLEs. In addition, the associations of some SLEs with SAs were significantly stronger among predicted high-risk than lower-risk respondents. Demographic rate decomposition showed that 59.5% (s.e. = 10.2) of the overall association between the predicted high-risk index and subsequent SAs was linked to these SLEs.

CONCLUSIONS

It might be possible to prevent a substantial proportion of post-separation/deactivation SAs by providing high-risk soldiers with targeted preventive interventions for exposure/vulnerability to commonly occurring SLEs.

The First Year After Military Service: Predictors of U.S. Veterans' Suicidal Ideation

INTRODUCTION

Little is known about predictors of military veterans' suicidal ideation as they transition from service to civilian life, a potentially high-risk period that represents a critical time for intervention. This study examined factors associated with veterans' suicidal ideation in the first year after military separation.

METHODS

A national sample of U.S. veterans (N=7,383) from The Veterans Metrics Initiative Study reported on their mental health, psychosocial well-being, and demographic/military characteristics in an online survey at 3 and 9 months after separation. Cross-validated random forest models and mean decrease in accuracy values were used to identify key predictors of suicidal ideation. Bivariate ORs were calculated to examine the magnitude and direction of main effects associations between predictors and suicidal ideation. Data were collected in 2016/2017 and analyzed in 2021.

RESULTS

In the first year after separation, 15.1% of veterans reported suicidal ideation. Endorsing depression symptoms and, to a lesser extent, identifying oneself as experiencing depression, were most predictive of suicidal ideation. Other psychopathology predictors included higher anxiety and posttraumatic stress disorder symptoms. Psychosocial well-being predictors included higher health satisfaction and functioning, community satisfaction and functioning, and psychological resilience. Logistic models performed similarly to random forest models, suggesting that relationships between predictors and suicidal ideation were better represented as main effects than interactions.

CONCLUSIONS

Results highlight the potential value of bolstering key aspects of military veterans' mental health and psychosocial well-being to reduce their risk for suicidal ideation in the first year after separation. Findings can inform interventions aimed at helping veterans acclimate to civilian life.

Partnered implementation of the veteran sponsorship initiative: protocol for a randomized hybrid type 2 effectiveness-implementation trial

BACKGROUND

The USA is undergoing a suicide epidemic for its youngest Veterans (18-to-34-years-old) as their suicide rate has almost doubled since 2001. Veterans are at the highest risk during their first-year post-discharge, thus creating a "deadly gap." In response, the nation has developed strategies that emphasize a preventive, universal, and public health approach and embrace the value of community interventions. The three-step theory of suicide suggests that community interventions that reduce reintegration difficulties and promote connectedness for Veterans as they transition to civilian life have the greatest likelihood of reducing suicide. Recent research shows that the effectiveness of community interventions can be enhanced when augmented by volunteer and certified sponsors (1-on-1) who actively engage with Veterans, as part of the Veteran Sponsorship Initiative (VSI).

METHOD/DESIGN

The purpose of this randomized hybrid type 2 effectiveness-implementation trial is to evaluate the implementation of the VSI in six cities in Texas in collaboration with the US Departments of Defense, Labor and Veterans Affairs, Texas government, and local stakeholders. Texas is an optimal location for this large-scale implementation as it has the second largest population of these young Veterans and is home to the largest US military installation, Fort Hood. The first aim is to determine the effectiveness of the VSI, as evidenced by measures of reintegration difficulties, health/psychological distress, VA healthcare utilization, connectedness, and suicidal risk. The second aim is to determine the feasibility and potential utility of a stakeholder-engaged plan for implementing the VSI in Texas with the intent of future expansion in more states. The evaluators will use a stepped wedge design with a sequential roll-out to participating cities over time. Participants (n=630) will be enrolled on military installations six months prior to discharge. Implementation efforts will draw upon a bundled implementation strategy that includes strategies such as ongoing training, implementation facilitation, and audit and feedback. Formative and summative evaluations will be guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework and will include interviews with participants and periodic reflections with key stakeholders to longitudinally identify barriers and facilitators to implementation.

DISCUSSION

This evaluation will have important implications for the national implementation of community interventions that address the epidemic of Veteran suicide. Aligned with the Evidence Act, it is the first large-scale implementation of an evidence-based practice that conducts a thorough assessment of TSMVs during the "deadly gap."

TRIAL REGISTRATION

ClinicalTrials.gov ID number: NCT05224440 . Registered on 04 February 2022.

Reculturation: A new perspective on military-civilian transition stress

Various forms of assistance are offered to help US Veterans achieve success in their post-military lives in recognition of their service. Despite the many successes, a significant number of Veterans continue to remain at risk for negative mental health outcomes, including suicidality and low levels of life satisfaction. These findings may be due to challenges arising from cultural identity dissonance. Problematic strategies used by Veterans to reduce this dissonance can result in a lack of belongingness, a key component in Joiner's Interpersonal Theory of Suicide. The authors suggest that research on the immigrant experience of acculturation may provide a new perspective to better understand issues of identity and sense of belonging in Veterans. Given that most Veterans return to the culture in which they grew up, the authors offer the term "reculturation." The authors propose clinical psychology focus on exploring the reculturation process of Veterans to support program engagement and suicide prevention.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Building a Life Worth Living During a Pandemic and Beyond: Adaptations of Comprehensive DBT to COVID-19

Our team at the Jefferson Center City Clinic for Behavioral Medicine has recently been challenged to find a synthesis between the need to adapt to circumstances associated with the COVID-19 pandemic, while at the same time retaining the spirit and essential components of comprehensive DBT. This fine balance between unwavering centeredness and compassionate flexibility is central to DBT (Linehan, 1993), and has proven essential during these times of uncertainty. This short article highlights challenges and innovations faced by our DBT Team, Skills Group, individual DBT sessions, phone coaching, and also our community at large, as we strive to help our patients and team members build a life worth living during and following a pandemic.

Antecedents of Suicide Among Active Military, Veteran, and Nonmilitary Residents of the Commonwealth of Virginia: The Role of Intimate Partner Problems

Intimate partner problems increase suicide risk, particularly among active service members and veterans. Age, marital status and military service status may modify the role of intimate partner problems in suicide. Methods: Participants included 6255 men who died by suicide at 18 years of age and older and who actively, previously, or never served in the military. Reports of intimate partner problems prior to suicide were documented by the Virginia Department of Health. Results: Unmarried active service members, above middle age, were more likely than veterans and individuals without prior military service to have associated reports of intimate partner problems. Conclusion: Life stages and relationship context may influence the role of intimate partner problems as a risk factor for suicide.

The deadly gap: Understanding suicide among veterans transitioning out of the military

In the period following separation from the military, service members face the challenge of transitioning to a post-military civilian life. Some evidence suggests these transitioning Veterans are at higher risk for suicide compared with both the broader Veteran population and the United States public, yet they often do not receive adequate support and resources. In this review, we use the Three-Step Theory of suicide to outline characteristics of transitioning Veterans and the transition process that may affect suicide risk. We then highlight relevant services available to this specific subgroup of Veterans and make recommendations that address barriers to care. Cumulatively, this literature suggests transitioning Veterans fall within a "deadly gap" between the end of their military service and transition into civilian life. This "deadly gap" consists of limited psychiatric services and increased suicide risk factors which together may explain the increase in suicide during this transition period.

Gender Differences in Lifetime Prevalence and Onset Timing of Suicidal Ideation and Suicide Attempt Among Post-9/11 Veterans and Nonveterans

BACKGROUND

Rising US suicide rates are particularly notable among military veterans, especially women. It is unknown whether these differences extend to suicidal ideation (SI) and suicide attempts (SA), which are major predictors of suicide. Literature comparing SI and SA prevalence and timing of onset between veterans and nonveterans is limited.

OBJECTIVE

The objective of this study was to estimate and compare SI and SA prevalence and onset timing relative to age and military service between veterans and nonveterans, by gender.

RESEARCH DESIGN

Gender-stratified analysis of cross-sectional data from the Comparative Health Assessment Interview Study. Generalized estimating equations logistic regression was used to compare prevalence and onset of SI and SA between time periods and across groups, controlling for years at risk in each time period.

SUBJECTS

National sample of 15,082 post-9/11 veterans (36.7% women) and 4638 nonveterans (30.5% women).

MEASURES

Columbia-Suicide Severity Rating Scale adapted to assess SI and SA relative to age (less than 18 y, 18 y and above) and military service (pre-, during, and post-military).

RESULTS

Veteran men experienced significantly higher odds of lifetime SI compared with nonveteran men (odds ratio=1.13), whereas veteran women experienced significantly higher odds of lifetime SA compared with nonveteran women (odds ratio=1.35). SI and SA onset varied considerably for veterans and nonveterans and by gender within veteran groups.

CONCLUSIONS

Veterans and nonveterans appear to differ in periods of risk for SI and SA. Furthermore, gender differences in SI and SA onset for veterans highlight the need for gender-informed veteran suicide prevention strategies that target periods of highest risk.

Expanded Roles and Recommendations for Stakeholders to Successfully Reintegrate Modern Warriors and Mitigate Suicide Risk

This article draws upon the legends of warriors from ancient Greece and other traditions to illuminate the journey of Modern Warriors (MWs) who have served in the United States military over the last century. It then turns to stakeholders that can assist current MWs in their reintegration to civilian life and mitigate suicide risk. Until this point, without an existing and coordinated local, federal, non-profit, and private system, rates of suicide for post-9/11 MWs after leaving the military have greatly increased, especially for young and women MWs. This is due in part to the military satisfying many of MWs’ needs by providing units, leaders, and a mission during the Departure and Initiation stages of the MW journey. However, as MWs exit the military and face the difficult task of reintegration, the absence of units, leaders, and mission leads to deteriorating psychological health and increasing suicide risk. Written primarily by post-9/11 MWs, this article proposes recommendations for stakeholders to better reintegrate MWs and mitigate suicide risk. The authors strive to develop a system that satisfies MWs’ reintegration needs and enables MWs to be well positioned to continue their next ‘mission’ – to serve and improve society.

Family Readiness Groups: Helping deployed Army National Guard soldiers and their families

Many have espoused the benefits of Family Readiness Groups (FRGs) for families of deployed soldiers. These include fostering family well-being (main effect) and buffering the family against the negative effects of stressful life events (moderating effect). Yet, few published studies have tested these hypothesized relationships. Survey responses gathered from returning deployed Army National Guard soldiers (N = 4,568 soldiers in 50 company-sized units) gave the opportunity to test hypothesized benefits of FRGs, both main and buffering effects. Half the sample of soldiers reported their families as having used FRGs. Two-thirds of the soldiers reported FRGs as being helpful to their families. On the whole, results supported hypotheses: More effective coping among family members was associated with FRG use (main effect), and FRGs appeared most beneficial to spouses who experienced more stressful events (buffering effect). FRG use and its associations with helpfulness to family and with family coping suggest FRGs are important resources for families of deployed soldiers, in particular, for families of reservists. Future directions for research and practice are proposed.

How Distress Tolerance Mediates the Relationship Between Posttraumatic Stress Disorder and the Interpersonal Theory of Suicide Constructs in a U.S. Military Sample

OBJECTIVES

Despite the general suicide rate within the military being comparable to the general population when comparing peers, there are certain branches of the military that have elevated risk. Specifically, the U.S. National Guard has suicide rates that are constantly higher than other military branches and civilian peers. The National Guard are a unique military population in which they frequently transition between military and civilian life. With these unique experiences and heightened risk, military suicide prevention efforts may benefit from further research within this population. Posttraumatic stress disorder (PTSD) is another concern amongst military personnel and has been linked to suicidal behavior.

METHODS

The current study examined the indirect effects that distress tolerance, a protective factor against suicide, has on the relationship between PTSD and constructs within a well-validated theory for suicide (the Interpersonal-Psychological Theory for suicidal behaviors) in a sample of U.S. Army National Guard personnel.

RESULTS

Results indicated that distress tolerance had a significant indirect effect on the relationship between PTSD and thwarted belongingness, perceived burdensomeness, and capability for suicide.

CONCLUSIONS

These findings are consistent with previous literature examining the relationship between distress tolerance and our outcome variables. These results could have important clinical implications, mainly that intervention strategies targeting distress tolerance could have significant impacts on suicide-relate thoughts.

Social and Psychological Risk and Protective Factors for Veteran Well-Being: The Role of Veteran Identity and Its Implications for Intervention

Social psychological theory hypothesizes that one’s identity, self-definitions, and meanings used for a particular social role fosters individual purpose in life and affects behavior in specific social situations. As such, it can be protective against the onset of psychological disorders. We examined this hypothesis with data collected from 1,730 military veterans recruited to study the health effects of warzone deployments. The sample was primarily male, older, and White. Our key independent variable was a Likert scale rating the prominence of a respondent’s veteran identity: how important it is to the person. Outcome variables included posttraumatic stress disorder (PTSD), suicide ideation, depression, alcohol misuse, and use of VA services. Bivariate analysis suggested that veterans with a prominent veteran identity are older, noncollege graduates, have less income, and had their first deployment to Vietnam. In multivariate analyses, study participants with a prominent veteran identity were less likely to exhibit suicide ideation, but more likely to misuse alcohol and use VA services. We found no differences for PTSD, self-rated health, or depression by veteran identity. Veterans who scored higher on the veteran identity scale appeared to be protected from suicidal thoughts, although they had an elevated risk for alcohol misuse.

Suicide attempts among activated soldiers in the U.S. Army reserve components

BACKGROUND

Although the majority of active duty U.S. Army soldiers are full-time personnel in the Active Component (AC), a substantial minority of soldiers on active duty are in the Reserve Components (RCs). These "citizen-soldiers" (Army National Guard and Army Reserve) represent a force available for rapid activation in times of national need. RC soldiers experience many of the same stressors as AC soldiers as well as stressors that are unique to their intermittent service. Despite the important role of RC soldiers, the vast majority of military mental health research focuses on AC soldiers. One important goal of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is to address this gap. Here we examine predictors of suicide attempts among activated RC soldiers.

METHODS

This longitudinal, retrospective cohort study used individual-level person-month records from Army and Department of Defense administrative data systems to examine socio-demographic, service-related, and mental health predictors of medically documented suicide attempts among activated RC soldiers during 2004-2009. Data from all 1103 activated RC suicide attempters and an equal-probability sample of 69,867 control person-months were analyzed using a discrete-time survival framework.

RESULTS

Enlisted soldiers comprised 84.3% of activated RC soldiers and accounted for 95.7% of all activated RC suicide attempts (overall rate = 108/100,000 person-years, more than four times the rate among officers). Multivariable predictors of enlisted RC suicide attempts included being female, entering Army service at age ≥ 25, current age < 30, non-Hispanic white, less than high school education, currently married, having 1-2 years of service, being previously deployed (vs. currently deployed), and history of mental health diagnosis (particularly when documented in the previous month). Predictors among RC officers (overall rate = 26/100,000 person-years) included being female and receiving a mental health diagnosis in the previous month. Discrete-time hazard models showed suicide attempt risk among enlisted soldiers was inversely associated with time in service.

CONCLUSIONS

Risk factors for suicide attempt in the RCs were similar to those previously observed in the AC, highlighting the importance of research and prevention focused on RC enlisted soldiers in the early phases of Army service and those with a recent mental health diagnosis.

Risk factors and timing of suicide attempts among US Army Reserve Component soldiers during deployment to the Afghanistan and Iraq wars: Results from the Army Study to Assess Risk and Resilience in Servicemembers

Objective: During the wars in Afghanistan and Iraq, suicidal behaviors increased among U.S. Army soldiers. Although Reserve Component (RC) soldiers (National Guard and Army Reserve) comprise approximately one third of those deployed in support of the wars, few studies have examined suicidal behaviors among these "citizen-soldiers". The objective of this study is to examine suicide attempt risk factors and timing among RC enlisted soldiers. Methods: This longitudinal, retrospective cohort study used individual-level person-month records from Army and Department of Defense administrative data systems to examine socio-demographic, service-related, and mental health predictors of medically documented suicide attempts among enlisted RC soldiers during deployment from 2004-2009. Data were analyzed using discrete-time survival models. Results: A total of 230 enlisted RC soldiers attempted suicide. Overall, the in-theater suicide attempt rate among RC soldiers was 81/100,000 person-years. Risk was highest in the fifth month of deployment (13.8 per 100,000 person-months). Suicide attempts were more likely among soldiers who were women (adjusted odds ratio, aOR = 2.5 [95% CI: 1.8-3.5]), less than high school educated (aOR = 1.8 [95% CI: 1.3-2.5]), in their first 2 years of service (aOR = 2.0 [95% CI: 1.2-3.4]), were currently married (aOR = 2.0 [95% CI: 1.5-2.7]), and had received a mental health diagnosis in the previous month (aOR = 24.7 [95% CI: 17.4-35.0]). Conclusions: Being female, early in service and currently married are associated with increased odds of suicide attempt in RC soldiers. Risk of suicide attempt was greatest at mid deployment. These predictors and the timing of suicide attempt for RC soldiers in-theater are largely consistent with those of deployed Active Component (Regular) soldiers. Results also reinforce and replicate the findings among Active Component soldiers related to the importance of a recent mental health diagnosis and the mid-deployment as a period of enhanced risk.

Characteristics of U.S. Army Reserve and National Guard couples who use family readiness programs

Use of family readiness programs (FRPs) by military families is not well understood. This work uses the Gelberg-Andersen Behavioral Model to identify characteristics of Reserve and National Guard (R/NG) couples who access FRPs. Data are from Operation: SAFETY, a study of R/NG soldiers and partners. Logistic regression models examined odds of accessing FRPs based on predisposing, enabling, and need factors. Greater length of military service, greater presence of non-military social ties, and civilian partner reports of adequate support during deployment were associated with higher likelihood of accessing FRPs. Results provide information on FRP utilization and may help inform outreach efforts.

Nonfatal Suicidal Behaviors in the Administrative Records of Activated U.S. Army National Guard and Army Reserve Soldiers, 2004-2009

OBJECTIVE

The U.S. Army suicide rate increased sharply during the wars in Iraq and Afghanistan. There is limited information about medically documented, nonfatal suicidal behaviors among soldiers in the Army's Reserve Component (RC), which is composed of the Army National Guard and Army Reserve. Here we examine trends and sociodemographic correlates of suicide attempts, suspicious injuries, and suicide ideation among activated RC soldiers.

METHODS

Data come from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) Historical Administrative Data Study (HADS), which integrates administrative records for all soldiers on active duty for the years 2004 through 2009 (n = 1.66 million).

RESULTS

We identified 2,937 unique RC soldiers on active duty with a nonfatal suicidal event documented at some point during the HADS study period. There were increases in the annual incidence rates of suicide attempts (71 to 204/100,000 person-years) and suicide ideation (326 to 425/100,000 person-years). Incidence rates for suspicious injuries also generally increased but were more variable. Using hierarchical classification rules, we identified the first instance of each soldier's most severe behavior (suicide attempt versus suspicious injury versus suicide ideation). For each of those suicide- or injury-related outcomes, we found increased risk among those who were female, younger, non-Hispanic White, less educated, never married, and lower-ranking enlisted. These sociodemographic associations significantly differed across outcomes, although the patterns were similar.

CONCLUSION

Results provide a broad overview of nonfatal suicidal trends in the RC during the period 2004 through 2009. They also demonstrate that integration of multiple administrative data systems enriches analysis of the predictors of such events.

Risk factors of suicidal ideation in a population of UK military veterans seeking support for mental health difficulties

Background

Little has been reported regarding the risk factors of suicidal ideation in individuals once they have left the military in the UK. The aim of this paper was to explore the risk factors associated with suicidal ideation in a sample of treatment-seeking veterans.

Methods

Using a cross-sectional design, participants included veterans (n=144) seeking treatment from a national mental health charity in the UK. Individuals completed questionnaires regarding their military experiences, pre-enlistment factors and health. Data were then linked to risk assessments extracted from clinical records.

Results

After controlling for relevant variables, suicidal ideation was significantly higher in veterans who were unemployed (OR 8.01; 95% CI 1.79 to 35.80), were early service leavers (OR 8.46; 95% CI 2.21 to 32.35) and those with a history of childhood adversity (OR 6.92; 95% CI 2.10 to 22.82). In addition, taking longer than 5 years to seek help was associated with a reduced risk of suicidal ideation (OR 0.10; 95% CI 0.06 to 0.87). There was no association between health outcomes and suicidal ideation.

Conclusions

Risk factors associated with suicidal ideation in this sample of veterans included: being unemployed, an early service leaver, taking less than 5 years to seek help and experiencing preservice adversity.

Distinguishing Levels of Suicide Risk in Depressed Male Veterans: The Role of Internalizing and Externalizing Psychopathology as Measured by the MMPI-2-RF

Suicide occurs at high rates among veterans, underscoring a need for improved identification of veterans at risk of engaging in suicidal behavior. Considering dimensions of psychopathology in the context of an ideation-to-action framework, the present study examined the utility of the Minnesota Multiphasic Personality Inventory–2–Restructured Form in distinguishing depressed, psychiatrically hospitalized male veterans ( N = 430) at varying levels of suicide risk. Analysis of variance and hierarchical logistic regression analyses indicated that internalizing scales differentiated depressed ideators ( n = 147) and depressed controls ( n = 143); and in line with expectations, both broad and narrowly focused externalizing scales provided incremental validity in distinguishing depressed attempters ( n = 140) from depressed ideators. Interactions between Suicidal/Death Ideation and externalizing scale scores were found to differentiate only depressed ideators from depressed controls. Clinical implications in the areas of suicide risk assessment and therapeutic interventions with suicidal veterans are discussed.

Homecoming of Citizen Soldiers: Postdeployment Problems and Service Use Among Army National Guard Soldiers

The present study described the types and amount of problems and services sought among returned deployed Army National Guard soldiers (4568 soldiers in 50 units). The study responds to gaps in the research literature to better understand community intervention needs of reservists. About half (48%) of the soldiers reported one or two problems, mostly those of psychological well-being, such as feelings of anger and frustration, upsetting memories, and troubled sleep (34% of the study sample), followed by problems of social support (18%), alcohol use (17%), feelings of isolation including suicidal thoughts (13%), and financial difficulties (11%). Having engaged in direct combat and having wounded or killed someone showed positive relationships with reported problems. One-third (35%) of soldiers who reported having used services went to one service and, generally, soldiers went to services related to their expressed problems. Variance in self-reported problems explained by service use was low, suggesting unsought postdeployment services.

Sex Differences in Suicide-Related Symptoms in a Large Military Sample

Little research has focused on suicide-related symptoms in female servicemembers, despite high rates of suicidal behaviors. This study examined sex differences in suicide-related risk factors in 3,374 U.S. Army Recruiters (91.9% male). Female servicemembers had a greater number of past major depressive and suicidal ideation episodes than males; there were no differences in suicide attempt histories or mental health visits. Females reported significantly fewer symptoms of current suicidal ideation, perceived burdensomeness, and acquired capability. No significant sex differences emerged for thwarted belongingness, insomnia, or agitation. Our findings provide evidence for sex differences in rates of suicide-related symptoms among military personnel.

Coincident alcohol dependence and depression increases risk of suicidal ideation among Army National Guard soldiers

PURPOSE

Suicide rates among military service members have risen dramatically, while drivers remain poorly understood. We examined the relationship between coincident alcohol dependence and depression in shaping risk of suicidal ideation among National Guard forces.

METHODS

We performed a longitudinal analysis using a randomly selected, population-based sample of Ohio Army National Guard soldiers. Telephone-based surveys of 1582 soldiers who participated in both wave 1 (2008-2009) and wave 2 (2009-2010) were analyzed.

RESULTS

Odds ratios (ORs) for suicidal ideation among those with versus without alcohol dependence were similar among nondepressed (OR = 3.85 [95% confidence intervals (CIs) = 1.18-12.52]) and depressed individuals (OR = 3.13 [95% CI = 0.88-11.14]); multiplicative interaction was not observed. In contrast, the risk differences (RDs) among those with versus without alcohol dependence diverged for those without depression (RD = 0.04 [95% CI = 0.02-0.07]) compared with those with depression (RD = 0.11 [95% CI = 0.06-0.18]); strong evidence of additive interaction was observed.

CONCLUSIONS

We found that alcohol dependence and depression interact statistically in shaping risk for incident suicidal ideation among Army National Guard service members. A high-risk prevention approach including population-based screening for suicidality among patients with alcohol dependence, depression, and particularly those with both conditions is warranted in military populations.

MORBID THOUGHTS AND SUICIDAL IDEATION IN IRAQ WAR VETERANS: THE ROLE OF DIRECT AND INDIRECT KILLING IN COMBAT

BACKGROUND

Although research has identified numerous risk factors for military suicide, the contribution of combat exposure to suicide risk has not been clearly established. Previous studies finding no association of suicidality with combat exposure have employed overgeneral measures of exposure, which do not differentiate among the varieties of combat experiences. This study disaggregated the forms of combat exposure to assess the contribution of combat-related killing to morbid thoughts and suicidal ideation (MTSI) in National Guard troops deployed to Iraq.

METHODS

We conducted parallel analyses of two related samples: a cross-sectional sample (n = 1,665) having postdeployment interview data only and a longitudinal subsample (n = 922) having pre- and postdeployment data. We used multiple logistic regression to examine the role of killing-related exposures, after controlling for general combat and other suicide risks, and examined interactions between killing and other suicide vulnerability factors.

RESULTS

Killing-related exposure approximately doubled the risk of MTSI in the cross-sectional multivariate model (Adjusted Odds Ratio [AOR] = 1.87; CI = 1.26-2.78) and the longitudinal model (AOR = 2.02; CI = 1.06-3.85), which also controlled for predeployment risks. Killing exposures further increased the MTSI risk associated with other suicide vulnerability factors, including depression (AOR = 14.89 for depression and killing vs. AOR = 9.92 for depression alone), alcohol dependence (AOR = 5.63 for alcohol and killing vs. 1.91 for alcohol alone), and readjustment stress (AOR = 4.90 for stress and killing vs. 1.48 for stress alone). General combat exposure had no comparable effects.

CONCLUSIONS

The findings underscore a need for assessment and treatment protocols that address the psychological effects of killing-related and other potentially "morally injurious" experiences among combat soldiers.

Improving Treatment Engagement for Returning Operation Enduring Freedom and Operation Iraqi Freedom Veterans With Posttraumatic Stress Disorder, Depression, and Suicidal Ideation

Posttraumatic stress disorder (PTSD) is associated with increased risk of suicidal ideation among veterans of Operation Enduring Freedom and Operation Iraqi Freedom. This report examined the effectiveness of a brief phone-based cognitive-behavioral intervention on treatment seeking among suicidal and nonsuicidal Operation Enduring Freedom and Operation Iraqi Freedom veterans who screened positive for PTSD. Participants were randomized to the intervention or control conditions. We found that suicidal participants, regardless of condition, were twice as likely to attend treatment as nonsuicidal participants. Participants assigned to the control condition who did not indicate suicidality at baseline were less likely to attend treatment at both the 1- and 6-month follow-up interviews. Qualitative findings of the suicidal participants indicated PTSD and depressive symptoms, low social support, and infrequent positive coping mechanisms. Our finding indicates the effectiveness of an intervention to motivate veterans with PTSD to initiate and remain in treatment. The intervention might be particularly useful prior to experiencing a psychological crisis.

Does Reintegration Stress Contribute to Suicidal Ideation Among Returning Veterans Seeking PTSD Treatment?

Although posttraumatic stress disorder (PTSD) and other psychiatric symptoms are well-established risk factors for suicidal ideation among returning veterans, less attention has been paid to whether the stress of reintegrating into civilian society contributes to suicidal ideation. Utilizing a sample of 232 returning veterans (95% male, mean age = 33.63 years) seeking PTSD treatment, this study tested whether reintegration difficulties contribute to suicidal ideation over and above the influence of PTSD symptoms, depression symptoms, and potential substance misuse. Logistic regressions indicated that reintegration stress had a unique effect on suicidal ideation over and above PTSD and depression symptoms. Reintegration stress interacted with substance misuse to predict suicidal ideation, such that the effect of reintegration stress on suicidal ideation was much larger for those with potential substance misuse. Exploratory analyses also examined which types of reintegration difficulties were associated with suicidal ideation, and found that difficulty maintaining military friendships, difficulty getting along with relatives, difficulty feeling like you belong in civilian society, and difficulty finding meaning/purpose in life were all significantly associated with suicidal ideation, beyond the effects of psychiatric symptoms and potential substance misuse. Findings highlight the importance of addressing reintegration stress for the prevention of suicide among returning veterans. Implications for treatment are discussed.

Prevalence and correlates of suicidal ideation and suicide attempts among veterans in primary care referred for a mental health evaluation

BACKGROUND

The Veterans Health Administration has made concerted efforts to increase mental health services offered in primary care. However, few studies have evaluated correlates of suicidal ideation and suicide attempt in veterans in primary care-mental health integration (PCMHI). The purpose of the present study is to examine associations between suicidal ideation and suicide attempts as dependent variables and demographic and clinical factors as the independent variables.

METHODS

Veterans (n=3004) referred from primary care to PCMHI were contacted for further assessment, which included past-year severity of suicidal thoughts (none, low, high) and attempts using the Paykel Suicide Scale, mental health disorders, and illicit drug use. Multinomial logistic regression models were used to identify correlates of suicidal ideation and suicide attempts.

RESULTS

Thoughts of taking one's life was endorsed by 24% of participants and suicide attempts were reported in 2%. In adjusted models, depression, psychosis, mania, PTSD and generalized anxiety disorder were associated with high severity suicidal ideation, but not suicide attempt. Illicit drug use was not associated with suicidal ideation, but was the only variable associated with suicide attempt.

LIMITATIONS

The study was cross-sectional, focused on one clinical setting, and the suicide attempt analyses had limited power.

CONCLUSIONS

PCMHI is a critical setting to assess suicidal ideation and suicide attempt and researchers and clinicians should be aware that the differential correlates of these suicide-related factors. Future research is needed to identify prospective risk factors and assess the utility of follow-up care in preventing suicide.

Military Veterans' Experiences with Suicidal Ideation: Implications for Intervention and Prevention

We sought to understand Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans' experiences with suicidal ideation. Semi-structured interviews with 34 OEF/OIF veterans addressed circumstances leading up to disclosure of suicidal ideation during brief clinical assessments. We used an iterative, inductive and deductive thematic analysis approach. Results revealed three pervasive, persistent domains that reinforce the uniqueness of veteran suicidal thoughts: military culture, difficult deployment experiences, and postdeployment adjustment challenges. Within postdeployment, we identified four themes that serve as intervention targets: adjusting to civilian culture, changes to sense of self, feeling overwhelmed by stressors, and lacking life purpose or meaning.

Mental health among reserve component military service members and veterans

Since 2001, the US military has increasingly relied on National Guard and reserve component forces to meet operational demands. Differences in preparation and military engagement experiences between active component and reserve component forces have long suggested that the psychiatric consequences of military engagement differ by component. We conducted a systematic review of prevalence and new onset of psychiatric disorders among reserve component forces and a meta-analysis of prevalence estimates comparing reserve component and active component forces, and we documented stage-sequential drivers of psychiatric burden among reserve component forces. We identified 27 reports from 19 unique samples published between 1985 and 2012: 9 studies reporting on the reserve component alone and 10 reporting on both the reserve component and the active component. The pooled prevalence for alcohol use disorders of 14.5% (95% confidence interval: 12.7, 15.2) among the reserve component was higher than that of 11.7% (95% confidence interval: 10.9, 12.6) among the active component, while there were no component differences for depression or post-traumatic stress disorder. We observed substantial heterogeneity in prevalence estimates reported by the reserve component. Published studies suggest that stage-sequential risk factors throughout the deployment cycle predicted alcohol use disorders, post-traumatic stress disorder and, to a lesser degree, depression. Improved and more standardized documentation of the mental health burden, as well as study of explanatory factors within a life-course framework, is necessary to inform mitigating strategies and to reduce psychiatric burden among reserve component forces.

Suicidal Ideation among Florida National Guard Members: Combat Deployment and Non-Deployment Risk and Protective Factors

This study examined relationships among risk/protective factors and suicidal ideation (SI) in deployed and non-deployed National Guard members, particularly examining for possible differential effects of deployment on SI. A total of 3,098 Florida National Guard members completed an anonymous online survey that assessed variables associated with SI including demographics, current psychiatric diagnoses, and pre-, during, and post-deployment experiences. Those deployed had significantly higher rates of SI (5.5%) than those not deployed (3.0%; p < .001). In multivariate analyses, among those not deployed, SI was significantly associated with major depressive disorder (p < .001), posttraumatic stress disorder (PTSD) (p < .001), prior psychological trauma (p < .01), and heavy/hazardous alcohol consumption (p < .05). In contrast, in the deployed, only PTSD (p < .001) and deployment-related mild traumatic brain injury (p < .05) were independently associated with SI. Risk and protective factors differed by deployment status in National Guard members suggesting the possible need for cohort-specific treatment targets to minimize SI.

Mixed methods study examining work reintegration experiences from perspectives of Veterans with mental health disorders

Recent findings have demonstrated that reintegration for Veterans is often challenging. One difficult aspect of reintegration—transitioning into the civilian workplace—has not been fully explored in the literature. To address this gap and examine work reintegration, this mixed methods study examined the perspectives of Veterans with mental health disorders receiving Department of Veterans Affairs healthcare. Forty Veterans rated factors that affect work success; participants also provided narratives on their most and least successful work experiences. We used t-tests and qualitative analysis to compare participants who did and did not serve in combat. Several themes relevant to work reintegration emerged in the narratives, particularly for Veterans who served in combat. An array of work difficulties were reported in the months following military discharge. In addition, Veterans who served in combat reported significantly more work barriers than Veterans who did not serve in combat, particularly health-related barriers. In conclusion, Veterans with mental health disorders who served in combat experienced more work reintegration difficulty than their counterparts who did not serve in combat. The role of being a Veteran affected how combat Veterans formed their self-concept, which also shaped their work success and community reintegration, especially during the early transition period.

Primary care clinician responses to positive suicidal ideation risk assessments in veterans of Iraq and Afghanistan

OBJECTIVE

To examine primary care clinician actions following positive suicide risk assessments administered to Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans.

METHODS

We identified OEF/OIF veterans with positive templated suicide risk assessments administered in primary care settings of three Veterans Affairs (VA) Medical Centers. National VA datasets and manual record review were used to identify and code clinician discussions and actions following positive assessments. Bivariate analyses were used to examine relationships between patient characteristics and discussions of firearms access and alcohol/drug use.

RESULTS

Primary care clinicians documented awareness of suicide risk assessment results for 157 of 199 (79%) patients with positive assessments. Most patients were assessed for mental health conditions and referred for mental health follow-up. Clinicians documented discussions about firearms access for only 15% of patients. Among patients whose clinicians assessed for substance abuse, 34% received recommendations to reduce alcohol or drug use. Depression diagnoses and suicidal ideation/behavior severity were significantly associated with firearms access discussions, while patient sex, military service branch, and substance abuse diagnoses were significantly associated with recommendations to reduce substance use.

CONCLUSION

Greater efforts are needed to understand barriers to clinicians' assessing, documenting and counseling once suicidal ideation is detected, and to develop training programs and systems changes to address these barriers.

Roles of physical and mental health in suicidal ideation in Canadian Armed Forces Regular Force veterans

OBJECTIVES

Suicide in recent veterans is an international concern. An association between mental disorders and suicide has been established, but less information is available about an association between physical health problems and suicide among veterans. This study extends this area of inquiry by examining the relationship of both physical and mental health problems with suicidal ideation in a representative national sample of Canadian veterans.

METHODS

Subjects were a stratified random sample of 2,658 veterans who had been released from the Canadian Armed Forces Regular Force during 1998-2007 and had participated in the 2010 Survey on Transition to Civilian Life. Associations between physical and mental health and past-year suicidal ideation were explored in multivariable regression models using three measures of physical and mental health.

RESULTS

The prevalence of suicidal ideation was 5.8% (95% confidence interval [CI]: 5.0%-6.8%). After adjustment for covariates, ideation was associated with gastrointestinal disorders (adjusted odds ratio [AOR] 1.66, CI: 1.03-2.65), depression or anxiety (AOR 5.06, CI: 2.97-8.62) and mood disorders (AOR 2.91, CI: 1.67-5.07); number of physical (AOR 1.22, CI: 1.05-1.42) and mental conditions (AOR 2.32, CI: 2.01-2.68); and SF-12 Health Survey physical health (AOR 0.98, CI: 0.96-0.99 for each 1 point increase) and mental health (AOR 0.88, CI: 0.87-0.89).

CONCLUSIONS

Physical health was independently associated with suicidal ideation after adjustment for mental health status and socio-demographic characteristics. The findings underscore the importance of considering physical health in population-based suicide prevention efforts and in mitigating suicide risk in individual veterans.

Prevalence and correlates of suicidal ideation among Operation Enduring Freedom and Operation Iraqi Freedom veterans

BACKGROUND

We sought to determine the prevalence and correlates of suicidal ideation (SI) among Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans following the Department of Veterans Affairs' (VA) 2007 implementation of required brief SI assessments for veterans who screen positive for depression and post-traumatic stress disorder.

METHODS

We retrospectively identified OEF/OIF veterans screened for depression using the Patient Health Questionnaire (PHQ-2) between April 2008 and September 2009 at three geographically-distinct VA Medical Centers' primary care or mental health clinics. Veteran responses to a two-item risk assessment tool (VA Pocket Card) or PHQ-9 9th item, administered following a positive depression screen (PHQ-2≥3), were determined using manual chart review. Generalized estimating equations were used to calculate adjusted odds ratios for demographic and clinical correlates of positive SI assessments.

RESULTS

Of 1340 OEF/OIF veterans with positive depression screens, 32.4% reported SI. In multivariate models, odds of SI were lower for non-Hispanic white veterans (AOR=0.68) and greater for those with PHQ-2≥5 (AOR=1.87), depression (AOR=1.45), bipolar disorder/schizophrenia (AOR=2.84), and 2 or ≥3 diagnoses (AORs=1.59 and 2.49, respectively).

LIMITATIONS

Study findings may not be generalizable to non-veteran patient populations and the study does not address the reliability and validity of tools employed for brief suicidal ideation assessment.

CONCLUSIONS

SI is common among OEF/OIF veterans who receive VA care, perhaps more so among non-white veterans. Targeting veterans with higher PHQ-2 scores for SI assessment should be considered to reduce patient and administrative burden.

"No one gets through it OK": the health challenge of coming home from war

Few studies have sought to explore the subjective experience of reintegration for veterans of the current Operations Enduring Freedom/Iraqi Freedom/New Dawn military campaigns, and even less attention has been given to discover strategies used by veterans to overcome difficulties with transitioning from life in a combat zone to life at home. Findings of this mixed-method study describe reintegration challenges faced by a sample of student veterans as well as some of the strategies they used in response to those challenges. This study provides direction for nurses and postsecondary educators to support veterans who struggle with their personal experience of coming home from the war.

Feasibility and desirability of web-based mental health screening and individualized education for female OEF/OIF reserve and national guard war veterans

Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Reserve and National Guard (RNG) service members have an increased risk for postdeployment mental health (MH) and readjustment problems, yet most do not access needed care. It is unknown if RNG servicewomen experiencing postdeployment readjustment symptoms are aware these may signify treatable MH concerns or if this knowledge activates care-seeking. The aims of this proof-of-concept study were to determine the feasibility of web-based MH screening for postdeployment MH symptoms to inform individualized psychoeducation, and to assess user perceptions about the online instrument and process, MH care access, and VA and other MH care. A midwestern sample (N = 131) of recently deployed (past 24 months) OEF/OIF RNG Army and Air Force servicewomen participated. High rates of combat experiences (95%) and military sexual trauma (50%) were reported. Positive screens for key symptoms of MH problems were prevalent. One third (31%) of satisfaction survey completers indicated online information reduced discomfort with seeking MH care; 42% reported they would subsequently seek MH assessment. Participants interviewed by telephone indicated that stigma and limited knowledge about women-specific services were key reasons servicewomen do not use MH care. This study demonstrated web-based screenings with individualized psychoeducation are implementable and favorable to RNG servicewomen.

Brief assessment for suicidal ideation in OEF/OIF veterans with positive depression screens

OBJECTIVES

We describe processes, rates, and patient and system correlates of brief structured assessments (BSAs) for suicidal ideation among Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans with positive depression screens.

METHODS

Electronic Veterans Affairs (VA) medical record and Department of Defense data were used to identify individual-level and BSA-process variables for 1662 OEF/OIF veterans at three VA Medical Centers.

RESULTS

Overall, 1349/1662 (81%) veterans received BSAs for suicidal ideation within 1 month of depression screening; 94% of BSAs were conducted within 1 day. Stratified analyses revealed significant intersite differences in veteran demographics, instruments used, clinical setting and staff performing assessments, and correlates of assessment completion. At two sites, men were more likely to be assessed than women [odds ratio (OR)=2.15 (95% confidence interval {CI}=1.06-4.38) and 3.14 (CI=1.27-7.76)]. In a combined model adjusted for intrasite correlation, assessment was less likely during months 8-12 and 13-18 of the study period [OR=0.39 (CI=0.28-0.54) and OR=0.48 (95% CI=0.35-0.68), respectively] and more likely to occur among veterans receiving depression or posttraumatic stress disorder diagnoses on the day of depression screening [OR=1.83 (CI=1.36-2.46) and OR=1.50 (CI=1.13-1.98), respectively].

CONCLUSIONS

Most veterans with positive depression screens receive timely BSAs for suicidal ideation. Processes used for brief assessment for suicidal ideation vary substantially across VA settings.

Adverse health consequences of the Iraq War

The adverse health consequences of the Iraq War (2003-11) were profound. We conclude that at least 116,903 Iraqi non-combatants and more than 4800 coalition military personnel died over the 8-year course. Many Iraqi civilians were injured or became ill because of damage to the health-supporting infrastructure of the country, and about 5 million were displaced. More than 31,000 US military personnel were injured and a substantial percentage of those deployed suffered post-traumatic stress disorder, traumatic brain injury, and other neuropsychological disorders and their concomitant psychosocial problems. Many family members of military personnel had psychological problems. Further review of the adverse health consequences of this war could help to minimise the adverse health consequences of, and help to prevent, future wars.

Suicidal behavior in war veterans

Military veterans represent a unique, heterogeneous population with suicide prevalence rates, risk factors and preventative management needs that differ from those of the rest of community. Veterans worldwide receive high proportions of their healthcare from community providers, and sensitivity to these distinct needs is required for optimized care. An overview of the recent prevalence-study literature, with a focus upon statistical design, is presented in order to provide a critical orientation within this field with high levels of popular media attention. Attention to psychiatric comorbidity, subthreshold symptomology, select signature disorders of contemporary conflicts (namely, post-traumatic stress disorder and traumatic brain injury), and veteran life narratives before, within and beyond military service will guide our review of risk factor assessment and management strategies. This critical review of the literature provides an overview of this active field of neuropsychiatric research with a select focus upon these topics of special interest.