Posttraumatic stress disorder and suicide risk among veterans: a literature review

Trajectories of posttraumatic stress symptoms following collective violence: A systematic review and meta-analyses

Although collective violence represents a significant public health concern, a limited number of longitudinal studies have addressed this topic, with no systematic reviews focusing on posttraumatic stress symptom (PTSS) trajectories. The present systematic review and meta-analyses examined PTSS prevalence and trajectories after exposure to collective violence. A systematic literature search across six databases (APA PsycInfo, APA PsycArticles, PSYINDEX, MEDLINE, ERIC, and PubMed) identified 771 studies that were screened for the following eligibility criteria: exposure to collective violence, adult sample, longitudinal design, PTSS assessment using validated measures, PTSS trajectories estimated using latent growth modeling, and report sample prevalence rate for each trajectory. Ten studies met the criteria, and five meta-analyses were performed to assess the overall prevalence of each trajectory. Most included studies (63.6%) identified four trajectories, characterized as low-stable, high-stable, decreasing, and delayed-worsening. The low-stable trajectory was the modal response, with a pooled prevalence of 58.0%, 95% CI [51.0, 65.0]. The high-stable prevalence was 7.0%, 95% CI [4.0, 19.0]; the decreasing trajectory was 13%, 95% CI [9.0, 17.0]; and the delayed-worsening trajectory was 8.0%, 95% CI [5.0, 10.0]. A fifth trajectory, moderately stable, had a prevalence of 19.0%, 95% CI [9.0, 29.0]. The trajectory models robustly identified clinically relevant patterns of response to collective violence, offering a contribution to the literature and a starting point for future research. Further studies are needed, as a better comprehension of symptom trajectories after collective violence events has important clinical and public health implications.

From posttraumatic stress symptoms to suicidal ideation among military veterans: Pathways founded on meaning in life and gratitude

Military veterans experience higher rates of suicidal ideation compared to nonveteran populations. Importantly, suicidal ideation often precedes and predicts fatal and nonfatal suicide attempts, and thus it is critical to better understand factors that increase risk for suicidal ideation to inform suicide prevention efforts in this population. One key predictor of suicidal ideation is exposure to traumatic experiences and their sequelae, particularly posttraumatic stress symptoms (PTSS). However, little work has explored how deficits in well-being contribute to this association among veterans. We tested two aspects of well-being-meaning in life and gratitude-as potential mechanisms underlying the pathway from PTSS to suicidal ideation among 7,388 men and women veterans who recently separated from service. A parallel mediation analysis revealed significant paths from more severe PTSS to more frequent suicidal ideation through diminished meaning in life, B = 0.005, SE = 0.001, 95% CI [0.004, 0.007], and gratitude, B = 0.001, SE = 0.001, 95% CI [< 0.001, 0.002]. Gender differences were also observed. Although the results related to meaning in life appeared to replicate across gender, pathways involving gratitude differed among men and women. Overall, our findings suggest that helping veterans build meaning and appreciation in everyday life may be a proactive and holistic approach to suicide prevention.

Associations Between PTSD Features and Firearm Ownership and Storage: Results From the PRImary Care Screening Methods (PRISM) Study

INTRODUCTION

Veterans and active duty service members are significantly more likely to die by suicide using firearms compared to the general population. Not-secure firearm storage (e.g., keeping guns loaded/in an unlocked location) is associated with greater risk for suicide and a third of veteran firearm owners store at least 1 personal firearm unsecured. Veterans and active duty service members are also significantly more likely to be diagnosed with posttraumatic stress disorder (PTSD) than the general population. Symptoms of PTSD are divided into 4 criteria: reexperiencing, avoidance, negative affect, and hyperarousal. Research has suggested that endorsement of hyperarousal symptoms is positively associated with unsecure firearm storage and that avoidance symptoms might be negatively associated with unsecure storage practices. The present study examined the relationship between self-reported firearm ownership and storage practices among each item from the Primary Care PTSD Screening for DSM-IV-TR (PC-PTSD-IV) to explore associations between PTSD features and firearm ownership and storage.

MATERIALS AND METHODS

Participants were recruited from primary care clinics across 5 military installations in the United States as part of a larger study (Mage = 45.4, SD = 16.9). Among participants (n = 2,685), most of our sample identified as male (51.3%) and white (67.3%) with 61.6% currently serving in the military, 16.8% retirees, and 21.6% family members. PTSD symptoms were assessed using the PC-PTSD-IV and a quarter met the clinical threshold for PTSD. Binomial and multinomial logistic regression analyses were used.

RESULTS

Among completed responses, 989 (38.1%) people reported owning guns; among gun owners, 386 (39.0%) reported that they were loaded, and 352 (35.6%) reported they were loaded and unlocked. Endorsement of specific items on the PC-PTSD-IV, including those specific to hyperarousal and avoidance, was not significantly associated with storing firearms loaded and/or in nonsecure locations when controlling for military service. Non-responses to items around firearm storage practices were significantly associated with those individuals meeting the clinical threshold for PTSD according to the PC-PTSD-IV and participants currently serving had higher odds of storing at least 1 personal firearm loaded and both loaded and unlocked.

CONCLUSIONS

Results from our study highlight similarities and departures from the previous literature on the connection between PTSD and non-secure firearm storage practices. Further research may examine (1) the relation between PTSD symptoms and firearm storage between active duty service members, retirees, and family members and (2) whether non-response to items regarding firearm ownership is systematic.

Clinical and psychological implications of post-traumatic stress in firefighters: a moderated network study

Firefighters are frequently exposed to trauma and may experience a unique symptom presentation of post-traumatic stress. Prior research has identified stronger associations between certain post-traumatic stress symptoms (e.g. detachment, intrusions, physiological reactivity) using network analysis. However, little is known about the effects of symptom severity and emergency work-related trauma on symptom networks. The present study probed the network structure of post-traumatic stress symptoms in trauma-exposed firefighters (N = 871) to model the dynamic interactions of psychological symptoms. We developed a network of post-traumatic stress symptoms and a network of post-traumatic stress with clinical covariates and used moderated network modelling to assess the effects of having PTSD and experiencing work-related trauma on the networks. We identified high edge correlations between several nodes (e.g. startle/hypervigilance, internal/external cue avoidance, detachment/lack of interest) and high centrality of detachment, external cue avoidance, and flashbacks. Additionally, having PTSD moderated positive network associations between risk-taking and suicidality and between distorted blame and post-traumatic cognitions. Work-related trauma moderated negative associations between appetite gain and loss and appetite loss and suicidality. Findings suggest that targeting specific symptoms of detachment, external cue avoidance, and flashbacks could allow for the development of effective trauma-informed interventions for these populations.

Circulating cell-free mitochondrial DNA levels and glucocorticoid sensitivity in a cohort of male veterans with and without combat-related PTSD

Circulating cell-free mitochondrial DNA (ccf-mtDNA) is a biomarker of cellular injury or cellular stress and is a potential novel biomarker of psychological stress and of various brain, somatic, and psychiatric disorders. No studies have yet analyzed ccf-mtDNA levels in post-traumatic stress disorder (PTSD), despite evidence of mitochondrial dysfunction in this condition. In the current study, we compared plasma ccf-mtDNA levels in combat trauma-exposed male veterans with PTSD (n = 111) with those who did not develop PTSD (n = 121) and also investigated the relationship between ccf mt-DNA levels and glucocorticoid sensitivity. In unadjusted analyses, ccf-mtDNA levels did not differ significantly between the PTSD and non-PTSD groups (t = 1.312, p = 0.191, Cohen's d = 0.172). In a sensitivity analysis excluding participants with diabetes and those using antidepressant medication and controlling for age, the PTSD group had lower ccf-mtDNA levels than did the non-PTSD group (F(1, 179) = 5.971, p = 0.016, partial η2 = 0.033). Across the entire sample, ccf-mtDNA levels were negatively correlated with post-dexamethasone adrenocorticotropic hormone (ACTH) decline (r = -0.171, p = 0.020) and cortisol decline (r = -0.149, p = 0.034) (viz., greater ACTH and cortisol suppression was associated with lower ccf-mtDNA levels) both with and without controlling for age, antidepressant status and diabetes status. Ccf-mtDNA levels were also significantly positively associated with IC50-DEX (the concentration of dexamethasone at which 50% of lysozyme activity is inhibited), a measure of lymphocyte glucocorticoid sensitivity, after controlling for age, antidepressant status, and diabetes status (β = 0.142, p = 0.038), suggesting that increased lymphocyte glucocorticoid sensitivity is associated with lower ccf-mtDNA levels. Although no overall group differences were found in unadjusted analyses, excluding subjects with diabetes and those taking antidepressants, which may affect ccf-mtDNA levels, as well as controlling for age, revealed decreased ccf-mtDNA levels in PTSD. In both adjusted and unadjusted analyses, low ccf-mtDNA levels were associated with relatively increased glucocorticoid sensitivity, often reported in PTSD, suggesting a link between mitochondrial and glucocorticoid-related abnormalities in PTSD.

Suicide risk profiles among service members and veterans exposed to suicide

OBJECTIVES

Rates of suicide exposure are high among service members and Veterans and are especially concerning given the link between suicide exposure and subsequent suicide risk. However, to date, it is unclear which individuals who are exposed to suicide are subsequently at high risk for suicide. Latent profile analysis (LPA) can provide information on unique risk profiles and subgroups of service members and Veterans who have higher suicide risk after suicide exposure, which has not yet been empirically studied. The purpose of this study was to utilize LPA to identify subgroups of service members and Veterans who are at the highest risk for suicidal thoughts and behaviors following suicide exposure.

METHODS

We analyzed data using LPA from 2570 service members and Veterans (82.1% male, 69.5% White, and 12.1% Latino/a/x) who completed the Military Suicide Research Consortium's Common Data Elements, a battery of self-report suicide-related measures. Psychopathology, substance use, mental health service utilization, interpersonal theory of suicide, and suicide exposure variables were used to validate classes.

RESULTS

Three latent classes emerged from analyses, one low-risk class and two-high risk classes with differing profile compositions (one primarily differentiated by anxiety symptoms and one differentiated by substance use).

CONCLUSION

Class-specific recommendations for suicide prevention efforts will be discussed.

Exploring the enigma of low prevalence of post-traumatic stress disorder in India

Introduction

Post-traumatic stress disorder (PTSD) is a chronic psychiatric condition associated with significant distress and dysfunction. While worldwide estimates of prevalence range from 3.9% to 24%, little research has been conducted to identify the prevalence of PTSD in the general population of India. This study analyzes data from the National Mental Health Survey 2015-2016, a comprehensive epidemiological study of mental health disorders in India, to explore the unique characteristics and prevalence of PTSD in the Indian population.

Materials and Methods

The National Mental Health Survey 2015-2016 employed a multiple-stage, stratified, cluster-sampling methodology, covering 39,532 individuals in 12 states of India. The Mini-International Neuropsychiatric Interview (MINI) version 6.0.0 was used to diagnose psychiatric disorders, including PTSD. A detailed analysis of sociodemographic profiles, prevalence patterns, comorbidities, economic and social impact, and treatment-seeking behavior was conducted. Firth penalized logistic regression was employed to identify associated sociodemographic factors.

Results

The study revealed a low prevalence of PTSD in India at 0.2%, significantly lower than global averages. Factors associated with PTSD included female gender, middle age (40-49 years), and urban residence. The study also highlighted a high rate of comorbid mood and anxiety disorders, substantial disability, poor treatment-seeking behavior, and significant suicidal risk among individuals with PTSD.

Conclusion

Our findings underscore the need for culturally informed diagnostic and management programs to accurately identify and address PTSD in the Indian population. Cultural nuances, stigma, and the use of Western-derived diagnostic instruments likely contribute to the underidentification and undertreatment of PTSD in India. The study emphasizes the importance of recognizing and addressing these challenges to improve mental health outcomes in India.

Examining the Association Between Moral Injury and Suicidal Behavior in Military Populations: A Systematic Review

The increasing number of suicides among military populations cannot be fully accounted for by conventional risk factors like Post-Traumatic Stress Disorder (PTSD). As a result, researchers and theorists propose that delving into the concept of Moral Injury could offer a more comprehensive understanding of the phenomenon of suicide. Moral Injury is not currently a recognized mental health disorder but can be associated with PTSD. Moral Injury is a multi-dimensional issue that profoundly affects emotional, psychological, behavioral, social, and spiritual well-being. The objective of this systematic review is to examine the association between Moral Injury and suicidal behavior (suicide ideation, plans and or suicide attempt) within military populations. The review will specifically concentrate on identifying and analyzing studies that have investigated the connection between these variables, with a specific focus on the context of military personnel both serving and former serving members. Of the 2214 articles identified as part of this review, 12 studies satisfied the research criteria with a total participant sample having an average age of 40.7 years. The male population accounted for 78.6% of the overall sample. Two studies were identified as high-quality, while the remaining ten were rated as moderate. The analysis of these twelve studies consistently affirms a connection between Moral Injury and suicidal behavior; most obviously, that exposure to morally injurious events substantially amplify the risk of suicide, with higher levels of potential exposure being linked to increased Moral Injury and heightened levels of suicidal behavior. Our review uncovered noteworthy findings regarding the association between Moral Injury and suicidal behavior, marking a pioneering effort in exploring this association and offering valuable insights into this emerging issue. Several limitations are noted regarding this review and recommendations are made concerning the need to prioritize, expand and employ longitudinal research designs that include non-military populations such as first responders (e.g., police, paramedics, firefighters) and medical, nursing, or allied health professionals-all disciplines known to be impacted by Moral Injury.

Diagnosed Posttraumatic Stress Disorder and Other Trauma-Associated Stress Disorders and Risk for Suicide Mortality

OBJECTIVE

Strong evidence exists for posttraumatic stress disorder (PTSD) as a risk factor for suicidal thoughts and behaviors across diverse populations. However, few empirical studies have examined PTSD and other trauma-associated stress disorders as risk factors for suicide mortality among health system populations. This study aimed to assess trauma-associated stress diagnoses as risk factors for suicide mortality in a U.S. health system population.

METHODS

This case-control, matched-design study examined individuals who died by suicide between 2000 and 2015 and had received care from nine U.S. health systems affiliated with the Mental Health Research Network (N=3,330). Individuals who died by suicide were matched with individuals from the general health system population (N=333,000): 120 individuals with PTSD who died by suicide were matched with 1,592 control group members, 84 with acute reaction to stress were matched with 2,218 control individuals, and 331 with other stress reactions were matched with 8,174 control individuals.

RESULTS

After analyses were adjusted for age and sex, individuals with any trauma-associated stress condition were more likely to have died by suicide. Risk was highest among individuals with PTSD (adjusted OR [AOR]=10.10, 95% CI=8.31-12.27), followed by those with other stress reactions (AOR=5.38, 95% CI=4.78-6.06) and those with acute reaction to stress (AOR=4.49, 95% CI=3.58-5.62). Patterns of risk remained the same when the analyses were adjusted for any comorbid psychiatric condition.

CONCLUSIONS

All trauma-associated stress disorders are risk factors for suicide mortality, highlighting the importance of health system suicide prevention protocols that consider the full spectrum of traumatic stress diagnoses.

A trauma-informed approach to suicide prevention for the COVID-19 pandemic

During the COVID-19 pandemic, researchers have questioned how the devastation of the pandemic might impact suicide rates. While initial evidence on suicide rates during the early stages of the pandemic is mixed, there are signs we should still remain vigilant. One way of conceptualizing the long-term effects of the pandemic is as a source of multiple traumatic events: the collective trauma of widespread illness and death and social upheaval, individual traumas from the virus itself (e.g., serious illness and disability, traumatic grief, vicarious trauma), traumas from the social and economic consequences (e.g., domestic violence, unemployment), and its intersections with pre-pandemic traumas and oppression. Given trauma is a well-established risk factor for suicide, this carries significant implications for suicide prevention in the wake of the pandemic. Yet access to trauma-informed care, education, and research remains limited. The pandemic presents a unique opportunity to address these gaps and implement a trauma-informed approach to suicide prevention. Building on existing frameworks, we describe how effective suicide prevention for the pandemic must incorporate trauma-informed and trauma-specific services, strategies, and policies; capacity building; collaborative research; and knowledge exchange. Attending to the traumatic effects of the pandemic may reduce the long-term impact on suicide rates.

Intentional Self-Harm Among US Veterans With Traumatic Brain Injury or Posttraumatic Stress Disorder: Retrospective Cohort Study From 2008 to 2017

BACKGROUND

Veterans with a history of traumatic brain injury (TBI) and/or posttraumatic stress disorder (PTSD) may be at increased risk of suicide attempts and other forms of intentional self-harm as compared to veterans without TBI or PTSD.

OBJECTIVE

Using administrative data from the US Veterans Health Administration (VHA), we studied associations between TBI and PTSD diagnoses, and subsequent diagnoses of intentional self-harm among US veterans who used VHA health care between 2008 and 2017.

METHODS

All veterans with encounters or hospitalizations for intentional self-harm were assigned "index dates" corresponding to the date of the first related visit; among those without intentional self-harm, we randomly selected a date from among the veteran's health care encounters to match the distribution of case index dates over the 10-year period. We then examined the prevalence of TBI and PTSD diagnoses within the 5-year period prior to veterans' index dates. TBI, PTSD, and intentional self-harm were identified using International Classification of Diseases diagnosis and external cause of injury codes from inpatient and outpatient VHA encounters. We stratified analyses by veterans' average yearly VHA utilization in the 5-year period before their index date (low, medium, or high). Variations in prevalence and odds of intentional self-harm diagnoses were compared by veterans' prior TBI and PTSD diagnosis status (TBI only, PTSD only, and comorbid TBI/PTSD) for each VHA utilization stratum. Multivariable models adjusted for age, sex, race, ethnicity, marital status, Department of Veterans Affairs service-connection status, and Charlson Comorbidity Index scores.

RESULTS

About 6.7 million veterans with at least two VHA visits in the 5-year period before their index dates were included in the analyses; 86,644 had at least one intentional self-harm diagnosis during the study period. During the periods prior to veterans' index dates, 93,866 were diagnosed with TBI only; 892,420 with PTSD only; and 102,549 with comorbid TBI/PTSD. Across all three VHA utilization strata, the prevalence of intentional self-harm diagnoses was higher among veterans diagnosed with TBI, PTSD, or TBI/PTSD than among veterans with neither diagnosis. The observed difference was most pronounced among veterans in the high VHA utilization stratum. The prevalence of intentional self-harm was six times higher among those with comorbid TBI/PTSD (6778/58,295, 11.63%) than among veterans with neither TBI nor PTSD (21,979/1,144,991, 1.92%). Adjusted odds ratios suggested that, after accounting for potential confounders, veterans with TBI, PTSD, or comorbid TBI/PTSD had higher odds of self-harm compared to veterans without these diagnoses. Among veterans with high VHA utilization, those with comorbid TBI/PTSD were 4.26 (95% CI 4.15-4.38) times more likely to receive diagnoses for intentional self-harm than veterans with neither diagnosis. This pattern was similar for veterans with low and medium VHA utilization.

CONCLUSIONS

Veterans with TBI and/or PTSD diagnoses, compared to those with neither diagnosis, were substantially more likely to be subsequently diagnosed with intentional self-harm between 2008 and 2017. These associations were most pronounced among veterans who used VHA health care most frequently. These findings suggest a need for suicide prevention efforts targeted at veterans with these diagnoses.

Suicidal behavior across a broad range of psychiatric disorders

Suicide is a leading cause of death worldwide. In 2020, some 12.2 million Americans seriously contemplated suicide, 3.2 million planned suicide attempts, and 1.2 million attempted suicide. Traditionally, the approach to treating suicidal behavior (SB) has been to treat the "underlying" psychiatric disorder. However, the number of diagnoses associated with SB is considerable. We could find no studies describing the range of disorders reported to be comorbid with SB. This narrative review summarizes literature documenting the occurrence of SB across the lifespan and the full range of psychiatric diagnoses, not only BPD and those that comprise MDE, It also describes the relevance of these observations to clinical practice, research, and nosology. The literature searches contained the terms "suicid*" and each individual psychiatric diagnosis and identified 587 studies. We did not include case reports, case series, studies only addressing suicidal ideation or non-suicidal self-injury (NSSI), studies on self-harm, not distinguishing between SB and NSSI and studies that did not include any individuals that met criteria for a specific DSM-5 diagnosis (n = 366). We found that SB (suicide and/or suicide attempt) was reported to be associated with 72 out of 145 diagnoses, although data quality varied. Thus, SB is not exclusively germane to Major Depressive Episode (MDE) and Borderline Personality Disorder (BPD), the only conditions for which it is a diagnostic criterion. That SB co-occurs with so many diagnoses reinforces the need to assess current and past SB regardless of diagnosis, and supports the addition of charting codes to the DSM-5 to indicate current or past SB. It also comports with new data that specific genes are associated with SB independent of psychiatric diagnoses, and suggests that SB should be managed with specific suicide prevention interventions in addition to treatments indicated for co-occurring diagnoses. SB diagnostic codes would help researchers and clinicians document and measure SB's trajectory and response to treatment over time, and, ultimately, help develop secondary and tertiary prevention strategies. As a separate diagnosis, SB would preclude situations in which a potentially life-threatening behavior is not accounted for by a diagnosis, a problem that is particularly salient when no mental disorder is present, as is sometimes the case.

Does ADT Influence the Risk of Suicidal Ideation among US Veteran Prostate Cancer Patients Pre-Exposed to PTSD?

Post-traumatic stress disorder (PTSD) is defined as a mental health disease that has a high probability of developing among individuals who have experienced traumatic events [...].

Experiential Avoidance, Posttraumatic Stress Disorder, and Self-Injurious Thoughts and Behaviors: A Moderation Analysis in a National Veteran Sample

Experiential avoidance (EA) is associated with posttraumatic stress disorder (PTSD) and self-injurious thoughts and behaviors (SITBs) across different populations, and extant literature has demonstrated a strong relationship between PTSD and SITBs. However, no study has explored the potential moderating role EA plays in the association of PTSD with nonsuicidal self-injury (NSSI), suicidal ideation, and suicide attempts. The objective of the present study was to determine if EA would moderate the association with PTSD and SITBs such that the association between PTSD and individuals SITBs would be stronger among individuals with higher EA. In a large national sample of Gulf War Era veterans (N = 1,138), EA was associated with PTSD, lifetime and past-year NSSI, current suicidal ideation, and lifetime suicide attempts in bivariate analyses. Multivariate analyses detected a significant EA by PTSD interaction on lifetime NSSI (AOR = 0.96), past-year NSSI (AOR = 1.03), and suicide attempts (AOR =1.03). Probing of the interactions revealed that the respective associations between PTSD, lifetime and past-year NSSI, and suicide attempts were stronger at lower levels of EA (i.e., better), counter to our hypotheses. These preliminary findings contextualize the relationship between these variables in a Gulf War veterans sample and signal the need to further investigate these relationships. Further, these findings highlight the need for advancement in assessment and intervention of EA and SITBs.

Suicide risk among combatants: The longitudinal contributions of pre-enlistment characteristics, pre-deployment personality factors and moral injury

BACKGROUND

Recent studies have shown that exposure to potentially morally injurious events (PMIEs) in deployment situations facilitates higher suicide risk among combatants. However, knowledge about pre-deployment factors that may moderate the negative contribution of PMIEs to suicide risk is rare. In this prospective study, we examined pre-enlistment characteristics and pre-deployment personality factors as possible moderators in the link between exposure to self, other, and betrayal dimensions of PMIEs and post-deployment suicide risk among Israeli active-duty combatants.

METHODS

A sample of 335 active-duty Israeli combatants participated in a 2.5-year prospective study with three waves of measurements: T1-12 months before enlistment, T2-6 months following enlistment (pre-deployment), and T3-18 months following enlistment (post-deployment). Participants were assessed via semi-structured interviews of personal characteristics (e.g., cognitive index) at T1, validated self-report measures of personality factors for emotional regulation, impulsivity, and aggression at T2, and combat exposure, PMIEs, and suicide risk at T3 between 2019 and 2021.

RESULTS

All three dimensions of PMIEs were significantly associated with higher suicidal risk among combatants. Importantly, higher levels of pre-deployment aggression and lower levels of emotional regulation moderated the association between PMIEs and suicide risk post-deployment, above and beyond pre-enlistment psychiatric difficulties and life events.

CONCLUSIONS

Our results highlight the roles of pre-deployment factors of emotional regulation and aggressiveness as possible moderators in the PMIEs-suicide risk link. These results emphasize the need for higher awareness of suicide risk among deployed combatants with low emotional regulation and high aggressiveness. Moreover, tailored interventions aiming to decrease emotional dysregulation and aggressiveness levels should be considered, as such interventions may help reduce suicide risk following combat-related transgressive acts.

Attention deficits as a key player in the symptomatology of posttraumatic stress disorder: A review

Posttraumatic stress disorder (PTSD) is a debilitating psychiatric disorder characterized by symptoms such as re-experiencing of the psychotrauma and hyperarousal. Although current literature mainly discusses the emotionally related aspects of these symptoms, studies also highlight the relation between re-experiencing, hyperarousability, and attention deficits, which are associated with poorer daily function and reduced quality of life. This review provides a comprehensive analysis of the existing research on attention deficits among adults with PTSD. A systematic search through five databases resulted in the inclusion of 48 peer-reviewed, English-language articles, describing 49 distinct studies. Using a total of 47 different attentional assessment tools, the majority of studies investigated sustained (n = 40), divided (n = 16), or selective (n = 14) attention. A total of 30 studies (61.2%) found significant correlations between PTSD symptoms and attention deficits, and 10 studies (20.4%) found that higher levels of attention deficits were predictive of worse PTSD symptoms. Moreover, neuroimaging results of six (f)MRI and three EEG studies identified various potential neurobiological pathways involved, including (pre)frontal attention networks. Together, the body of research shows that attention deficits in individuals with PTSD are common and occur in surroundings with emotionally neutral stimuli. Nonetheless, current treatment strategies do not target these attentional difficulties. We propose a novel perspective to PTSD diagnosis and treatment strategies based on attention deficits and their relation with top-down regulation of re-experiencing and subsequent other PTSD symptoms.

Effectiveness of Operation K9 Assistance Dogs on Suicidality in Australian Veterans with PTSD: A 12-Month Mixed-Methods Follow-Up Study

Post-traumatic stress disorder (PTSD) is a pervasive disorder among both current and ex-serving Australian Defence Force (ADF) members. Studies have shown current psychological and pharmacological treatments for PTSD are suboptimal in veterans, with high dropout rates and poor adherence to treatment protocols. Therefore, evaluating complementary interventions, such as assistance dogs, is needed for veterans who may not receive the ultimate benefit from traditional therapies. The present longitudinal mixed-method study examined the effectiveness of Operation K9 assistance dogs among sixteen veterans with PTSD, specifically, their effects on suicidality, PTSD, depression, and anxiety from baseline to 12 months post-matching. Self-reported measures were completed prior to receiving their dog (baseline) and at three time points (3, 6, and 12 months) following matching. The Clinician-Administered PTSD Scale for DSM-5 was used to assess the severity of every PTSD case. Veterans participated in a semi-structured interview 3 months post-matching. Whilst there was a reduction in the proportion of veterans reporting any suicidality, there was no significant change in the probability of veterans reporting suicidality between time points. There was a significant effect of time on PTSD, depression, and anxiety symptoms. Three major themes emerged from qualitative data analysis: life changer, constant companion, and social engagement. Qualitative data suggest assistance dogs can have a positive impact on important areas of daily life and support veterans in achieving some of the prerequisites for health, including access to services, transport, education, employment, and development of new and diverse social and community connections. Connections were key in improving health and wellbeing. This study exemplifies the power of human-animal relationships and adds emphasis to the need to take these seriously and create supportive healthy environments for veterans with PTSD. Our findings could be used to inform public health policy and service delivery, in line with the Ottawa Charter action areas and indicate that for veterans with PTSD, assistance dogs may be a feasible adjunct intervention.

Subjective cognitive difficulties and posttraumatic stress disorder interact to increase suicide risk among middle-aged and older US military veterans

OBJECTIVES

To examine the role of subjective cognitive difficulties (SCD), posttraumatic stress disorder (PTSD), and their interaction in predicting suicidal ideation and current suicidal intent in middle-aged and older United States (US) military veterans.

DESIGN

Population-based cross-sectional study.

SETTING AND PARTICIPANTS

Data were analyzed from the 2019 to 2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 3602 US veterans aged 50 years and older (mean age = 69.0).

MEASUREMENTS

Questionnaires including the Medical Outcomes Study Cognitive Functioning Scale (SCD), PTSD Checklist for DSM-5 (PTSD), Patient Health Questionnaire-9 (suicidal ideation in the previous two weeks), and the Suicide Behaviors Questionnaire-Revised (current suicidal intent).

RESULTS

A total of 154 (4.4%) veterans screened positive for current PTSD, 239 (6.7%) reported past two-week suicidal ideation, and 37 (1.0%) reported current suicidal intent. The probability of suicidal ideation among veterans with both SCD and PTSD was more than six times higher than that observed in the full sample (44.5% vs. 6.7%) and more than 2.5 times higher than that observed in veterans with SCD and no PTSD (44.5% vs. 17.5%). Veterans with both subjective memory and concentration difficulties were more likely to report suicidal intent, though the interaction between SCD and PTSD was not significantly associated with suicidal intent.

CONCLUSION

Middle-aged and older U.S. veterans with subjective cognitive impairment and PTSD report higher rates of suicidal ideation than those with SCD alone. Interventions targeting SCD and PTSD may mitigate suicide risk among middle-aged and older veterans.

Impact of residential PTSD treatment on suicide risk in veterans

INTRODUCTION

In 2019, 17 veterans died by suicide every day. Various suicide prevention treatments have emerged, yet limited research has explored the impact of Post Traumatic Stress Disorder (PTSD) treatment on suicidal ideation and behaviors.

METHODS

This study examines the impact of Cognitive Processing Therapy (CPT) on suicidal ideation among veterans in three residential PTSD programs (women's, men's, and PTSD/Traumatic Brain Injury). Interview and self-report data were collected from veterans (n = 446) throughout treatment.

RESULTS

Over 50% of veterans reported current suicidal ideation and a history of suicide attempts prior to treatment. Variables that predicted change in suicidal ideation included prior suicide attempt (β = 0.21, p = 0.022), change in CAPS-5 total score (β = 0.28, p = 0.038), employment status (β = -0.20, p = 0.035) and history of suicide attempt (β = 0.25, p = 0.009). Those without a previous suicide attempt made greater gains in CPT treatment than those with a previous suicide attempt.

CONCLUSION

Following 7 weeks of CPT residential treatment, a decrease in PTSD symptoms was significantly associated with a reduction in suicidal ideation. Implications are that CPT can reduce suicide risk in a variety of Veteran cohorts with differing trauma types.

Comparing Trauma Treatment Outcomes Between Homeless and Housed Veterans in a VA PTSD Clinical Program

Homeless veterans are likely to experience Post Traumatic Stress Disorder (PTSD). Homelessness itself is traumatic, and PTSD may exacerbate homelessness risk for veterans. Often, PTSD goes untreated in this subpopulation of veterans. Our study examined trauma-focused treatment (TFT) and non-TFT initiation and completion in a sample of housed and homeless veterans being served by a PTSD clinical team in Washington, DC. Findings included a high percentage of veterans who experienced homelessness in the sample and lower treatment completion rates among homeless veterans compared to housed veterans. This difference was no longer significant when comparing only those veterans who engaged in treatment, reinforcing the critical role of treatment engagement in successful treatment completion across populations.

A Paucity of Data on Veterans 65 and Older and Risk of Suicide: A Systematic Review

Older veterans are vastly underrepresented in studies that shape national suicide prevention strategies. This is of great concern because factors that impact younger veterans may not be as robust in later life. Although younger veterans have higher rate of suicide, the highest counts of death by suicide are in older veterans. However, it remains unclear from the extant literature what factors may influence increased or decreased risk of late-life suicide in veterans. The objective of this systematic review was to identify risk and protective factors related to suicide outcomes (i.e., ideation, attempt, death, or suicide-related behavior [SRB]) among older veterans. Furthermore, it offers data regarding future study directions and hypothesis generation for late-life suicide research and for informing potential intervention and prevention efforts in this area. We searched 4 databases from inception up to May 5, 2022. We screened 2,388 abstracts for inclusion and 508 articles required full text review. The final sample included 19 studies published between 2006 and 2022. We found five domains of factors studied (i.e., neuropsychiatric, social determinants of health, aging stereotypes, residential and supportive housing settings, and multifactorial-neuropsychiatric/mental health and physical health) with more risk factors than protective factors reported. Across the three suicide outcomes only neuropsychiatric factors were consistently identified as risk factors. Neuropsychiatric factors also comprised the largest group of risk factors studied. More innovative targets to consider for intervention and more innovative methods to predict suicide in late-life are needed. There is also continued necessity to design suicide prevention interventions for older veterans given lethality trends.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Research of the Coronavirus Anxiety, Post-Traumatic Stress, Generalized Anxiety Disorder, Quality of Life, and Stress Coping Styles in COVID-19 Survivors

The COVID-19 survivors suffer from severe psychosocial challenges related to the current pandemic. In this context, it was aimed to evaluate the coronavirus anxiety, generalized anxiety disorder (GAD), and post-traumatic stress symptoms (PTSS) and also determine the quality of life (QOL), and coping styles with stress in survivors by comparing them with non-COVID controls (NCs). This study was conducted from April 15 to October 15, 2021, as a cross-sectional study design. The study included 339 survivors who were confirmed with COVID-19 through clinical tests in the last 3 months and 321 NCs who had not been infected with COVID-19. Besides sociodemographic and clinical data, a set of valid and reliable assessment tools were used to measure outcomes of coronavirus anxiety, coping styles, post-traumatic stress, generalized anxiety, and quality of life. The total scores of IES-R, GAD-7, and CAS were significantly higher in survivors than in the NCs. These results revealed that survivors manifested higher levels of coronavirus anxiety, generalized anxiety, and post-traumatic stress symptoms (p < 0.05). In survivors,  the rates of GAD and coronavirus anxiety were found to be 59.3% and 25.7%, respectively. Additionally, the majority of survivors (89.4%) reported the severity of anxiety as moderate to severe, and also almost two-thirds of them reported the psychological impact of the pandemic as moderate to severe. Furthermore, survivors were found to have a lower quality of life. The findings of this study indicate that survivors experienced higher levels of coronavirus anxiety, generalized anxiety, and post-traumatic stress, and had lower QOL. In addition, it was determined that survivors haven't been using active styles adequately in coping with stress. Thus, psychological intervention studies should be conducted and public mental health strategies should be developed. Providing psychosocial support and psychological guidance will contribute to mental health well-being, and improve the QOL and coping strategies.

Risk factors for suicide in the Vietnam-era twin registry

BACKGROUND

The risk of suicide among Veterans is of major concern, particularly among those who experienced a combat deployment and/or have a history of PTSD.

DESIGN AND METHODS

This was a retrospective cohort study of post-discharge suicide among Vietnam-era Veterans who are members of the Vietnam Era Twin (VET) Registry. The VET Registry is a national sample of male twins from all branches of the military, both of whom served on active duty between 1964 and 1975. Military service and demographic factors were available from the military records. Service in-theater was based on military records; combat exposure and PTSD symptoms were assessed in 1987 by questionnaire. Mortality follow-up, from discharge to 2016, is identified from Department of Veterans Affairs, Social Security Administration, and National Death Index records; suicide as a cause of death is based on the International Classification of Death diagnostic codes from the death certificate. Statistical analysis used Cox proportional hazards regression to estimate the association of Vietnam-theater service, combat exposure, and PTSD symptoms with suicide while adjusting for military service and demographic confounding factors.

RESULTS

From the 14,401 twins in the VET Registry, there were 147 suicide deaths during follow-up. In adjusted analyses, twins who served in the Vietnam theater were at similar risk of post-discharge suicide compared with non-theater Veterans; there was no association between combat and suicide. An increase in severity of PTSD symptoms was significantly associated with an increased risk of suicide in adjusted analyses (hazard ratio = 1.13 per five-point increase in symptom score; 95% CI: 1.02-1.27).

CONCLUSIONS

Service in the Vietnam theater is not associated with greater risk of suicide; however, PTSD symptom severity poses a degree of risk of suicide in Vietnam-era Veterans. Adequate screening for PTSD in Veterans may be promising to identify Veterans who are at increased risk of suicide.

Longitudinal relationships between guilt and suicide risk among adolescents in a postdisaster context: Mediating roles of rumination and posttraumatic stress disorder

OBJECTIVE

To analyze the pathways and mechanisms underlying the impact of guilt on suicide risk using a well-controlled longitudinal study, we examined the mediating roles of intrusive rumination, deliberate rumination, and posttraumatic stress disorder (PTSD) in this association.

METHOD

Four hundred and eight adolescent survivors (M_age  = 14.05 years) were assessed using self-report questionnaires three and a half years and four and a half years after the Ya'an earthquake. The self-report questionnaires included the Trauma Exposures Questionnaire, the Interpersonal Guilt Questionnaire, the Event-Related Rumination Inventory, the PTSD Checklist for the DSM-5, and the Child Behavior Problems Questionnaire.

RESULTS

The results indicated that guilt had a direct and positive effect on suicide risk. Intrusive rumination and PTSD mediated the relationship between guilt and suicide risk. Guilt could increase deliberate rumination, but deliberate rumination did not significantly predict PTSD and suicide risk.

CONCLUSION

Negative postdisaster emotions, such as guilt, can enhance the combined effects of cognition and psychological disorders on suicide risk. Guilt affects suicide risk indirectly through intrusive rumination and PTSD but not through deliberate rumination.

Shame as a Mediator in the Association Between Emotion Dysregulation and Posttraumatic Stress Disorder Symptom Reductions Among Combat Veterans in a Residential Treatment Program

Emotion dysregulation (ED) can be defined as one's inability to effectively respond to and manage internal experiences and the expression of emotion. ED has been linked to the development and maintenance of posttraumatic stress disorder (PTSD), with recent research suggesting that reductions in ED may predict improved treatment outcomes among both civilian and veteran populations. However, few studies have examined how changes in ED may predict treatment outcomes among veterans with PTSD and whether certain core features of PTSD, such as shame, may act as potential mediators in the association between ED and PTSD symptom reductions. The present study sought to explore facets of ED, feelings of shame, and PTSD symptoms among 43 combat veterans upon their admission and discharge to a residential PTSD program. The results demonstrated that all variables of interest significantly decreased from admission to discharge, ds = 0.75-1.84. Correlations indicated that reductions in ED, R² = .184, and shame, R² = .228, were associated with reductions in PTSD symptoms. However, the association between reductions in ED and PTSD was significantly mediated by reductions in shame. Overall, these results suggest that higher levels of emotion regulation may partially affect PTSD symptoms through reductions in shame. This may explain the efficacy of frontline PTSD treatments, as they explicitly focus on the processing of one's traumatic experience by reducing PTSD symptoms through regulation techniques that target emotional-behavioral cycles, which may include the shame-withdraw cycle.

Post-traumatic Stress Disorder Symptoms and Quality of Life of COVID-19 Survivors at 6-Month Follow-Up: A Cross-Sectional Observational Study

Background: Post-traumatic stress disorder (PTSD) is the most common psychiatric sequelae among novel coronavirus disease (COVID-19) patients. The aim of this study was to determine the prevalence of PTSD symptoms, PTSD-related factors, and its relationship with quality of life at long-term follow-up in hospitalized COVID-19 survivors. Methods: A cross-sectional study was undertaken to evaluate the health consequences of hospitalized COVID-19 survivors. All participants were interviewed face-to-face through a series of questionnaires: a researcher-developed symptom questionnaire, the Post-traumatic Stress Disorder Checklist-Civilian Version, the Generalized Anxiety Disorder 7-item, and the 36-item Short Form. Results: A total of 574 participants were enrolled with an average age of 57 years. The median follow-up time post-discharge was 193.9 days (SD = 15.32). Among the participants, 77.9% of survivors presented with at least one symptom, where fatigue or muscle weakness (47.9%) was reported the most frequently, followed by chest distress (29.4%) and sleep difficulty (29.4%). The prevalence of PTSD was 11.15% [95% confidence interval (CI): 8.56, 13.73] with a cut-off score of 44. Factors such as respiratory symptoms [odds ratio (OR): 3.53; 95% CI: 1.68-7.42], anxiety (OR: 14.64; 95% CI: 7.09-30.21), and sleep difficulty (OR: 2.17; 95% CI: 1.14-4.16) were positively related to PTSD. Those COVID-19 survivors with potential PTSD had significantly lower quality of life than those without (P < 0.05). Conclusion: Our study illustrated that a significant number of COVID-19 survivors were suffering from physical or mental distress to varying degrees at 6 months post-discharge. People with PTSD were more likely to experience persistent respiratory symptoms and sleep difficulty, as well as anxiety and a decreased quality of life. Such survivors require greater attention to their mental health, particularly the PTSD symptoms at the early phase, which may play an important role in the recovery of both the physical and psychological health of COVID-19 survivors.

Resilience to Suicidal Ideation Among U.S. Military Veterans with Posttraumatic Stress: Results from the National Health and Resilience in Veterans Study

Veterans with combat exposure experience high rates of posttraumatic stress symptoms (PTSS) and associated suicidal ideation. The current study examined whether social support (i.e., social connectedness and social engagement) and protective psychological factors (i.e., resilience and altruism) moderated the relation between PTSS and suicidal ideation severity in a sample of 149 U.S. military combat veterans who served in the Vietnam War or Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND). Consistent with expectations, initial PTSS were positively associated with concurrent and three-year follow-up severity of suicidal ideation. Moderation analyses revealed the relation between initial PTSS and concurrent suicidal ideation severity was no longer significant at above average levels of social connectedness, social engagement, and psychological resilience. Further, the relation between initial PTSS and suicidal ideation severity three years later continued to be buffered by above average levels of social engagement. Results suggest social connectedness, psychological resilience, and social engagement help moderate initial severe thoughts of suicide linked to PTSS, while social engagement might be the strongest protective factor against severe suicidal ideation over time. Empirically-supported prevention and treatment efforts enhancing social engagement may help promote resilience to severe PTSS-related suicidal ideation among veterans from Vietnam and OEF/OIF/OND combat eras.

Reductions in guilt cognitions following prolonged exposure and/or sertraline predict subsequent improvements in PTSD and depression

BACKGROUND AND OBJECTIVES

Reduction of trauma related negative cognitions, such as guilt, is thought to be a mechanism of change within PTSD treatments like prolonged exposure (PE). Research suggests PE can directly address guilt cognitions. However, whether pharmacotherapies for PTSD can remains unclear.

METHODS

Data from a randomized controlled trial of PE plus placebo (PE + PLB), sertraline plus enhanced medication management (SERT + EMM), and their combination (PE + SERT) in 195 Veterans from recent wars was analyzed.

RESULTS

The unadjusted means and mixed-effects model showed guilt decreased significantly over the follow-up time as expected; however, contrary to our hypothesis, PE conditions were not associated with greater reductions in guilt than the SERT + EMM condition. As hypothesized, week 12 reduction in guilt predicted post-treatment (weeks 24-52) reduction in PTSD and depression, but not impairments in function.

LIMITATIONS

Generalizability of findings is limited by the sample being comprised of combat Veterans who were predominantly male, not on SSRI at study entry, willing to be randomized to therapy or medication, and reporting low levels of guilt. To reduce differences in provider attention, SERT + EMM was administered over 30 min to include psychoeducation and active listening; it is unknown if this contributed to effects on guilt.

CONCLUSIONS

PE + PLB, SERT + EMM, and PE + SERT were equally associated with reduction in trauma related guilt. Reducing trauma related guilt may be a pathway to reducing PTSD and posttraumatic depression symptoms. Further study is needed to determine how best to treat trauma related guilt and to understand the mechanisms by which guilt improves across different treatments for PTSD.

A Comparison of Dimensional and Categorical Approaches to Characterizing the Association Between Posttraumatic Stress Disorder and Future Suicide Attempts

The present study compared the utility of categorical (i.e., diagnostic status) and dimensional (i.e., symptom severity) approaches to measuring posttraumatic stress disorder (PTSD) in predicting future suicide attempts among participants in a nationwide, longitudinal study of U.S. military veterans who were deployed in support of operations in Iraq or Afghanistan after the September 11, 2001, terrorist attacks (9/11) and were enrolled in Veterans Health Administration services (N = 1,649). Following an initial assessment of PTSD symptoms, we assessed for suicide attempts at two subsequent time points (M = 28.74 months, SD = 8.72 and M = 55.11 months, SD = 6.89 following the initial assessment). Between the initial and final assessments, 125 participants (7.58%) made at least one suicide attempt. All categorical and dimensional indicators of PTSD predicted suicide attempts at both time points except the categorical indicator for reexperiencing symptoms. Categorical indicators predicting suicide attempts demonstrated excellent sensitivity but poor specificity and overall accuracy. The point along the continuum at which PTSD symptom severity was most accurate regarding the prediction of future suicide attempts was well above the threshold previously established as indicating a probable diagnosis. Although this score was less sensitive than diagnostic indicators, it demonstrated greater specificity and overall accuracy in predicting future suicide attempts. The present results indicate that veterans whose PTSD symptoms satisfy the diagnostic criteria have a higher risk of future suicide attempts, but this risk appears to be even higher for veterans with symptom levels above the diagnostic threshold.

Fluid vulnerability theory as a framework for understanding the association between posttraumatic stress disorder and suicide: A narrative review

Suicide is a persistent issue in the United States and across the globe. A large body of published research shows that posttraumatic stress disorder (PTSD) increases the risk of suicidal ideation, suicidal behaviors, and death by suicide. However, the existing literature examining why that association might pertain is widely dispersed across disciplines (e.g., psychology, nursing) and lacks an integrative theoretical framework, making it difficult to conceptualize the current state of science in this area. Therefore, the primary aims of this narrative review were to (a) provide a comprehensive and interdisciplinary critique of the current state of knowledge regarding mechanisms that underlie the association between PTSD and suicide and (b) organize that knowledge according to a specified theoretical framework. The framework guiding this review is "fluid vulnerability theory," a diathesis-stress model of suicide that emphasizes the dynamic nature of suicide risk across cognitive, emotional, behavioral, and physiological domains. A summary of the findings, including patterns that emerged, gaps that remain, and recommendations for the advancement of science and practice in this area are addressed in this narrative review.

Perceived social stigma, self-concealment, and suicide risk among North Korean refugee women exposed to traumatic events

INTRODUCTION

Suicide among North Korean (NK) refugee women is one of the most concerning public health problems in South Korea. Pre-resettlement trauma exposure and post-resettlement factors can contribute to suicide risk among NK refugee women; however, few studies have explored these associations.

METHODS

This study aimed to assess suicidal ideation and suicide attempts among NK refugee women in South Korea (N = 212) and to examine the impact of pre-resettlement trauma exposure on suicide risk. Perceived social stigma and self-concealment in the post-resettlement phases were investigated as moderating factors for suicide risk related to trauma exposure using multiple regression analyses.

RESULTS

Trauma exposure significantly increased suicidal ideation severity and the risk of suicide attempt. Furthermore, perceived social stigma significantly moderated this relationship such that the impact of trauma exposure in the pre-resettlement phases was amplified as perceived social stigma increased.

CONCLUSION

Based on our study findings, professionals working with refugee populations should assess for perceived social stigma and exposure to traumatic events to reduce and prevent suicidal ideation and attempts.

Treating Veterans at Risk for Suicide: An Examination of the Safety, Tolerability, and Outcomes of Cognitive Processing Therapy

Individuals with posttraumatic stress disorder (PTSD) are at increased risk for suicidal thoughts and behaviors; however, clinicians often report apprehension about recommending trauma-focused therapy to patients with an increased risk of suicide. The present study aimed to evaluate the safety, tolerability, and response to cognitive processing therapy (CPT) among a sample of military veterans with PTSD and increased suicide risk. A secondary aim was to provide a clinically useful definition of high suicide risk. Chart review was used to classify the suicide risk level of 290 veterans who participated in CPT at a Veterans Affairs clinic. Treatment outcomes in veterans with different suicide risk levels were also gathered and compared. Over 50% (n = 155) of the sample demonstrated increased suicide risk, and 1.0% (n = 3) engaged in suicidal behavior after initiating treatment. To date, hospital records show no suicide deaths since 2016 among clinic patients who received CPT. Suicide risk level was not associated with CPT tolerability, and PTSD symptom change was equivalent across groups, ps = .085-.976. Veterans across groups reported clinically significant reductions in PTSD symptoms. The tested suicide risk categorization schemes performed similarly in differentiating the odds of CPT completion and PTSD symptom reduction. These results suggest that veterans with PTSD and an increased risk of suicide, including those with previous suicide attempts and current ideation, can tolerate and benefit from CPT. Additional variables must be considered to truly determine the acute and imminent suicide risk that would deem CPT to be contraindicated.

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

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

Clinical features and psychiatric comorbidities in military veterans with schizophrenia with or without suicidality

Suicide is currently among the leading causes of death among individuals with schizophrenia. Reducing mortality from suicide remains a major clinical challenge in the care of veterans with schizophrenia. There is a need to increase our understanding of what elevates suicide risk in veterans with schizophrenia as a first step towards the future development of suicide prevention interventions. This study compared demographic and clinical features of military veterans with schizophrenia with vs. without suicidality to determine specific risk factors for suicidality. The sample consisted of two groups of veterans with schizophrenia: suicide ideators and/or attempters (SIA) and individuals without a history of suicidal ideation or attempts (no-SIA). Participants were interviewed using the Structured Clinical Interview for DSM-5 Axis I disorders (SCID-I), Positive and Negative Syndrome Scale for Schizophrenia (PANSS), Hamilton Depression Rating Scale (HDRS), and Schizotypal Personality Questionnaire (SPQ). In bivariate analyses, the PANSS-Positive Symptom scores, PANSS-General Psychopathology scores, HDRS total score, HDRS-Paranoid symptoms item score, and SPQ total scores were higher among SIA compared with no-SIA patients. In this unique clinical sample of veterans with schizophrenia, SIA patients were more likely to have mood disorders, post-traumatic stress disorder (PTSD), and/or alcohol use disorder in comparison to the no-SIA group. Logistic regression analysis indicated that the HDRS total score and presence/absence of comorbid mood disorder drive the difference between the groups. These results indicate that suicide risk assessment in veterans with schizophrenia should include identifying individuals with comorbid mood disorders/symptoms, PTSD, alcohol use disorder, marked positive symptoms, and schizotypal features.

The protective role of reasons for living on suicidal cognitions for military affiliated individuals with a positive PTSD screen in primary care settings

BACKGROUND

Identifying and enhancing protective beliefs is essential in reducing suicide risk among military-affiliated individuals. The goal of this study was to examine if specific reasons for living impact the relationship between PTSD and suicidal cognitions among military-affiliated individuals in primary care settings.

METHODS

Participants included 2,685 U.S. military personnel and their adult beneficiaries recruited from primary care clinics. Participants completed the Primary Care Posttraumatic Stress Disorder Screen, Suicide Cognitions Scale, and Brief Reasons for Living Inventory.

RESULTS

Responsibility to family and survival and coping beliefs-were related to suicidal cognitions with higher levels associated with less suicidal cognitions and a weaker relationship between PTSD and suicidal cognitions. By contrast, fear of suicide and fear of social disapproval were associated with more suicidal cognitions, and the link between positive PTSD screen and suicidal cognitions was stronger for individuals with higher levels of fear of social disapproval. Moral objection did not predict suicidal cognitions and did not moderate the relationship between PTSD and suicidal cognitions.

LIMITATIONS

The limitations of the study include that measures were done in primary care and brief screeners were often used. Additionally, the study is cross-sectional in nature, whereas some of the symptoms and outcome variables likely fluctuate over time.

CONCLUSIONS

Findings suggest not all reasons for living are not equally influential and, among military-affiliated individuals with a positive PTSD screen, bolstering reasons for living related to responsibility to family and survival and coping skills could be particularly impactful in reducing suicide cognitions.

The role of emotion dysregulation in the association between posttraumatic stress disorder symptoms and suicidal thoughts and behaviors among veterans

OBJECTIVE

Although research has established a link between posttraumatic stress disorder (PTSD) symptoms and suicidal thoughts and behaviors (STBs), little is known about factors that may accentuate this relation. This study evaluated the influences of negative and positive emotion dysregulation on the association between PTSD symptoms and STBs among veterans.

METHODS

Four-hundred and sixty-five trauma-exposed military veterans in the community (M age  = 38.00, 71.4% male, 69.5% White) completed online questionnaires.

RESULTS

Negative emotion dysregulation did not moderate the relation between PTSD symptoms and STBs. Results showed significant interactive effects of PTSD symptoms and positive emotion dysregulation on STBs, such that PTSD symptoms were more strongly related to STBs at high (vs. low) levels of positive emotion dysregulation. This effect was sustained across domains of positive emotion dysregulation.

CONCLUSIONS

Findings suggest a potential need to consider positive emotion dysregulation in the assessment and treatment of STBs among veterans with PTSD symptoms.

What work-related exposures are associated with post-traumatic stress disorder? A systematic review with meta-analysis

OBJECTIVES

Although there is evidence that work-related exposures cause post-traumatic stress disorder (PTSD), there are few quantitative studies assessing the degree to which these factors contribute to PTSD. This systematic review with meta-analysis identified work-related exposures associated with PTSD, and quantified their contribution to this disorder.

METHODS

We searched Medline, PsycINFO, Embase, PILOTS and Web of Science (2005-10 September 2019) for longitudinal studies on work-related exposures and PTSD. We described included articles, and conducted meta-analyses for exposures with sufficient homogeneous information. We performed subgroup analyses for risk of bias, study design and PTSD ascertainment. We assessed evidence quality using Grades of Recommendations, Assessment, Development and Evaluation, and estimated population attributable fractions.

RESULTS

After screening 8590 records, we selected 33 studies (n=5 719 236). From what was moderate quality evidence at best, we identified various work-related exposures that were associated with PTSD, mainly involving individuals in the military and first responder (eg, police or fire brigade) occupations. These exposures included the number of army deployments (OR: 1.15 (95% CI 1.14 to 1.16)), combat exposure (OR 1.89 (95% CI 1.46 to 2.45)), army deployment (OR 1.79 (95% CI 1.45 to 2.21)) and confrontation with death (OR 1.63 (95% CI 1.41 to 1.90)). Effects were robust across subgroups and exposures attributed modestly (7%-34%) to PTSD. We identified additional exposures in other occupations, including life threats, being present during an attack, and hearing about a colleague's trauma.

CONCLUSIONS

We identified various work-related exposures associated with PTSD and quantified their contribution. While exposure assessment, PTSD ascertainment and inconsistency may have biased our findings, our data are of importance for development of preventive interventions and occupational health guidelines.

When reintegration fails: Stigmatization drives the ongoing violence of ex-combatants in Eastern Democratic Republic of the Congo

Reintegration of ex-combatants involves multiple challenges. In addition to the trauma-related psychological sequelae, social obstacles in the community can aggravate psychopathological aggressive tendencies and lead to the continuation of violence in civilian life. However, the association between others' negative attitudes and ex-combatants' ongoing perpetration of violence remains largely unexplored. Between September 2018 and May 2019, we assessed a representative community sample of adults in Eastern DR Congo (N = 1,058) and measured trauma exposure, perpetration, mental health problems (PTSD, depression, and appetitive aggression), perceived stigma (shame, perceived lack of social acknowledgement), experienced stigma, and skepticism toward reintegration with ex-combatants. Male ex-combatants (12%, n = 129) had more past trauma and violence perpetration than other community members and a greater number of recent conflicts (including both victimization and perpetration) within the community and with strangers/organized violence. They reported more experienced stigma, more severe PTSD symptoms but were less skeptical about reintegration. Ex-combatants' ongoing violence was predicted by an interplay of the community's skepticism toward reintegration and ex-combatants' perceived and recently experienced stigma (often attributed to the armed group history) and mental health problems, in addition to lifetime traumatization. These findings promote the need for combined interventions that address individual mental health problems including aggression and collective discriminatory attitudes and behaviors.

The Effect of PTSD Symptom Change on Suicidal Ideation in a Combined Military and Civilian Sample Engaged in Cognitive Processing Therapy

In light of the well-established relationship between posttraumatic stress disorder (PTSD) and suicidal ideation (SI), there has been a push for treatments that simultaneously improve symptoms of PTSD and decrease SI. Using data from a randomized controlled hybrid implementation-effectiveness trial, the current study investigated the effectiveness of Cognitive Processing Therapy (CPT; Resick, Monson, & Chard, 2016) on PTSD and SI. The patient sample (N = 188) was diverse in military and veteran status, gender, and comorbidity, and 73% of the sample endorsed SI at one or more points during CPT. Participants demonstrated significant improvement in SI over the course of CPT. Multilevel growth curve modeling revealed a significant association between PTSD symptom change and change in SI. Results from cross-lagged multilevel regressions indicated that PTSD symptoms predicted SI in the next session, yet SI in a given session did not predict PTSD symptoms in the next session. Potentially relevant clinical factors (i.e., military status, gender, depression diagnosis, baseline SI, study consultation condition) were not associated with the relationship between PTSD symptoms and SI. These results add to the burgeoning literature suggesting that evidence-based treatments for PTSD, like CPT, reduce suicidality in a range of individuals with PTSD, and that this reduction is predicted by improvements in PTSD symptoms.

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

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

Predictors of Unbearability, Unlovability, and Unsolvability in Veterans With Military-Sexual-Trauma-Related Posttraumatic Stress Disorder

Military sexual trauma (MST) and posttraumatic stress disorder (PTSD) both increase risk for suicidal self-directed violence (SDV). Suicide cognitions (i.e., unbearability, unlovability, and unsolvability) are strong predictors of future suicidal SDV. The present study investigated potential predictors of unbearability, unlovability, and unsolvability in veterans with MST-related PTSD. Suicide cognitions, depression, PTSD, quality of life, trauma-related negative cognitions, physical health functioning, mental health functioning, and childhood sexual assault were assessed in 12 male and 103 female veterans with MST-related PTSD. Higher depression scores, greater trauma-related negative cognitions about self, and poorer physical health functioning predicted increased unbearability scores. Greater trauma-related negative cognitions about self and self-blame, higher level of education, and higher depression scores predicted increased unlovability scores. Higher depression scores and greater trauma-related negative cognitions about self predicted increased unsolvability scores. In veterans with MST-related PTSD who express unbearability, unlovability, and unsolvability, assessing and addressing depression, trauma-related negative cognitions about self and self-blame, and physical health functioning may be an important step in reducing SDV.

Shame as a Moderator between Emotion Dysregulation and Posttraumatic Stress Disorder Severity among Combat Veterans Seeking Residential Treatment

BACKGROUND

Growing evidence suggests that emotion dysregulation may be predictive of posttraumatic stress disorder (PTSD) severity, with emotional non-acceptance, lack of counter strategies, impulse control deficits, and lack of emotional awareness all being positive predictors. However, findings have been mixed. This may be due to no previous study examining the association between emotion dysregulation and PTSD severity with shame, a maintaining factor of PTSD, as a potential moderator.

METHODS

The present study examined the relationship between emotion dysregulation, shame, and PTSD severity among 78 male combat veterans (mean age = 42.19) upon their admission to a residential combat PTSD program.

RESULTS

Results demonstrated that shame and all facets of emotion dysregulation (except lack of emotional awareness & clarity) were positively associated with PTSD severity. Shame moderated the relationship between lack of emotional awareness and strategies. Among those at or below the sample mean on shame, lack of access to strategies was a positive predictor of PTSD severity. Comparatively, among those with high levels of shame, emotional awareness predicted greater PTSD severity, while among those with low levels of shame, emotional awareness predicted lower PTSD severity.

LIMITATIONS

Limitations included reliance on self-report questionnaires and an all-male sample.

CONCLUSIONS

Thus, emotion dysregulation may only predict PTSD severity among those reporting lower levels of shame, suggesting the importance of addressing shame as well as emotion dysregulation deficits among those with PTSD. Moreover, emotional awareness may be either a risk or protective factor depending on levels of shame.

Social support, social network size, and suicidal ideation: A nine-year longitudinal analysis from the Mind Your Heart Study

Substantial research has investigated the impact of social support on the development and course of suicidal thoughts and behaviors. However, its measurement has been inconsistent, and different facets of social support may have differential effects on suicidal ideation (SI). The present study used data from 743 veterans recruited between 2008 and 2010 as part of the Mind Your Heart Study to investigate the relationship between two aspects of social support (social network size and perceived social support) and SI over 9 years. Using the 9th item of the PHQ-9, we created two composite scores: (1, chronicity) the proportion of years the participant endorsed SI and (2, severity) the severity of SI across the follow-up period. We found that, when modeled individually, both larger social network size and greater perceived social support predicted lower SI chronicity (β=-.16, β = -0.19 respectively; ps < .001) and lower SI severity (β=-0.15 and β = -0.19, respectively; ps < .001). However, when modeled together and controlling for PTSD and depression symptoms, increased social network size but not perceived social support predicted lower SI chronicity (β=-0.09, p = .01 and β = 0.02, p = .48, respectively) and SI severity (β=-0.07, p = .045 and β = 0.01, p = .71, respectively). These findings suggest that social network size may be an important target for intervention, and that future work is needed to better delineate the effect of different features of social support on risk for suicide.

STUDY OF SUICIDE BEHAVIOR IN JOINT FORCE OPERATION VETERANS IN EASTERN UKRAINE AND IN LIQUIDATORS OF THE CONSEQUENCES OF THE CHORNOBYL ACCIDENT

The article is devoted to the problem of completed suicides among veterans of the Joint Forces for National Securityand Defense operation in Donetsk and Luhansk regions (JFO) and liquidators of the consequences of the Chornobylaccident (LCCA). The results of the analysis of surveys of families and close associates of JFO veterans who committed a completed suicide in the period 2014-2019 are presented. The survey was conducted as part of criminal proceedings initiated on the facts of suicide.

OBJECTIVE

to analyze the current dynamics of suicidal behavior in veterans of JFO and the impact of psychosocialfactors on its development and compare with the relevant indicators among LCCA at the Chornobyl nuclear powerplant.

MATERIALS AND METHODS

175 questionnaires are presented, socio-demographic characteristics are compiled and psychosocial factors that influenced the development of suicidal behavior in environmental protection veterans areidentified. An analysis of the status of such studies among liquidators of the Chornobyl accidents.

RESULTS

the data analysis of suicidal behavior in veterans of environmental protection, the impact on its development of psychosocial factors and comparison with the indicators among LCCA at the Chornobyl Nuclear PowerPlant.

CONCLUSIONS

The results of the study show that in emergency situations, mostly men from all regions of the country, both professional servicemen and civilians, are involved in its elimination. It has been proven that while performing their official duties, the veterans of JFO and LCCA at the Chornobyl nuclear power plant experienced mental stress. But most of them, returning home, did not seek medical treatment, prevent the development of diseasesand their complications and remained for a long time without proper medical, social and psychological care.

PTSD and obesity in U.S. military veterans: Prevalence, health burden, and suicidality

Post-traumatic stress disorder (PTSD) and obesity are prevalent among U.S. military veterans, though less is known about the mental and physical health burden and suicidality of co-occurring PTSD and obesity in this population. A nationally representative sample of the U.S. veterans was used to assess PTSD and obesity prevalence, co-occurrence and relationships with mental and physical health measures. A total of 16.4% of veterans screened positive for current PTSD, 32.7% for obesity, and 5.8% for co-occurring PTSD and obesity. Relative to obesity-only veterans, veterans with co-occurring PTSD and obesity had elevated likelihoods of mental and physical health concerns (most notably major depressive and generalized anxiety disorders), suicidality, and migraine headaches, and higher body mass indices. Relative to veterans with PTSD alone, individuals with comorbid PTSD and obesity had elevated likelihoods of suicidal ideation, nicotine dependence, mental health treatment, migraine headaches, diabetes, hypertension, and insomnia. A significant minority of U.S. veterans has co-occurring PTSD and obesity, which is associated with substantial mental and physical health burden, including elevated suicidality.  Results underscore the importance of integrative assessment, monitoring, and treatment approaches for PTSD and obesity in this population.

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

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