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Edwards E, Osterberg T, Coolidge B, Greene AL, Epshteyn G, Gorman D, Ruiz D, El-Meouchy P. Military experiences, connection to military identity, and time since military discharge as predictors of United States veteran suicide risk. MILITARY PSYCHOLOGY 2024; 36:465-478. [PMID: 37204335 PMCID: PMC11407380 DOI: 10.1080/08995605.2023.2209006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 04/12/2023] [Indexed: 05/20/2023]
Abstract
Veterans navigating the military-to-civilian transition appear at elevated risk for suicide. However, research on the transition-suicide association often fails to consider co-occurring risk factors. The independent association of time since military discharge and suicide among veterans therefore remains unclear. Data from 1,495 post-Vietnam community veterans provided estimates of suicide risk, military-based stressful experiences, connection to military identity, and recency of military discharge. Hierarchical regression analyses examined independent, incremental utility of factors associated with suicide risk after controlling for quality of life, age, and duration of military service among the total veteran sample and a subsample discharged from military service within five years prior. The resulting model explained 41% of variance in suicide risk in the total veteran sample and 51% of variance in suicide risk in the recently discharged subsample. Recency of discharge, combat exposure, moral injury, poor quality of life, and poor psychological wellness showed statistically significant, independent associations with suicide risk, whereas connection to military identity did not show significant, independent associations. Results highlight the salience of the military-to-civilian transition as an independent risk factor for veteran suicide even after controlling for military-based stressful experiences, military identity, quality of life, age, and service duration.
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Affiliation(s)
- Emily Edwards
- Department of Veterans Affairs, VISN 2 MIRECC, Bronx, New York
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Terra Osterberg
- Department of Veterans Affairs, VISN 2 MIRECC, Bronx, New York
| | - Brettland Coolidge
- Department of Veterans Affairs, VISN 2 MIRECC, Bronx, New York
- Department of Psychology, University of Central Florida, Orlando, Florida
| | - Ashley L Greene
- Department of Veterans Affairs, VISN 2 MIRECC, Bronx, New York
- Department of Psychiatry, Icahn School of Medicine, New York, New York
| | - Gabriella Epshteyn
- Department of Veterans Affairs, VISN 2 MIRECC, Bronx, New York
- Department of Psychology, University of Rhode Island, Kingston, Rhode Island
| | - Daniel Gorman
- Department of Veterans Affairs, VISN 2 MIRECC, Bronx, New York
| | - Danny Ruiz
- Department of Veterans Affairs, VISN 2 MIRECC, Bronx, New York
| | - Paul El-Meouchy
- Department of Veterans Affairs, VISN 2 MIRECC, Bronx, New York
- Department of Psychology, Fielding Graduate University, Santa Barbara, California
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2
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Oltvolgyi CG, Meurk C, Heffernan E. Suicide and suicidality in Australian Defence Force veterans: A systematic scoping review. Aust N Z J Psychiatry 2024; 58:760-774. [PMID: 38650320 PMCID: PMC11370192 DOI: 10.1177/00048674241246443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
OBJECTIVE Increased suicidality and suicide deaths among veterans of the Australian Defence Force have gained recent prominence. A systematic scoping review was conducted to identify, summarise and synthesise the existing literature relating to Australian veteran suicide and suicidality, with the objective of identifying future research priorities. METHODS We conducted a PRISMA-compliant systematic search on PubMed/MEDLINE, Embase and CINAHL databases for all manuscripts reporting primary data on suicide and suicidality in Australian veterans. The search was supplemented by grey literature and a search of reference lists. Manuscripts of any study type, published in the English language since the Vietnam era, were eligible for inclusion. RESULTS A total of 26 articles and reports, utilising a variety of mostly quantitative approaches, were included in the review. Findings, especially in larger and more recent studies, indicate increased suicidality in the veteran population. Suicide deaths appeared to increase with transition out of the military. Mental illness was identified as an important risk factor for suicide and suicidality. Current service was identified as a protective factor against suicide. There was mixed evidence regarding the impact of operational deployment on suicide and suicidality. CONCLUSIONS Gaps were identified in relation to the relative contributions to risk from transition, the various psychosocial correlates (for example, relationships, finances, employment), pre-service factors and the extent to which these are causal or mediating in nature. A better understanding of health service utilisation would also aid in targeting preventive efforts. Future research in these areas is warranted.
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Affiliation(s)
- Csongor G Oltvolgyi
- School of Public Health, The University of Queensland, Herston, QLD, Australia
- Queensland Centre for Mental Health Research, Wacol, QLD, Australia
| | - Carla Meurk
- School of Public Health, The University of Queensland, Herston, QLD, Australia
- Queensland Centre for Mental Health Research, Wacol, QLD, Australia
| | - Ed Heffernan
- School of Public Health, The University of Queensland, Herston, QLD, Australia
- Queensland Centre for Mental Health Research, Wacol, QLD, Australia
- Queensland Forensic Mental Health Service, Brisbane, QLD, Australia
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3
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Coppola EC, MacDermid Wadsworth S, Taylor ZE, Schwab-Reese L, Christ SL. Military service and sociodemographic determinants of depressive symptom trajectories. SOCIAL SCIENCE RESEARCH 2024; 123:103062. [PMID: 39256029 DOI: 10.1016/j.ssresearch.2024.103062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 08/08/2024] [Accepted: 08/10/2024] [Indexed: 09/12/2024]
Abstract
Little is known about preservice depressive symptoms, their linkages to subsequent depressive symptoms, and the role of sociodemographic factors in shaping depressive symptoms of those who serve in the military. Using data from the National Longitudinal Study of Adolescent to Adult Health (n = 18,910), we modeled depressive symptom trajectories from baseline (Mage = 15.67) through midlife and compared differences in depressive symptoms between participants who did and did not enter military service. Those who served in the military went on to develop lower levels of depressive symptoms than civilians during their prime military service years, even after accounting for sociodemographic factors that shape pathways into military service. Differences in depressive symptoms by military affiliation were no longer significant by their mid-30s. Results provided a more complete account of depressive symptom patterns associated with military service by including data on individuals before and during military service.
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Affiliation(s)
- Elizabeth C Coppola
- Department of Human Development and Family Studies, Purdue University, USA; VA Connecticut Healthcare System, West Haven, CT, USA.
| | | | - Zoe E Taylor
- Department of Human Development and Family Studies, Purdue University, USA
| | | | - Sharon L Christ
- Department of Human Development and Family Studies, Purdue University, USA
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Walton TO, Graupensperger S, Walker DD, Kaysen D. Alcohol use disorder as a moderator of the relationship between posttraumatic stress disorder and suicidality among military personnel. ALCOHOL, CLINICAL & EXPERIMENTAL RESEARCH 2024; 48:1096-1106. [PMID: 38796793 DOI: 10.1111/acer.15313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 02/02/2024] [Accepted: 03/11/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Alcohol use disorder (AUD), posttraumatic stress disorder (PTSD), and suicide are substantial public health concerns among military service members, yet the nature of their relationships is not well understood. Here, we tested the hypothesis that AUD moderates the relationship between PTSD symptom severity and suicidal ideation. METHODS This secondary analysis uses data collected at baseline for a randomized clinical trial. The sample consists of 160 active-duty service members from three service branches (Army, Air Force, and Navy). All participants met diagnostic criteria for PTSD and were not engaged in evidence-based PTSD treatment at the time of enrollment. Zero-inflated Poisson generalized linear regression models were used to test the associations of PTSD and AUD symptom severity with the presence and severity of suicidal ideation. RESULTS Findings suggest that AUD symptom severity moderates (i.e., amplifies) the relationship between PTSD symptoms and severity of suicidal ideation among military personnel with untreated PTSD. Among service members with mild or absent AUD, we found no significant association between PTSD symptoms and the severity of suicidal ideation. However, when AUD severity was average (i.e., sample mean) or high (mean + 1SD), PTSD symptoms were significantly positively associated with the severity of suicidal ideation. CONCLUSIONS This study highlights the importance of assessing AUD and PTSD as a part of suicide risk evaluations of veterans. The results also provide strong support for the maintenance and further development in the military health system of treatment programs that simultaneously address AUD and PTSD comorbidity.
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Affiliation(s)
- Thomas O Walton
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Scott Graupensperger
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Denise D Walker
- School of Social Work, University of Washington, Seattle, Washington, USA
| | - Debra Kaysen
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, California, USA
- National Center for PTSD, VA Palo Alto Health Care System, Palo Alto, California, USA
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Williamson C, Croak B, Simms A, Fear NT, Sharp ML, Stevelink SAM. Risk and protective factors for self-harm and suicide behaviours among serving and ex-serving personnel of the UK Armed Forces, Canadian Armed Forces, Australian Defence Force and New Zealand Defence Force: A systematic review. PLoS One 2024; 19:e0299239. [PMID: 38669252 PMCID: PMC11051630 DOI: 10.1371/journal.pone.0299239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/06/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Self-harm and suicide behaviours are a major public health concern. Several factors are associated with these behaviours among military communities. Identifying these factors may have important implications for policy and clinical services. The aim of this review was to identify the risk and protective factors associated with self-harm and suicide behaviours among serving and ex-serving personnel of the United Kingdom Armed Forces, Canadian Armed Forces, Australian Defence Force and New Zealand Defence Force. METHODS A systematic search of seven online databases (PubMed, Web of Science, Embase, Global Health, PsycINFO, PTSDpubs and CINAHL) was conducted alongside cross-referencing, in October 2022. Following an a priori PROSPERO approved protocol (CRD42022348867), papers were independently screened and assessed for quality. Data were synthesised using a narrative approach. RESULTS Overall, 28 papers were included: 13 from Canada, 10 from the United Kingdom, five from Australia and none from New Zealand. Identified risk factors included being single/ex-relationship, early service leavers, shorter length of service (but not necessarily early service leavers), junior ranks, exposure to deployment-related traumatic events, physical and mental health diagnoses, and experience of childhood adversity. Protective factors included being married/in a relationship, higher educational attainment, employment, senior ranks, and higher levels of perceived social support. CONCLUSION Adequate care and support are a necessity for the military community. Prevention and intervention strategies for self-harm and suicide behaviours may be introduced early and may promote social networks as a key source of support. This review found a paucity of peer-reviewed research within some populations. More peer-reviewed research is needed, particularly among these populations where current work is limited, and regarding modifiable risk and protective factors.
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Affiliation(s)
- Charlotte Williamson
- King’s Centre for Military Health Research, King’s College London, London, United Kingdom
| | - Bethany Croak
- King’s Centre for Military Health Research, King’s College London, London, United Kingdom
| | - Amos Simms
- Academic Department of Military Mental Health, King’s College London, London, United Kingdom
- British Army, London, United Kingdom
| | - Nicola T. Fear
- King’s Centre for Military Health Research, King’s College London, London, United Kingdom
- Academic Department of Military Mental Health, King’s College London, London, United Kingdom
| | - Marie-Louise Sharp
- King’s Centre for Military Health Research, King’s College London, London, United Kingdom
| | - Sharon A. M. Stevelink
- King’s Centre for Military Health Research, King’s College London, London, United Kingdom
- Department of Psychological Medicine, King’s College London, London, United Kingdom
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6
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Slavin AZ, Fischer IC, Pietrzak RH. Differential associations of adverse childhood experiences and mental health outcomes in U.S. military veterans. J Psychiatr Res 2024; 172:261-265. [PMID: 38412789 DOI: 10.1016/j.jpsychires.2024.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/23/2024] [Accepted: 02/20/2024] [Indexed: 02/29/2024]
Abstract
Adverse childhood experiences (ACEs) are robustly associated with adverse mental health outcomes across the lifespan. Military veterans may be particularly vulnerable to adverse mental health effects of ACEs given their potentially higher prevalence of childhood traumas and compounding effects of military service-related traumas. To date, however, scarce research has examined the differential impact of individual ACEs on mental health outcomes in population-based samples of veterans. To address this gap, we analyzed data from the National Health and Resilience in Veterans Study (NHRVS), which surveyed a nationally representative sample of 4069 U.S. veterans, to examine the association between specific ACEs and major depressive, generalized anxiety, and posttraumatic stress disorders, and suicidal thoughts and behaviors. Results of multivariable logistic regression analyses revealed that emotional neglect and sexual abuse were most consistently associated with these outcomes, even after adjustment for the number of ACEs endorsed. Collectively, results of this study underscore the importance of assessing for specific ACEs-most notably childhood emotional neglect and sexual abuse-and treating these potentially unresolved childhood traumas in veterans.
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Affiliation(s)
- Alana Z Slavin
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.
| | - Ian C Fischer
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA; U.S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Robert H Pietrzak
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA; U.S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, West Haven, CT, USA; Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA
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Kok BC, Dux M, Lee-Wilk T, Clarke-Walper K, Wilk JE. Differential impact of type of killing on posttraumatic stress disorder symptoms in U.S. Army soldiers deployed to Afghanistan. J Trauma Stress 2023; 36:1151-1156. [PMID: 37705140 DOI: 10.1002/jts.22971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/12/2023] [Accepted: 07/16/2023] [Indexed: 09/15/2023]
Abstract
Over the past 20 years, U.S. military conflicts in Iraq and Afghanistan have been marked by high rates of combat and wartime killings. Research on Vietnam-era service members suggests that the type of killing (i.e., killing a combatant vs. noncombatant) is an important predictor of later mental health problems, including posttraumatic stress disorder (PTSD). The present study aimed to update these findings by exploring the impact of type of killing on PTSD symptoms using a sample of postdeployment active duty U.S. Army personnel (N = 875). Using multiple regression analysis, we found that the act of killing a noncombatant was significantly associated with PTSD symptoms, B = 7.50, p < .001, whereas killing a combatant was not, B = -0.85, p = .360. This remained significant after controlling for demographic variables, depressive symptoms, and general combat experiences. These findings support the need for thoughtful postdeployment screenings and targeted clinical interventions.
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Affiliation(s)
- Brian C Kok
- VA Maryland Health Care System, Baltimore, Maryland, USA
| | - Moira Dux
- VA Maryland Health Care System, Baltimore, Maryland, USA
| | - Terry Lee-Wilk
- VA Maryland Health Care System, Baltimore, Maryland, USA
| | - Kristina Clarke-Walper
- Department of Military Psychiatry, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Joshua E Wilk
- Department of Military Psychiatry, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
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8
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Orak U, Yildiz M, Aydogdu R, Koenig HG, Pietrzak RH. The relationship between combat exposure and suicide risk in U.S. military veterans: Exploring the role of posttraumatic stress symptoms and religious coping. J Affect Disord 2023; 341:77-87. [PMID: 37634819 DOI: 10.1016/j.jad.2023.08.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 07/19/2023] [Accepted: 08/23/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Rising suicide rates in the U.S. veteran population are a growing concern. Combat exposure has been identified as a potential predictor of suicide risk, but factors that may mediate the relation between combat exposure and suicide risk, and the role of potential coping mechanisms remain largely understudied. To address this gap, this study examined the association between lifetime combat exposure and current suicide risk; whether this association is mediated by posttraumatic stress disorder (PTSD) symptoms; and whether direct and/or indirect associations with combat exposure are moderated by organizational, non-organizational, and intrinsic religiosity. METHODS Data were analyzed from the National Health and Resilience in Veterans Study (2019-2020; n = 3843). Ordinary least squares and conditional process analyses were conducted to evaluate the conditional direct and indirect predictors of suicide risk. RESULTS PTSD symptoms significantly mediated the association between combat exposure and suicide risk. Intrinsic religiosity showed significant moderation and reduced the coefficient of PTSD symptoms predicting suicide risk but increased the coefficient of combat exposure predicting PTSD symptoms. LIMITATIONS In this cross-sectional, observational study, no conclusions can be made regarding causality. CONCLUSIONS Results of this study suggest a multifaceted relationship between combat exposure, PTSD, religiosity/spirituality, and suicide risk in U.S. veterans, and underscore the importance of PTSD and religious coping as part of ongoing suicide prevention efforts in this population.
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Affiliation(s)
- Ugur Orak
- Department of Sociology and Anthropology, Middle Tennessee State University, Murfreesboro, TN, USA.
| | - Muhammed Yildiz
- Applied Sociology Department, Utah Tech University, St. George, UT, USA
| | - Ramazan Aydogdu
- Division of General Education and Health Studies, Baptist Health Sciences University, Memphis, TN, USA
| | - Harold G Koenig
- Department of Psychiatry and Behavioral Sciences, Department of Medicine, Duke University Medical Center, Durham, NC, USA; Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Robert H Pietrzak
- U.S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, USA; Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA; Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA
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9
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Schafer KM, Wilson E, Joiner T. Traumatic brain injury and suicidality among military veterans: The mediating role of social integration. J Affect Disord 2023; 338:414-421. [PMID: 37364657 DOI: 10.1016/j.jad.2023.06.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 06/01/2023] [Accepted: 06/20/2023] [Indexed: 06/28/2023]
Abstract
Suicide is a widespread public health concern, including among military Veterans. Traumatic brain injuries (TBIs) and lack of social integration have both been shown to increase risk for suicidality, an outcome that includes, among other suicide-related variables, suicidal ideation, suicide attempts, and suicide death. Interestingly, TBIs have also been identified as a risk factor for social integration problems. In this cross-sectional study we investigated associations between TBI, social integration, and suicidality. Additionally, mediation analysis was used to test whether social integration mediated the association between TBI and suicidality. A sample of 1469 military Veterans (male, n = 1004, 67.2 %; female, n = 457, 32.3 %; transgender/non-binary/prefer not to say, n = 8, 0.5 %) completed an online survey as part of the Military Health and Well-Being Project. TBI was negatively associated with social integration (r = -0.084, p < .001) and positively with suicidality (r = 0.205, p < .001). Social integration was negatively associated with suicidality (r = -0.161, p < .001). Finally, social integration partially mediated the relationship between TBI and social integration (B = 0.121, 95 % CI [0.031-0.23]). This work shows that in the context of TBI, lack of social integration may promote suicidality. It provides support for many theories of suicide which propose social problems as a risk factor of suicide-related outcomes. It further highlights social integration as potential fodder for novel interventions for suicidality, an approach that would have transtheoretical support.
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Affiliation(s)
| | - Emma Wilson
- Kings College London, United States; Florida State University, United States
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10
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Silva MA, Gonzalez AV, Tang X, Carnahan ND, Klyce DW, Liou-Johnson V, Martin AM, Moberg JM, Dreer LE. Examining the Relationship Between Sleep Apnea Diagnosis and Suicide Risk in Veterans With Traumatic Brain Injury: A VA TBI Model Systems Study. J Head Trauma Rehabil 2023; 38:359-367. [PMID: 36727802 DOI: 10.1097/htr.0000000000000856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Obstructive sleep apnea (OSA) is a common sleep disorder in people with traumatic brain injury (TBI). Although sleep disturbances have been associated with an increased risk of suicide compared with the general population, the relationship between OSA and suicide risk after TBI is not well documented. In this study, we hypothesized that OSA diagnosis would predict suicide risk in veterans with TBI. SETTING Five Veterans Affairs (VA) Polytrauma Rehabilitation Centers. PARTICIPANTS Participants were drawn from the VA TBI Model Systems study, with follow-up interviews at year 1 ( n = 392), year 2 ( n = 444), year 5 ( n = 498), or year 10 ( n = 252) post-TBI (7.8%-14.5% follow-up attrition). DESIGN This was a retrospective analysis from observational data using logistic regression with repeated measurements. Suicide ideation and suicide attempts were examined as outcomes at each follow-up to evaluate the relationship between OSA and suicide risk after adjusting for other risk factors determined a priori via literature review. MAIN MEASURES Suicidal ideation (Patient Health Questionnaire-9 item 9), suicide attempt during the past year (self-reported), and OSA diagnosis (self-reported). RESULTS Contrary to study hypotheses, OSA diagnosis had no statistically significant association with suicide ideation or attempt after accounting for known predictors. However, greater depression symptoms, headache severity, and pre-TBI suicidal ideation and attempts predicted suicide risk at follow-up after accounting for other predictors. CONCLUSIONS Results of this study did not support a relationship between OSA and suicide risk, possibly due to methodological limitations of OSA measurement. Future research on this topic should include objective measures of OSA severity and OSA treatment including adherence. Although suicide is a low base rate occurrence, the impact is disastrous and further research is needed to mitigate suicide risk.
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MESH Headings
- Humans
- Brain Injuries, Traumatic/diagnosis
- Brain Injuries, Traumatic/epidemiology
- Brain Injuries, Traumatic/complications
- Retrospective Studies
- Sleep Apnea, Obstructive/diagnosis
- Sleep Apnea, Obstructive/epidemiology
- Sleep Apnea, Obstructive/complications
- Stress Disorders, Post-Traumatic/diagnosis
- Stress Disorders, Post-Traumatic/epidemiology
- Stress Disorders, Post-Traumatic/complications
- Suicidal Ideation
- Suicide, Attempted
- Veterans
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Affiliation(s)
- Marc A Silva
- Mental Health and Behavioral Sciences Section (Drs Silva, Gonzalez, and Martin) and Research Service (Mr Moberg), James A. Haley Veterans' Hospital, Tampa, Florida; Dept. of Internal Medicine and Dept. of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa (Dr Silva); Tampa VA Research and Education Foundation, Tampa, Florida (Dr Tang); Central Virginia VA Health Care System, Richmond (Drs Carnahan and Klyce); Dept. of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond (Dr Klyce); Sheltering Arms Institute, Richmond, Virginia (Dr Klyce); VA Palo Alto Healthcare Center, Palo Alto, California (Dr Liou-Johnson); Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, California (Dr Liou-Johnson); Traumatic Brain Injury Center of Excellence (TBICoE), Tampa, Florida (Mr Moberg); and University of Alabama at Birmingham (Dr Dreer). Dr Carnahan is now affiliated with the Department of Physical Medicine and Rehabilitation at Johns Hopkins, Baltimore, Maryland
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Patel TA, Blakey SM, Halverson TF, Mann AJD, Calhoun PS, Beckham JC, Pugh MJ, Kimbrel NA. Experiential Avoidance, Posttraumatic Stress Disorder, and Self-Injurious Thoughts and Behaviors: A Moderation Analysis in a National Veteran Sample. Int J Cogn Ther 2023; 1:10.1007/s41811-023-00164-2. [PMID: 37360585 PMCID: PMC10288701 DOI: 10.1007/s41811-023-00164-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 06/28/2023]
Abstract
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.
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Affiliation(s)
- Tapan A. Patel
- Department of Psychology, Florida State University; Tallahassee, FL
| | | | - Tate F. Halverson
- Durham VA Health Care System; Durham, NC
- VA Mid-Atlantic Mental Illness Research, Education and Clinical Center; Durham, NC
| | | | - Patrick S. Calhoun
- Durham VA Health Care System; Durham, NC
- VA Mid-Atlantic Mental Illness Research, Education and Clinical Center; Durham, NC
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine; Durham, NC
| | - Jean C. Beckham
- Durham VA Health Care System; Durham, NC
- VA Mid-Atlantic Mental Illness Research, Education and Clinical Center; Durham, NC
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine; Durham, NC
| | - Mary J. Pugh
- VA Salt Lake City Healthcare System, Salt Lake City; UT
- University of Utah School of Medicine Department of Medicine; Salt Lake City, UT
| | - Nathan A. Kimbrel
- Durham VA Health Care System; Durham, NC
- VA Mid-Atlantic Mental Illness Research, Education and Clinical Center; Durham, NC
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine; Durham, NC
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Brown LA, Zhu Y, Coon H, Young-McCaughan S, Fina BA, Dondanville KA, Hernandez AM, Litz BT, Mintz J, Maurer DM, Kelly KM, Peterson AL, Bryan CJ, Williamson DE. Phenotypic predictors of suicide subtypes from pre-to postdeployment in active duty military personnel. J Psychiatr Res 2023; 160:163-170. [PMID: 36804111 PMCID: PMC11420699 DOI: 10.1016/j.jpsychires.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 02/02/2023] [Accepted: 02/06/2023] [Indexed: 02/09/2023]
Abstract
Military service members are at increased risk for suicide, but there are few strategies for detecting those who are at highest risk after a deployment. Using all available data collected from 4119 Military service members before and after their deployment to Iraq for Operation Iraqi Freedom, we tested whether predeployment characteristics clustered together to predict postdeployment suicidal risk. Latent class analysis showed that three classes best characterized the sample at predeployment. Class 1 had significantly higher scores on PTSD severity pre- and postdeployment than Classes 2 and 3 (Ps < .001). At postdeployment, Class 1 also had a greater proportion of endorsement of lifetime and past year suicidal ideation than Classes 2 and 3 (Ps < .05) and a greater proportion of lifetime suicide attempts than Class 3 (P < .001). Class 1 also had a greater proportion of endorsement of past-30-days intention to act on suicidal thoughts than Classes 2 and 3 (Ps < .05) and past-30-days specific plan for suicide than Classes 2 and 3 (Ps < .05). The study showed that based only on predeployment data, it is possible to determine which service members might be at highest risk for suicidal ideation and behavior at postdeployment.
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Affiliation(s)
- Lily A Brown
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA.
| | - Yiqin Zhu
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - Hillary Coon
- Department of Psychiatry, University of Utah, Salt Lake City, UT, USA
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA; Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Brooke A Fina
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Katherine A Dondanville
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Ann Marie Hernandez
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA; Valiant Mental Health, San Antonio, TX, USA
| | - Brett T Litz
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, MA, USA; Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA; Department of Psychological and Brain Sciences, Boston University, Boston, MA, USA
| | - Jim Mintz
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA; Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX, USA; Department of Population Health Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Douglas M Maurer
- Department of Family and Community Medicine, Carl R. Darnall Army Medical Center, Fort Hood, Texas, USA; Madigan Army Medical Center, Joint Base Lewis-McChord, Tacoma, WA, USA
| | - Kevin M Kelly
- Department of Family and Community Medicine, Carl R. Darnall Army Medical Center, Fort Hood, Texas, USA; Office of Consultants to the Army Surgeon General, Washington, DC, USA
| | - Alan L Peterson
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA; Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX, USA; Department of Psychology, University of Texas at San Antonio, San Antonio, TX, USA
| | - Craig J Bryan
- Department of Psychiatry and Behavioral Health, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Douglas E Williamson
- Department of Psychiatry & Behavioral Sciences, Duke University, Durham, NC, USA; Durham VA Medical Center, Durham, NC, USA
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13
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Campbell-Sills L, Kautz JD, Choi KW, Naifeh JA, Aliaga PA, Jain S, Sun X, Kessler RC, Stein MB, Ursano RJ, Bliese PD. Effects of prior deployments and perceived resilience on anger trajectories of combat-deployed soldiers. Psychol Med 2023; 53:2031-2040. [PMID: 34802475 PMCID: PMC9124235 DOI: 10.1017/s0033291721003779] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/26/2021] [Accepted: 09/01/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Problematic anger is frequently reported by soldiers who have deployed to combat zones. However, evidence is lacking with respect to how anger changes over a deployment cycle, and which factors prospectively influence change in anger among combat-deployed soldiers. METHODS Reports of problematic anger were obtained from 7298 US Army soldiers who deployed to Afghanistan in 2012. A series of mixed-effects growth models estimated linear trajectories of anger over a period of 1-2 months before deployment to 9 months post-deployment, and evaluated the effects of pre-deployment factors (prior deployments and perceived resilience) on average levels and growth of problematic anger. RESULTS A model with random intercepts and slopes provided the best fit, indicating heterogeneity in soldiers' levels and trajectories of anger. First-time deployers reported the lowest anger overall, but the most growth in anger over time. Soldiers with multiple prior deployments displayed the highest anger overall, which remained relatively stable over time. Higher pre-deployment resilience was associated with lower reports of anger, but its protective effect diminished over time. First- and second-time deployers reporting low resilience displayed different anger trajectories (stable v. decreasing, respectively). CONCLUSIONS Change in anger from pre- to post-deployment varies based on pre-deployment factors. The observed differences in anger trajectories suggest that efforts to detect and reduce problematic anger should be tailored for first-time v. repeat deployers. Ongoing screening is needed even for soldiers reporting high resilience before deployment, as the protective effect of pre-deployment resilience on anger erodes over time.
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Affiliation(s)
| | - Jason D. Kautz
- Department of Organizations, Strategy, and International Management, University of Texas at Dallas, Dallas, TX, USA
| | - Karmel W. Choi
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Psychiatric and Neurodevelopmental Genetics Unit, Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Stanley Center for Psychiatric Research, Broad Institute, Boston, MA, USA
| | - James A. Naifeh
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Pablo A. Aliaga
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA, USA
| | - Xiaoying Sun
- Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA, USA
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Murray B. Stein
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
- VA San Diego Healthcare System, San Diego, CA, USA
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA, USA
| | - Robert J. Ursano
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Paul D. Bliese
- Department of Management, Darla Moore School of Business, University of South Carolina, Columbia, SC, USA
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14
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Holliday R, Nichter B, Holder N, Hill ML, Monteith LL, Norman SB, Pietrzak RH. Childhood Sexual Abuse and Military Sexual Trauma Interact to Increase Suicide Risk: Results from a Nationally Representative Veteran Sample. JOURNAL OF INTERPERSONAL VIOLENCE 2023; 38:5354-5369. [PMID: 36124932 DOI: 10.1177/08862605221120909] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Childhood sexual abuse (CSA) and military sexual trauma (MST) are prevalent among veterans. Such exposures are associated with adverse mental-health sequelae, including elevated risk for suicidal thoughts and behaviors. Nonetheless, prior studies have largely focused upon discrete experiences of CSA or MST in circumscribed samples. In the current study, we analyzed data from a large, nationally representative sample of 4,069 US military veterans to examine main and interactive effects of CSA and MST in relation to suicidal thoughts and behaviors. After accounting for sociodemographics, psychiatric comorbidity, and trauma-related characteristics, we detected a significant interaction between MST and CSA as it related to report of past-year suicidal ideation, lifetime suicide attempt, and risk for future suicide attempt. These findings underscore the impact of sexual trauma throughout the lifespan, highlighting the continued importance of screening for trauma exposure and connecting veterans to appropriate, evidence-based treatment to decrease their risk for suicidal thoughts and behaviors.
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Affiliation(s)
- Ryan Holliday
- VA Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention, Aurora, CO, USA
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Nicholas Holder
- San Francisco VA Health Care System, San Francisco, CA, USA
- University of California, San Francisco, School of Medicine, San Francisco, CA, USA
| | | | - Lindsey L Monteith
- VA Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention, Aurora, CO, USA
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sonya B Norman
- University of California San Diego, La Jolla, CA, USA
- VA San Diego Healthcare System, San Diego, CA, USA
- National Center for PTSD, Executive Division, White River Junction, VT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Robert H Pietrzak
- Yale School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
- Yale School of Public Health, New Haven, CT, USA
- National Center for PTSD, Clinical Neurosciences Division, West Haven, CT, USA
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15
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Ruiz F, Burgo-Black L, Hunt SC, Miller M, Spelman JF. A Practical Review of Suicide Among Veterans: Preventive and Proactive Measures for Health Care Institutions and Providers. Public Health Rep 2023; 138:223-231. [PMID: 35403486 PMCID: PMC10031829 DOI: 10.1177/00333549221085240] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Suicide rates among veterans are higher than those of the general US population. Although veterans compose only 7.6% of the US population, nearly 14% of American adult suicides are among veterans. The rate of suicide is 1.5 times higher among all veterans and 2.1 times higher among female veterans compared with the general population. Only 47% of all veterans are enrolled in the US Department of Veterans Affairs (VA) Healthcare System, leaving a large number either not receiving health care or receiving it outside the VA. Recent legislation has improved access to care for veterans outside the VA, highlighting the need for a broad public health approach to address veteran suicide and the need for all health care institutions and clinicians to be familiar with the unique health concerns in this population. The purpose of this narrative review was to summarize the risk factors contributing to veteran suicide and to provide guidance on how to assess and mitigate these risks. Suicide is preventable through recognition of risk and prompt intervention. Health care providers both inside and outside the VA system are uniquely situated at the intersection of the many contributing factors to veteran suicide and should have a structured, proactive approach to address the problem.
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Affiliation(s)
- Frank Ruiz
- Frank H. Netter MD School of
Medicine–Quinnipiac University, North Haven, CT, USA
| | - Lucile Burgo-Black
- VA Connecticut Healthcare System, West
Haven, CT, USA
- Department of General Internal
Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Stephen C. Hunt
- VA Puget Sound Healthcare Systems,
Seattle, WA, USA
- University of Washington School of
Medicine, Seattle, WA, USA
| | - Matthew Miller
- Office of Mental Health and Suicide
Prevention, US Department of Veterans Affairs, Washington, DC, USA
- Suicide Prevention Program and Veterans
Crisis Line, Office of Mental Health and Suicide Prevention, US Department of
Veterans Affairs, Washington, DC, USA
| | - Juliette F. Spelman
- VA Connecticut Healthcare System, West
Haven, CT, USA
- Department of General Internal
Medicine, Yale School of Medicine, New Haven, CT, USA
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16
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Cohen-Koren R, Garbi D, Gordon S, Yavnai N, Erlich Shoham Y, Shelef L. Predictors of Emotional Distress in Combat Military Flight Engineers. Mil Med 2023; 188:e301-e310. [PMID: 34050755 DOI: 10.1093/milmed/usab219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/24/2021] [Accepted: 05/20/2021] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE Exposure to distressing sights (DSs) during combat missions may cause emotional distress. The present study aimed to investigate the association between exposure to DSs involving severe injuries and fatalities during rescue missions and emotional distress, in Israeli Air Force (IAF) helicopter flight engineers (FEs). METHODS Cross-sectional design using self-report questionnaires. The independent variables included demographics, personal, and military variables-exposure to DSs throughout a whole career service. The dependent variables included Depression (Beck Depression Inventory); State-Trait Anxiety Inventory; Post-traumatic stress disorder (PTSD Checklist-PCL-5); Somatization (Patient Health Questionnaire); Maslach Burnout Inventory; and Coping Strategies (The Brief COPE). The variables PTSD, depression, and anxiety were examined twice: once as dichotomous variables according to the pathology cutoff point and again as a continuous variable to reveal the intensity of symptoms. RESULTS Participants were 106 IAF helicopter FEs (mean age = 39.32, SD = 8.75). Linear regression revealed that initial exposure to distressing battlefield sights (i.e., exposure to severe injuries and fatalities) was a predictor of depression symptoms. Career service FEs aged 31-40 were found to be at the highest risk of emotional distress, with a predictive factor for anxiety symptoms. Use of nonadaptive coping strategies was found to predict depressive symptoms, anxiety symptoms, and post-traumatic stress symptoms. CONCLUSION A significant association was found between exposure to DSs involving severe injuries and fatalities during rescue missions and anxiety, depression, somatization, and burnout. This population is generally perceived as tough and resilient, and this study has a unique contribution in identifying its vulnerabilities. Psychological intervention is crucial after participating in such missions.
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Affiliation(s)
| | - Dror Garbi
- Psychology Branch, Israeli Air Force, Ramat-Gan 5262000, Israel
| | - Shirley Gordon
- Psychology Branch, Israeli Air Force, Ramat-Gan 5262000, Israel
| | - Nirit Yavnai
- Medical Corps, Israel Defense Force, Ramat-Gan 5262000, Israel
| | | | - Leah Shelef
- Psychology Branch, Israeli Air Force, Ramat-Gan 5262000, Israel
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17
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Tanji F, Miyamoto S, Iwasawa A, Ohta H, Ono K. Association Between History of Psychiatric Disorder and Degree of Physical Injury Among Suicide Attempters: Secondary Data Analysis in a Japanese Rural Area. J Prim Care Community Health 2023; 14:21501319231212317. [PMID: 37981733 PMCID: PMC10658764 DOI: 10.1177/21501319231212317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/18/2023] [Accepted: 10/19/2023] [Indexed: 11/21/2023] Open
Abstract
INTRODUCTION While there may be differences in the choice of suicide methods between attempters with and those without a history of psychiatric disorders, it is not clear whether these differences predict the actual degree of physical injury. The present study aimed to investigate the association between the history of psychiatric disorder and the degree of physical injury among suicide attempters in a Japanese rural area. METHODS We conducted a cross-sectional study analyzing secondary data of 806 suicide attempters from April 2012 to March 2022 obtained from a Japanese rural city. The exposure variable was a history of psychiatric disorders. The primary outcome was the degree of physical injury of suicide attempters: moderate and severe. We conducted a multivariate Poisson regression analysis to estimate the prevalence ratios (PRs) and 95% confidence intervals (CIs). RESULTS Among 806 suicide attempters, a significant negative association between the history of psychiatric disorder and the degree of physical injury was observed (PR = 0.40; 95% CI, 0.28-0.59). Those with and without psychiatric disorders were more likely to choose low- and severe-lethality suicide methods such as drug or psychotropic overdoses and hanging or deep wrist injuries, respectively (P < .001). CONCLUSIONS The present study highlights the importance of considering suicide attempters, both with and without psychiatric disorders, while formulating targeted suicide prevention strategies.
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Affiliation(s)
- Fumiya Tanji
- Akita University Graduate School of Health Sciences, Akita, Japan
- Akita University Suicide Prevention Research Center, Akita, Japan
| | - Syohei Miyamoto
- Akita University Suicide Prevention Research Center, Akita, Japan
| | - Atsushi Iwasawa
- Akita University Suicide Prevention Research Center, Akita, Japan
| | - Hidenobu Ohta
- Akita University Graduate School of Health Sciences, Akita, Japan
- Akita University Suicide Prevention Research Center, Akita, Japan
| | - Kyoichi Ono
- Akita University Suicide Prevention Research Center, Akita, Japan
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18
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Walker LE, Poltavskiy E, Howard JT, Janak JC, Watrous J, Alcover K, Pettey WBP, Ambardar S, Meyer E, Gundlapalli AV, Stewart IJ. Suicide attempts and mental health diagnoses in combat-injured service members: A retrospective cohort study. Suicide Life Threat Behav 2022; 53:227-240. [PMID: 36576267 DOI: 10.1111/sltb.12938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 08/19/2022] [Accepted: 12/05/2022] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Examinations of risk factors for suicide attempt in United States service members at high risk of mental health diagnoses, such as those with combat injuries, are essential to guiding prevention and intervention efforts. METHODS Retrospective cohort study of 8727 combat-injured patients matched to deployed, non-injured patients utilizing Department of Defense and Veterans Affairs administrative records. RESULTS Combat injury was positively associated with suicide attempt in the univariate model (HR = 1.75, 95% CI 1.5-2.1), but lost significance after adjustment for mental health diagnoses. Utilizing Latent Transition Analysis in the combat-injured group, we identified five mental/behavioral health profiles: (1) Few mental health diagnoses, (2) PTSD and depressive disorders, (3) Adjustment disorder, (4) Multiple mental health comorbidities, and (5) Multiple mental health comorbidities with alcohol use disorder (AUD). Multiple mental health comorbidities with AUD had the highest suicide attempt rate throughout the study and more than four times that of Multiple mental health comorbidities in the first study year (23.4 vs. 5.1 per 1000 person years, respectively). CONCLUSION Findings indicate that (1) combat injury's impact on suicide attempt is attenuated by mental health and (2) AUD with multiple mental health comorbidities confers heightened suicide attempt risk in combat-injured service members.
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Affiliation(s)
- Lauren E Walker
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA.,Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Eduard Poltavskiy
- David Grant USAF Medical Center, Travis AFB, Fairfield, California, USA
| | | | | | - Jessica Watrous
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,Leidos Inc., San Diego, California, USA
| | - Karl Alcover
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Warren B P Pettey
- VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Shiva Ambardar
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Eric Meyer
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Adi V Gundlapalli
- VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Ian J Stewart
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,Military Cardiovascular Outcomes Research (MiCOR), Bethesda, Maryland, USA
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19
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Adams RS, Forster JE, Gradus JL, Hoffmire CA, Hostetter TA, Larson MJ, Walsh CG, Brenner LA, Adams RS, Forster JE, Gradus JL, Hoffmire CA, Hostetter TA, Larson MJ, Walsh CG, Brenner LA. Time-dependent suicide rates among Army soldiers returning from an Afghanistan/Iraq deployment, by military rank and component. Inj Epidemiol 2022; 9:46. [PMID: 36564780 PMCID: PMC9783392 DOI: 10.1186/s40621-022-00410-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND To date, knowledge is limited regarding time-dependent suicide risk in the years following return from deployment and whether such rates vary by military rank (i.e., enlisted, officer) or component (i.e., active duty, National Guard, reserve). To address these gaps in knowledge, the objectives of this study were to determine and compare postdeployment suicide rates and trends (percent change over time), and hazard rates for Army soldiers, by rank and component (measured at the end of the deployment). METHODS Longitudinal cohort study of 860,930 Army soldiers returning from Afghanistan/Iraq deployment in fiscal years 2008-2014 from the Substance Use and Psychological Injury Combat study. Death by suicide was observed from the end of the first deployment in the study period through 2018 (i.e., the most recently available mortality data) for up to 11 years of follow-up. Analyses were conducted in 2021-2022. RESULTS Adjusting for age, lowest-ranking Junior Enlisted (E1-E4) soldiers had a suicide rate 1.58 times higher than Senior Enlisted (E5-E9)/Warrant Officers (95% CI [1.24, 2.01]) and 2.41 times higher than Officers (95% CI [1.78, 3.29]). Suicide rates among lower-ranking enlisted soldiers remained elevated for 11 years postdeployment. Overall and annual postdeployment suicide rates did not differ significantly across components. Comparisons across rank and component for females were generally consistent with the full cohort results. CONCLUSIONS Lower-ranking enlisted soldiers had the highest rate of suicide, underscoring the importance of understanding rank as it relates to social determinants of health. For over a decade following Afghanistan/Iraq deployment, lower-enlisted rank during deployment was associated with an elevated rate of suicide; thereby suggesting that postdeployment prevention interventions targeting lower-ranking military members are warranted.
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Affiliation(s)
- Rachel Sayko Adams
- grid.189504.10000 0004 1936 7558Department of Health Law, Policy and Management, Boston University School of Public Health, 715 Albany Street, Boston, MA 02118 USA ,grid.253264.40000 0004 1936 9473Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA USA ,VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, CO USA
| | - Jeri E. Forster
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, CO USA ,grid.430503.10000 0001 0703 675XUniversity of Colorado, Anschutz Medical Campus, Aurora, CO USA
| | - Jaimie L. Gradus
- grid.189504.10000 0004 1936 7558Department of Epidemiology, Boston University School of Public Health, Boston University, Boston, MA USA
| | - Claire A. Hoffmire
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, CO USA ,grid.430503.10000 0001 0703 675XUniversity of Colorado, Anschutz Medical Campus, Aurora, CO USA
| | - Trisha A. Hostetter
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, CO USA
| | - Mary Jo Larson
- grid.253264.40000 0004 1936 9473Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA USA
| | - Colin G. Walsh
- grid.412807.80000 0004 1936 9916Departments of Biomedical Informatics, Medicine, and Psychiatry, Vanderbilt University Medical Center, Nashville, TN USA
| | - Lisa A. Brenner
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, CO USA ,grid.430503.10000 0001 0703 675XUniversity of Colorado, Anschutz Medical Campus, Aurora, CO USA
| | - Rachel Sayko Adams
- grid.189504.10000 0004 1936 7558Department of Health Law, Policy and Management, Boston University School of Public Health, 715 Albany Street, Boston, MA 02118 USA ,grid.253264.40000 0004 1936 9473Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA USA ,VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, CO USA
| | - Jeri E. Forster
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, CO USA ,grid.430503.10000 0001 0703 675XUniversity of Colorado, Anschutz Medical Campus, Aurora, CO USA
| | - Jaimie L. Gradus
- grid.189504.10000 0004 1936 7558Department of Epidemiology, Boston University School of Public Health, Boston University, Boston, MA USA
| | - Claire A. Hoffmire
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, CO USA ,grid.430503.10000 0001 0703 675XUniversity of Colorado, Anschutz Medical Campus, Aurora, CO USA
| | - Trisha A. Hostetter
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, CO USA
| | - Mary Jo Larson
- grid.253264.40000 0004 1936 9473Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA USA
| | - Colin G. Walsh
- grid.412807.80000 0004 1936 9916Departments of Biomedical Informatics, Medicine, and Psychiatry, Vanderbilt University Medical Center, Nashville, TN USA
| | - Lisa A. Brenner
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, CO USA ,grid.430503.10000 0001 0703 675XUniversity of Colorado, Anschutz Medical Campus, Aurora, CO USA
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20
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Crocker LD, Jurick SM, Merritt VC, Keller AV, Hoffman SN, Davey DK, Jak AJ. Mechanisms through which executive dysfunction influences suicidal ideation in combat-exposed Iraq and Afghanistan veterans. Clin Neuropsychol 2022; 36:2073-2092. [PMID: 34524071 DOI: 10.1080/13854046.2021.1974566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
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.
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Affiliation(s)
- Laura D Crocker
- Research Service, VA San Diego Healthcare System, San Diego, CA, USA.,Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, CA, USA
| | - Sarah M Jurick
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, CA, USA.,Department of Psychiatry, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Victoria C Merritt
- Research Service, VA San Diego Healthcare System, San Diego, CA, USA.,Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, CA, USA.,Department of Psychiatry, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Amber V Keller
- San Diego Joint Doctoral Program in Clinical Psychology, San Diego State University/University of California, San Diego, CA, USA
| | - Samantha N Hoffman
- San Diego Joint Doctoral Program in Clinical Psychology, San Diego State University/University of California, San Diego, CA, USA
| | - Delaney K Davey
- Research Service, VA San Diego Healthcare System, San Diego, CA, USA
| | - Amy J Jak
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, CA, USA.,Department of Psychiatry, School of Medicine, University of California San Diego, La Jolla, CA, USA.,Psychology Service, VA San Diego Healthcare System, San Diego, CA, USA
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21
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Senecal G, Adorno RL, LaFleur R, McNamara KA. Autoethnographic Family Case Study: Combat Veteran PTSD and its Effects on Familial Dynamics, Parenting, and Marriage. JOURNAL OF VETERANS STUDIES 2022. [DOI: 10.21061/jvs.v8i3.309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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22
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Renkiewicz GK, Hubble MW. Secondary Traumatic Stress in Emergency Services Systems Project: Quantifying the Effect of Personal Trauma Profiles on Lifetime Prevalence of Suicidality in Emergency Medical Services Personnel. Air Med J 2022; 41:463-472. [PMID: 36153144 DOI: 10.1016/j.amj.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 03/28/2022] [Accepted: 04/07/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE Within the last 20 years, there has been a 500% increase in public safety suicides, the exact cause of which is unknown. METHODS This was a cross-sectional survey of emergency medical services (EMS) personnel. Nine EMS agencies were selected to participate based on geography and population. The survey assessed sociodemographic, occupational, and military factors. Childhood adversity and traumatic experiences were evaluated using the Adverse Childhood Experiences Questionnaire and the Life Events Checklist for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, respectively. Using factors significant in univariate analyses, a logistic regression was conducted to determine predictors of suicidality while controlling for potential confounders. RESULTS A total of 681 EMS providers participated; 56.1% were male, 12.6% were minorities, and 72.8% were paramedics. Nearly a quarter (24.4%) had considered suicide. Approximately twice as many had received counseling for a stress-related event, and 1.5 times as many identified as currently in counseling. Indigenous populations were 4.76 times more likely to have suicidality (odds ratio [OR] = 4.76; 95% confidence interval [CI], 1.22-18.62). Suicidality was 97% more likely in EMS professionals with prior military service (OR = 1.97; 95% CI, 1.08-3.57) and 2.22 times more likely in sexual minorities (OR = 2.22; 95% CI, 1.16-4.25). Emotional abuse (OR = 1.86; 95% CI, 1.08-3.21) and burnout (OR = 2.88; 95% CI, 1.78-4.66) were also predictive. CONCLUSIONS Suicidality is an indisputable concern for the EMS profession and represents a multifaceted issue that must be addressed.
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Affiliation(s)
- Ginny K Renkiewicz
- Health Sciences Program, Rush University, Chicago, IL; Department of Healthcare Administration, Methodist University, Fayetteville, NC.
| | - Michael W Hubble
- Department of Emergency Medical Science, Wake Technical Community College, Raleigh, NC
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23
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Schwartz G, Halperin E, Levi-Belz Y. Moral Injury and Suicide Ideation Among Combat Veterans: The Role of Trauma-Related Shame and Collective Hatred. JOURNAL OF INTERPERSONAL VIOLENCE 2022; 37:NP13952-NP13977. [PMID: 33858258 DOI: 10.1177/08862605211007932] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Exposure to potentially morally injurious events (PMIEs) among combat veterans has been acknowledged as a significant stressful combat event that may lead to mental health problems, including suicide ideation (SI). Several studies have examined the risk and protective factors that can explain the conditions in which PMIEs may contribute to the development and maintenance of SI. However, the contribution of social-emotional factors has yet to be examined. In the current study, we examined the association between PMIE-Self and SI among combat veterans and explored the mediating role of trauma-related shame and the moderation role of collective hatred in this association. A volunteer sample of 336 Israeli combat veterans was recruited, completing self-report questionnaires in a cross-sectional study. Results indicated that PMIE-Self was positively associated with SI, and trauma-related shame mediated this association. Moreover, collective hatred moderated both their direct (PMIE-SI) and indirect (PMIE-Shame-SI) association. Notably, collective hatred had an inverse role for each of the associations. Thus, collective hatred was found to comprise both a risk and a protective factor for SI following PMIE-Self. The current findings highlight the crucial contribution of trauma-related shame and collective hatred to the association between moral injury and suicidality. Moreover, the findings demonstrate that even years after their military service release, combat veterans exposed to PMIEs may still feel consumed by painful memories and maintain premonitions of a foreshortened future. Furthermore, the findings help to better understand the dynamics of collective hatred and the challenge of modifying it.
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24
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McGuire AP, Fagan JG, Tsai J, Merians AN, Nichter B, Norman SB, Southwick SM, Pietrzak RH. Dispositional gratitude predicts the development of psychopathology and suicidal behaviors: Results from a 7-year population-based study of U.S. military veterans. J Psychiatr Res 2022; 149:168-176. [PMID: 35278781 PMCID: PMC9017955 DOI: 10.1016/j.jpsychires.2022.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 02/15/2022] [Accepted: 02/28/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Dispositional gratitude has been implicated as a psychological characteristic that may modulate risk for mental health outcomes. Using a population-based sample of U.S. military veterans, this study evaluated the association between dispositional gratitude and the development of psychopathology and suicidal behaviors over a 7-year period. METHODS A nationally representative sample of U.S. veterans was surveyed at four timepoints across seven years. Analyses were restricted to veterans without incident outcomes at baseline. Multivariable analyses were conducted to examine the relation between baseline levels of dispositional gratitude and risk of developing (a) major depressive disorder (MDD), generalized anxiety disorder (GAD), or posttraumatic stress disorder (PTSD); (b) suicidal ideation; and (c) suicide attempts. RESULTS A total 9.6% of veterans developed MDD, GAD, and/or PTSD, 9.5% developed suicidal ideation, and 2.8% reported having attempted suicide over the 7-year follow-up period. Among veterans with high levels of dispositional gratitude, incidence was lower for MDD/GAD/PTSD (8.0%), suicidal ideation (6.8%), and suicide attempts (1.5%). Conversely, veterans with low dispositional gratitude were at substantially higher risk of developing MDD/GAD/PTSD (27.7%), suicidal ideation (33.6%), and suicide attempts (20.3%). CONCLUSIONS High dispositional gratitude may help protect against the development of psychopathology and suicidal behaviors in U.S. military veterans, whereas low gratitude may increase risk of developing these outcomes. Collectively, these results support the potential utility of enhancing gratitude as part of primary prevention efforts for veterans, service members, and other populations at heightened risk for adverse mental health outcomes.
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Affiliation(s)
- Adam P McGuire
- Department of Psychology and Counseling, The University of Texas at Tyler, 3900 University Blvd, Tyler, TX, 75799, USA; VISN 17 Center of Excellence for Research on Returning War Veterans, 4800 Memorial Dr (151C), Waco, TX, 76711, USA; Central Texas Veterans Health Care System, 1901 Veterans Memorial Dr, Temple, TX 76504, USA.
| | - Joanna G Fagan
- Department of Psychology and Counseling, The University of Texas at Tyler, 3900 University Blvd, Tyler, TX, 75799, USA
| | - Jack Tsai
- U.S. Department of Veterans Affairs National Center on Homelessness Among Veterans, Tampa, FL, USA; School of Public Health, University of Texas Health Science Center at Houston, 1200 Pressler Street, Houston, TX, 77030, USA; Department of Psychiatry, Yale School of Medicine, 300 George St #901, New Haven, CT, 06511, USA
| | - Addie N Merians
- Department of Psychiatry, Yale School of Medicine, 300 George St #901, New Haven, CT, 06511, USA; U.S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT, 06516, USA
| | - Brandon Nichter
- Department of Psychiatry, University of California San Diego, La Jolla, CA, 92093, USA
| | - Sonya B Norman
- Department of Psychiatry, University of California San Diego, La Jolla, CA, 92093, USA; National Center for PTSD, VA Medical Center, 215 N Main St, White River Junction, VT, 05005, USA; VA Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Dr, San Diego, CA, 92161, USA
| | - Steven M Southwick
- Department of Psychiatry, Yale School of Medicine, 300 George St #901, New Haven, CT, 06511, USA
| | - Robert H Pietrzak
- Department of Psychiatry, Yale School of Medicine, 300 George St #901, New Haven, CT, 06511, USA; U.S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT, 06516, USA; Department of Social and Behavioral Sciences, Yale School of Public Health, 60 College St, New Haven, CT, 06510, USA
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25
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Naifeh JA, Ursano RJ, Stein MB, Mash HBH, Aliaga PA, Fullerton CS, Dinh HM, Vance MC, Wynn GH, Kao TC, Sampson NA, Kessler RC. Risk of suicide attempt in reserve versus active component soldiers during deployment to the wars in Iraq and Afghanistan. Suicide Life Threat Behav 2022; 52:24-36. [PMID: 34032314 DOI: 10.1111/sltb.12770] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/12/2021] [Accepted: 02/14/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Little is known about the degree to which U.S. Army soldiers in the Reserve Components (Army National Guard and Army Reserve) and Active Component (Regular Army) differ with respect suicide attempt (SA) risk during high-stress times, such as deployment. METHOD Using administrative person-month records of enlisted soldiers on active duty during 2004-2009, we identified 1170 soldiers with a medically documented SA during deployment and an equal-probability control sample of other deployed soldiers (n = 52,828 person-months). Logistic regression analyses examined the association of Army component (Guard/Reserve vs. Regular) with SA before and after adjusting for socio-demographic and service-related predictors. RESULTS Guard/Reserve comprised 32.1% of enlisted soldiers and 19.7% of suicide attempters in-theater, with a SA rate of 81/100,000 person-years (vs. 157/100,000 person-years among Regular; rate ratio = 0.5 [95% CI = 0.5-0.6]). Risk peaked near mid-deployment for both groups but was consistently lower for Guard/Reserve throughout deployment. Guard/Reserve had lower odds of SA after adjusting for covariates (OR = 0.7 [95%CI = 0.6-0.8]). Predictors of SA were similar between components. CONCLUSIONS Guard/Reserve and Regular soldiers had similar patterns and predictors of SA during deployment, but Guard/Reserve had lower risk even after controlling for important risk factors. Additional research is needed to understand the lower SA risk among Guard/Reserve in-theater.
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Affiliation(s)
- James A Naifeh
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Robert J Ursano
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Murray B Stein
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA.,Department of Family Medicine & Public Health, University of California San Diego, La Jolla, CA, USA.,VA San Diego Healthcare System, San Diego, CA, USA
| | - Holly B Herberman Mash
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Pablo A Aliaga
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Carol S Fullerton
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Hieu M Dinh
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Mary C Vance
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Gary H Wynn
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Tzu-Cheg Kao
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Nancy A Sampson
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Ronald C Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
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26
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Campbell-Sills L, Flynn PJ, Choi KW, Ng THH, Aliaga PA, Broshek C, Jain S, Kessler RC, Stein MB, Ursano RJ, Bliese PD. Unit cohesion during deployment and post-deployment mental health: is cohesion an individual- or unit-level buffer for combat-exposed soldiers? Psychol Med 2022; 52:121-131. [PMID: 32517825 PMCID: PMC9341401 DOI: 10.1017/s0033291720001786] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Unit cohesion may protect service member mental health by mitigating effects of combat exposure; however, questions remain about the origins of potential stress-buffering effects. We examined buffering effects associated with two forms of unit cohesion (peer-oriented horizontal cohesion and subordinate-leader vertical cohesion) defined as either individual-level or aggregated unit-level variables. METHODS Longitudinal survey data from US Army soldiers who deployed to Afghanistan in 2012 were analyzed using mixed-effects regression. Models evaluated individual- and unit-level interaction effects of combat exposure and cohesion during deployment on symptoms of post-traumatic stress disorder (PTSD), depression, and suicidal ideation reported at 3 months post-deployment (model n's = 6684 to 6826). Given the small effective sample size (k = 89), the significance of unit-level interactions was evaluated at a 90% confidence level. RESULTS At the individual-level, buffering effects of horizontal cohesion were found for PTSD symptoms [B = -0.11, 95% CI (-0.18 to -0.04), p < 0.01] and depressive symptoms [B = -0.06, 95% CI (-0.10 to -0.01), p < 0.05]; while a buffering effect of vertical cohesion was observed for PTSD symptoms only [B = -0.03, 95% CI (-0.06 to -0.0001), p < 0.05]. At the unit-level, buffering effects of horizontal (but not vertical) cohesion were observed for PTSD symptoms [B = -0.91, 90% CI (-1.70 to -0.11), p = 0.06], depressive symptoms [B = -0.83, 90% CI (-1.24 to -0.41), p < 0.01], and suicidal ideation [B = -0.32, 90% CI (-0.62 to -0.01), p = 0.08]. CONCLUSIONS Policies and interventions that enhance horizontal cohesion may protect combat-exposed units against post-deployment mental health problems. Efforts to support individual soldiers who report low levels of horizontal or vertical cohesion may also yield mental health benefits.
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Affiliation(s)
| | - Patrick J. Flynn
- Department of Management, Innovation, and Entrepreneurship, Poole College of Management, North Carolina State University, Raleigh, NC, USA
| | - Karmel W. Choi
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Psychiatric and Neurodevelopmental Genetics Unit, Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Stanley Center for Psychiatric Research, Broad Institute, Boston, MA, USA
| | - Tsz Hin H. Ng
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Pablo A. Aliaga
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Catherine Broshek
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Sonia Jain
- Department of Family Medicine and Public Health, University of California San Diego, La Jolla, CA, USA
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Murray B. Stein
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
- Department of Family Medicine and Public Health, University of California San Diego, La Jolla, CA, USA
- VA San Diego Healthcare System, San Diego, CA, USA
| | - Robert J. Ursano
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Paul D. Bliese
- Department of Management, Darla Moore School of Business, University of South Carolina, Columbia, SC, USA
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27
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Morgan NR, Aronson KR, Perkins DF, Doucette CE, Bleser JA, Davenport K, Vogt D, Copeland LA, Finley EP, Gilman CL. The interaction of exposure to adverse childhood and combat experiences on the current mental health of new post-9/11 veterans. JOURNAL OF COMMUNITY PSYCHOLOGY 2022; 50:204-220. [PMID: 33624843 DOI: 10.1002/jcop.22523] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 06/12/2023]
Abstract
Military veterans have greater exposure to adverse childhood experiences (ACEs) than civilians and many also encounter warfare exposures, which can increase the likelihood of mental health problems. The purpose of this study was to test an interaction between childhood traumas and warfare exposures on the mental health of a sample of nearly 10,000 new post-9/11 veterans. Results revealed that male veterans exposed to one or two ACEs, but no warfare, were more likely to experience anxiety, depression, suicidal thinking, and angry outbursts than the reference group (i.e., no ACEs and no warfare exposure). Female veterans exposed to one or two ACEs, but no warfare, were only more likely to experience suicidal thinking. Male and female veterans exposed to three or more ACEs and no warfare were more likely to experience probable posttraumatic stress disorder (PTSD), anxiety, depression, suicidality, and angry outbursts. Among those veterans who experienced corollaries of combat only (e.g., seeing someone killed or seriously wounded), male, but not female veterans were more likely to have probable PTSD, anxiety, and depression. Veterans exposed to warfare (i.e., combat and the corollaries of combat), irrespective of ACEs exposure, were the most likely to report mental health symptoms. Implications for community-based mental health services are discussed.
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Affiliation(s)
- Nicole R Morgan
- Clearinghouse for Military Family Readiness at Penn State University, State College, Pennsylvania, USA
| | - Keith R Aronson
- Clearinghouse for Military Family Readiness at Penn State University, State College, Pennsylvania, USA
- Social Science Research Institute at Penn State University, University Park, Pennsylvania, USA
- Department of Biobehavioral Health, Penn State University, University Park, Pennsylvania, USA
| | - Daniel F Perkins
- Clearinghouse for Military Family Readiness at Penn State University, State College, Pennsylvania, USA
- Social Science Research Institute at Penn State University, University Park, Pennsylvania, USA
- Department of Agricultural Economics, Sociology and Education, Penn State University, University Park, Pennsylvania, USA
| | - Carly E Doucette
- Clearinghouse for Military Family Readiness at Penn State University, State College, Pennsylvania, USA
| | - Julia A Bleser
- Clearinghouse for Military Family Readiness at Penn State University, State College, Pennsylvania, USA
| | - Katie Davenport
- Clearinghouse for Military Family Readiness at Penn State University, State College, Pennsylvania, USA
| | - Dawne Vogt
- Women's Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Laurel A Copeland
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts, USA
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
- Department of Psychiatry, UT Health San Antonio, San Antonio, Texas, USA
| | - Erin P Finley
- Veterans Evidence-based Research Dissemination and Implementation Center, South Texas Veterans Health Care System, San Antonio, Texas, USA
- Departments of Medicine and Psychiatry, UT Health San Antonio, San Antonio, Texas, USA
| | - Cynthia L Gilman
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
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Kovnick MO, Young Y, Tran N, Teerawichitchainan B, Tran TK, Korinek K. The Impact of Early Life War Exposure on Mental Health among Older Adults in Northern and Central Vietnam. JOURNAL OF HEALTH AND SOCIAL BEHAVIOR 2021; 62:526-544. [PMID: 34622692 PMCID: PMC8633195 DOI: 10.1177/00221465211039239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Most Vietnamese young adults who experienced the American War were exposed to war-related violence, which can exert a lifelong impact. We analyze survey data collected among northern and central Vietnamese older adults in the 2018 Vietnam Health and Aging Study (N = 2,447) to examine the association between various war traumas, psychological distress, and suicidal ideation. Informed by life course and stress process perspectives, we use structural equation models with multiple mediators to analyze the relationship between mental health outcomes and five types of wartime stress exposure: loss of family and friends, witnessing death, malevolent living conditions, life threat, and moral injury. Our findings reveal enduring mental health impacts of war among survivors. Wartime stress exposure's influence on mental health is mediated by recent comorbidities and stressful life events. Loss of family members, witnessing death, and malevolent living conditions during war are particularly salient risks for psychological distress.
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Affiliation(s)
| | | | - Nhung Tran
- University of Utah, Salt Lake City, UT, USA
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29
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A sex-stratified analysis of suicidal ideation correlates among deployed post-9/11 veterans: Results from the survey of experiences of returning veterans. J Affect Disord 2021; 294:824-830. [PMID: 34375209 DOI: 10.1016/j.jad.2021.07.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 06/18/2021] [Accepted: 07/11/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Suicide rates are higher among veterans than non-veterans; this difference is particularly salient for females. Knowledge is sparse regarding correlates of suicidal ideation (SI) among female veterans, particularly in non-VHA samples. As such, and given that SI confers a strong risk for subsequent suicidal behavior, this study aimed to: (1) compare prevalence of recent SI by sex; and (2) determine whether deployment stressors, mental health symptoms, and recent psychosocial stressors are associated with recent SI, by sex, among post-9/11 veterans. METHODS A sex-stratified analysis of cross-sectional data from 809 post-9/11, deployed veterans was conducted using the Survey of Experiences of Returning Veterans (SERV); statistical interactions between sex and correlates of interest were assessed. RESULTS Self-reported prevalence of recent SI did not differ by sex. A statistically significant interaction between sex and combat was observed; greater combat experience was associated with increased SI for females only. While significant interactions were not observed for other correlates, differences in significant predictors and predictor effect sizes were noted across sex-stratified models. Recent housing and financial concerns were only associated with increased SI prevalence among females, whereas concern about other recent stressful life events was associated with increased SI prevalence only among males. LIMITATIONS This is a cross-sectional analysis of a national survey with limited power to detect statistical sex interactions. CONCLUSIONS While correlates of SI are relatively consistent for males and females notable differences suggest that tailored assessment and intervention based on sex may hold merit in mitigating SI among post-9/11 era Veterans.
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30
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Khan AJ, Campbell-Sills L, Sun X, Kessler RC, Adler AB, Jain S, Ursano RJ, Stein MB. Association Between Responsibility for the Death of Others and Postdeployment Mental Health and Functioning in US Soldiers. JAMA Netw Open 2021; 4:e2130810. [PMID: 34724553 PMCID: PMC8561325 DOI: 10.1001/jamanetworkopen.2021.30810] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Rates of suicidal thoughts and behaviors (STBs) in US soldiers have increased sharply since the terrorist attacks on September 11, 2001, and postdeployment posttraumatic stress disorder (PTSD) remains a concern. Studies show that soldiers with greater combat exposure are at an increased risk for adverse mental health outcomes, but little research has been conducted on the specific exposure of responsibility for the death of others. OBJECTIVE To examine the association between responsibility for the death of others in combat and mental health outcomes among active-duty US Army personnel at 2 to 3 months and 8 to 9 months postdeployment. DESIGN, SETTING, AND PARTICIPANTS This cohort study obtained data from a prospective 4-wave survey study of 3 US Army brigade combat teams that deployed to Afghanistan in 2012. The sample was restricted to soldiers with data at all 4 waves (1-2 months predeployment, and 2-3 weeks, 2-3 months, and 8-9 months postdeployment). Data analysis was performed from December 12, 2020, to April 23, 2021. MAIN OUTCOMES AND MEASURES Primary outcomes were past-30-day PTSD, major depressive episode, STBs, and functional impairment at 2 to 3 vs 8 to 9 months postdeployment. Combat exposures were assessed using a combat stress scale. The association of responsibility for the death of others during combat was tested using separate multivariable logistic regression models per outcome adjusted for age, sex, race and ethnicity, marital status, brigade combat team, predeployment lifetime internalizing and externalizing disorders, and combat stress severity. RESULTS A total of 4645 US soldiers (mean [SD] age, 26.27 [6.07] years; 4358 men [94.0%]) were included in this study. After returning from Afghanistan, 22.8% of soldiers (n = 1057) reported responsibility for the death of others in combat. This responsibility was not associated with any outcome at 2 to 3 months postdeployment (PTSD odds ratio [OR]: 1.23 [95% CI, 0.93-1.63]; P = .14; STB OR: 1.19 [95% CI, 0.84-1.68]; P = .33; major depressive episode OR: 1.03 [95% CI, 0.73-1.45]; P = .87; and functional impairment OR: 1.12 [95% CI, 0.94-1.34]; P = .19). However, responsibility was associated with increased risk for PTSD (OR, 1.42; 95% CI, 1.09-1.86; P = .01) and STBs (OR, 1.55; 95% CI, 1.03-2.33; P = .04) at 8 to 9 months postdeployment. Responsibility was not associated with major depressive episode (OR, 1.30; 95% CI, 0.93-1.81; P = .13) or functional impairment (OR, 1.13; 95% CI, 0.94-1.36; P = .19). When examining enemy combatant death only, the pattern of results was unchanged for PTSD (OR, 1.44; 95 CI%, 1.10-1.90; P = .009) and attenuated for STBs (OR, 1.46; 95 CI%, 0.97- 2.20; P = .07). CONCLUSIONS AND RELEVANCE This cohort study found an association between being responsible for the death of others in combat and PTSD and STB at 8 to 9 months, but not 2 to 3 months, postdeployment in active-duty soldiers. The results suggest that delivering early intervention to those who report such responsibility may mitigate the subsequent occurrence of PTSD and STBs.
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Affiliation(s)
- Amanda J. Khan
- Department of Psychiatry, University of California San Diego, La Jolla
| | | | - Xiaoying Sun
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Amy B. Adler
- Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Sonia Jain
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla
| | - Robert J. Ursano
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Murray B. Stein
- Department of Psychiatry, University of California San Diego, La Jolla
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla
- Psychiatry Service, Veterans Affairs San Diego Healthcare System, San Diego, California
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31
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Knobloch LK, Owens JL, Gobin RL. Spiritual care for combat trauma: A qualitative evaluation of REBOOT Combat Recovery. MILITARY PSYCHOLOGY 2021. [DOI: 10.1080/08995605.2021.1962183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Leanne K. Knobloch
- Department of Communication, University of Illinois, Urbana-Champaign, Illinois, USA
| | | | - Robyn L. Gobin
- Department of Kinesiology and Community Health, University of Illinois, Urbana-Champaign, Illinois, USA
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32
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Schuman DL, Buchanan S, Boehler J, Flaherty C. The suicide of Private Danny Chen: An interpersonal theory perspective. DEATH STUDIES 2021; 46:2467-2476. [PMID: 34486948 DOI: 10.1080/07481187.2021.1972365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Despite considerable prevention and intervention efforts, military suicide rates have increased. Although most research on active-duty military suicide has focused on combat exposure, evidence shows that bullying, hazing, and race are understudied risk factors for military suicide. According to the interpersonal theory of suicide, thwarted belongingness, perceived burdensomeness, and acquired capability are necessary components for enacting a suicide death. In this theoretically-based interpersonal case analysis of the suicide death of Private Danny Chen, an American soldier of Chinese descent, we explore how bullying, hazing, and race may have intersected with other vulnerabilities to result in his death.
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Affiliation(s)
- Donna L Schuman
- School of Social Work, University of Texas at Arlington, Arlington, TX, USA
| | - Steven Buchanan
- College of Social Work, University of Kentucky, Lexington, KY, USA
| | - Jason Boehler
- School of Social Work, Florida State University, Tallahassee, FL, USA
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33
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Goldner L, Shelef L, Goldstein BA, Scharf M. Understanding processes that advance suicidal behavior among Israeli active duty soldiers: A mediation model. J Clin Psychol 2021; 78:590-601. [PMID: 34380174 DOI: 10.1002/jclp.23237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 06/08/2021] [Accepted: 07/28/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVES The current study was aimed to identify the factors and mechanisms that promote nonsuicidal self-injury and suicidal ideation (SI) as precursors of suicidal behaviors in a sample of 553 Israeli active-duty soldiers. METHODS A mediation model was used to examine the contribution of posttraumatic stress disorder (PTSD) symptoms, emotion-regulation difficulties, habituation, and risk-taking behaviors to soldiers' self-injury and SI. RESULTS Results indicated direct effects between PTSD symptoms and self-injury and SI, as well as between emotion regulation difficulties and self-injury. Indirect effects were found between PTSD symptoms and nonsuicidal self-injury (NSSI) through the mechanisms of habituation and risk-taking behavior and between difficulties in emotion regulation and NSSI through the mechanism of risk-taking behaviors. CONCLUSION To tackle soldiers' suicidal behaviors, clinicians might assess soldiers' PTSD symptoms and difficulties in emotion regulation and intervene by lessening their access to thrill-seeking situations and situations that increase habituation to pain and death.
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Affiliation(s)
- Limor Goldner
- School of Creative Arts Therapies, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | - Leah Shelef
- Mental Health Unit, Medical Corps, Israel Defense Forces, Ramat Gan, Israel
| | - Becky Amit Goldstein
- Mental Health Unit, Medical Corps, Israel Defense Forces, Ramat Gan, Israel.,Department of Counseling and Human Development, University of Haifa, Haifa, Israel
| | - Miri Scharf
- Department of Counseling and Human Development, University of Haifa, Haifa, Israel
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34
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Bryant-Lees KB, Martinez RN, Frise A, Bryan CJ, Goodman T, Chappelle W, Thompson W. Predictors and protective factors for suicide ideation across remotely piloted aircraft career fields. MILITARY PSYCHOLOGY 2021. [DOI: 10.1080/08995605.2021.1902181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Kinsey B. Bryant-Lees
- NeuroStat Analytical Solutions LLC, Vienna, Virginia, USA
- Department of Psychological Science, Northern Kentucky University, Highland Heights, Kentucky, USA
| | - Rachael N. Martinez
- Aerospace Medicine Department, US Air Force School of Aerospace Medicine, Wright-Patterson Air Force Base, Fairborn, Ohio, USA
| | - Anna Frise
- NeuroStat Analytical Solutions LLC, Vienna, Virginia, USA
| | - Craig J. Bryan
- Department of Psychiatry and Behavioral Health, The Ohio State University, Columbus, Ohio, USA
| | - Tanya Goodman
- NeuroStat Analytical Solutions LLC, Vienna, Virginia, USA
| | - Wayne Chappelle
- Aerospace Medicine Department, US Air Force School of Aerospace Medicine, Wright-Patterson Air Force Base, Fairborn, Ohio, USA
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35
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Nichter B, Norman SB, Maguen S, Pietrzak RH. Moral injury and suicidal behavior among US combat veterans: Results from the 2019-2020 National Health and Resilience in Veterans Study. Depress Anxiety 2021; 38:606-614. [PMID: 33666315 DOI: 10.1002/da.23145] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 02/12/2021] [Accepted: 02/16/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Recent research suggests that exposure to potentially morally injurious experiences (PMIEs) may be associated with increased risk for suicidal behavior among US combat veterans, but population-based data on these associations are scarce. This study examined the association between PMIEs with current suicidal ideation (SI), lifetime suicide plans (SP), and suicide attempts (SA) in a contemporary, nationally representative sample of combat veterans. METHODS Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of US combat veterans (n = 1321). PMIEs were assessed using the Moral Injury Events Scale (MIES). Multivariable logistic regression analyses were conducted to examine associations between MIES total scores and specific types of PMIEs with suicidal behavior. RESULTS Thirty-six point three percent of veterans reported at least one PMIE. Perceived transgressions by self, others, and betrayal were associated with SI, SP, and SA (odds ratios [ORs] = 1.21-1.27, all p s < .05), after adjusting for sociodemographic, trauma, and psychiatric characteristics. MIES total scores were significantly, albeit weakly, associated with SP (OR = 1.03, p < .01), but not SI/SA. Depression, posttraumatic stress disorder (PTSD), and age emerged as the strongest correlates of SI/SP/SA (14.9%-38.1% of explained variance), while PMIEs accounted for a comparatively modest amount of variance (3.3%-8.9%). CONCLUSIONS Reports of potentially morally injurious experiences are prevalent among US combat veterans, and associated with increased risk for suicidal behavior, above and beyond severity of combat exposure, PTSD, and depression. Implications for clinical practice and future research are discussed, including the need for methodological advancements in the measurement of moral injury.
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Affiliation(s)
- Brandon Nichter
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA
| | - Sonya B Norman
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA.,National Center for PTSD, Vermont, Vermont, USA.,VA Center of Excellence for Stress and Mental Health, San Diego, California, USA
| | - Shira Maguen
- San Francisco VA Health Care System, San Francisco, California, USA.,University of California-San Francisco, San Francisco, California, USA
| | - Robert H Pietrzak
- National Center for PTSD, VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
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36
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Sokol Y, Gromatsky M, Edwards ER, Greene AL, Geraci JC, Harris RE, Goodman M. The deadly gap: Understanding suicide among veterans transitioning out of the military. Psychiatry Res 2021; 300:113875. [PMID: 33901974 DOI: 10.1016/j.psychres.2021.113875] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 03/13/2021] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Yosef Sokol
- Transitioning Servicemember/Veteran and Suicide Prevention Center (TASC), United States; VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, United States; Icahn School of Medicine at Mt. Sinai Hospital, United States.
| | - Molly Gromatsky
- Transitioning Servicemember/Veteran and Suicide Prevention Center (TASC), United States; VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, United States; Icahn School of Medicine at Mt. Sinai Hospital, United States
| | - Emily R Edwards
- Transitioning Servicemember/Veteran and Suicide Prevention Center (TASC), United States; VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, United States; Icahn School of Medicine at Mt. Sinai Hospital, United States
| | - Ashley L Greene
- Transitioning Servicemember/Veteran and Suicide Prevention Center (TASC), United States; VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, United States; Icahn School of Medicine at Mt. Sinai Hospital, United States
| | - Joseph C Geraci
- Transitioning Servicemember/Veteran and Suicide Prevention Center (TASC), United States; VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, United States; Resilience Center for Veterans & Families, Teachers College, Columbia University, United States; Icahn School of Medicine at Mt. Sinai Hospital, United States; Columbia University, United States; Syracuse University, Institute for Veterans and Military Families, United States
| | - Rachel E Harris
- VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, United States; William Paterson University, United States
| | - Marianne Goodman
- Transitioning Servicemember/Veteran and Suicide Prevention Center (TASC), United States; VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, United States; Icahn School of Medicine at Mt. Sinai Hospital, United States
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37
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Gromatsky M, Edwards ER, Sullivan SR, Goodman M, Hazlett EA. Distinguishing veterans with suicidal ideation from suicide attempt history: The role of emotion reactivity. Suicide Life Threat Behav 2021; 51:572-585. [PMID: 33665891 DOI: 10.1111/sltb.12744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/11/2020] [Accepted: 10/02/2020] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Growing evidence suggests emotion reactivity-sensitivity and intensity of emotional experience-may represent a diathesis for suicide risk. However, our understanding of its ability to differentiate risk for suicidal ideation (SI) from suicide attempt (SA) is limited. METHOD This study compares Veterans with SI (n = 81) to Veterans with SA (n = 177) history on factors relevant to emotion reactivity to determine which variable(s) best differentiate groups. Variables examined are multimodal: (a) self-report: childhood trauma, combat exposure; (b) clinician-assessed: non-suicidal self-injury (NSSI), structured diagnostic interview of psychopathology; and (c) psychophysiological: affect-modulated startle (AMS; proxy for amygdala reactivity and emotion reactivity) to unpleasant pictures was examined in a subset (n = 90). RESULTS SA history was independently predicted by NSSI history, MDD, PTSD, and SUD diagnosis. Childhood trauma and combat exposure did not differentiate groups. The composite risk index demonstrated good accuracy (AUC=0.71, sensitivity=0.90, specificity=0.49). Only AMS independently predicted SA history when added to the model and accuracy was improved (AUC=0.82, sensitivity=0.85, specificity=0.56). CONCLUSION NSSI history, MDD, PTSD, and SUD diagnosis may be salient risk factors for this population. However, emotion reactivity is a more parsimonious predictor of SA history among Veterans suggesting it is an important treatment target among Veterans with SI.
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Affiliation(s)
- Molly Gromatsky
- VISN 2 Mental Illness Research Education and Clinical Center (MIRECC), Bronx, NY, USA
| | - Emily R Edwards
- VISN 2 Mental Illness Research Education and Clinical Center (MIRECC), Bronx, NY, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sarah R Sullivan
- VISN 2 Mental Illness Research Education and Clinical Center (MIRECC), Bronx, NY, USA
| | - Marianne Goodman
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA
| | - Erin A Hazlett
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA
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38
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Graziano RC, Aunon FM, LoSavio ST, Elbogen EB, Beckham JC, Dillon KH. A network analysis of risk factors for suicide in Iraq/Afghanistan-era veterans. J Psychiatr Res 2021; 138:264-271. [PMID: 33872963 PMCID: PMC8192445 DOI: 10.1016/j.jpsychires.2021.03.065] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 03/22/2021] [Accepted: 03/29/2021] [Indexed: 01/19/2023]
Abstract
Suicidal ideation (SI) is a prevalent issue in the veteran population. A number of factors have been identified as risk factors for suicidal ideation (SI) in veterans, including suicide attempts, depression, posttraumatic stress disorder (PTSD), and drug use. However, clinicians' ability to predict suicide is poor, particularly given the interplay between various factors such as previous suicide attempts. As such, there is a gap in our knowledge of which factors most saliently predict suicide risk and which should be targets for interventions designed to lower SI. Network analysis, a method allowing for an examination of how variables relate within the context of a network of factors, may bridge this gap by simultaneously evaluating the interrelationships between risk factors for suicide in veterans. Current study used network analysis and data from 2268 Iraq/Afghanistan-era military veterans to examine the relationships between suicidal ideation and several factors related to suicide risk, such as past suicide attempts, PTSD symptoms, depression, drug use, trauma exposure. Partial correlation network results showed suicidal ideation to be strongly related to depression, with smaller connections to past suicide attempts and anger. Additionally, past suicide attempts was strongly related to history of childhood trauma and weakly related to problematic drug use and PTSD symptoms. These results offer valuable information for both predicting suicide risk and differentiating targets for interventions lowering suicide risk in veterans.
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Affiliation(s)
| | | | - Stefanie T. LoSavio
- Durham VA Health Care System, Durham, NC,Duke University Medical Center, Durham, NC
| | - Eric B. Elbogen
- Duke University Medical Center, Durham, NC,VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, NC,National Center on Homelessness Among Veterans, Washington, DC
| | - Jean C. Beckham
- Durham VA Health Care System, Durham, NC,Duke University Medical Center, Durham, NC,VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, NC
| | | | - Kirsten H. Dillon
- Durham VA Health Care System, Durham, NC,Duke University Medical Center, Durham, NC,VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, NC,Correspondence concerning this article should be sent to: Kirsten H. Dillon, PhD, Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705,
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39
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Sadler N, Van Hooff M, Bryant RA, Lawrence-Wood E, Baur J, McFarlane A. Suicide and suicidality in contemporary serving and ex-serving Australian Defence Force personnel. Aust N Z J Psychiatry 2021; 55:463-475. [PMID: 33726567 DOI: 10.1177/0004867421998751] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The risk of suicide in contemporary serving and ex-serving Australian Defence Force personnel is an area of significant concern, driving government-directed inquiries, community campaigns and most recently, the establishment of a permanent National Commissioner for Defence and Veteran Suicide Prevention. This concern is mirrored in international militaries and despite investment in prevention programmes, suicide is a leading cause of death in military populations. This review seeks to summarise recent findings from Australian research regarding the magnitude and factors associated with suicide and suicidality in contemporary serving and ex-serving Australian Defence Force populations and discusses research findings, implications and future opportunities. METHODS Initial review of the prevalence of suicide and suicidality in the general community and military populations is presented, followed by review of recent research findings pertaining to suicides and suicidal thoughts, plans and attempts in contemporary serving and ex-serving Australian Defence Force personnel. Key findings are presented from the 2010 Australian Defence Force Mental Health and Wellbeing Prevalence Study and the 2015 Transition and Wellbeing Research Programme. RESULTS Differences between serving and ex-serving Australian Defence Force cohorts were observed, with rates of completed suicide in ex-serving Australian Defence Force males more than double that of serving Australian Defence Force males, and increased risk for suicidality observed among those who had recently transitioned out of full-time Australian Defence Force service. Risk for increased suicidality and completed suicide is particularly evident for younger males of lower ranks, and those who have been medically discharged. CONCLUSIONS The findings provide insight into career phases and groups that should be followed-up and targeted for prevention and early intervention programmes, including prior to and several years following transition out of full-time military service. Further research to better understand the factors that influence those who develop suicidal ideation, and those who progress to plans and attempts, will inform a more sophisticated approach to suicide prevention programmes.
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Affiliation(s)
- Nicole Sadler
- Phoenix Australia Centre for Posttraumatic Mental Health and Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
| | - Miranda Van Hooff
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Richard A Bryant
- School of Psychology, University of New South Wales Sydney, Sydney, NSW, Australia
| | - Ellie Lawrence-Wood
- Phoenix Australia Centre for Posttraumatic Mental Health and Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
| | - Jenelle Baur
- Phoenix Australia Centre for Posttraumatic Mental Health and Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
| | - Alexander McFarlane
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
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40
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Krauss SW, Zust J, Frankfurt S, Kumparatana P, Riviere LA, Hocut J, Sowden WJ, Adler AB. Distinguishing the Effects of Life Threat, Killing Enemy Combatants, and Unjust War Events in U.S. Service Members. J Trauma Stress 2021; 34:357-366. [PMID: 33301629 DOI: 10.1002/jts.22635] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 11/09/2020] [Accepted: 11/11/2020] [Indexed: 11/08/2022]
Abstract
Although previous studies have identified behavioral health risks associated with combat exposure, it is unclear which types of combat events are associated with these risks, particularly regarding contrasts among the risks associated with life-threatening experiences, killing combatants, and exposure to unjust war events, such as killing a noncombatant or being unable to help civilian women and children. In the present study, we examined surveys from 402 soldiers following deployment (i.e., baseline) and again 13 months later (i.e., Year 1). Regression analyses were conducted across a range of behavioral health (e.g., posttraumatic stress disorder, depression, suicide ideation, anxiety, somatic, insomnia, aggression) and benefit-finding measures, each controlling for two combat event categories while assessing the predictive utility of a third. The results suggested that life-threatening events were associated with poor behavioral health at baseline, relative risk (RR) = 10.00, but not at Year 1, RR = 2.67. At both baseline and Year 1, killing enemy combatants was not associated with behavioral health, RRs = 1.67-3.33, but was positively associated with benefit-finding, RRs = 26.67-40.00. Exposure to unjust war events was associated with a transdiagnostic pattern of behavioral health symptoms at baseline, RR = 40.00, and Year 1, RR = 23.33. Overall, the results suggest unjust war event exposure is particularly injurious, above and beyond exposure to other combat-related events. Future research can build on these findings to develop clearer descriptions of the combat events that might place service members at risk for moral injury and inform the development of assessment and treatment options.
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Affiliation(s)
- Stephen W Krauss
- Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
| | - Jeffrey Zust
- Evangelical Lutheran Church in America, Chicago, Illinois, USA
| | - Sheila Frankfurt
- VISN 17 Center of Excellence for Research on Returning War Veterans, Waco, Texas, USA
- Central Texas VA Healthcare System, Temple, Texas, USA
- College of Medicine, Texas A&M University, College Station, Texas, USA
| | - Pam Kumparatana
- Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
| | - Lyndon A Riviere
- Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
| | - Joy Hocut
- Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
| | - Walter J Sowden
- Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
- Tripler Army Medical Center, Honolulu, Hawaii, USA
| | - Amy B Adler
- Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
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41
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LeardMann CA, Matsuno RK, Boyko EJ, Powell TM, Reger MA, Hoge CW. Association of Combat Experiences With Suicide Attempts Among Active-Duty US Service Members. JAMA Netw Open 2021; 4:e2036065. [PMID: 33528551 PMCID: PMC7856539 DOI: 10.1001/jamanetworkopen.2020.36065] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 12/14/2020] [Indexed: 12/02/2022] Open
Abstract
Importance There is uncertainty about the role that military deployment experiences play in suicide-related outcomes. Most previous research has defined combat experiences broadly, and a limited number of cross-sectional studies have examined the association between specific combat exposure (eg, killing) and suicide-related outcomes. Objective To prospectively examine combat exposures associated with suicide attempts among active-duty US service members while accounting for demographic, military-specific, and mental health factors. Design, Setting, and Participants This cohort study analyzed data from the Millennium Cohort Study, an ongoing prospective longitudinal study of US service members from all military branches. Participants were enrolled in 4 phases from July 1, 2001, to April 4, 2013, and completed a self-administered survey at enrollment and every 3 to 5 years thereafter. The population for the present study was restricted to active-duty service members from the first 4 enrollment phases who deployed in support of the wars in Iraq and Afghanistan. Questionnaire data were linked with medical encounter data through September 30, 2015. Data analyses were conducted from January 10, 2017, to December 14, 2020. Exposures Combat exposure was examined in 3 ways (any combat experience, overall combat severity, and 13 individual combat experiences) using a 13-item self-reported combat measure. Main Outcomes and Measures Suicide attempts were identified from military electronic hospitalization and ambulatory medical encounter data using the International Classification of Diseases, Ninth Revision codes. Results Among 57 841 participants, 44 062 were men (76.2%) and 42 095 were non-Hispanic White individuals (72.8%), and the mean (SD) age was 26.9 (5.3) years. During a mean (SD) follow-up period of 5.6 (4.0) years, 235 participants had a suicide attempt (0.4%). Combat exposure, defined broadly, was not associated with suicide attempts in Cox proportional hazards time-to-event regression models after adjustments for demographic and military-specific factors; high combat severity and certain individual combat experiences were associated with an increased risk for suicide attempts. However, these associations were mostly accounted for by mental disorders, especially posttraumatic stress disorder. After adjustment for mental disorders, combat experiences with significant association with suicide attempts included being attacked or ambushed (hazard ratio [HR], 1.55; 95% CI, 1.16-2.06), seeing dead bodies or human remains (HR, 1.34; 95% CI, 1.01-1.78), and being directly responsible for the death of a noncombatant (HR, 1.81; 95% CI, 1.04-3.16). Conclusions and Relevance This study suggests that deployed service members who experience high levels of combat or are exposed to certain types of combat experiences (involving unexpected events or those that challenge moral or ethical norms) may be at an increased risk of a suicide attempt, either directly or mediated through a mental disorder.
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Affiliation(s)
- Cynthia A. LeardMann
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos, San Diego, California
| | - Rayna K. Matsuno
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos, San Diego, California
| | - Edward J. Boyko
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Epidemiology, University of Washington School of Public Health, Seattle
- Department of Medicine, University of Washington School of Medicine, Seattle
| | - Teresa M. Powell
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos, San Diego, California
| | - Mark A. Reger
- Veterans Affairs Puget Sound Healthcare System, Seattle, Washington
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
| | - Charles W. Hoge
- Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland
- Psychiatry Division, Office of the Army Surgeon General, Falls Church, Virginia
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42
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Griffith J, J Bryan C. Deployment Experiences and Suicidal Behaviors Related to Interpersonal Violence Perpetration Among Army National Guard Soldiers. VIOLENCE AND VICTIMS 2020; 35:841-860. [PMID: 33372113 DOI: 10.1891/vv-d-18-00174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
An issue of major policy interest in the U.S. military has been interpersonal violence (IPV), especially relative to the frequent and lengthy deployments of U.S. service members to Iraq and Afghanistan. Lacking, however, are estimates of perpetrators of IPV, in particular, for reservists who have been 30% of the ground combat force. In the present study, Army National Guard soldiers (N = 4,567 in 50 company-sized units) responded to questions about deployment and combat, IPV, and suicidal behaviors. Over a tenth (12.2%) of the soldiers reported having done any aggressive behaviors toward significant others or children during postdeployment. More lengthy and repeated deployments were associated with perpetration of IPV. Having killed or wounded someone and having experienced some form of combat trauma were much more strongly associated with IPV perpetration. Suicidal behaviors were associated with having committed IPV, with the greatest risk associated with suicide attempts. Findings are discussed in terms of underlying mechanisms of both IPV perpetration and suicidal behaviors.
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Affiliation(s)
- James Griffith
- National Center for Veterans Studies, University of Utah, Salt Lake City, Utah
| | - Craig J Bryan
- Department of Psychiatry and Behavioral Health, The Ohio State University, Wexner Medical Center
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43
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Glenn JJ, Dillon KH, Dennis PA, Patel TA, Mann AJ, Calhoun PS, Kimbrel NA, Beckham JC, Elbogen EB. Post-traumatic symptom severity mediates the association between combat exposure and suicidal ideation in veterans. Suicide Life Threat Behav 2020; 50:1167-1172. [PMID: 32770773 PMCID: PMC7746613 DOI: 10.1111/sltb.12678] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 04/08/2020] [Accepted: 05/07/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Previous studies of military veterans have produced mixed findings regarding whether combat exposure is directly related to suicidal ideation or is indirectly related to suicidal ideation via its influence on other factors. The present study used a longitudinal design to test the hypothesis that post-traumatic stress disorder (PTSD) symptom severity mediates the effect of combat exposure on suicidal ideation in veterans. METHOD Participants included 319 post-9/11 veterans (83.4% male; 42.1% White/52.1% Black; Mage = 39.7) assessed at baseline, 6, and 12 months. Structural equation modeling and bootstrapped confidence intervals were employed to examine the direct and indirect relationships between combat exposure, suicidal ideation, and PTSD symptom severity. RESULTS Results from the mediation model, in which demographic variables and non-combat trauma were included as covariates, revealed that the indirect effect of combat exposure on suicidal ideation via PTSD symptom severity was statistically significant, accounting for 64.1% of the covariance between combat exposure and suicidal ideation. CONCLUSIONS This study provides longitudinal evidence that the effects of combat exposure on suicidal ideation are mediated by PTSD symptom severity, suggesting the importance of targeting such symptoms in treatment to mitigate suicide risk among veterans with combat exposure.
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Affiliation(s)
- Jeffrey J. Glenn
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, NC, USA
| | - Kirsten H. Dillon
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, NC, USA
- Duke University Medical Center, Durham, NC, USA
| | - Paul A. Dennis
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, NC, USA
- Duke University Medical Center, Durham, NC, USA
| | - Tapan A. Patel
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, NC, USA
| | - Adam J. Mann
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, NC, USA
| | - Patrick S. Calhoun
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, NC, USA
- Duke University Medical Center, Durham, NC, USA
- VA Center for Health Services Research in Primary Care, Durham, NC, USA
| | - Nathan A. Kimbrel
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, NC, USA
- Duke University Medical Center, Durham, NC, USA
- VA Center for Health Services Research in Primary Care, Durham, NC, USA
| | - Jean C. Beckham
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, NC, USA
- Duke University Medical Center, Durham, NC, USA
| | - Eric B. Elbogen
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, NC, USA
- Duke University Medical Center, Durham, NC, USA
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Nichter B, Hill M, Norman S, Haller M, Pietrzak RH. Associations of childhood abuse and combat exposure with suicidal ideation and suicide attempt in U.S. military veterans: a nationally representative study. J Affect Disord 2020; 276:1102-1108. [PMID: 32777648 DOI: 10.1016/j.jad.2020.07.120] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 07/14/2020] [Accepted: 07/28/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Military veterans with a history of childhood abuse are at increased risk for suicidality. To date, however, little research has examined whether exposure to childhood abuse may heighten veterans' susceptibility to the effects of combat exposure and increase risk for suicidal behavior. This study examined whether childhood abuse has an additive or interactive effect on the association between combat exposure and suicide-related outcomes in a national sample of veterans. METHODS Data were from the National Health and Resilience in Veterans Study, a nationally representative survey of U.S. veterans (n = 3,157). Analyses compared veterans with/without current suicidal ideation and lifetime suicide attempts (SI/SA) on sociodemographic, military, and clinical characteristics; and examined the unique contribution of childhood physical and sexual abuse and combat exposure, and their interaction, with SI/SA. RESULTS After adjusting for sociodemographic characteristics and lifetime trauma burden, a significant interaction emerged between childhood sexual abuse and combat exposure predicting SI, such that combat-exposed veterans with histories of abuse were nearly three times more likely to currently be contemplating suicide relative to those without such histories. Childhood sexual abuse predicted lifetime suicide attempt, above and beyond sociodemographic characteristics, lifetime trauma burden, and combat exposure. LIMITATIONS Cross-sectional design precludes causal inference. CONCLUSIONS Results indicate that childhood sexual abuse exposure may operate both independently and synergistically with combat exposure to increase risk for suicidality among veterans. Findings suggest that veterans who experience childhood sexual abuse represent a subgroup that may be especially vulnerable to experiencing suicidal ideation following combat exposure.
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Affiliation(s)
- Brandon Nichter
- Department of Psychiatry, University of California, San Diego, CA 92093, United States.
| | - Melanie Hill
- Department of Psychiatry, University of California, San Diego, CA 92093, United States; VA San Diego Healthcare System, San Diego, CA, United States
| | - Sonya Norman
- Department of Psychiatry, University of California, San Diego, CA 92093, United States; National Center for PTSD, White River Junction, VT, United States; VA Center of Excellence for Stress and Mental Health, San Diego, CA, United States
| | - Moira Haller
- Department of Psychiatry, University of California, San Diego, CA 92093, United States; VA San Diego Healthcare System, San Diego, CA, United States
| | - Robert H Pietrzak
- National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT, United States; Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
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Goldberg SB, Riordan KM, Sun S, Kearney DJ, Simpson TL. Efficacy and acceptability of mindfulness-based interventions for military veterans: A systematic review and meta-analysis. J Psychosom Res 2020; 138:110232. [PMID: 32906008 PMCID: PMC7554248 DOI: 10.1016/j.jpsychores.2020.110232] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/12/2020] [Accepted: 08/26/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Military veterans report high rates of psychiatric and physical health symptoms that may be amenable to mindfulness-based interventions (MBIs). Inconsistent prior findings and questions of fit between MBIs and military culture highlight the need for a systematic evaluation of this literature. OBJECTIVE To quantify the efficacy and acceptability of MBIs for military veterans. DATA SOURCES We searched five databases (MEDLINE/PubMed, CINAHL, Scopus, Web of Science, PsycINFO) from inception to October 16th, 2019. STUDY SELECTION Randomized controlled trials (RCTs) testing MBIs in military veterans. RESULTS Twenty studies (k = 16 unique comparisons, N = 898) were included. At post-treatment, MBIs were superior to non-specific controls (e.g., waitlist, attentional placebos) on measures of posttraumatic stress disorder (PTSD), depression, general psychological symptoms (i.e., aggregated across symptom domains), quality of life / functioning, and mindfulness (Hedges' gs = 0.32 to 0.80), but not physical health. At follow-up (mean length = 3.19 months), MBIs continued to outperform non-specific controls on general psychological symptoms, but not PTSD. MBIs were superior to specific active controls (i.e., other therapies) at post-treatment on measures of PTSD and general psychological symptoms (gs = 0.19 to 0.25). Participants randomized to MBIs showed higher rates of attrition than those randomized to control interventions (odds ratio = 1.98). Several models were not robust to tests of publication bias. Study quality and risk of bias assessment indicated several areas of concern. CONCLUSIONS MBIs may improve psychological symptoms and quality of life / functioning in veterans. Questionable acceptability and few high-quality studies support the need for rigorous RCTs, potentially adapted to veterans.
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Nichter B, Hill M, Norman S, Haller M, Pietrzak RH. Impact of specific combat experiences on suicidal ideation and suicide attempt in U.S. military veterans: Results from the National Health and Resilience in Veterans Study. J Psychiatr Res 2020; 130:231-239. [PMID: 32846327 DOI: 10.1016/j.jpsychires.2020.07.041] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 06/01/2020] [Accepted: 07/30/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND A burgeoning body of research suggests that specific types of combat experiences may be a stronger predictor of suicidality among veterans than a history of combat exposure itself. To date, however, little population-based data exist about these associations in representative samples of veterans. This study examined the association between overall severity of combat exposure and specific combat experiences with suicidal ideation and suicide attempt(s) (SI/SA) in a nationally representative sample of combat veterans. METHODS Data were from the National Health and Resilience in Veterans Study, a nationally representative survey of U.S. combat veterans (n = 1100). Analyses (a) compared veterans with/without current SI and lifetime SA on sociodemographic, military, and clinical characteristics; and (b) examined associations between overall combat exposure and specific combat experiences, and SI/SA. RESULTS Hierarchical regression analyses revealed that overall combat exposure was positively, albeit weakly, associated with SI/SA, after adjusting for sociodemographic characteristics and lifetime trauma burden [odds ratios (ORs) = 1.02-1.03]. Combat experiences involving direct exposure to death, killing, or grave injury were independently associated with SI/SA (ORs = 1.46-1.70), whereas several general combat experiences (e.g., combat patrols) were negatively associated with SI/SA (ORs = 0.44-0.65). DISCUSSION Results indicate that U.S. combat veterans who have witnessed others be killed or wounded in combat are at substantially higher risk for SI/SA relative to those without such histories. Collectively, findings suggest that combat exposure, when examined as an aggregate severity measure, may yield a poor prognostication of suicide risk, as it may be insufficiently sensitive to detect the effects of specific combat-related experiences.
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Affiliation(s)
- Brandon Nichter
- Department of Psychiatry, University of California, San Diego, CA, USA.
| | - Melanie Hill
- Department of Psychiatry, University of California, San Diego, CA, USA; VA San Diego Healthcare System, San Diego, CA, USA
| | - Sonya Norman
- Department of Psychiatry, University of California, San Diego, CA, USA; National Center for PTSD, White River Junction, VT, USA; VA Center of Excellence for Stress and Mental Health, San Diego, CA, USA
| | - Moira Haller
- Department of Psychiatry, University of California, San Diego, CA, USA; VA San Diego Healthcare System, San Diego, CA, USA
| | - Robert H Pietrzak
- National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT, USA; Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
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Chu C, Zuromski KL, Bernecker SL, Gutierrez PM, Joiner TE, Liu H, Naifeh JA, Stein MB, Ursano RJ, Nock MK. A test of the interpersonal theory of suicide in a large, representative, retrospective and prospective study: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Behav Res Ther 2020; 132:103688. [PMID: 32731055 PMCID: PMC10351027 DOI: 10.1016/j.brat.2020.103688] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/28/2020] [Accepted: 06/19/2020] [Indexed: 11/28/2022]
Abstract
The interpersonal theory of suicide hypothesizes that perceived burdensomeness, thwarted belongingness, and hopelessness lead to active suicidal thoughts and individuals with active suicidal thoughts and elevated capability for suicide are most likely to attempt suicide. We retrospectively and prospectively tested this theory in a large sample of 7677 U.S. Army soldiers followed post-deployment for up to nine months. The interaction of perceived burdensomeness and hopelessness (OR = 2.59) was significantly associated with lifetime suicidal thoughts; however, the interactions of thwarted belongingness and perceived burdensomeness and of thwarted belongingness and hopelessness were not. Consistent with the theory, capability for suicide prospectively predicted suicide attempts during and following deployment (OR = 1.22); however, among soldiers reporting lifetime suicidal thoughts, capability did not predict attempts, only perceived burdensomeness did (OR = 1.36). Results supported some, but not all, theory hypotheses, suggesting that additional constructs may be needed to better identify the psychological factors that lead soldiers to attempt suicide.
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Affiliation(s)
- Carol Chu
- Department of Psychology, Harvard University, Cambridge, MA, USA.
| | - Kelly L Zuromski
- Department of Psychology, Harvard University, Cambridge, MA, USA
| | | | - Peter M Gutierrez
- Rocky Mountain Mental Illness Research, Education and Clinical Center, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA; University of Colorado School of Medicine, Department of Psychiatry, Aurora, CO, USA
| | - Thomas E Joiner
- Department of Psychology, Florida State University, Tallahassee, FL, USA
| | - Howard Liu
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - James A Naifeh
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University School of Medicine in Bethesda, MD, USA
| | - Murray B Stein
- Departments of Psychiatry and Family Medicine & Public Health, University of California San Diego, La Jolla, CA, USA; VA San Diego Healthcare System, San Diego, CA, USA
| | - Robert J Ursano
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University School of Medicine in Bethesda, MD, USA
| | - Matthew K Nock
- Department of Psychology, Harvard University, Cambridge, MA, USA
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Weiss EL, Kranke D, Barmak SA. Military Veterans Serving as Volunteers: What Social Workers Need to Know. SOCIAL WORK 2020; 65:299-301. [PMID: 32710118 DOI: 10.1093/sw/swaa023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 05/30/2019] [Accepted: 06/03/2019] [Indexed: 06/11/2023]
Affiliation(s)
- Eugenia L Weiss
- is clinical professor of social work, Suzanne Dworak-Peck School of Social Work, University of Southern California, 669 West 34th Street, MRF 201, Los Angeles, CA 90089
| | - Derrick Kranke
- is health science specialist, Veterans Emergency Management Evaluation Center (VEMEC), U.S. Department of Veterans Affairs, North Hills, CA
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Mathes BM, Quick AD, Albanese BJ, Morabito DM, Bedford CE, Schmidt NB. Hostility and Suicide Risk Among Veterans: The Mediating Role of Perceived Burdensomeness. COGNITIVE THERAPY AND RESEARCH 2020. [DOI: 10.1007/s10608-020-10082-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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50
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Zuromski KL, Bernecker SL, Chu C, Wilks CR, Gutierrez PM, Joiner TE, Liu H, Naifeh JA, Nock MK, Sampson NA, Zaslavsky AM, Stein MB, Ursano RJ, Kessler RC. Pre-deployment predictors of suicide attempt during and after combat deployment: Results from the Army Study to Assess Risk and Resilience in Servicemembers. J Psychiatr Res 2020; 121:214-221. [PMID: 31865211 PMCID: PMC6953717 DOI: 10.1016/j.jpsychires.2019.12.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/04/2019] [Accepted: 12/05/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Deployment-related experiences might be risk factors for soldier suicides, in which case identification of vulnerable soldiers before deployment could inform preventive efforts. We investigated this possibility by using pre-deployment survey and administrative data in a sample of US Army soldiers to develop a risk model for suicide attempt (SA) during and shortly after deployment. METHODS Data came from the Army Study to Assess Risk and Resilience in Servicemembers Pre-Post Deployment Survey (PPDS). Soldiers completed a baseline survey shortly before deploying to Afghanistan in 2011-2012. Survey measures were used to predict SAs, defined using administrative and subsequent survey data, through 30 months after deployment. Models were built using penalized regression and ensemble machine learning methods. RESULTS Significant pre-deployment risk factors were history of traumatic brain injury, 9 + mental health treatment visits in the 12 months before deployment, young age, female, previously married, and low relationship quality. Cross-validated AUC of the best penalized and ensemble models were .75-.77. 21.3-40.4% of SAs occurred among the 5-10% of soldiers with highest predicted risk and positive predictive value (PPV) among these high-risk soldiers was 4.4-5.7%. CONCLUSIONS SA can be predicted significantly from pre-deployment data, but intervention planning needs to take PPV into consideration.
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Affiliation(s)
- Kelly L. Zuromski
- Department of Psychology, Harvard University, Cambridge, MA, USA,Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Samantha L. Bernecker
- Department of Psychology, Harvard University, Cambridge, MA, USA,Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Carol Chu
- Department of Psychology, Harvard University, Cambridge, MA, USA,Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Chelsey R. Wilks
- Department of Psychology, Harvard University, Cambridge, MA, USA,Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Peter M. Gutierrez
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, USA,Rocky Mountain Mental Illness Research, Education, and Clinical Center, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
| | - Thomas E. Joiner
- Department of Psychology, Florida State University, Tallahassee, FL, USA
| | - Howard Liu
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - James A. Naifeh
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University School of Medicine, Bethesda, MD, USA
| | - Matthew K. Nock
- Department of Psychology, Harvard University, Cambridge, MA, USA
| | - Nancy A. Sampson
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Alan M. Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Murray B. Stein
- Departments of Psychiatry and Family Medicine and Public Health, University of California San Diego, La Jolla, CA, USA
| | - Robert J. Ursano
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University School of Medicine, Bethesda, MD, USA
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
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