Increased risk of attempted suicide in Australian veterans is associated with total and permanent incapacitation, unemployment and posttraumatic stress disorder severity

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

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.

Suicide and suicidality in Australian Defence Force veterans: A systematic scoping review

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.

Suicide Ideation, Plans, and Attempts Among Military Veterans vs Nonveterans With Disability

Importance

People with disability are at heightened risk for suicide ideation, planning, and attempt, with risk growing as the number of disabling limitations increases. Military veterans have higher rates of suicide deaths and disability relative to nonveterans.

Objective

To evaluate whether veteran status is associated with greater risk for suicide in those with disability.

Design, Setting, and Participants

This survey study used cross-sectional self-reported data from US adults who participated in the 2015-2020 National Survey on Drug Use and Health. Data were weighted to represent the population. Data analysis was conducted from July to August 2022.

Main Outcomes and Measures

Suicide ideation, planning, and attempt served as primary outcomes. Disability status (present or absent) and number of disabling limitations (1, 2, or ≥3) served as factors. Veteran status was determined based on self-report (veteran or nonveteran). Multivariable logistic regression examined suicide ideation, planning, and attempt as a function of veteran status and disability variables.

Results

Participants included 231 099 US veterans and nonveterans, representing 236 551 727 US adults, of whom 20.03% (weighted n = 47 397 876) reported a disabling limitation, 8.92% were veterans (weighted n = 21 111 727; 16.0% aged 35-49 years; 91.0% men; 6.7% Hispanic; 10.9% non-Hispanic Black; and 78.4% non-Hispanic White) and 91.08% were nonveterans (weighted n = 215 440 000; 25.4% aged 35-49 years; 44.0% male; 16.5% Hispanic; 11.7% non-Hispanic Black; and 63.3% non-Hispanic White). Overall, 4.39% reported suicide ideation, planning, or attempt (weighted n = 10 401 065). Among those with no disability, veteran status was associated with higher risk of suicide planning (adjusted odds ratio [AOR], 1.71; 95% CI, 1.17-2.49). Among those with 1 or 2 disabling limitations, being a veteran was associated with a lower risk of suicide planning (AOR, 0.57; 95% CI, 0.34-0.95) and history of attempt (AOR, 0.46; 95% CI, 0.24-0.88).

Conclusions and Relevance

In this study of how suicide risk differs as a function of disability and veteran status, risk for death by suicide was lower among veterans with disability relative to nonveterans with disability. Veteran status may mitigate risk for suicide given increased receipt of more disability-related care through the Department of Veterans Affairs. Further research would extend this line of inquiry by examining the cause and type of disability as well as perceptions of disability on self-worth. It is possible that physical wounds of war are protective because of the meaning and value of service to one's country.

A Randomized Controlled Trial Evaluating the Effectiveness of Supported Employment Integrated in Primary Care

OBJECTIVES

Mental health issues can cause serious problems in occupational functioning, including higher rates of unemployment. Individual placement and support (IPS) is an evidence-based supported employment intervention that is typically integrated within a mental health setting; however, many primary care patients view referral to a mental health clinic as stigmatizing. Thus, this study examined whether delivery of IPS in a primary care setting provides an effective treatment option and avoids unnecessary delays in obtaining competitive employment.

METHODS

U.S. military veterans (N=119) who had a diagnosis in a broad range of nonpsychotic psychiatric disorders and who were receiving care from Veterans Health Administration (VHA) patient-aligned care teams were prospectively randomly assigned to IPS (N=58) or standard VHA non-IPS vocational rehabilitation (VR) (N=61). The primary outcome was achievement of steady worker status, defined as holding a competitive job for ≥6 months of the 12-month follow-up.

RESULTS

As hypothesized, a significantly greater proportion of IPS participants achieved steady worker status (45%), compared with VR participants (25%) (p=0.02; odds ratio=2.49, 95% confidence interval=1.14-5.43). On average, the IPS participants worked significantly more weeks (p=0.003) and earned significantly more income (p=0.033) from competitive jobs, compared with VR participants.

CONCLUSIONS

The results provide supporting evidence for offering IPS within primary care with the aim of restoring meaningful and sustained competitive employment for veterans living with a mental disorder. Such modifications could improve veterans' vocational outcomes, moving a significantly greater number of disabled veterans back to full and productive lives in the community.

Strengthening the feedback culture in a postgraduate residency program

BACKGROUND

Feedback is defined as specific information presented to a learner that facilitates professional development through the process of reflection. Timely provision of constructive feedback to learner is important in optimizing the learning curve. The aim of the current study was to see the effectiveness of various interventions on feedback practices of faculty members.

METHODS

This is a quasi-experimental study (pre- and postdesign). It was conducted from November 2009 to March 2011 at The Aga Khan University, Pakistan. Faculty development workshops, allotment of specified feedback time, and restructuring of residency feedback forms were done as interventions. Data collection was done pre- and postintervention. Resident's and faculty satisfaction regarding the feedback process were evaluated using a prepiloted questionnaire. Paired t-test was applied to assess the effect of interventions on faculty and resident's satisfaction.

RESULTS

The mean satisfaction scores of residents were significantly improved (P < 0.05). Pre- and postintervention faculty satisfaction score also demonstrated significant difference in overall satisfaction level, from 47.88 ± 13.92 to 63.40 ± 8.72 (P < 0.05).

DISCUSSION

This study showed improved faculty engagement and satisfaction for the provision of feedback to the trainee resident. Strengthening this, culture requires continuous reinforcement, individualized feedback to the faculty members regarding their feedback practices, and continuing faculty development initiatives.

Leave no one behind? Transitioning from the military to civilian life in New Zealand

Transition from the military environment into a civilian environment is a topic that has seen increasing attention within the last two decades. There is, in the literature, a clearly articulated issue that transition from the military to the civilian world is somewhat different to transitioning from school to work, or from career to career, or from work to retirement. Many, but not all, of the extant examples regarding military transition are case studies, focus groups or small-scale qualitative surveys. The following article details a large-scale survey that took place in New Zealand in 2019. From just over 1400 responses, a wide range of information was gathered. The aim of the survey was to uncover the experiences of military who had undergone transition within New Zealand. In this respect, the survey was exploratory. We report here the qualitative results that expand the existing body of knowledge of military transition. Our results are in line with international results and demonstrate that a large majority of respondents had a less than desirable transition experience. The contribution made therefore is a reinforcement that current practice in this area is needing a great deal of attention. The following outlines the experiences our New Zealand-based respondents had and how this mirrors the extant international literature. As this was the first survey of its kind to attract large numbers of respondents within New Zealand, the results and discussion that follow present aspects of transition that the Ministry of Defence and the New Zealand Defence Force may wish to consider when planning future transition programmes.

Deadly falls into wells: A retrospective study of 72 autopsy cases from Kairouan, Tunisia

Falls are a traumatic event that represents a major public health problem worldwide. The literature is rich in published studies of falls from heights, but only a few articles have focused on falls into wells. The region of Kairouan, in central Tunisia, is characterized by an arid climate, hence the abundance of wells for watering crops. In this study, 72 cases of deadly falls into wells were retrospectively investigated at the Department of Forensic Medicine in Kairouan over eight years (01/01/2008 to 31/12/2015). A male predominance was found (sex ratio of 2.42), with a mean age of 29 ± 16.1 years. Sixty-five cases (90.3%) were from rural areas, 62.5% had a low level of education, and 50% were unemployed. In our series, the deceased fell from a distance between 3 and 70 meters with an average of 28.3 m. The falls occurred into functional wells in 61.1%, which were filled with water in 51.4%, and were unprotected in 88.9%. Autopsy findings showed bone fractures in 51.4% of cases of which 44.4% were rib fractures. Visceral injuries were identified in 55.6% of cases. The predominant manner of death was suicide (73.2%), and severe polytrauma was the most frequent cause of death (52.8%). This study highlights the need for increased safety measures to keep wells covered and protected in order to prevent these falls.