Relation between traumatic events and suicide attempts in Canadian military personnel

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.

Predictors of negative moral appraisals and their association with symptoms of post-traumatic stress and depression in the context of COVID-19 related stressors

Research on moral injury (MI) suggests that negative moral appraisals of stressful events can impact mental health in high-stakes occupational contexts (e.g., military). Few studies have examined these associations in the general population, limiting the generalisability of findings. Furthermore, factors that may predispose an individual to adverse outcomes in the context of moral stressors remain largely unknown. The objectives of this study were to (1) explore the applicability of the MI construct to stressors experienced by the general public during the COVID-19 pandemic; (2) explore how trait differences in sense of duty, religiosity/spirituality, anxiety sensitivity, and guilt, shame, and anger, predict negative moral appraisals of COVID-19 stressors. Participants (n = 355) completed an online survey assessing exposure to and appraisals of COVID-19 stressors, mental health symptoms, and dispositional characteristics (i.e., trait emotions, anxiety sensitivity, sense of duty, religiosity/spirituality). Path analysis revealed specific indirect associations between self-based moral appraisals and posttraumatic stress disorder (PTSD) and depression through guilt, and between both self- and other-based moral appraisals and PTSD and depression through anger. Number of COVID-19 stressors had no influence on associations. Sense of duty, reparative guilt, and anxiety sensitivity best predicted negative moral appraisals. Findings partially support the applicability of the MI construct outside the occupational context.

Prevalence of suicidality and associated factors of suicide risk in a representative community sample of families in three East African refugee camps

PURPOSE

To assess the prevalence of suicidality and associated factors of suicide risk in a sample of Burundian refugee families living in three refugee camps in Tanzania.

METHODS

Children (n = 230) and their parents (n = 460) were randomly selected and interviewed about suicidality (suicidal ideation, plans, and attempts) and a range of sociodemographic, psychological, and environmental factors. Multinomial logistic regression analyses were conducted to examine factors associated with children and parents' lower and moderate or high current suicide risk.

RESULTS

Past-month prevalence of suicidal ideation, plans, and attempts were 11.3%, 0.9% and 0.9%, respectively, among children; 37.4%, 7.4% and 5.2%, respectively, among mothers; and 29.6%, 4.8% and 1.7%, respectively, among fathers. Older age in years (aORlower = 2.20, 95% CI 1.38-3.51; aORmoderate/high = 3.03, 95% CI 1.15-7.99) and higher levels of posttraumatic stress disorder symptoms (aORlower = 1.64, 95% CI 1.05-2.57; aORmoderate/high = 2.30, 95% CI: 1.02-5.16), internalizing (aORmoderate/high = 2.88, 95% CI 1.33-6.26) and externalizing problems (aORlower = 1.56, 95% CI: 1.06-2.31; aORmoderate/high = 3.03, 95% CI 1.42-6.49) were significantly positively associated with children's current suicide risk. For mothers, higher perceived instrumental social support (aORmoderate/high = 0.05, 95% CI < 0.01-0.58) was significantly negatively related to suicide risk, whereas exposure to community violence (aORlower = 1.97, 95% CI 1.30-2.99; aORmoderate/high = 1.59, 95% CI 1.00-2.52), living in larger households (aORlower = 1.74, 95% CI 1.17-2.57), and higher psychological distress (aORmoderate/high = 1.67, 95% CI 1.05-2.67) were significantly positively associated with suicide risk. For fathers, higher perceived instrumental social support (aORmoderate/high = 0.04, 95% CI < 0.01-0.44) and having more years of formal education (aORmoderate/high = 0.58, 95% CI 0.34-0.98) were significantly negatively and exposure to war-related trauma (aORmoderate/high = 1.81, 95% CI 1.03-3.19) was significantly positively associated with suicide risk.

CONCLUSION

Prevention programs should target psychopathology, community violence and social support to mitigate children and parents' current suicide risk.

Fractured Personhood, Suicide, and Lessons from Those Nearing Death

Sometimes dying patients teach us things that apply across the entirety of the life cycle. There is a significant literature indicating that some patients toward end of life covet an earlier, or hastened, death. Many of the things that move patients toward a wish to die can be subsumed under the rubric of fractured personhood. This idea describes a state of brokenness, causing people to feel they are no longer the person they once were, and that the person they have become is no longer worthy of living. This article explores the idea of fractioned personhood, and how this concept might inform our understanding of self-harm and suicide within the general population.

Physical and psychological challenges faced by military, medical and public safety personnel relief workers supporting natural disaster operations: a systematic review

Natural disasters, including floods, earthquakes, and hurricanes, result in devastating consequences at the individual and community levels. To date, much of the research reflecting the consequences of natural disasters focuses heavily on victims, with little attention paid to the personnel responding to such disasters. We conducted a systematic review of the challenges faced by military, medical and public safety personnel supporting natural disaster relief operations. Specifically, we report on the current evidence reflecting challenges faced, as well as positive outcomes experienced by military, medical and public safety personnel following deployment to natural disasters. The review included 382 studies. A large proportion of the studies documented experiences of medical workers, followed by volunteers from humanitarian organizations and military personnel. The most frequently reported challenges across the studies were structural (i.e., interactions with the infrastructure or structural institutions), followed by resource limitations, psychological, physical, and social challenges. Over 60% of the articles reviewed documented positive or transformative outcomes following engagement in relief work (e.g., the provision of additional resources, support, and training), as well as self-growth and fulfillment. The current results emphasize the importance of pre-deployment training to better prepare relief workers to manage expected challenges, as well as post-deployment supportive services to mitigate adverse outcomes and support relief workers’ well-being.

The military spouse experience of living alongside their serving/veteran partner with a mental health issue: A systematic review and narrative synthesis

INTRODUCTION

Military healthcare studies have reported a wide range of mental health issues amongst military personnel. Globally, mental health issues are one of the main causes of ill health. Military personnel have a greater prevalence of mental health issues than that of the general population. The impact of mental health issues can be wide and far reaching for family and carers. This systematic narrative review explores the military spouse experience of living alongside their serving or veteran partner with a mental health issue.

METHODS

The systematic review performed was based on the PRISMA guide for searching, screening, selecting papers for data extraction and evaluation. Studies were identified from CINHAL, ASSIA, Proquest Psychology, Proquest Nursing & Allied Health source, Proquest Dissertations & Theses, ETHOS, PsychArticles, Hospital collection, Medline, Science Direct Freedom Collection and hand searching of citations and reference lists.

RESULTS

Twenty-seven studies were included in the narrative synthesis. Five overarching themes from the experiences of military spouses' living alongside their serving/veteran partners mental health issue were identified: caregiver burden, intimate relationships, psychological/psychosocial effects on the spouse, mental health service provision and spouse's knowledge and management of symptoms.

CONCLUSIONS

The systematic review and narrative synthesis identified that the majority of studies focused on spouses of veterans, very few were specific to serving military personnel, but similarities were noted. Findings suggest that care burden and a negative impact on the intimate relationship is evident, therefore highlight a need to support and protect the military spouse and their serving partner. Likewise, there is a need for greater knowledge, access and inclusion of the military spouse, in the care and treatment provision of their serving partner's mental health issue.

Associations between sexual assault and suicidal thoughts and behavior: A meta-analysis

OBJECTIVE

The goal of the present study was to conduct a quantitative review to determine the degree to which specific forms of suicidality (i.e., lifetime and past-year suicidal ideation and attempts) are associated with sexual assault (SA). It also examined whether the strength of the association between SA and suicidality was moderated by sample characteristics or the type of suicidality assessed.

METHOD

A subset of studies (25 samples and 36 effects, reflecting N = 88,376 participants) from a prior meta-analysis assessing associations between SA and psychopathology was examined. Included studies provided the prevalence of suicidality in subsamples that had and had not been exposed to SA and/or an odds ratio comparing the prevalence in these groups. Random effects metaregression models aggregated prevalence estimates and odds ratios for lifetime and past-year suicidal ideation and suicide attempts in individuals in SA and no-SA groups. Analyses also examined whether sample characteristics (i.e., percent women, college sample) or type of suicidality moderated the magnitude of odds ratios.

RESULTS

Subsamples exposed to SA reported a substantially higher prevalence of suicidality (27.25%) compared with unassaulted subsamples (9.37%). There were significantly higher rates of lifetime and past-year suicidal ideation, and lifetime suicide attempts in assaulted subsamples than in unassaulted subsamples. No tested moderators had significant associations with the strength of the relationship between SA and suicidality.

CONCLUSION

Findings underscore the robust relationship between SA and both suicidal ideation and attempts and suggest that identifying moderators and mediators that explain it is a key directive for future research. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Associations among child abuse history, deployment-related traumatic events, mental disorders, and suicidal behaviors in Canadian Regular Force personnel

Increasing attention has been focused on suicidal behavior among military personnel. Exposure to deployment-related traumatic events (DRTEs) and child abuse (CA) both have been associated with mental disorders and suicidal behaviors among military personnel. Thus, the primary objectives of this study were to examine (a) sex differences in CA history and DRTEs, past-year mental disorders, and past-year suicide-related outcomes and (b) independent, cumulative, and interactive effects of CA history and DRTEs on past-year mental disorders and suicide outcomes among Canadian military personnel. Data were from the representative Canadian Forces Mental Health Survey collected in 2013 (N = 8,161; response rate = 79.8%). The results indicated a high prevalence of trauma exposure, with sex differences noted for specific trauma types. Both CA history and DRTEs were strongly associated with mental disorders, CA history: aORs = 1.60-2.44; DRTEs; aORs = 1.67-3.88. Cumulative, but not interactive, effects were noted for the effects of CA history and DRTEs on most mental disorders. Associations between CA history and DRTEs on suicide outcomes were largely indirect via their impact on mental disorders. Information regarding the role of specific types of predeployment trauma on mental disorders and suicidal behavior can be used to develop more targeted prevention and intervention strategies aimed at improving the mental health of military personnel.

Intimate Partner Violence (IPV) in Military and Veteran Populations: A Systematic Review of Population-Based Surveys and Population Screening Studies

Intimate partner violence (IPV) may be a major concern in military and veteran populations, and the aims of this systematic review were to (1) provide best available estimates of overall prevalence based on studies that are most representative of relevant populations, and (2) contextualise these via examination of IPV types, impacts, and context. An electronic search of PsycINFO, CINHAL, PubMed, and the Cochrane Library databases identified studies utilising population-based designs or population screening strategies to estimate prevalence of IPV perpetration or victimisation reported by active duty (AD) military personnel or veterans. Random effects meta-analyses were used for quantitative analyses and were supplemented by narrative syntheses of heterogeneous data. Thirty-one studies involving 172,790 participants were included in meta-analyses. These indicated around 13% of all AD personnel and veterans reported any recent IPV perpetration, and around 21% reported any recent victimisation. There were higher rates of IPV perpetration in studies of veterans and health service settings, but no discernible differences were found according to gender, era of service, or country of origin. Psychological IPV was the most common form identified, while there were few studies of IPV impacts, or coercive and controlling behaviours. The findings demonstrate that IPV perpetration and victimisation occur commonly among AD personnel and veterans and highlight a strong need for responses across military and veteran-specific settings. However, there are gaps in understanding of impacts and context for IPV, including coercive and controlling behaviours, which are priority considerations for future research and policy.

Understanding public reactions to state security officials' suicide cases in online news comments

Little is known about public reactions to state security officials' suicide in Muslim countries like Pakistan. To explore readers' reactions in online comments, we analyzed 1,765 comments related to 10 news stories about suicide published in five mainstream English newspapers. The findings revealed six themes: stress, depression, and mental health issues; controversial investigation reports and misinformation; need for stronger accountability to address corruption in the country; criticizing media and security institutions; sympathy for the deceased and their families; and suicide and Islam. We recommend that suicide prevention organizations should monitor audience comments to devise and suggest resources for the public.

Nightmares mediate the association between traumatic event exposure and suicidal ideation in frontline medical workers exposed to COVID-19

BACKGROUND

Trauma experience increases the risk of suicidal ideation, but little is known about potentially psychological mechanisms underlying this relationship. This study aims to examine the relationship between coronavirus disease 2019 (COVID-19)-related traumatic event (CTE) exposure and suicidal ideation among hospital workers, and identify mediating roles of sleep disturbances in this relationship.

METHODS

Workers in seven designated hospitals in Wuhan, China, were invited to participate in an online survey from May 27, 2020, to July 31, 2020. Participants completed a self-report questionnaire to evaluate demographic characteristics, level of CTE exposures, nightmare frequency, insomnia severity, symptoms of depression and anxiety, and suicidal ideation. A series of correlation analyses were performed, and a mediation model was generated to examine correlations between CTE exposure, sleep disturbances, and suicidal ideation.

RESULTS

A total of 16,220 hospital workers were included in the final analysis, 13.3% of them reported suicidal ideation in the past month. CTE exposure was significantly associated with insomnia severity, nightmare frequency, and suicidal ideation. After controlling potential confounders, nightmares but not insomnia, depression, or anxiety were shown to be independent risk factors for suicidal ideation. Pathway analyses showed that the relationship between CTE exposure and suicidal ideation was fully mediated by nightmares (proportion mediated 66.4%) after adjusting for demographic characteristics and psychological confounders.

LIMITATIONS

Cross-sectional design precluded the investigation of causal relationships.

CONCLUSIONS

CTE exposure increases risk of hospital workers' suicidal ideation that is mediated by nightmares, suggesting nightmares intervention might be considered as a component when developing suicide prevention strategies.

Adverse childhood experiences and mental health in military recruits: Exploring gender as a moderator

Adverse childhood experiences (ACEs) have consistently been associated with adult psychopathology and are commonly reported among military populations, with women more likely to report many types of ACEs than men. Limited research has examined the role of gender in the association between ACEs and mental health in military populations. The current study assessed the significance of gender differences in ACEs and mental health and explored the associations among these variables in a sample of Canadian Armed Forces recruits/officer cadets. Analyses with cross-sectional Recruit Health Questionnaire (RHQ) data from 50,603 recruits/officer cadets indicated that women were more likely to report witnessing domestic violence, experiencing sexual abuse, and living with someone with mental health problems or alcohol misuse, odds ratios (ORs) = 1.22-4.35, ps < .001. Women were more likely to screen positive for depression, adjusted (aORs) = 1.25-1.49, p < .001-p = .002, and anxiety, aORs = 2.00-2.33, ps < .001, before basic military training. ACEs were associated with screening positive for probable mental health conditions, aORs = 1.54-6.13, p < .001-p = .017. A significant interaction suggested the association between childhood sexual abuse and depression was stronger for men, aOR = 2.49, p < .001, than women, aOR = 1.63, p = .002, as was the association between childhood sexual abuse and posttraumatic stress disorder, men: aOR = 6.06, p < .001, women: aOR = 3.36, p < .001. These results underscore the importance of considering gender and childhood trauma in mental health interventions with military personnel.

Associations between courses of posttraumatic stress disorder and physical health conditions among Canadian military personnel

BACKGROUND

Posttraumatic stress disorder (PTSD) and physical health conditions commonly co-occur and are both prevalent among military personnel. This study examined how courses of PTSD (no PTSD, remitted, new onset, persistent/recurrent) are associated with physical health conditions, among a population-based sample of Canadian military personnel.

METHOD

We analyzed data from the 2002 Canadian Community Health Survey-Mental Health and Well-being-Canadian Forces supplement (CCHS-CF) and the 2018 Canadian Armed Forces Members and Veterans Mental Health Follow-Up Survey (CAFVMHS; N = 2941). Multivariable logistic regressions examined associations between PTSD courses (reference = no PTSD) and physical health conditions.

RESULTS

In general, physical health conditions were more prevalent among symptomatic PTSD courses compared to no PTSD. After adjustment, new onset PTSD was associated with increased odds of all physical health conditions with the exception of ulcers and cancer (AOR range: 1.41-2.31) and remitted PTSD was associated with increased odds of diabetes (AOR = 2.31).

CONCLUSION

Results suggest that new onset PTSD may be most strongly associated with physical health conditions. Findings may inform targeted screening and intervention methods among military personnel with PTSD and physical health conditions.

Course and Predictors of Major Depressive Disorder in the Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey: Cours et Prédicteurs du Trouble de Dépression Majeure Dans l'Enquête de Suivi Sur la Santé Mentale Auprès Des Membres des Forces Armées Canadiennes et des ex-Militaires

OBJECTIVES

The present report is the first study of Canadian military personnel to use longitudinal survey data to identify factors that determine major depressive episodes (MDEs) over a period of 16 years.

METHODS

The study used data from the Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey (CAFVMHS) collected in 2018 (n = 2,941, response rate 68.7%) and linked baseline data from the same participants that were collected in 2002 when they were Canadian Regular Force members. The study used structured interviews to identify 5 common Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition mental disorders and collected demographic data, as well as information about traumatic experiences, childhood adversities, work stress, and potential resilience factors. Respondents were divided into 4 possible MDE courses: No Disorder, Remitting, New Onset, and Persistent/Recurrent. Relative risk ratios (RRRs) from multinomial regression models were used to evaluate determinants of these outcomes.

RESULTS

A history of anxiety disorders and post-traumatic stress disorder (RRRs: 1.50 to 20.55), mental health service utilization (RRRs: 1.70 to 12.34), veteran status (RRRs: 1.64 to 2.15), deployment-associated traumatic events (RRRs: 1.71 to 2.27), sexual traumas (RRRs: 1.91 to 2.93), other traumas (RRRs: 1.67 to 2.64), childhood adversities (RRRs: 1.39 to 1.97), avoidance coping (RRRs 1.09 to 1.49), higher frequency of religious attendance (RRRs: 1.54 to 1.61), and work stress (RRRs: 1.05 to 1.10) were associated with MDE courses in most analyses. Problem-focused coping (RRRs: 0.73 to 0.91) and social support (RRRs: 0.95 to 0.98) were associated with protection against MDEs.

CONCLUSIONS

The time periods following deployment and trauma exposure and during the transition from active duty to veteran status are particularly relevant for vulnerability to depression in military members. Interventions that enhance problem-focused coping and social support may be protective against MDEs in military members.

Rationale and Methodology of the 2018 Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey (CAFVMHS): A 16-year Follow-up Survey: Raison D'être Et Méthodologie De L'enquête De Suivi Sur La Santé Mentale Des Membres Des Forces Armées Canadiennes Et Des Anciens Combattants, 2018 (ESSMFACM)

OBJECTIVE

Knowledge is limited regarding the longitudinal course and predictors of mental health problems, suicide, and physical health outcomes among military and veterans. Statistics Canada, in collaboration with researchers at the University of Manitoba and an international team, conducted the Canadian Armed Forces Members and Veterans Mental Health Follow-Up Survey (CAFVMHS). Herein, we describe the rationale and methods of this important survey.

METHOD

The CAFVMHS is a longitudinal survey design with 2 time points (2002 and 2018). Regular Force military personnel who participated in the first Canadian Community Health Survey Cycle 1.2-Mental Health and Well-Being, Canadian Forces Supplement (CCHS-CFS) in 2002 (N = 5,155) were reinterviewed in 2018 (n = 2,941). The World Mental Health Survey-Composite International Diagnostic Interview was used with the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria.

RESULTS

The CAFVMHS includes 2,941 respondents (66% veterans; 34% active duty) and includes data on mental disorder diagnoses, physical health conditions, substance use, medication use, general health, mental health services, perceived need for care, social support, moral injury, deployment experiences, stress, physical activity, military-related sexual assault, childhood experiences, and military and sociodemographic information.

CONCLUSIONS

The CAFVMHS provides a unique opportunity to further understand the health and well-being of military personnel in Canada over time to inform intervention and prevention strategies and improve outcomes. The data are available through the Statistics Canada Research Data Centres across Canada and can be used cross-sectionally or be longitudinally linked to the 2002 CCHS-CFS data.

Course and Predictors of Posttraumatic Stress Disorder in the Canadian Armed Forces: A Nationally Representative, 16-Year Follow-up Study: Cours et prédicteurs du trouble de stress post-traumatique dans les Forces armées canadiennes: une étude de suivi de 16 ans nationalement représentative

OBJECTIVE

This study examined baseline risk and protective predictors and interim correlates of the persistence/recurrence, remission, and onset of posttraumatic stress disorder (PTSD) in a 16-year prospective, nationally representative sample of Canadian Forces members and veterans.

METHODS

The 2018 Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey is a prospective study of 2,941 regular force service members and veterans who participated in the 2002 Canadian Community Health Survey on Mental Health and Wellbeing: Canadian Forces Supplement (n = 5,155; ages 15 to 64 years; response rate 68%). PTSD diagnoses in 2002 and 2018 were used to create 4 groups: (1) no lifetime, (2) remitted, (3) new onset, and (4) persistent/recurrent PTSD. Multinomial regressions were conducted to identify predictors of PTSD courses.

RESULTS

Female sex, being a junior noncommissioned member (vs. officer), and land (vs. air) operations in 2002 were associated with all PTSD courses relative to no lifetime PTSD (relative risk ratio [RRR] range: 1.28 to 3.65). After adjusting for sociodemographic variables, baseline predictors of all PTSD courses included lifetime mental disorder, history of mental health care utilization, all trauma type categories (deployment-associated, sexual, "other"), and the number of lifetime traumatic events (RRR range: 1.14 to 8.95). New ("since 2002") traumas, transitioning to veteran status, and alcohol dependence were mostly associated with the new onset and persistent/recurrent PTSD courses (RRR range: 1.79 to 4.31), while mental health care utilization and greater avoidance coping were associated with all PTSD courses (RRR range: 1.10 to 17.87). Protective factors for several PTSD courses at one or both time points included social support, social network size, and problem-focused coping (RRR range: 0.71 to 0.98).

CONCLUSIONS

This is the first population-based survey to examine the longitudinal course of PTSD in Canadian Forces members. Prevention and intervention programs focused on bolstering social support and active coping strategies as possible protective factors/correlates may help mitigate the development and persistence of PTSD.

Segmenting or Summing the Parts? A Scoping Review of Male Suicide Research in Canada

OBJECTIVE

Suicide in Canadian men is high and rising. Research consistently indicates increased suicide risk in male subgroups including sexual minority, Indigenous, middle-aged, and military men. The current scoping review addresses the research question: Among male subgroups featured in Canadian suicide research, what are the key findings to inform suicide prevention efforts?.

METHOD

A scoping review was undertaken in accord with PRISMA-ScR guidelines. Structured searches were conducted in CIHAHL, Medline, PsychInfo, and Web of Science to identify studies reporting suicidality (suicidal ideation, plans and/or attempts) and suicide among men in Canada. Inclusion criteria comprised primary empirical studies featuring Canadian male subgroups published in English from 2009 to 2020 inclusive.

RESULTS

Sixty-eight articles met the inclusion criteria, highlighting significant rates of male suicidality and/or suicide in 3 categories: (1) health inequities (n = 29); (2) age-specific (n = 30); and (3) occupation (n = 9). The health inequities category included sexual minority men, Indigenous, and other marginalized males (i.e., homeless, immigrant men, and men who use opiates). Age-specific men focused on adolescents and youth, and middle-aged and older males. Active military, veterans, and first responders featured in the occupation category. Studies compared at risk male subgroups to females, general male populations, and/or other marginalized groups in emphasizing mental health disparities and increased suicide risk. Some men's suboptimal connections to existing mental health care services were also highlighted.

CONCLUSION

While male subgroups who are vulnerable to suicidality and suicide were consistently described, these insights have not translated to tailored upstream suicide prevention services for Canadian boys and men. There may be some important gains through integrating social and mental health care services for marginalized men, implementing school-based masculinity programs for adolescent males, orientating clinicians to the potential for men's mid-life suicide risks (i.e., separation, bereavement, retirement) and lobbying employers to norm help-seeking among activate military, veterans, and first responder males.

Deconstructing the role of the exposome in youth suicidal ideation: Trauma, neighborhood environment, developmental and gender effects

Environment (E) is pivotal in explaining variability in brain and behavior development, including suicidal ideation (SI) and behavior. It is therefore critical to systematically study relationships among environmental exposures (i.e., exposome) and suicidal phenotypes. Here, we evaluated the role of individual-level adversity and neighborhood environment and their interaction (E x E) in association with youth SI. Sample included youth (N = 7,054, ages 11–21) from the Philadelphia Neurodevelopmental Cohort, which investigated clinical phenotypes in a diverse US community population. We examined cross-sectional associations of environmental exposures with lifetime history of SI (n = 671), focusing on interactions between individual-level exposures to assaultive trauma (n = 917) and neighborhood-level socioeconomic status (SES) quantified using geocoded Census data. Models included potential confounds and overall psychopathology. Results showed that assaultive trauma was strongly associated with SI (OR = 3.3, 95%CI 2.7–4, p < .001), while low SES was not (p = .395). Both assault and low SES showed stronger association with SI in females, and in early adolescence (all E X gender/age interactions, p < .05). In traumatized youths, lower SES was associated with less SI, with no SES effects on SI in non-traumatized youths (Assault X SES interaction, Wald = 8.19, p = .004). Associations remained significant controlling for overall psychopathology. No single SES variable emerged above others to explain the moderating effect of SES. These findings may suggest a stress inoculation effect in low SES, where youths from higher SES are more impacted by the deleterious trauma-SI association. Determining which environmental factors contribute to resilience may inform population specific suicide prevention interventions. The cross-sectional study design limits causal inferences.

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Environment (E) is key in shaping development of suicidal ideation (SI).

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We integrated individual-level trauma exposure and neighborhood-level data on socioeconomic status (SES) in N=7,054 youths.

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Trauma was robustly associated with youth SI in our cohort, while SES had no association with SI.

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Only in youth with history of assaultive trauma, low SES was associated with lower SI rates (trauma by SES interaction).

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Results suggest a stress inoculation effect that was shown in animal models, but has not been shown in human suicide research.

#metoo? The association between sexual violence history and parturients' gynecological health and mental well-being

PURPOSE

Sexual violence is a global health problem. We aimed to evaluate the association between self-reported history of sexual violence and parturients' health behaviors, focusing on routine gynecological care, and mental well-being.

METHODS

This was a retrospective questionnaire-based study, including mothers of newborns delivered at the "Soroka" University Medical Center (SUMC). Participants were asked to complete three validated questionnaires, including: screening for sexual violence history (SES), post-traumatic stress disorder (PDS) and post-partum depression (EPDS). Additionally, a demographic, pregnancy and gynecological history data questionnaire was completed, and medical record summarized. Multiple analyses were performed, comparing background and outcome variables across the different SES severity levels. Multivariable regression models were constructed, while adjusting for confounding variables.

RESULTS

The study included 210 women. Of them, 26.3% (n = 57) reported unwanted sexual encounter, 23% (n = 50) reported coercion, 1.8% (n = 4) assault and attempted rape, and 1.4% (n = 3) reported rape. A significant association was found between sexual violence history and neglected gynecological care, positive EPDS screening, and reporting experiencing sexual trauma. Several multivariable regression models were constructed, to assess independent associations between sexual violence history and gynecological health-care characteristics, as well as EPDS score. Sexual violence history was found to be independently and significantly associated with a negative relationship with the gynecologist, avoidance of gynecological care, sub-optimal routine gynecological follow-up, and seeking a gynecologist for acute symptoms (adjusted OR = 0.356; 95% CI 0.169-0.749, adjusted OR = 0.369; 95% CI 0.170-0.804, adjusted OR = 2.255; 95% CI 1.187-4.283, and adjusted OR = 2.113; 95% CI 1.085-4.111, respectively), as well as with the risk of post-partum depression (adjusted OR = 4.46; 95% CI 2.03-9.81). All models adjusted for maternal age and ethnicity.

CONCLUSION

Sexual violence history is extremely common among post-partum women. It is independently associated with post-partum depression, neglected gynecological care, a negative relationship with the gynecologist, and with reporting of experiencing sexual trauma. Identifying populations at risk and taking active measures, may reduce distress and improve emotional well-being and family function.

Associations of childhood abuse and combat exposure with suicidal ideation and suicide attempt in U.S. military veterans: a nationally representative study

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.

What Differentiates Prisoners Who Attempt Suicide from Those Who Experience Suicidal Ideation? A Nationally Representative Study

OBJECTIVE

Many people who think about suicide do not engage in suicidal behavior. Identifying risk factors implicated in the process of behavioral enaction is crucial for suicide prevention, particularly in high-risk groups such as prisoners.

METHOD

Cross-sectional data were drawn from a nationally representative sample of 17,891 prisoners (79% men) in the United States. We compared prisoners who attempted suicide (attempters; n = 2,496) with those who thought about suicide but never made an attempt (ideators; n = 1,716) on a range of established risk factors.

RESULTS

More than half (59%) of participants who experienced suicidal ideation had also attempted suicide. Violent offending, trauma, brain injury, alcohol abuse, and certain mental disorders distinguished attempters from ideators.

CONCLUSION

Our results fit within recent ideation-to-action theories that emphasize the role of a capability for suicide in the transition from thoughts to acts of suicide.

Prevalence of Self-Reported Intimate Partner Violence Victimization Among Military Personnel: A Systematic Review and Meta-Analysis

BACKGROUND

Research on intimate partner violence (IPV) in the military has tended to focus on military personnel as perpetrators and civilian partners/spouses as victims. However, studies have found high levels of IPV victimization among military personnel. This article systematically reviews studies of the prevalence of self-reported IPV victimization among military populations.

METHODS

Searches of four electronic databases (Embase, Medline, PsycINFO, and Web of Science) were supplemented by reference list screening. Meta-analyses of the available data were performed, where possible, using the random effects model.

RESULTS

This review included 28 studies with a combined sample of 69,808 military participants. Overall, similar or higher prevalence rates of physical IPV victimization were found among males compared to females and this was supported by a meta-analytic subgroup analysis: pooled prevalence of 21% (95% confidence interval [CI] = [17.4, 24.6]) among males and 13.6% among females (95% CI [9.5, 17.7]). Psychological IPV was the most prevalent type of abuse, in keeping with findings from the general population. There were no studies on sexual IPV victimization among male personnel. Evidence for the impact of military factors, such as deployment or rank, on IPV victimization was conflicting.

DISCUSSION

Prevalence rates varied widely, influenced by methodological variation among studies. The review highlighted the lack of research into male IPV victimization in the military and the relative absence of research into impact of IPV. It is recommended that future research disaggregates results by gender and considers the impact of IPV, in order that gender differences can be uncovered.

Sex differences in type of lifetime trauma and suicidal ideation mediated by post-traumatic stress and anxio-depressive disorders in older adults

OBJECTIVES

Examine the association between trauma and daily stressors, post-traumatic stress syndrome (PTSS), anxio-depressive disorders, and suicidal ideation in older adults.

DESIGN

A cross-sectional study.

SETTING AND PARTICIPANTS

This study included 1446 older adults recruited in primary care practices (2011-2013) and participating in Quebec's longitudinal study on health services in the elderly.

MEASUREMENTS

Lifetime trauma and PTSS was assessed using the validated PTSS scale for older adults based on scores from the Impact of Events Scale-Revised, number of lifetime traumatic events and interference with daily activities. The presence of an anxio-depressive disorder was based on physician diagnoses. Path analyses were conducted to determine the pathways between trauma, daily stressors, PTSS and anxio-depressive disorders and SI. Analyses were conducted on the overall sample and by sex.

RESULTS

Seven percent and 12% reported SI and PTSS. In males, traumas of sexual assault, violence/stalked, war/combat/imprisonment and daily hassles were directly associated with SI. In females, daily hassles were directly associated with SI. In males, a number of traumas were associated with SI through the mediating effect of PTSS and anxio-depressive disorders. In females, PTSS but not anxio-depressive disorders mediated the relationship between traumas and daily stressors, and suicidal ideation.

CONCLUSIONS

The effects of lifetime traumas persist well into older age. Traumas leading to SI differ between males and females as do the pathways and comorbidity with PTSS and anxio-depressive disorders. This highlights differences in etiologic patterns, which may be used in primary care practice to identify symptom profiles of older persons at risk of suicidal ideation.

Prevalence and correlates of suicidal ideation in Korean firefighters: a nationwide study

BACKGROUND

It is generally known that firefighters are at increased risk of suicide. However, the prevalence and correlates of suicidal ideation in firefighters have not been thoroughly described to date. The aim of this study was to measure the 1-year prevalence of suicidal ideation in firefighters and to investigate the correlates of past-year suicidal ideation among the demographic, occupational and clinical characteristics.

METHOD

A web-based survey was conducted using a self-reported questionnaire. A total of 45,698 Korean firefighters were included for analysis. The prevalence of suicidal ideation in the past year was calculated and its correlates were elucidated using a multivariable logistic regression analysis.

RESULTS

The 1-year prevalence of suicidal ideation was 10.66% in Korean firefighters. Recent traumatic experience, high levels of occupational stress from physical work environment and emotional labor, as well as current duty of officer were significant correlates of suicidal ideation in the previous year, even after controlling for the effects of PTSD and depressive symptoms. With respect to demographic factors, female gender and marital status of divorced/separated/widowed were identified to be associated with suicidal ideation in the previous year among firefighters.

CONCLUSIONS

The 1-year prevalence of suicidal ideation was high in Korean firefighters and was associated with various occupational factors as well as psychiatric symptoms. Early detection and management of these risk factors could reduce the risk of suicidal ideation in firefighters.

Protective correlates of suicidality among veterans with histories of posttraumatic stress disorder and major depressive disorder: Results from the National Health and Resilience in Veterans Study

BACKGROUND

Although several studies have identified risk factors for suicidal behaviors in general samples of Veterans, fewer studies have examined protective factors, particularly in high-risk samples. To address this gap, we examined protective correlates of suicidal ideation (SI) and suicide attempts (SA) in a sample of Veterans with histories of posttraumatic stress disorder (PTSD) and/or major depressive disorder (MDD).

METHOD

Data were analyzed from a nationally representative sample of 3157 U.S. Veterans who completed the first wave of a web-based survey as part of the National Health and Resilience in Veterans Study (NHRVS). Of this sample, 577 Veterans met criteria for history of PTSD, MDD or both.

RESULTS

Multivariable logistic regression analyses were used to examine relationships between protective factors (curiosity, resilience, purpose in life, dispositional gratitude, optimism, and community integration) and suicidal behaviors (SI and SA). The prevalence of any SI during the previous two weeks was 29.4% and the prevalence of lifetime SA was 28.0%. After adjusting for relevant sociodemographic and military characteristics, greater purpose in life, curiosity, and optimism were negatively associated with SI. None of the protective correlates were associated with SA.

LIMITATIONS

Given the cross-sectional nature of this study, conclusions about causality cannot be made. The assessment of suicidality also was limited to three self-report items.

CONCLUSION

Results provide a characterization of protective factors for suicidality, and may help inform prevention and treatment approaches designed to mitigate suicide risk among high-risk military Veterans.

The Sexual Harassment-Suicide Connection in the U.S. Military: Contextual Effects of Hostile Work Environment and Trusted Unit Leaders

Sexual harassment has been associated with suicidal behaviors, and with the rise in suicides in the U.S. military, sexual harassment's role in suicide has been of growing interest. Lacking are studies that examine group- or unit-level variables in the relationship of sexual harassment to suicidal behaviors (thoughts, plans, and attempts). In this study, survey data from soldiers (12,567 soldiers in 180 company-sized units) who completed the Unit Risk Inventory administered during calendar year 2010 were analyzed using hierarchical linear modeling. At the individual level, sexual harassment was associated with a fivefold increase for risk of suicide. Reporting that leaders could be trusted was associated with a decreased suicide risk by about one-third. There was no statistically significant interaction between sexual harassment and trusted leaders in predicting the suicidal behaviors. At the group level, units or companies having higher levels of sexual harassment also had soldiers three times more at risk for suicide. A cross-leveling effect was also observed: Among units having higher levels of sexual harassment, the negative correlation (buffering effect of unit leaders on suicidal behaviors) was diminished. Implications of findings for preventing sexual harassment and suicide risk are discussed.

Contribution of traumatic deployment experiences to the burden of mental health problems in Canadian Armed Forces personnel: exploration of population attributable fractions

PURPOSE

Mental health problems are prevalent after combat; they are also common in its absence. Estimates of deployment-attributability vary. This paper quantifies the contribution of different subtypes of occupational trauma to post-deployment mental health problems.

METHODS

Participants were a cohort of 16,193 Canadian personnel undergoing post-deployment mental health screening after return from the mission in Afghanistan. The screening questionnaire assessed post-traumatic stress disorder, depression, panic disorder, generalized anxiety disorder, and exposure to 30 potentially traumatic deployment experiences. Logistic regression estimated adjusted population attributable fractions (PAFs) for deployment-related trauma, which was treated as count variables divided into several subtypes of experiences based on earlier factor analytic work.

RESULTS

The overall PAF for overall deployment-related trauma exposure was 57.5% (95% confidence interval 44.1, 67.7) for the aggregate outcome of any of the four assessed problems. Substantial PAFs were seen even at lower levels of exposure. Among subtypes of trauma, exposure to a dangerous environment (e.g., receiving small arms fire) and to the dead and injured (e.g., handling or uncovering human remains) had the largest PAFs. Active combat (e.g., calling in fire on the enemy) did not have a significant PAF.

CONCLUSIONS

Military deployments involving exposure to a dangerous environment or to the dead or injured will have substantial impacts on mental health in military personnel and others exposed to similar occupational trauma. Potential explanations for divergent findings in the literature on the extent to which deployment-related trauma contributes to the burden of mental disorders are discussed.

Risk Factors Associated With Attempted Suicide Among US Army Soldiers Without a History of Mental Health Diagnosis

IMPORTANCE

The US Army suicide attempt rate increased sharply during the wars in Afghanistan and Iraq. Although soldiers with a prior mental health diagnosis (MH-Dx) are known to be at risk, little is known about risk among those with no history of diagnosis.

OBJECTIVE

To examine risk factors for suicide attempt among soldiers without a previous MH-Dx.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective longitudinal cohort study using administrative data from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), person-month records were identified for all active-duty Regular Army enlisted soldiers who had a medically documented suicide attempt from January 1, 2004, through December 31, 2009 (n = 9650), and an equal-probability sample of control person-months (n = 153 528). Data analysis in our study was from September 16, 2017, to June 6, 2018. In a stratified sample, it was examined whether risk factors for suicide attempt varied by history of MH-Dx.

MAIN OUTCOMES AND MEASURES

Suicide attempts were identified using Department of Defense Suicide Event Report records and International Classification of Diseases, Ninth Revision, Clinical Modification E95 × diagnostic codes. Mental health diagnoses and related codes, as well as sociodemographic, service-related, physical health care, injury, subjection to crime, crime perpetration, and family violence variables, were constructed from Army personnel, medical, legal, and family services records.

RESULTS

Among 9650 enlisted soldiers with a documented suicide attempt (74.8% male), 3507 (36.3%) did not have a previous MH-Dx. Among soldiers with no previous diagnosis, the highest adjusted odds of suicide attempt were for the following: female sex (odds ratio [OR], 2.6; 95% CI, 2.4-2.8), less than high school education (OR, 1.9; 95% CI, 1.8-2.0), first year of service (OR, 6.0; 95% CI, 4.7-7.7), previously deployed (OR, 2.4; 95% CI, 2.1-2.8), promotion delayed 2 months or less (OR, 2.1; 95% CI, 1.7-2.6), past-year demotion (OR, 1.6; 95% CI, 1.3-1.8), 8 or more outpatient physical health care visits in the past 2 months (OR, 3.3; 95% CI, 2.9-3.8), past-month injury-related outpatient (OR, 3.0; 95% CI, 2.8-3.3) and inpatient (OR, 3.8; 95% CI, 2.3-6.3) health care visits, previous combat injury (OR, 1.6; 95% CI, 1.0-2.4), subjection to minor violent crime (OR, 1.6; 95% CI, 1.1-2.4), major violent crime perpetration (OR, 2.0; 95% CI, 1.3-3.0), and family violence (OR, 2.9; 95% CI, 1.9-4.4). Most of these variables were also associated with suicide attempts among soldiers with a previous MH-Dx, although the strength of associations differed.

CONCLUSIONS AND RELEVANCE

Suicide attempt risk among soldiers with unrecognized mental health problems is a significant and important challenge. Administrative records from personnel, medical, legal, and family services systems can assist in identifying soldiers at risk.

Documented family violence and risk of suicide attempt among U.S. Army soldiers

Suicide attempt (SA) rates in the U.S. Army increased substantially during the wars in Afghanistan and Iraq. This study examined associations of family violence (FV) history with SA risk among soldiers. Using administrative data from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), we identified person-month records of active duty, Regular Army, enlisted soldiers with medically documented SAs from 2004 to 2009 (n = 9650) and a sample of control person-months (n = 153,528). Logistic regression analyses examined associations of FV with SA, adjusting for socio-demographics, service-related characteristics, and prior mental health diagnosis. Odds of SA were higher in soldiers with a FV history and increased as the number of FV events increased. Soldiers experiencing past-month FV were almost five times as likely to attempt suicide as those with no FV history. Odds of SA were elevated for both perpetrators and those who were exclusively victims. Male perpetrators had higher odds of SA than male victims, whereas female perpetrators and female victims did not differ in SA risk. A discrete-time hazard function indicated that SA risk was highest in the initial months following the first FV event. FV is an important consideration in understanding risk of SA among soldiers.

Examination of the heterogeneity in PTSD and impulsivity facets: A latent profile analysis

The experience of traumatizing events and resulting posttraumatic stress disorder (PTSD) symptomology relates to a range of impulsive behaviors. While both PTSD and impulsivity are heterogeneous and multidimensional constructs, no research has used person-centered approaches to examine subgroups of individuals based on these response endorsements. Hence, our study examined PTSD-impulsivity typologies and their construct validity in two samples: university students (n = 412) and community participants recruited through Amazon's MTurk (n = 346). Measures included the Stressful Life Events Screening Questionnaire (PTEs), PTSD Checklist for DSM-5 (PTSD severity), UPPS Impulsive Behavior Scale (negative urgency, lack of premeditation, lack of perseverance, sensation seeking). Dimensions of Anger Reaction Scale (anger), and the Patient Health Questionnaire-9 (depression). For both samples, results of latent profile analyses indicated a best-fitting 3-class solution: High, Moderate, and Low PTSD-Negative Urgency. Negative urgency was the most distinguishing impulsivity facet. Anger and depression severity significantly predicted membership in the more severe symptomatology classes. Thus, individuals can be meaningfully categorized into three subgroups based on PTSD and impulsivity item endorsements. We provide some preliminary evidence for a negative urgency subtype of PTSD characterized by greater depression and anger regulation difficulties; and underscore addressing emotional regulation skills for these subgroup members.

Traumatization, Loneliness, and Suicidal Ideation among Former Prisoners of War: A Longitudinally Assessed Sequential Mediation Model

Although highly researched among veterans, the underlying mechanisms of suicidal ideation (SI) among former prisoners of war (ex-POWs), especially in the long-term, have rarely been investigated. Furthermore, while posttraumatic stress symptoms (PTSS) and loneliness have been individually associated with veteran SI, and both may be differentially implicated by captivity versus war traumas, the interplay between them has yet to be examined. Filling this gap, the current longitudinal study examined a hypothetical sequential model wherein war captivity, compared with combat-induced trauma, is implicated in worse PTSS, which is then implicated in worse loneliness and PTSS, which together may explain subsequent SI. Two groups of Israeli veterans of the 1973 Yom Kippur War, 163 ex-POWs and 185 matched non-captive veterans were assessed 18 (T1) and 30 (T2) years after the war. Analyses indicated that compared with war, captivity was implicated in worse PTSS, which was implicated in worse loneliness, and these worked in tandem to implicate SI. Loneliness, however, was not directly affected by the type of trauma, nor was its relation to SI linked to its implication in subsequent PTSS. These results may inform future research and clinical practice as the study underscores the importance of both PTSS and loneliness in ex-POWs' long-term SI.

Trauma characteristics, post-traumatic symptoms, psychiatric disorders and suicidal behaviours: Results from the 2007 Australian National Survey of Mental Health and Wellbeing

OBJECTIVE

The current study examined whether trauma characteristics such as the type and number of traumatic events were associated with three suicidal behaviours (i.e. ideation, plan and attempt) after adjusting for sociodemographic factors, post-traumatic symptoms and history of psychiatric disorders.

METHOD

Data came from the 2007 Australian National Survey of Mental Health and Wellbeing ( N = 8841). Respondents were asked about exposure to 28 traumatic events that occurred during their lifetime. Suicidal behaviours were measured using three statements about whether the person ever seriously thought about or planned or attempted suicide.

RESULTS

Sexual violence and exposure to multiple traumatic events were particularly associated with suicidal behaviours. The presence of the emotional numbing symptom cluster and co-occurrence of three psychiatric disorders (major depressive disorder, alcohol use disorder and substance use disorder) also increased the odds of suicidal behaviours. Analysis of age of onset revealed that the mean age of traumatic exposure was earlier than the age at which suicidal behaviours emerged.

CONCLUSIONS

The current study is the first to demonstrate that sexual violence and exposure to multiple traumatic events are associated with suicidal behaviours in a representative sample of Australian adults. The results underline the potential benefits of thorough assessment of trauma history, post-traumatic symptoms and history of psychiatric disorders and their additive contribution in suicide risk among trauma victims. These findings can be used by clinicians and researchers for early intervention programmes.

Deployment-Related Traumatic Events and Suicidal Behaviours in a Nationally Representative Sample of Canadian Armed Forces Personnel

OBJECTIVE

Worldwide, there has been substantial controversy with respect to whether military deployment is a risk factor for suicidal behaviour. The present study examined the relationship between lifetime exposure to deployment and deployment-related traumatic events (DRTEs) and past-year suicidal ideation (SI), suicidal plans (SP), and suicidal attempts (SA).

METHOD

Data were analysed from the 2013 Canadian Forces Mental Health Survey (8161 respondents; response rate, 79.8%; aged 18-60 years). A total of 12 individual items assessed exposure to DRTEs (e.g., combat, witnessing human atrocities, feeling responsible for the death of Canadian or ally personnel, knowing someone who was injured or killed). We examined each individual DRTE type as well as the number of types of DRTEs in relation to suicidal behaviour.

RESULTS

Lifetime deployment was not significantly associated with suicidal behaviour. In models adjusted for sociodemographic variables, most of the individual DRTE items and the DRTE count variable were significantly associated with suicidal behaviours (adjusted odds ratio ranged between 1.10 and 5.32). When further adjusting for child abuse exposure, these associations were minimally attenuated, and some became nonsignificant. In models adjusting for mental disorders and child abuse, most DRTEs and number of types of DRTEs became nonsignificant in relation to SI, SP, and SA.

CONCLUSIONS

Active military personnel exposed to increasing number of DRTEs are at increased risk for SI, SP, and SA. However, most of the association between DRTEs and suicidal behaviour is accounted for by child abuse exposure and mental disorders.

The impact of antecedent trauma exposure and mental health symptoms on the post-deployment mental health of Afghanistan-deployed Australian troops

BACKGROUND

Both traumatic deployment experiences and antecedent traumas increase personnel's risk of developing PTSD and depression. However, only cross-sectional studies have assessed whether antecedent trauma moderates stress reactions to deployment experiences. This study prospectively examines whether antecedent trauma moderates the association between deployment trauma and post-deployment PTSD and depressive symptoms after accounting for antecedent mental health problems, in a large Australian Defence Force (ADF) sample.

METHODS

In the ADF Middle East Area of Operations Prospective Study, currently-serving military personnel deployed to Afghanistan across 2010-2012 (n = 1122) completed self-reported measures at pre-deployment and post-deployment.

RESULTS

Within multivariable regressions, associations between deployment trauma and PTSD and depressive symptoms at post-deployment were stronger for personnel with greater antecedent trauma. However, once adjusting for antecedent mental health problems, these significant interaction effects disappeared. Instead, deployment-related trauma and antecedent mental health problems showed direct associations with post-deployment mental health problems. Antecedent trauma was also indirectly associated with post-deployment mental health problems through antecedent mental health problems. Similar associations were seen with prior combat exposure as a moderator.

LIMITATIONS

Antecedent and deployment trauma were reported retrospectively. Self-reports may also suffer from social desirability bias, especially at pre-deployment.

CONCLUSIONS

Our main effects results support the pervasive and cumulative negative effect of trauma on military personnel, regardless of its source. While antecedent trauma does not amplify personnel's psychological response to deployment trauma, it is indirectly associated with increased post-deployment mental health problems. Antecedent mental health should be considered within pre-deployment prevention programs, and deployment-trauma within post-operational screening.

Sexual assault victimization and psychopathology: A review and meta-analysis

Sexual assault (SA) is a common and deleterious form of trauma. Over 40years of research on its impact has suggested that SA has particularly severe effects on a variety of forms of psychopathology, and has highlighted unique aspects of SA as a form of trauma that contribute to these outcomes. The goal of this meta-analytic review was to synthesize the empirical literature from 1970 to 2014 (reflecting 497 effect sizes) to understand the degree to which (a) SA confers general risk for psychological dysfunction rather than specific risk for posttraumatic stress, and (b) differences in studies and samples account for variation in observed effects. Results indicate that people who have been sexually assaulted report significantly worse psychopathology than unassaulted comparisons (average Hedges' g=0.61). SA was associated with increased risk for all forms of psychopathology assessed, and relatively stronger associations were observed for posttraumatic stress and suicidality. Effects endured across differences in sample demographics. The use of broader SA operationalizations (e.g., including incapacitated, coerced, or nonpenetrative SA) was not associated with differences in effects, although including attempted SA in operationalizations resulted in lower effects. Larger effects were observed in samples with more assaults involving stranger perpetrators, weapons, or physical injury. In the context of the broader literature, our findings provide evidence that experiencing SA is major risk factor for multiple forms of psychological dysfunction across populations and assault types.

Gender Differences in Machine Learning Models of Trauma and Suicidal Ideation in Veterans of the Iraq and Afghanistan Wars

Suicide rates among recent veterans have led to interest in risk identification. Evidence of gender-and trauma-specific predictors of suicidal ideation necessitates the use of advanced computational methods capable of elucidating these important and complex associations. In this study, we used machine learning to examine gender-specific associations between predeployment and military factors, traumatic deployment experiences, and psychopathology and suicidal ideation (SI) in a national sample of veterans deployed during the Iraq and Afghanistan conflicts (n = 2,244). Classification, regression tree analyses, and random forests were used to identify associations with SI and determine their classification accuracy. Findings converged on several associations for men that included depression, posttraumatic stress disorder (PTSD), and somatic complaints. Sexual harassment during deployment emerged as a key factor that interacted with PTSD and depression and demonstrated a stronger association with SI among women. Classification accuracy for SI presence or absence was good based on the receiver operating characteristic area under the curve, men = .91, women = .92. The risk for SI was classifiable with good accuracy, with associations that varied by gender. The use of machine learning analyses allowed for the discovery of rich, nuanced results that should be replicated in other samples and may eventually be a basis for the development of gender-specific actuarial tools to assess SI risk among veterans.

Painful and provocative events scale and fearlessness about death among Veterans: Exploratory factor analysis

BACKGROUND

The interpersonal theory of suicide suggests three proximal risk factors for suicide: perceived burdensomeness, thwarted belongingness, and acquired capability. Previous literature indicates that repetitive exposure to painful and provocative events is related to increased acquired capability for suicide. Despite this, research related to the assessment of painful and provocative events has been insufficient. Research has inconsistently administered the Painful and Provocative Events Scale (PPES; a painful and provocative events assessment), and no study has examined the factor structure of the English PPES. This study explored the factor structure of the PPES and the relation between factors and fearlessness about death.

METHODS

The sample was a cross-sectional, self-report study comprised of 119 Veterans (Mage = 46.5, SD = 13.5).

RESULTS

Findings from an exploratory factor analysis indicated a four-factor solution for the PPES; however, no factor from the PPES significantly related to fearlessness about death (measured by the Acquired Capability for Suicide Scale - Fearlessness About Death Scale; all p >.21).

LIMITATIONS

Cross-sectional, small Veteran sample.

CONCLUSIONS

Findings suggest that the PPES lacks the psychometric properties necessary to reliably investigate painful and provocative factors. Consequently, this measure may not reliably capture and explain how painful and provocative events relate to fearlessness about death, which is a barrier to improving suicide risk assessment and prediction. Recommendations for the construction of a new PPES are offered.

Systematic review of mental health disorders and intimate partner violence victimisation among military populations

PURPOSE

There is growing awareness of the problem of intimate partner violence (IPV) among military populations. IPV victimisation has been shown to be associated with mental disorder. A better understanding of the link between IPV and mental disorder is needed to inform service development to meet the needs of military families. We aimed to systematically review the literature on the association between IPV victimisation and mental health disorders among military personnel.

METHODS

Searches of four electronic databases (Embase, Medline, PsycINFO, and Web of Science) were supplemented by reference list screening. Heterogeneity among studies precluded a meta-analysis.

RESULTS

Thirteen studies were included. There was stronger evidence for an association between IPV and depression/alcohol problems than between IPV and PTSD. An association between IPV and mental health problems was more frequently found among veterans compared to active duty personnel. However, the link between IPV and alcohol misuse was more consistently found among active duty samples. Finally, among active duty personnel psychological IPV was more consistently associated with depression/alcohol problems than physical/sexual IPV. The review highlighted the lack of research on male IPV victimisation in the military.

CONCLUSIONS

There is evidence that the burden of mental health need may be significant among military personnel who are victims of IPV. The influence of attitudes towards gender in the military on research in this area is discussed. Further research is needed to inform development of services and policy to reduce IPV victimisation and the mental health consequences among military personnel.

Latent classes of childhood poly-victimization and associations with suicidal behavior among adult trauma victims: Moderating role of anger

The aims of the present study were first to identify discrete patterns of childhood victimization experiences including crime, child maltreatment, peer/sibling victimization, sexual violence, and witnessing violence among adult trauma victims using latent class analysis; second, to examine the association between class-membership and suicidal behavior, and third to investigate the differential role of dispositional anger on the association between class-membership and suicidal behavior. We hypothesized that those classes with accumulating exposure to different types of childhood victimization (e.g., poly-victimization) would endorse higher suicidal behavior, than the other less severe classes, and those in the most severe class with higher anger trait would have stronger association with suicidal behavior. Respondents were 346 adults (N=346; M_age=35.0years; 55.9% female) who had experienced a lifetime traumatic event. Sixty four percent had experienced poly-victimization (four or more victimization experiences) and 38.8% met the cut-off score for suicidal behavior. Three distinct classes emerged namely, the Least victimization (Class 1), the Predominantly crime and sibling/peer victimization (Class 2), and the Poly-victimization (Class 3) classes. Regression analysis controlling for age and gender indicated that only the main effect of anger was significantly associated with suicidal behavior. The interaction term suggested that those in the Poly-victimization class were higher on suicidal behavior as a result of a stronger association between anger and suicidal behavior in contrast to the association found in Class 2. Clinical implications of findings entail imparting anger management skills to facilitate wellbeing among adult with childhood poly-victimization experiences.

Trends in suicidal behaviour and use of mental health services in Canadian military and civilian populations

BACKGROUND

In the context of the Canadian mission in Afghanistan, substantial media attention has been placed on mental health and lack of access to treatment among Canadian Forces personnel. We compared trends in the prevalence of suicidal behaviour and the use of mental health services between Canadian military personnel and the general population from 2002 to 2012/13.

METHODS

We obtained data for respondents aged 18-60 years who participated in 4 nationally representative surveys by Statistics Canada designed to permit comparisons between populations and trends over time. Surveys of the general population were conducted in 2002 (n = 25 643) and 2012 (n = 15 981); those of military personnel were conducted in 2002 (n = 5153) and 2013 (n = 6700). We assessed the lifetime and past-year prevalence of suicidal ideation, plans and attempts, as well as use of mental health services.

RESULTS

In 2012/13, but not in 2002, military personnel had significantly higher odds of both lifetime and past-year suicidal ideation than the civilian population (lifetime: adjusted odds ratio [OR] 1.32, 95% confidence interval [CI] 1.17-1.50; past year: adjusted OR 1.34, 95% CI 1.09-1.66). The same was true for suicidal plans (lifetime: adjusted OR 1.64, 95% CI 1.35-1.99; past year: adjusted OR 1.66, 95% CI 1.18-2.33). Among respondents who reported past-year suicidal ideation, those in the military had a significantly higher past-year utilization rate of mental health services than those in the civilian population in both 2002 (adjusted OR 2.02, 95% CI 1.31-3.13) and 2012/13 (adjusted OR 3.14, 95% CI 1.86-5.28).

INTERPRETATION

Canadian Forces personnel had a higher prevalence of suicidal ideation and plans in 2012/13 and a higher use of mental health services in 2002 and 2012/13 than the civilian population.

Prevalence Comparison of Past-year Mental Disorders and Suicidal Behaviours in the Canadian Armed Forces and the Canadian General Population

OBJECTIVE

Military personnel in Canada and elsewhere have been found to have higher rates of certain mental disorders relative to their corresponding general populations. However, published Canadian data have only adjusted for age and sex differences between the populations. Additional differences in the sociodemographic composition, labour force characteristics, and childhood trauma exposure in the populations could be driving these prevalence differences. Our objective is to compare the prevalence of past-year mental disorders and suicidal behaviours in the Canadian Armed Forces Regular Force with the rates in a representative, matched sample of Canadians in the general population (CGP).

METHODS

Data sources were the 2013 Canadian Forces Mental Health Survey and the 2012 Canadian Community Health Survey-Mental Health. CGP sample was restricted to match the age range, employment status, and history of chronic conditions of Regular Force personnel. An iterative proportional fitting method was used to approximate the marginal distribution of sociodemographic and childhood trauma variables in both samples.

RESULTS

Relative to the matched CGP, Regular Force personnel had significantly higher rates of past-year major depressive episode, generalized anxiety disorder, and suicide ideation. However, lower rates of alcohol use disorder were seen in Regular Force personnel relative to the matched CGP sample.

CONCLUSIONS

Factors other than differences in sociodemographic composition and history of childhood trauma account for the excess burden of mental disorders and suicidal behaviours in the Canadian Armed Forces. Explanations to explore in future research include occupational trauma, selection effects, and differences in the context of administration of the 2 surveys.

Mental health of Canadian Armed Forces Veterans: review of population studies

Introduction. The mental health of Canadian Armed Forces (CAF) populations emerged as an important concern in the wake of difficult CAF deployments in the 1990s. This article is the first comprehensive summary of findings from subsequent surveys of mental health and well-being in CAF Veterans, undertaken to inform mental health service renewals by CAF Health Services and Veterans Affairs Canada (VAC). Methods. Epidemiological findings in journal publications and government reports were summarized from four cross-sectional national surveys: a survey of Veterans participating in VAC programs in 1999 and three surveys of health and well-being representative of whole populations of Veterans in 2003, 2010, and 2013. Results. Although most Veterans had good mental health, many had mental health problems that affected functioning, well-being, and service utilization. Recent Veterans had a higher prevalence of mental health problems than the general Canadian population, earlier-era Veterans, and possibly the serving population. There were associations between mental health conditions and difficult adjustment to civilian life, physical health, and multiple socio-demographic factors. Mental health problems were key drivers of disability. Comparisons with other studies were complicated by methodological, era, and cultural differences. Discussion. The survey findings support ongoing multifactorial approaches to optimizing mental health and well-being in CAF Veterans, including strong military-to-civilian transition support and access to effective mental and physical health services. Studies underway of transitioning members and families in the peri-release period of the military-to-civilian transition and longitudinal studies of mental health in Veterans will address important knowledge gaps.

Risk among Combat Veterans with Post-traumatic Stress Disorder: The Impact of Psychosocial Factors on the Escalation of Suicidal Risk

INTRODUCTION

The purpose of this study was to (a) evaluate the influence of post-traumatic stress disorder (PTSD) and other comorbid disorders on suicidal risk among combat veterans and (b) evaluate the impact of psychosocial factors on the escalation of suicidal risk.

METHODS

Data were gathered from a random and representative sample of 215 Kosovo War veterans. Subjects were assessed for the presence of lifetime and current psychiatric disorders according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Revision (DSM-IV TR) using the following questionnaires: Harvard Trauma Questionnaire (HTQ), Beck's Depression Inventory (BDI) and Beck's Suicide Intent Scale (BSIS).

RESULTS

Suicidal ideations were observed in 44 (20.5%) of the 215 subjects. High suicide risk was found in 31.8% veterans diagnosed with PTSD and comorbid major depressive disorder. In addition, high suicide risk was also observed in the group of unemployed veterans, veterans dissatisfied with social/economic attainment and veterans dissatisfied with living conditions.

CONCLUSION

Our study showed that socioeconomic factors contributes to the deterioration of symptoms of major depression, PTSD and other comorbid disorders, with a direct impact of worsening suicidal ideations and suicidal behavior among war veterans.

The association of military and premilitary sexual trauma with risk for suicide ideation, plans, and attempts

Military sexual trauma is a strong predictor of psychiatric disorders and negative health outcomes among military personnel and veterans, but little is known about its relationship with suicide risk. The current study investigates the association of military sexual trauma with suicide risk among 464 U.S. military personnel and veterans enrolled in college classes. Results indicate that premilitary sexual assault was associated with significantly increased risk for later suicide ideation, plans, and attempts during military service. Unwanted sexual experiences occurring during military service was associated with significantly increased risk for suicide ideation and suicide plans for male participants. When considered simultaneously, premilitary sexual trauma showed relatively stronger associations with suicide risk among women whereas military sexual trauma showed relatively stronger associations with suicide risk among men. Results suggest differences in the relation of sexual trauma to suicide risk among male and female military personnel and veterans.

Understanding the elevated suicide risk of female soldiers during deployments

BACKGROUND

The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) has found that the proportional elevation in the US Army enlisted soldier suicide rate during deployment (compared with the never-deployed or previously deployed) is significantly higher among women than men, raising the possibility of gender differences in the adverse psychological effects of deployment.

METHOD

Person-month survival models based on a consolidated administrative database for active duty enlisted Regular Army soldiers in 2004-2009 (n = 975,057) were used to characterize the gender × deployment interaction predicting suicide. Four explanatory hypotheses were explored involving the proportion of females in each soldier's occupation, the proportion of same-gender soldiers in each soldier's unit, whether the soldier reported sexual assault victimization in the previous 12 months, and the soldier's pre-deployment history of treated mental/behavioral disorders.

RESULTS

The suicide rate of currently deployed women (14.0/100,000 person-years) was 3.1-3.5 times the rates of other (i.e. never-deployed/previously deployed) women. The suicide rate of currently deployed men (22.6/100,000 person-years) was 0.9-1.2 times the rates of other men. The adjusted (for time trends, sociodemographics, and Army career variables) female:male odds ratio comparing the suicide rates of currently deployed v. other women v. men was 2.8 (95% confidence interval 1.1-6.8), became 2.4 after excluding soldiers with Direct Combat Arms occupations, and remained elevated (in the range 1.9-2.8) after adjusting for the hypothesized explanatory variables.

CONCLUSIONS

These results are valuable in excluding otherwise plausible hypotheses for the elevated suicide rate of deployed women and point to the importance of expanding future research on the psychological challenges of deployment for women.

Cumulative trauma, hyperarousal, and suicidality in the general population: a path analysis

Although trauma exposure and posttraumatic stress disorder (PTSD) both have been linked to suicidal thoughts and behavior, the underlying basis for this relationship is not clear. In a sample of 357 trauma-exposed individuals from the general population, younger participant age, cumulative trauma exposure, and all three Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, PTSD clusters (reexperiencing, avoidance, and hyperarousal) were correlated with clinical levels of suicidality. However, logistic regression analysis indicated that when all PTSD clusters were considered simultaneously, only hyperarousal continued to be predictive. A path analysis confirmed that posttraumatic hyperarousal (but not other components of PTSD) fully mediated the relationship between extent of trauma exposure and degree of suicidal thoughts and behaviors.