Firearm leadership: Development, analysis, and application of a novel concept to message secure storage of firearms in the military

Suicide remains a leading cause of death in the United States (U.S.) Armed Forces. Access to firearms increases the risk of death by suicide due to the high lethality of firearm-related injuries (~90% in suicide attempts) and the highly dynamic nature of suicide which includes rapid change from low- to high-risk states. Critical gaps remain in research, programming, and communication amongst scientists, Department of Defense (DoD) programmatic leaders, front-line commanders, and service members. To enhance communication and coordination, in June 2022, the first-ever national "Firearm Suicide Prevention in the Military: Messaging and Interventions Summit" was held, with discussion of Firearm Leadership, a concept that emphasizes the importance of communication about lethal means safety (LMS) among military leaders and service members. Through a discussion of scientific literature, the points identified during the Summit, as well as presenting illustrative case examples derived from suicide death reviews, we aim to provide a conceptual model for the benefits of Firearm Leadership and how some barriers can be overcome. Following the Summit, further discussions on "Firearm Leadership" led to the development of a Firearm Leadership Factsheet.

Psychometric properties of the PTSD Checklist for DSM-5 (PCL-5) anchored to one's own suicide attempt

OBJECTIVE

Emerging evidence indicates that a nontrivial proportion of suicide attempt (SA) survivors develop clinically significant posttraumatic stress disorder (PTSD) symptoms related to their suicide attempt (SA-PTSD). However, SA-PTSD is rarely assessed in either clinical practice or research studies, due at least in part to a lack of research examining approaches to assessing SA-PTSD. This study examined the factor structure, internal consistency, and concurrent validity of scores on a version of the PTSD Checklist for DSM-5 (PCL-5) specifically anchored to one's own SA (PCL-5-SA).

METHOD

We recruited a sample of 386 SA survivors who completed the PCL-5-SA and related self-report measures.

RESULTS

A confirmatory factor analysis (CFA) that specified a 4-factor model consistent with the DSM-5 conceptualization of PTSD indicated that the PCL-5-SA had acceptable fit in our sample, χ²(161) = 758.03, RMSEA = 0.10, 90% CI =[0.09-0.11], CFI = 0.90, and SRMR = 0.06. The PCL-5-SA total and subfactor scores demonstrated good internal consistency (ωs = 0.88-0.95). Significant positive correlations of PCL-5-SA scores with anxiety sensitivity cognitive concerns, expressive suppression, depression symptoms, and negative affect provided evidence for concurrent validity (rs = .25-.62).

CONCLUSION

Results suggest that SA-PTSD, when measured with a specific version of the PCL-5, is a conceptually coherent construct that operates consistent with the DSM-5 conceptualization of PTSD stemming from other traumatic events. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Project Safe Guard: Challenges and opportunities of a universal rollout of peer-delivered lethal means safety counseling at a US military installation

INTRODUCTION

The US Department of Defense recommends lethal means safety counseling (LMSC) to promote firearm injury prevention via secure storage of personal firearms. We describe the rollout of a universal, peer-delivered adaptation of Project Safe Guard (PSG)-a brief, single-session LMSC discussion-at a US Space Force installation.

METHOD

Program evaluation data were collected via anonymous, voluntary, and online surveys. Of approximately 862 eligible active-duty service members and embedded civilians, 324 completed the preprogram survey and 68 and 37 completed the 1- and 2-month follow-ups, respectively.

RESULTS

At preprogram, 69.1% agreed that peer-delivered LMSC is appropriate. After rollout, 100% of the 222 firearm locking devices available to service members were requested from the on-base Violence Prevention Integrator. The effectiveness of PSG was indeterminable due to the low survey response rates.

CONCLUSIONS

Despite strong preprogram support for peer-delivered LMSC and behavioral indicators of secure firearm storage (e.g., firearm locking device requests), several challenges limited the uptake and evaluability of the PSG program in this naturalistic environment, including military survey fatigue and competing mission priorities. Additional work is needed to determine the effectiveness of peer-delivered LMSC in a military context. Sustained base support and military-civilian collaborations will be critical.

Emergency medical services (EMS) clinicians' views on EMS-delivered interventions to promote secure firearm storage practices

INTRODUCTION

Lethal means safety counseling (LMSC) to promote secure firearm storage may reduce the risk of firearm-involved deaths, including suicide. We examined if emergency medical services (EMS) clinicians, including emergency medical technicians and paramedics, may be suitable LMSC messengers.

METHOD

We conducted a web-based survey of 229 US EMS clinicians.

RESULTS

While few EMS clinicians supported EMS-delivered LMSC to all patients (17.0%), most supported EMS-delivered LMSC to patients in an acute suicidal crisis (64.2%) or with a known suicide attempt history (55.9%). Barriers to EMS-delivered LMSC included lack of training (73.4%), perceptions that LMSC is outside EMS clinicians' scope of practice (58.1%), and lack of standard operating procedures (56.3%). Most reported at least some interest in receiving training on EMS-delivered LMSC (67.7%). Participants holding more accurate beliefs about the link between firearm storage practices and suicide risk, as well as the efficacy of LMSC, were more likely to support EMS-delivered LMSC across patient scenarios (ORs = 2.18-5.21, ps <0.01) and express interest in receiving LMSC training (ORs = 3.78-5.43, ps <0.001).

CONCLUSION

Given that many EMS clinicians interface with patients at elevated suicide risk, targeted LMSC training may be strategic; however, research is needed to determine if and how EMS clinicians might be viable LMSC messengers.

Benchmarking secondary outcomes to posttraumatic stress disorder symptom change in response to cognitive processing and written exposure therapy for posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) has high comorbidity with other psychiatric conditions, including depression, generalized anxiety, and suicidality. Evidence-based treatments (EBTs) for PTSD are effective at reducing PTSD symptoms. However, evidence on the impact of PTSD EBTs on comorbid conditions is mixed and often uses pre-post analyses, which disregards PTSD symptom response. This study replicated and extended prior work on benchmarking quality of life to PTSD symptom response to a broader range of secondary outcomes using a research-based metric of clinically meaningful PTSD symptom change. Ninety-five active duty military members seeking treatment for PTSD participated in a randomized noninferiority trial examining two cognitive behavioral therapies for PTSD: Written Exposure Therapy and Cognitive Processing Therapy. Participants completed clinician-administered and self-rating assessments at baseline and 10 weeks post-first treatment session and were classified as PTSD treatment responders or nonresponders. Data were analyzed using generalized linear mixed effects models with repeated measures with fixed effects of time and PTSD symptom response category. PTSD treatment responders experienced significant improvements in secondary outcomes; nonresponders demonstrated statistically significant, but not clinically meaningful, comorbid symptom change. Our findings provide evidence that successfully treating PTSD symptoms may also positively impact psychiatric comorbidity.

Older Adults' Preferences Regarding Firearm Locking Device Use: Results of a National Survey

OBJECTIVES

Use of firearm locking devices may reduce the risk of suicide and injury among older adults. This study describes older adults' preferences when choosing a firearm locking device.

METHODS

We conducted a secondary analysis of a nationally representative survey of US adult firearm owners (N = 2,152). We compared older adults (≥65y) with relatively younger adults (<65y), stratified by self-reported gender.

RESULTS

The top three factors cited as impacting firearm locking device selection included speed (53.6%) and ease of firearm access from device (52.4%), and cost of the device (28.7%). These top factors were comparable for all adults across genders. A larger proportion of older vs younger males reported that a primary preference was whether the device allows the firearm to remain loaded with ammunition; smaller proportions of older vs younger males reported strength of device (device durability) and costs.

CONCLUSIONS

Preference among older adults, particularly older males, for locking devices that maintain the firearms easy to access - especially, loaded with ammunition - might impact firearm injury prevention efforts for this high-risk group.

CLINICAL IMPLICATIONS

For harm reduction, use of any firearm locking device may reduce the risk of firearm injury or death. Clinicians are encouraged to explore reasons for locking device selection within motivational interviewing frameworks.

A practical risk calculator for suicidal behavior among transitioning U.S. Army soldiers: results from the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS)

BACKGROUND

Risk of suicide-related behaviors is elevated among military personnel transitioning to civilian life. An earlier report showed that high-risk U.S. Army soldiers could be identified shortly before this transition with a machine learning model that included predictors from administrative systems, self-report surveys, and geospatial data. Based on this result, a Veterans Affairs and Army initiative was launched to evaluate a suicide-prevention intervention for high-risk transitioning soldiers. To make targeting practical, though, a streamlined model and risk calculator were needed that used only a short series of self-report survey questions.

METHODS

We revised the original model in a sample of n = 8335 observations from the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS) who participated in one of three Army STARRS 2011-2014 baseline surveys while in service and in one or more subsequent panel surveys (LS1: 2016-2018, LS2: 2018-2019) after leaving service. We trained ensemble machine learning models with constrained numbers of item-level survey predictors in a 70% training sample. The outcome was self-reported post-transition suicide attempts (SA). The models were validated in the 30% test sample.

RESULTS

Twelve-month post-transition SA prevalence was 1.0% (s.e. = 0.1). The best constrained model, with only 17 predictors, had a test sample ROC-AUC of 0.85 (s.e. = 0.03). The 10-30% of respondents with the highest predicted risk included 44.9-92.5% of 12-month SAs.

CONCLUSIONS

An accurate SA risk calculator based on a short self-report survey can target transitioning soldiers shortly before leaving service for intervention to prevent post-transition SA.

Psychometric Properties of the Self-Injurious Thoughts and Behaviors Interview-Short Form Among U.S. Active Duty Military Service Members and Veterans

We assessed the interrater reliability, convergent validity, and discriminant validity of the Self-Injurious Thoughts and Behaviors Interview-Short Form (SITBI-SF) in a sample of 1,944 active duty service members and veterans seeking services for posttraumatic stress disorder (PTSD) and related conditions. The SITBI-SF demonstrated high interrater reliability and good convergent and discriminant validity. The measurement properties of the SITBI-SF were comparable across service members and veterans. Approximately 8% of participants who denied a history of suicidal ideation on the SITBI-SF reported suicidal ideation on a separate self-report questionnaire (i.e., discordant responders). Discordant responders reported significantly higher levels of PTSD symptoms than those who denied suicidal ideation on both response formats. Findings suggest that the SITBI-SF is a reliable and valid interview-based measure of suicide-related thoughts and behaviors for use with military service members and veterans. Suicide risk assessment might be optimized if the SITBI-SF interview is combined with a self-report measure of related constructs.

Firearm Suicide Prevention in the U.S. Military: Recommendations From a National Summit

The U.S. DoD has identified firearm suicide prevention as a key operational priority. One vital approach to addressing firearm suicides is through promoting lethal means safety, which involves the voluntary use of secure storage for personally owned firearms and/or temporarily moving firearms out of the home during risk periods. Despite promising approaches to lethal means safety, critical gaps remain in research, programming, and communication among and across scientists, DoD programmatic leaders, front-line commanders, and service members. To address these gaps, the first-ever national "Firearm Suicide Prevention in the Military: Messaging and Interventions Summit" was convened in June 2022, bringing together DoD personnel and researchers with expertise in firearm suicide prevention and lethal means safety. The Summit identified 10 recommendations to enhance firearm suicide prevention messaging and interventions in the U.S. military, including (1) repeal or amend prohibitions on questioning service members about personal firearms; (2) develop, examine, and use common language for firearm injury prevention; (3) implement a universal approach to training on comprehensive firearm injury prevention; (4) encourage leadership across disciplines and levels; (5) aim for broad culture change; (6) support innovative research; (7) consider various outcome measures; (8) promote "cultural competence" for better communication; (9) reduce territorialism; and (10) develop creative partnerships. Ultimately, these recommendations can facilitate productive partnerships with a shared goal: to develop, test, and implement strategies that standardize lethal means safety and reduce firearm suicides and other firearm injuries or harm among service members.

Firearm locking device preferences among firearm owners in the USA: a systematic review

BACKGROUND

Preventing firearm-involved injuries is a critical public health priority. Firearm locking devices can prevent firearm injuries, such as suicide and unintentional shootings, as well as theft. Various firearm locking devices exist; however, little is known about firearm owners' preferred locking devices for secure firearm storage. In this systematic review, we examined existing literature on preferred locking devices for secure storage of personal firearms among United States (US) firearm owners with the purpose of understanding practical implications and needs for future research.

METHODS

We searched 8 major databases, as well as the grey literature, for English-language sources published on or before January 24, 2023, that empirically examined firearm locking device preferences. Following PRISMA guidelines, coders independently screened and reviewed 797 sources using pre-determined criteria. Overall, 38 records met inclusion criteria and were included in this review.

RESULTS

The majority of studies measure and report on participant use of various types of locking devices, but few go on to measure preference between device options and the attributes and features that may contribute to an individual's preference. Included studies suggest that a preference for larger devices, such as lockboxes and gun safes, may exist among US firearm owners.

CONCLUSIONS

Review of included studies suggests that current prevention efforts may not be aligned with firearm owners' preferences. Additionally, findings from this systematic review emphasize the need for additional methodological rigorous research to understand firearm locking device preferences. Expanded knowledge in this area will result in actionable data and foundational best practices for programming that encourages behavior change concerning secure storage of personal firearms to prevent injury and death.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Firearm ownership and storage practices among United States firefighters and emergency medical services personnel

Compared with the general U.S. population, firefighters (FF) and emergency medical services (EMS) workers (FF + EMS personnel) are at increased risk for firearm suicide. Although secure firearm storage is associated with reduced risk of firearm suicide, no study has examined the prevalence and sociodemographic correlates of firearm ownership and storage practices among U.S. FF + EMS personnel. A total of 141 U.S. FF + EMS personnel completed a structured, web-based self-report questionnaire. Overall, 76.6% (n = 108) of FF + EMS personnel in our sample reported owning a personal firearm, among whom 85.2% (n = 92) reported owning more than one firearm. Among firearm owners, 42.6% (n = 46) reported secure firearm storage (i.e., unloaded and locked) and 57.4% (n = 62) reported nonsecure firearm storage (i.e., loaded and/or unlocked). FF + EMS personnel who cited personal safety as the only reason for firearm ownership, as opposed to reporting other or multiple reasons for ownership (e.g., hunting), were at increased odds of reporting nonsecure storage practices (69.4% vs. 47.5%; OR = 2.51, 95% CI [1.14, 5.55], p = .023). Most FF + EMS personnel in our sample reported firearm ownership, and approximately half of the firearm owners reported nonsecure firearm storage practices. Promoting secure firearm storage practices among FF + EMS personnel might decrease risk of firearm suicide and other forms of firearm-related injuries. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Lethal means safety counseling among firearm-owning U.S. National Guard personnel: Hyperarousal symptoms as a moderator of treatment outcomes

The U.S. Department of Defense and other stakeholders recommend lethal means safety counseling (LMSC) to reduce suicide risk among military service members. Despite the promise of LMSC, few studies have examined moderators of LMSC treatment outcomes, such as posttraumatic stress disorder (PTSD) symptoms. Individuals with elevated PTSD symptoms are characteristically hypervigilant to threat and are more likely to store their firearms unsafely, which might impact their treatment response to LMSC. In this secondary analysis of the Project Safe Guard LMSC intervention, 209 firearm-owning members of the Mississippi National Guard completed self-report surveys (M [SD] age = 35.2 [10.1] years; 86.6% male, 79.4% White). We used logistic regression to examine the moderating effect of PTSD symptoms (PTSD Checklist for DSM-5; e.g., hyperarousal symptoms) on the association between treatment groups (LMSC vs. control; cable lock provision vs. no cable lock provision) and the use of new locking devices at 6-month follow-up. At 6-month follow-up, 24.9% (n = 52) of participants reported new firearm locking device use. The interaction between hyperarousal symptoms and LMSC (vs. control) was significant. Specifically, LMSC increased the use of new firearm locking devices relative to control at 6-month follow-up for individuals with low/medium, but not high, levels of baseline hyperarousal symptoms. Hyperarousal symptoms did not moderate the association between cable lock provision (vs. no cable lock provision) and use of new locking devices. Findings suggest that existing LMSC interventions need to be adapted for use with service members with elevated hyperarousal symptoms. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Assessment of Firearm Storage Practices in the US, 2022

IMPORTANCE

Secure firearm storage may help reduce firearm injury and death. Broad implementation requires more granular assessments of firearm storage practices and greater clarity on circumstances that may prevent or promote the use of locking devices.

OBJECTIVE

To develop a more thorough understanding of firearm storage practices, obstacles to using locking devices, and circumstances in which firearm owners would consider locking unsecured firearms.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional, nationally representative survey of adults residing in 5 US states who owned firearms was administered online between July 28 and August 8, 2022. Participants were recruited via probability-based sampling.

MAIN OUTCOMES AND MEASURES

Firearm storage practices were assessed via a matrix provided to participants in which firearm-locking devices were described both via text and images. Locking mechanisms (key/personal identification number [PIN]/dial vs biometric) were specified for each type of device. Obstacles to the use of locking devices and circumstances in which firearm owners would consider locking unsecured firearms were assessed via self-report items developed by the study team.

RESULTS

The final weighted sample included 2152 adult (aged ≥18 years), English-speaking firearm owners residing in the US; the sample was predominantly male (66.7%). Among the 2152 firearm owners, 58.3% (95% CI, 55.9%-60.6%) reported storing at least 1 firearm unlocked and hidden, with 17.9% (95% CI, 16.2%-19.8%) reporting storing at least 1 firearm unlocked and unhidden. Gun safes were the most frequently used device both among participants who use keyed/PIN/dial locking mechanisms (32.4%; 95% CI, 30.2%-34.7%) and those who use biometric locking mechanisms (15.6%; 95% CI, 13.9%-17.5%). Those who do not store firearms locked most frequently noted a belief that locks are unnecessary (49.3%; 95% CI, 45.5%-53.1%) and a fear that locks would prevent quick access in an emergency (44.8%; 95% CI, 41.1%-48.7%) as obstacles to lock usage. Preventing access by children was the most often reported circumstance in which firearm owners would consider locking unsecured firearms (48.5%; 95% CI, 45.6%-51.4%).

CONCLUSIONS AND RELEVANCE

In this survey study of 2152 firearm owners, consistent with prior research, unsecure firearm storage was common. Firearm owners appeared to prefer gun safes relative to cable locks and trigger locks, indicating that locking device distribution programs may not match firearm owners' preferences. Broad implementation of secure firearm storage may require addressing disproportionate fears of home intruders and increasing awareness of the risks associated with household firearm access. Furthermore, implementation efforts may hinge on broader awareness of the risks of ready firearm access beyond unauthorized access by children.

Identifying factors associated with elevated suicidal intent among U.S. military veterans

OBJECTIVE

Suicidal intent is a risk factor for engagement in suicidal behavior, use of violent means, and suicide mortality. Yet, scarce research has examined factors associated with suicidal intent among U.S. military veterans, a population at high risk for suicide. This study examined vulnerability factors associated with suicidal intent in a population-based sample of U.S. veterans.

METHODS

Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a representative sample of 4069 U.S. veterans. Analyses estimated the prevalence of current suicidal intent (i.e., veterans' report that they would likely attempt suicide in the future) and examined factors most strongly associated with suicidal intent.

RESULTS

Forty-nine veterans (1.4%; 95% confidence interval = 1.0-1.8%) reported suicidal intent. Recurrent past-year suicidal ideation (≥2 times), low dispositional gratitude, current depression, current insomnia, childhood sexual abuse, and a prior suicide attempt were most strongly associated with suicidal intent (7.1-50.1% of the total explained variance). Veterans with several of these co-occurring factors were at highest risk for suicidal intent; of veterans with 0, ≥1, ≥2, ≥3, and ≥4 of these factors, 0.1%, 4.4%, 10.8%, 19.5%, and 28.1% reported suicidal intent, respectively.

DISCUSSION

Specific vulnerability factors, particularly when co-occurring, may increase veterans' intention of attempting suicide. Findings underscore the importance for clinicians to continuously assess suicidal intent when working with this population, particularly as veterans' reports of suicidal thinking increases.

Prospective Associations of Military Discharge Characterization with Post-active Duty Suicide Attempts and Homelessness: Results from the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS)

INTRODUCTION

Active duty service members transitioning to civilian life can experience significant readjustment stressors. Over the past two decades of the United States' longest sustained conflict, reducing transitioning veterans' suicidal behavior and homelessness became national priorities. However, it remains a significant challenge to identify which service members are at greatest risk of these post-active duty outcomes. Discharge characterization, which indicates the quality of an individual's military service and affects eligibility for benefits and services at the Department of Veterans Affairs, is a potentially important indicator of risk.

MATERIALS AND METHODS

This study used data from two self-report panel surveys of the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS) (LS1: 2016-2018, n = 14,508; and LS2: 2018-2019, n = 12,156), which were administered to respondents who previously participated while on active duty in one of the three Army STARRS baseline self-report surveys (2011-2014): the New Soldier Study (NSS), a survey of soldiers entering basic training; All Army Study, a survey of active duty soldiers around the world; and the Pre-Post Deployment Study, a survey of soldiers before and after combat deployment. Human Subjects Committees of the participating institutions approved all recruitment, informed consent, and data collection protocols. We used modified Poisson regression models to prospectively examine the association of discharge characterization (honorable, general, "bad paper" [other than honorable, bad conduct, dishonorable], and uncharacterized [due to separation within the first 180 days of service]) with suicide attempt (subsample of n = 4334 observations) and homelessness (subsample of n = 6837 observations) among those no longer on active duty (i.e., separated or deactivated). Analyses controlled for other suicide attempt and homelessness risk factors using standardized risk indices that were previously developed using the LS survey data.

RESULTS

Twelve-month prevalence rates of self-reported suicide attempts and homelessness in the total pooled LS sample were 1.0% and 2.9%, respectively. While not associated with suicide attempt risk, discharge characterization was associated with homelessness after controlling for other risk factors. Compared to soldiers with an honorable discharge, those with a bad paper discharge had an increased risk of homelessness in the total sample (relative risk [RR] = 4.4 [95% CI = 2.3-8.4]), as well as within subsamples defined by which baseline survey respondents completed (NSS vs. All Army Study/Pre-Post Deployment Study), whether respondents had been separated (vs. deactivated), and how much time had elapsed since respondents were last on active duty.

CONCLUSIONS

There is a robust association between receiving a bad paper discharge and post-separation/deactivation homelessness. Policies that enhance transition assistance and access to mental healthcare for high-risk soldiers may aid in reducing post-separation/deactivation homelessness among those who do not receive an honorable discharge.

Firearms Access among Pediatric Patients at Risk for Suicide

BACKGROUND

Approximately 2,900 youth who die by suicide each year in the United States use a firearm. To inform lethal means safety counseling efforts, this study aimed to describe firearm access among youth deemed at risk for suicide in pediatric medical settings.

METHODS

Youth who presented to one of four urban pediatric medical centers were screened for suicide risk and access to firearms. Suicide risk was determined by a positive screen on the Ask Suicide-Screening Questions (ASQ) tool. Firearm access was assessed via a structured questionnaire.

RESULTS

This secondary analysis analyzed data from 1065 youth aged 10 to 17 years. Overall, 110 (10.3%) participants screened positive for suicide risk. Among those at risk, 28% (31/110) reported guns kept in or around their home, 8% (9/110) had access to a firearm, and 5% (6/110) reported that bullets were not stored separately from the guns.

CONCLUSIONS

Over a quarter of youth at risk for suicide reported a firearm stored in or around their home. To ensure the safety of young people at risk for suicide, clinicians should assess whether youth have access to firearms and conduct lethal means safety counseling with youths, as developmentally appropriate, and their parent/caregivers.HIGHLIGHTS28% of pediatric patients deemed "at risk" for suicide in this study reported a firearm kept in or around their home.Among youth at risk for suicide, 8% reported having access to a firearm.These results add further evidence that it is important for clinicians to conduct lethal means safety counseling with patients and their families.

Non-response to questions about suicide ideation and attempts among veterans: Results from the National Health and Resilience in Veterans Study

OBJECTIVES

Veterans who decline to provide information on their history of self-injurious thoughts and behaviors (SITBs) may be at elevated suicide risk. We examined associations between non-response to a question assessing lifetime SITBs and proxy variables of suicide risk.

METHODS

In this population-based cross-sectional study of 4069 US veterans, responses to the Suicidal Behaviors Questionnaire-Revised were examined to group veterans into one of three categories: (1) denied lifetime SITBs, (2) reported lifetime SITBs, or (3) declined to respond.

RESULTS

Overall, 69.5% of veterans denied a SITB history, 29.5% reported a SITB history, and 1.0% declined to provide information regarding SITBs. In adjusted analyses, veterans who declined to provide information on SITBs were significantly more likely than veterans who explicitly denied lifetime SITBs to screen positive for posttraumatic stress disorder; report lifetime non-suicidal self-injury; and report elevated levels of total trauma burden, externalizing behaviors, loneliness, received social support, and provided social support. Across these constructs, veterans who declined to provide SITB information were statistically indistinguishable from veterans who explicitly reported lifetime SITBs.

CONCLUSIONS

Veterans who decline to provide information about suicidal thoughts and behaviors may represent a covert group at elevated risk for suicide.

Examining Factors Influencing the Differential Reporting of Suicide Attempt History Among Undergraduates at Elevated Suicide Risk

AIM

Prior studies suggest that individuals may respond inconsistently to different assessments of suicide attempt (SA) history; yet, little is known regarding why inconsistent reporting of SA history may occur. The overarching goal of this study was to examine individuals' self-reported reasons for inconsistently responding to different self-report measures designed to assess SA history.

METHODS

Young adults who reported a lifetime history of suicidal ideation (N = 141) completed three different self-report measures of SA history: the (1) Beck Scale for Suicide Ideation (BSS), (2) Suicidal Behaviors Questionnaire-Revised (SBQ-R), and (3) Self-Injurious Thoughts and Behaviors Interview-Short Form (SITBI-SF). All measures were administered in a randomized order to control for potential order effects. Descriptive statistics were used to test study aims.

RESULTS

Of the sample, 75% of participants denied an SA history across all three measures, 16% reported an SA history across all measures ("consistent responders"), and 9% responded inconsistently to SA history measures ("inconsistent responders"). Of the 9% (n = 12) of participants who inconsistently responded to SA history measures, the most commonly reported reasons for inconsistent reporting were that the definition of the term "attempt" was not made clear and that the participant did not read the SA history probes carefully.

CONCLUSION

Findings from this study underscore a need for increased efforts to improve SA history assessments.HIGHLIGHTSSome individuals may provide inconsistent responses across different suicide attempt measures.Confusion about the definition of a "suicide attempt" may lead to inconsistent responding.Further research is needed to improve our assessment of suicide attempt history.

Analysis of Methods of Suicide Among US Military Veterans Recently Separated From Military Service

This cohort study compares firearm, suffocation, and poisoning suicide rates among recently separated veterans with those among the general veteran population and examines demographic and military characteristics associated with risk of method-specific suicide mortality among recently separated veterans.

Local implementation evaluation of a suicide prevention predictive model at a large VA health care system

BACKGROUND

The Veterans Health Administration (VHA) implemented REACH VET, which analyzes health records to identify veterans at statistically elevated risk for suicide and other adverse outcomes compared to other veterans in VHA. This project evaluated REACH VET program implementation at a large VA health care system by examining program fidelity and treatment engagement, receipt of suicide prevention interventions, and suicide-related behaviors in the 6 months following identification.

METHODS

Over a 12-month period, 218 unique cases were identified by REACH VET within a local VA system. Data were extracted from the VA's electronic medical records.

RESULTS

Protocol adherence for required clinical and administrative steps was 94% and above. After identification, 88% received outpatient mental health treatment, 21% had a psychiatric hospitalization, and 83% engaged in Safety Planning around the time of identification or in the following six months. Twenty-six percent of cases were identified by another existing method for identifying high-risk veterans. Five percent had a medically documented suicide attempt, and none were known to die by suicide in the following 6 months.

CONCLUSIONS

Local evaluation suggested high protocol fidelity and high engagement in mental health and suicide prevention services following identification among veterans who remained at elevated risk in the 6 months that followed.

Predicting suicide attempts among U.S. Army soldiers after leaving active duty using information available before leaving active duty: results from the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS)

Suicide risk is elevated among military service members who recently transitioned to civilian life. Identifying high-risk service members before this transition could facilitate provision of targeted preventive interventions. We investigated the feasibility of doing this by attempting to develop a prediction model for self-reported suicide attempts (SAs) after leaving or being released from active duty in the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS). This study included two self-report panel surveys (LS1: 2016-2018, LS2: 2018-2019) administered to respondents who previously participated while on active duty in one of three Army STARRS 2011-2014 baseline self-report surveys. We focus on respondents who left active duty >12 months before their LS survey (n = 8899). An ensemble machine learning model using predictors available prior to leaving active duty was developed in a 70% training sample and validated in a 30% test sample. The 12-month self-reported SA prevalence (SE) was 1.0% (0.1). Test sample AUC (SE) was 0.74 (0.06). The 15% of respondents with highest predicted risk included nearly two-thirds of 12-month SAs and over 80% of medically serious 12-month SAs. These results show that it is possible to identify soldiers at high post-transition self-report SA risk before the transition. Future model development is needed to examine prediction of SAs assessed by administrative data and using surveys administered closer to the time of leaving active duty.

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

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

Advancements in the understanding of PTSD and suicide risk: Introduction to a special section

Individuals with elevated symptoms of posttraumatic stress disorder (PTSD) or a PTSD diagnosis are at increased risk of thinking about, attempting, and dying by suicide. Yet, there remain key gaps in the field’s understanding of the relation between PTSD and suicidal thoughts and behaviors. In response, Psychological Trauma: Theory, Research, Practice, and Policy organized this Special Section on PTSD and Suicide Risk. The articles included in this Special Section represent innovations in the understanding of the link between PTSD and suicidality across various at-risk populations and units of analysis. This Special Section additionally contains articles that address key data analytic and assessment considerations, paving the way for methodologically rigorous future research. Ultimately, it is my hope and belief that advancements in the scientific understanding of PTSD and suicide risk will contribute to decreases in suffering and decreases in suicide deaths.

Identifying Central Symptoms and Bridge Pathways Between Autism Spectrum Disorder Traits and Suicidality Within an Active Duty Sample

OBJECTIVE

This study employed network analysis to characterize central autism spectrum disorder (ASD) traits and suicide symptoms within an active duty military sample as well as to identify symptoms that may bridge between ASD traits and suicidality (i.e., suicidal ideation and behaviors).

METHOD

Participants were active duty U.S. military service members (N = 287). Autism spectrum traits, suicidality, depression, and suicide related constructs were assessed online via self-report.

RESULTS

Within the combined ASD trait-suicidality network, suicide rumination, suicide behaviors, and depression had the highest strength centrality. The most central bridge symptoms between ASD and suicidality were thwarted belongingness, social skills deficits, and depressive symptoms.

CONCLUSIONS

Social skills deficits and thwarted belongingness may function as a meaningful bridge between ASD symptoms and suicidality within active duty members. Individuals with ASD symptoms who additionally present with high levels of thwarted belongingness and/or considerable social skills deficits may be at increased risk for suicidality.HIGHLIGHTSWithin an ASD-suicidality network, social skills deficits, low belonging, and depression had the greatest bridge strength.Although low belonging emerged as a bridge symptom, perceived burdensomeness did not.Suicide rumination, suicide behaviors, and depression were the most central symptom in an ASD-suicidality network.Symptoms related to social skills deficits may connect ASD traits and suicidality.

Psychometric properties of the Depressive Symptom Index-Suicidality Subscale (DSI-SS) in an adult psychiatric sample

The Depressive Symptom Index-Suicidality Subscale (DSI-SS) is a four-item self-report measure of suicidal ideation severity widely used across research and clinical contexts. However, the psychometric properties of the English-language version of the DSI-SS have not been extensively examined within a psychiatric sample, and important properties of this scale (e.g., sensitivity to change) have yet to be examined. Within a sample of 448 adult psychiatric patients enrolled in a partial hospital program (PHP), we examined several measurement properties of the DSI-SS, including its factor structure, internal consistency, validity, and sensitivity to change, as well as the presence of differential item functioning (DIF). Confirmatory factor analysis that specified a one-factor model indicated that the DSI-SS had good model fit. DSI-SS scores demonstrated good internal consistency, ω = .90 [95% CI = .89-.91], convergent validity (rs = .52-.74), discriminant validity (rs = .12-.27), and sensitivity to change. None of the four DSI-SS items evinced statistically significant DIF across age, gender, sexual orientation, or PHP referral source (i.e., outpatient step-up vs. inpatient step-down). These findings suggest that the DSI-SS is a psychometrically sound self-report measure that can be used in real-world clinical settings and research contexts to reliably and validly assess suicidal ideation severity. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Considerations in the assessment of help-seeking and mental health service use in suicide prevention research

OBJECTIVE

The connection of individuals at elevated suicide risk to mental healthcare services represents a critical component of suicide prevention efforts. This article provides recommendations for enhancing the assessment of help-seeking and mental health service use within the context of suicide prevention research.

METHOD

We discuss evidence-based and theoretical rationale for improving current approaches to assessing help-seeking and mental health service use among at-risk individuals.

RESULTS

Recommendations are offered within three domains: (a) consideration of the spectrum of connection to care, (b) assessment of the degree to which mental healthcare services seek to and effectively target suicidal symptoms, and (c) evaluation of the sources and types of treatment and care sought and received by at-risk individuals.

CONCLUSIONS

To further our understanding of how to bolster connection to care and improve experiences with mental healthcare services among individuals at elevated suicide risk, it is imperative that stakeholders precisely capture the degree, efficacy/effectiveness, and nature of care sought and received by individuals. In so doing, research gaps might be better identified and, ultimately, mental healthcare services might be better leveraged as tools to prevent suicide and support individuals in creating lives they perceive to be worth living.

PTSD symptoms among trauma-exposed adults admitted to inpatient psychiatry for suicide-related concerns

Individuals admitted to inpatient psychiatry for suicide-related concerns are at increased risk of suicide post-discharge, necessitating an understanding of factors, such as posttraumatic stress disorder (PTSD), that are associated with suicide-related hospitalizations. In this study, we examined if individuals admitted for suicide-related concerns were more likely than those admitted for other reasons to have elevated PTSD symptoms or a probable PTSD diagnosis. We also examined the moderating role of impulsivity. Participants were 188 trauma-exposed adult psychiatric inpatients (M [SD]age = 33.6 y [11.7 y], 63.3% male, 46.3% white). We used the Life Events Checklist for DSM-5, PTSD Checklist for DSM-5, Beck Scale for Suicide Ideation, and Barratt Impulsiveness Scale-11 to assess trauma exposure, PTSD symptoms, suicidal ideation severity, and impulsivity, respectively. We controlled for trauma load, number of psychiatric diagnoses, and comorbid depressive and substance use disorders. Patients admitted for suicide-related concerns (55.3%; n = 104), compared with those admitted for other reasons (44.7%; n = 84), had more severe PTSD symptoms, corresponding to medium-to-large effect sizes; associations were stronger at higher levels of impulsivity. Additionally, patients admitted for suicide-related concerns were nearly four times more likely than their counterparts to screen positive for a provisional PTSD diagnosis. Among the subset of individuals admitted for suicide-related concerns, greater PTSD symptoms were associated with more severe suicidal ideation. In sum, PTSD symptoms are elevated among psychiatric inpatients admitted for suicide-related concerns, and among this subgroup, greater PTSD symptom severity covaries with suicidal ideation severity. Screening for and treating PTSD, and attending to cooccurring impulsivity, in psychiatric inpatients may reduce suicide risk.

Suicidal ideation in the context of prospective firearm ownership

Most suicide deaths in the United States are enacted with a firearm, and recent and first-time purchasers of firearms represent at-risk groups. This study aimed to examine differences in indicators of suicide risk among individuals who either (a) reported current firearm ownership/access or (b) denied current firearm ownership/access but reported an intention to obtain a firearm (i.e., prospective firearm owners). Participants were 96 young adults with a lifetime history of suicidal ideation and firearm ownership, access, or interest. We assessed recent suicidal ideation severity with the Depressive Symptom Index-Suicidality Subscale (DSI-SS) and sought to internally replicate findings with the Patient Health Questionnaire (PHQ-9) item 9. Fifty-two (54.2%) participants reported firearm ownership/access and 44 (45.8%) identified as prospective firearm owners. Prospective firearm owners had significantly greater DSI-SS suicidal ideation severity scores compared with those who already own/have access to a firearm, corresponding to a medium effect size; results were consistent with the PHQ-9 suicidal ideation item. Findings of this initial investigation suggest that the intention to commence firearm ownership might represent an at-risk period, especially for individuals with a history of suicidal thinking. Replication of findings in larger and more clinically severe samples is needed.

Mental Health Outcomes of Premature Discharge from United States Air Force Basic Military Training

INTRODUCTION

Each year, a substantial proportion of trainees who enter the U.S. Air Force (USAF) Basic Military Training (BMT) are unable to complete training. Reentry to civilian life poses significant challenges, including finding employment, establishing a new career path, and paying for education. To our knowledge, no study has examined the association of discharge from USAF BMT and mental health symptoms. Utilizing a sample of 85 individuals discharged from USAF BMT for reasons other than mental health concerns, the present study aimed to: (1) characterize the severity of current depression and anxiety symptoms; (2) examine the relationship between the severity of current depression and anxiety symptoms and sociodemographic variables; and (3) determine whether or not a trainee agreed with the decision to be discharged from BMT is associated with differing severities of depression or anxiety symptoms.

MATERIALS AND METHODS

Participants were individuals who were prematurely discharged from USAF BMT for reasons other than mental health issues. Premature discharge is defined as any trainee who was unable to complete BMT in the USAF and was subsequently sent home. Participants were recruited from online Facebook groups for individuals who were prematurely discharged from USAF BMT. Participants were administered a battery of self-report questionnaires through a web-based survey platform. A structured demographic overview was administered to all participants to assess for age, gender, reason for discharge, amount of time spent in BMT, amount of time spent in medical hold, and whether or not the trainee agreed with the decision to be discharged. The Patient Health Questionnaire-9 (PHQ-9) was used to assess current symptoms consistent with depression. The Generalized Anxiety Disorder-7 (GAD-7) was used to assess current symptoms consistent with anxiety. Descriptive statistics were used to assess overall depression and anxiety rates, and analyses of covariance (ANCOVAs) were used to analyze group differences. This study was approved by the Institutional Review Board (IRB) at Florida State University (FSU).

RESULTS

In total, 85 participants (42.4% = female) were accounted for in these data. Regarding depression symptom severity, 58.8% of participants (n = 50) indicated moderate or higher levels of depression symptoms. Regarding anxiety symptoms, 45.9% of participants (n = 39) indicated moderate or higher levels of anxiety symptoms. There were no significant differences reported regarding depression or anxiety symptoms across gender, age, amount of time spent in BMT, and amount of time spent in medical hold. Significant differences were found between depression and anxiety symptoms and whether or not a trainee agreed with the decision to be discharged from the USAF, such that trainees who did not agree with this decision reported higher levels of depression and anxiety symptoms.

CONCLUSIONS

The findings of this study indicate that this population of trainees who were prematurely discharged from USAF BMT for reasons other than mental health concerns has high levels of depression and anxiety symptoms. Discharge from BMT may be associated with substantial distress when the individual disagrees with the reason for discharge. Enhanced procedures and continued research regarding their postdischarge well-being seem warranted.

Association of Suicide Risk With Transition to Civilian Life Among US Military Service Members

IMPORTANCE

Although interest is high in addressing suicide mortality after the transition from military to civilian life, little is known about the risk factors associated with this transition. To support the ongoing suicide surveillance work of the US Department of Veterans Affairs (VA) Office of Mental Health and Suicide Prevention, examining these factors is important for targeting suicide prevention efforts.

OBJECTIVE

To examine the prevalence, patterns, and associated characteristics of suicide mortality among US service members after separation from military active status.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective population-based cohort study obtained demographic and military service data from the VA/Department of Defense Identity Repository. Individuals who served on active duty in the US Army, Navy, Air Force, Marine Corps, or Coast Guard after September 11, 2001, and who separated from active status between January 1, 2010, and December 31, 2017, were included in the cohort. Data analyses were conducted from September 9, 2019, to April 1, 2020.

MAIN OUTCOMES AND MEASURES

Suicide mortality within 6 years after separation from military service.

RESULTS

A total of 1 868 970 service members (1 572 523 men [84.1%]; mean [SD] age at separation, 30.9 [9.9] years) separated from the military during the study period. Through the end of the study period (December 31, 2017), 3030 suicides (2860 men and 170 women) were identified as having occurred within 6 years of separation from the military. Statistically significant differences in suicide risk were found by demographic and military service characteristics. Suicide rates after separation were time dependent, generally peaking 6 to 12 months after separation and declining only modestly over the study period. Male service members had a statistically significantly higher hazard of suicide than their female counterparts (hazard ratio [HR], 3.13; 95% CI, 2.68-3.69). Younger individuals (aged 17-19 years; HR, 4.46 [95% CI, 3.71-5.36]) had suicide hazard rates that were approximately 4.5 times higher than those who transitioned at an older age (≥40 years). Service branch remained a risk factor for suicide even 6 years after separation; those who separated from the Marine Corps (HR, 1.55; 95% CI, 1.36-1.78) and the Army (HR, 1.48; 95% CI, 1.31-1.67) had a higher hazard than those who transitioned from the Air Force. The hazard for those who separated from the active component was higher than for those who separated from the reserve component (HR, 1.29; 95% CI, 1.18-1.42). Service members with a shorter length of service had a higher hazard (HR, 1.26; 95% CI, 1.11-1.42) than those with a longer service history.

CONCLUSIONS AND RELEVANCE

Results of this study show that not all service members who recently transitioned from military life had the same risk of suicide. The data suggest that awareness of military service and demographic characteristics can help identify those most at risk for suicide to target prevention efforts.

Reasons for Living and Suicide Attempts Among Young Adults With Lifetime Suicide Ideation

Background: Previous work suggests that reasons for living (RFL) are associated with suicide ideation; however, the relationship between RFL and suicide attempts among individuals with suicide ideation remains unclear. Such an examination is necessary to delineate whether RFL are associated with suicide attempts above and beyond their association with suicide ideation. Aims: This study examined the relationship between RFL and suicide attempts among young adults with a lifetime history of suicide ideation. Method: Undergraduate students (N = 163) completed surveys assessing demographics, suicidal thoughts and behaviors, and RFL. Results: Individuals with a history of both suicide ideation and attempt reported significantly lower RFL than individuals with a history of suicide ideation but no suicide attempt. Among individual RFL-YA subscales, only Coping Beliefs was significantly associated with a suicide attempt history. Limitations: The cross-sectional nature of this study precludes any conclusions about the potential protective effects of RFL against suicide attempts, and the college student sample limits generalizability of the findings. Conclusion: Further research is needed to understand whether RFL prospectively predict suicide attempts among individuals with suicide ideation and whether interventions that bolster RFL might reduce suicide risk.

Examining the interaction of autism spectrum disorder-related traits and unit cohesion on suicide risk among military personnel

BACKGROUND

Suicide rates are elevated among United States (U.S.) military service members. Research has found that service members with autism spectrum disorder-related (ASD-related) traits are at increased risk for suicide. Complementary lines of inquiry have suggested that unit cohesion is a protective factor against developing suicidal ideation in military service members. However, given the social difficulties inherent in ASD, it is unclear whether unit cohesion might protect against suicide risk in this population.

METHOD

Our sample consisted of 285 active duty U.S. military service members recruited online. We examined the interaction between ASD-related traits (as measured by the Autism Spectrum Quotient [AQ]), unit cohesion, and suicide risk (as measured by the Suicidal Behaviors Questionnaire-Revised [SBQ-R]). We also conducted exploratory analyses to examine whether unit cohesion attenuates the association between ASD-related traits and suicidal intent.

RESULTS

Elevated ASD-related traits were independently associated with higher levels of global suicide risk; however, unit cohesion was not independently associated with suicide risk. Unit cohesion did not significantly interact with ASD-related traits to predict suicide risk. Finally, we found that elevated ASD-related traits and unit cohesion have an independent effect on current suicidal intent.

DISCUSSION

Our findings suggest that unit cohesion might not buffer the effect of ASD-related traits on suicide risk. However, our results do show that greater unit cohesion may be independently associated with decreased suicidal intent. This study is limited by a cross-sectional design and use of self-report measures.

Military Suicide Research Consortium common data elements: Bifactor analysis and longitudinal predictive ability of suicidal ideation and suicide attempts within a clinical sample

To enhance and standardize the assessment of suicidal self-directed violence (SDV) in military populations, the Military Suicide Research Consortium developed the Common Data Elements (CDEs). Previous research supported the CDEs as assessing a higher-order factor of suicidal SDV in military populations. The present study had two aims: 1) confirm the bifactor structure of the CDEs in a high-risk sample, and 2) assess the ability of the factorially derived suicidal SDV factor to predict suicide attempts and return to care for suicidal ideation over 3-month follow-up. Utilizing a sample of service members referred for a psychiatric evaluation (N = 1,044), the CDE structure was assessed with confirmatory bifactor modeling. Logistic regressions and receiver operating characteristic (ROC) analyses were used to assess the suicidal SDV risk factor's prediction of suicide attempts and return to care for suicidal ideation during follow-up (n = 758). Bifactor modeling suggested adequate fit for the overarching suicidal SDV risk factor. Logistic regressions supported the overarching suicidal SDV risk factor as a predictor of suicide attempts (OR = 4.07, p < .001) and return to care for suicidal ideation (OR = 2.81, p < .001) over follow-up. However, ROC analyses suggested that the model including the suicidal SDV risk factor was only significantly better at classifying suicide attempts over follow-up (not return to care for suicidal ideation) than the model that did not include it (AUC difference = 0.15, p < .001). Findings suggest that the shared variance assessed across CDEs better predicts future suicide attempts beyond any individual suicide-related constructs. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Suicidal behaviors among American Indian/Alaska Native firefighters: Evidence for the role of painful and provocative events

Firefighters represent a group at elevated suicide risk. Identifying segments of the fire service at increased risk may facilitate the targeted provision of suicide prevention initiatives. Among the general population, American Indian/Alaska Native (AI/AN) individuals report higher rates of suicide attempts. This study sought to examine suicide attempt rates among AI/AN firefighters and to determine if greater exposure to painful and provocative events and/or fearlessness about death explains the relationship between AI/AN identity and suicidal behaviors. A total of 917 US firefighters completed a web-based mental health survey (6.2% AI/AN). Participants completed a modified version of the Self-Injurious Thoughts and Behaviors Interview-Short Form, the Painful and Provocative Events Scale, and the Acquired Capability for Suicide Scale-Fearlessness About Death scale. Bootstrap mediation analyses were conducted, controlling for years of service as a firefighter. Although AI/AN firefighters accounted for only 6.2% of the sample, they accounted for 34.4% of the career suicide attempts. AI/AN firefighters were 16.31 (95% CI = 7.96, 33.42) times more likely to report a career suicide attempt history than non-AI/AN firefighters, adjusting for years of service as a firefighter. Painful and provocative events, but not fearlessness about death, was a statistically significant mediator of the relationship between AI/AN identity and suicide attempts. Firefighters identifying as AI/AN represent a subgroup within the fire service at increased risk for suicide. Findings suggest that greater exposure to painful and provocative events among AI/AN firefighters may explain the elevated suicide risk among this population.

Autism-related traits and suicide risk among active duty U.S. military service members

Suicide rates within the U.S. military are elevated. The interpersonal theory of suicide, supported within military samples, suggests that social disconnectedness confers risk for suicide. Autism spectrum disorder (ASD) is characterized by symptoms-difficulties in social communication/interaction (SCI) and restricted and repetitive behaviors (RRBs)-that contribute to social disconnectedness. To our knowledge, no study has examined ASD-related traits and suicide risk among active duty U.S. military service members. Participants included 292 active duty U.S. military service members (M [SD] age = 28.67 [7.40] years, 68.5% male, 78.1% White). The Autism Spectrum Quotient, Repetitive Behaviours Questionnaire-2 for Adults, Self-Injurious Thoughts and Behaviors Interview-Short Form, and Interpersonal Needs Questionnaire assessed for SCI difficulties, RRBs, suicidal symptoms, and interpersonal theory of suicide constructs (i.e., perceived burdensomeness, thwarted belongingness), respectively. Elevated levels of SCI difficulties and RRBs were associated with increased odds of reporting suicidal thoughts and behaviors occurring since joining the military, controlling for the number of years of service and suicidal symptoms occurring prior to joining the military. Perceived burdensomeness and thwarted belongingness statistically accounted for the relationship between ASD-related traits and suicidal ideation occurring since joining the military; a rival mediator, emotion dysregulation, was not a significant mediator. Among active duty U.S. military service members, greater ASD-related traits were associated with an increased likelihood of reporting suicidal thoughts and behaviors occurring since joining the military. Clinical efforts targeting perceived burdensomeness and thwarted belongingness might reduce suicide risk among military service members with elevated ASD-related traits. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The intersection of PTSD symptoms and firearm storage practices within a suicide prevention framework: Findings from a U.S. Army National Guard sample

Soldiers in the U.S. Army National Guard are at elevated risk for suicide compared to soldiers in the other components. Most suicides by military service members, including members of the U.S. Army National Guard, are enacted with personal firearms. The unsafe storage of firearms is associated with increased risk for death by suicide. Therefore, efforts to elucidate modifiable factors associated with unsafe firearm storage have the potential to inform military suicide prevention efforts. PTSD hyperarousal symptoms are characterized in part by a heightened sense of being "on guard" for potential dangers and might contribute to an increased likelihood of storing firearms unsafely. This study sought to examine if more severe PTSD hyperarousal symptoms are associated with greater unsafe firearm storage practices. Participants were 327 U.S. Army National Guard personnel (M [SD]_age = 26.90 [7.45] years; 93.3% male; 77.8% White/Caucasian). Firearm storage practices were assessed via a structured questionnaire. PTSD symptoms (reexperiencing, avoidance, numbing, hyperarousal) were assessed via the PTSD Checklist-Military Version (PCL-M). Logistic regression analyses were utilized. Elevated PTSD hyperarousal symptoms were significantly associated with storing firearms loaded and/or in nonsecure locations, even after controlling for the effects of the other PTSD symptom clusters. Sensitivity analyses revealed that the pattern of findings remained consistent among participants with a deployment history and when controlling for the effects of agitation symptoms. Findings of this study suggest that U.S. Army National Guard personnel who experience elevated PTSD hyperarousal symptoms are more likely to store their firearms unsafely. Implications for military suicide prevention are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).