Suicide Among Soldiers: A Review of Psychosocial Risk and Protective Factors

Preferences in Information Processing: Understanding Suicidal Thoughts and Behaviors among Active Duty Military Service Members

The present study examined Preferences in Information Processing (PIP), an emerging model of understanding suicidal thoughts and behaviors (STBs), in a clinical military sample for the first time. Constructs of need for affect (NFA; i.e., extent to which one engages or avoids emotional content) and need for cognition (NFC; i.e., extent of preference for and enjoyment of cognitive effort) are central individual differences of the PIP model hypothesized to be associated with STBs. Data (n = 200 active duty personnel) were drawn from medical records and self-report questionnaires from two outpatient treatment settings in a military hospital. Primary findings include: (1) moderate positive bivariate associations of NFA avoidance with mental health symptoms and lifetime STBs; (2) consistent patterns in which NFA approach buffers the negative associations of depression with life STBs, clinical suicide risk, perceived burdensomeness and thwarted belonging. Recommendations are offered for military suicide prevention, and future suicide theory testing.

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.

Risk for depression and suicidal ideation among food insecure US veterans: data from the National Health and Nutrition Examination Study

BACKGROUND

Suicide and food insecurity (i.e., lack of access to food) are two major issues that affect US Veterans.

PURPOSE

Using a US-based sample, we evaluated the association between food insecurity and suicidal ideation among Veterans. Because depression often precedes suicide, we also examined the association between food insecurity and depression.

METHODS

Using data from 2630 Veterans who participated in the National Health and Nutrition Examination Survey 2007-2016, we conducted an adjusted linear regression model to evaluate the association between food insecurity (measured using 18-item Household Food Security Survey) and depression (measured using PHQ-9) and an adjusted binary logistic regression model to evaluate the association between food insecurity and suicidal ideation (measured using PHQ-9 Question 9). Models were adjusted for gender, age, income-to-poverty ratio, race/ethnicity, and education level.

RESULTS

Of the sample, 11.5% were food insecure, depression scores averaged 2.86 (SD = 4.28), and 3.7% endorsed suicidal ideation. Veterans with marginal (β = 0.68, 95%CI [0.09,1.28]), low (β = 1.38, 95%CI [0.70,2.05]) or very low food security (β = 3.08, 95%CI [2.34, 3.83]) had significantly increased depression scores compared to food secure Veterans. Veterans with low (OR = 2.15, 95%CI [1.08, 4.27]) or very low food security (OR = 3.84, 95%CI [2.05, 7.20]) had significantly increased odds for suicidal ideation compared to food secure Veterans.

CONCLUSION

Food insecurity in Veterans is associated with increased depression symptoms and suicidal ideation. This association strengthens as food insecurity worsens. Veterans with food insecurity should be screened for depression and suicidal ideation. Simultaneously, depression treatment plans and suicide prevention programs should consider basic needs like food security.

Polygenic risk for major depression is associated with lifetime suicide attempt in US soldiers independent of personal and parental history of major depression

Suicide is a major public health problem. The contribution of common genetic variants for major depressive disorder (MDD) independent of personal and parental history of MDD has not been established. Polygenic risk score (using PRS-CS) for MDD was calculated for US Army soldiers of European ancestry. Associations between polygenic risk for MDD and lifetime suicide attempt (SA) were tested in models that also included parental or personal history of MDD. Models were adjusted for age, sex, tranche (where applicable), and 10 principal components reflecting ancestry. In the first cohort, 417 (6.3%) of 6,573 soldiers reported a lifetime history of SA. In a multivariable model that included personal [OR = 3.83, 95% CI:3.09-4.75] and parental history of MDD [OR = 1.43, 95% CI:1.13-1.82 for one parent and OR = 1.64, 95% CI:1.20-2.26 for both parents), MDD PRS was significantly associated with SA (OR = 1.22 [95% CI:1.10-1.36]). In the second cohort, 204 (4.2%) of 4,900 soldiers reported a lifetime history of SA. In a multivariable model that included personal [OR = 3.82, 95% CI:2.77-5.26] and parental history of MDD [OR = 1.42, 95% CI:0.996-2.03 for one parent and OR = 2.21, 95% CI:1.33-3.69 for both parents) MDD PRS continued to be associated (at p = .0601) with SA (OR = 1.15 [95% CI:0.994-1.33]). A soldier's PRS for MDD conveys information about likelihood of a lifetime SA beyond that conveyed by two predictors readily obtainable by interview: personal or parental history of MDD. Results remain to be extended to prospective prediction of incident SA. These findings portend a role for PRS in risk stratification for suicide attempts.

Prevalence and Trends in Suicidal Behavior Among US Military Veterans During the COVID-19 Pandemic

IMPORTANCE

The COVID-19 pandemic has raised considerable concerns about increased risk for suicidal behavior among US military veterans, who already had elevated rates of suicide before the pandemic.

OBJECTIVE

To examine longitudinal changes in suicidal behavior from before the COVID-19 pandemic to nearly 10 months into the pandemic and identify risk factors and COVID-related variables associated with new-onset suicide ideation (SI).

DESIGN, SETTING, AND PARTICIPANTS

This population-based prospective cohort study used data from the first and second wave of the National Health and Resilience in Veterans Study, conducted from November 18, 2019, to December 19, 2020. Median dates of data collection for the prepandemic and peripandemic assessments were November 21, 2019, and November 14, 2020, nearly 10 months after the start of the COVID-19 public health emergency in the US. A total of 3078 US military veterans aged 22 to 99 years were included in the study.

MAIN OUTCOMES AND MEASURES

Past-year SI and suicide attempts.

RESULTS

In this cohort study of 3078 US veterans (mean [SD] age, 63.2 [14.7] years; 91.6% men; 79.3% non-Hispanic White veterans, 10.3% non-Hispanic Black veterans, and 6.0% Hispanic veterans), 233 (7.8%) reported past-year SI, and 8 (0.3%) reported suicide attempts at the peripandemic assessment. Past-year SI decreased from 10.6% prepandemic (95% CI, 9.6%-11.8%) to 7.8% peripandemic (95% CI, 6.9%-8.8%). A total of 82 veterans (2.6%) developed new-onset SI over the follow-up period. After adjusting for sociodemographic and military characteristics, the strongest risk factors and COVID-19-related variables for new-onset SI were low social support (odds ratio [OR], 2.77; 95% CI, 1.46-5.28), suicide attempt history (OR, 6.31; 95% CI, 2.71-14.67), lifetime posttraumatic stress disorder and/or depression (OR, 2.25; 95% CI, 1.16-4.35), past-year alcohol use disorder severity (OR, 1.06; 95% CI, 1.01-1.12), COVID-19 infection (OR, 2.41; 95% CI, 1.41-5.01), and worsening of social relationships during the pandemic (OR, 1.47; 95% CI, 1.16-1.88).

CONCLUSIONS AND RELEVANCE

The results of this cohort study suggest that despite grim forecasts that the COVID-19 pandemic would exacerbate suicidality among US military veterans, the rate of SI decreased at the population level nearly 10 months into the pandemic. Veterans who were infected with COVID-19 were more than twice as likely to report SI, which suggests the need for future research to examine the potential link between COVID-19 infection and suicidal behavior.

Association Between Responsibility for the Death of Others and Postdeployment Mental Health and Functioning in US Soldiers

IMPORTANCE

Rates of suicidal thoughts and behaviors (STBs) in US soldiers have increased sharply since the terrorist attacks on September 11, 2001, and postdeployment posttraumatic stress disorder (PTSD) remains a concern. Studies show that soldiers with greater combat exposure are at an increased risk for adverse mental health outcomes, but little research has been conducted on the specific exposure of responsibility for the death of others.

OBJECTIVE

To examine the association between responsibility for the death of others in combat and mental health outcomes among active-duty US Army personnel at 2 to 3 months and 8 to 9 months postdeployment.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study obtained data from a prospective 4-wave survey study of 3 US Army brigade combat teams that deployed to Afghanistan in 2012. The sample was restricted to soldiers with data at all 4 waves (1-2 months predeployment, and 2-3 weeks, 2-3 months, and 8-9 months postdeployment). Data analysis was performed from December 12, 2020, to April 23, 2021.

MAIN OUTCOMES AND MEASURES

Primary outcomes were past-30-day PTSD, major depressive episode, STBs, and functional impairment at 2 to 3 vs 8 to 9 months postdeployment. Combat exposures were assessed using a combat stress scale. The association of responsibility for the death of others during combat was tested using separate multivariable logistic regression models per outcome adjusted for age, sex, race and ethnicity, marital status, brigade combat team, predeployment lifetime internalizing and externalizing disorders, and combat stress severity.

RESULTS

A total of 4645 US soldiers (mean [SD] age, 26.27 [6.07] years; 4358 men [94.0%]) were included in this study. After returning from Afghanistan, 22.8% of soldiers (n = 1057) reported responsibility for the death of others in combat. This responsibility was not associated with any outcome at 2 to 3 months postdeployment (PTSD odds ratio [OR]: 1.23 [95% CI, 0.93-1.63]; P = .14; STB OR: 1.19 [95% CI, 0.84-1.68]; P = .33; major depressive episode OR: 1.03 [95% CI, 0.73-1.45]; P = .87; and functional impairment OR: 1.12 [95% CI, 0.94-1.34]; P = .19). However, responsibility was associated with increased risk for PTSD (OR, 1.42; 95% CI, 1.09-1.86; P = .01) and STBs (OR, 1.55; 95% CI, 1.03-2.33; P = .04) at 8 to 9 months postdeployment. Responsibility was not associated with major depressive episode (OR, 1.30; 95% CI, 0.93-1.81; P = .13) or functional impairment (OR, 1.13; 95% CI, 0.94-1.36; P = .19). When examining enemy combatant death only, the pattern of results was unchanged for PTSD (OR, 1.44; 95 CI%, 1.10-1.90; P = .009) and attenuated for STBs (OR, 1.46; 95 CI%, 0.97- 2.20; P = .07).

CONCLUSIONS AND RELEVANCE

This cohort study found an association between being responsible for the death of others in combat and PTSD and STB at 8 to 9 months, but not 2 to 3 months, postdeployment in active-duty soldiers. The results suggest that delivering early intervention to those who report such responsibility may mitigate the subsequent occurrence of PTSD and STBs.

Predictors of Suicide Attempt Within 30 Days After First Medically Documented Suicidal Ideation in U.S. Army Soldiers

OBJECTIVE

The authors sought to identify predictors of imminent suicide attempt (within 30 days) among U.S. Army soldiers following their first documented suicidal ideation.

METHODS

Using administrative data from the Army Study to Assess Risk and Resilience in Servicemembers, the authors identified 11,178 active-duty Regular Army enlisted soldiers (2006-2009) with medically documented suicidal ideation and no prior medically documented suicide attempts. The authors examined risk factors for suicide attempt within 30 days of first suicidal ideation using logistic regression analyses, including sociodemographic and service-related characteristics, psychiatric diagnoses, physical health care visits, injuries, and history of family violence or crime perpetration or victimization.

RESULTS

Among soldiers with first documented suicidal ideation, 830 (7.4%) attempted suicide, 46.3% of whom (N=387) attempted suicide within 30 days (rate, 35.4 per 1,000 soldiers). Following a series of multivariate analyses, the final model identified females (odds ratio=1.3, 95% CI=1.0, 1.8), combat medics (odds ratio=1.6, 95% CI=1.1, 2.2), individuals with an anxiety disorder diagnosis prior to suicidal ideation (odds ratio=1.3, 95% CI=1.0, 1.6), and those who received a sleep disorder diagnosis on the same day as the recorded suicidal ideation (odds ratio=2.3, 95% CI=1.1, 4.6) as being more likely to attempt suicide within 30 days. Black soldiers (odds ratio=0.6, 95% CI=0.4, 0.9) and those who received an anxiety disorder diagnosis on the same day as suicidal ideation (odds ratio=0.7, 95% CI=0.5, 0.9) were less likely.

CONCLUSIONS

Suicide attempt risk is highest in the first 30 days following ideation diagnosis and is more likely among women, combat medics, and soldiers with an anxiety disorder diagnosis before suicidal ideation and a same-day sleep disorder diagnosis. Black soldiers and those with a same-day anxiety disorder diagnosis were at decreased risk. These factors may help identify soldiers at imminent risk of suicide attempt.

Social closeness and support are associated with lower risk of suicide among U.S. Army soldiers

OBJECTIVE

We tested the aspects of social support, unit cohesion, and religiosity hypothesized to be protective factors for suicide among U.S. service members.

METHODS

This case-control study compared U.S. Army soldiers who died by suicide while on active duty (n = 135) to controls of two types: those propensity score-matched on known sociodemographic risk factors (n = 128); and those controls who had thought about, but not died by, suicide in the past year (n = 108). Data included structured interviews of next of kin (NOK) and Army supervisors (SUP) for each case and control soldier. Logistic regression analyses were used to examine predictors of suicide.

RESULTS

Perceived social closeness and seeking help from others were associated with decreased odds of suicide, as reported by SUP (OR = 0.2 [95% CI = 0.1, 0.5]) and NOK (OR = 0.4 [95% CI = 0.2, 0.8]). Novel reports by SUP informants of high levels of unit cohesion/morale decreased odds of suicide (OR = 0.1 [95% CI = 0.0, 0.2]). Contrary to study hypotheses, no religious affiliation was associated with lower odds of suicide (OR = 0.3 [95% CI = 0.2, 0.6]).

CONCLUSIONS

Perceived social closeness and unit/group cohesion are associated with lower odds of suicide. These results point toward social intervention strategies as testable components of suicide prevention programs.

Financial costs to the U.S. Army for suicides by newly enlisted Soldiers

OBJECTIVE

To estimate the financial burden to the U.S. Army of suicide by enlisted Soldiers during their first year of service.

METHODS

This analysis included new Army enlisted Soldiers who started initial entry training from October 2012 through September 2016 and subsequently died by suicide within their first year of service. Outpatient and inpatient direct medical, direct nonmedical, recruiting, and training costs to the Army were calculated.

RESULTS

During the 48-month observational study period, 29 Soldiers died by suicide within their respective first year of service. The described financial costs accrued by the Army as a result of these deaths were $152,271-with an average of $6,091 per healthcare utilizer. Recruiting and training costs were $1,115,860 for all suicide cases.

CONCLUSION

Average direct cost per healthcare utilizer increased during a Soldier's first year of service. This may be associated with the transition through different phases of training and to the first operational duty station.

PUBLIC HEALTH IMPLICATIONS

Results obtained through this cost-of-illness analysis may serve as baseline metrics to inform future cost-effectiveness studies.

The suicide of Private Danny Chen: An interpersonal theory perspective

Despite considerable prevention and intervention efforts, military suicide rates have increased. Although most research on active-duty military suicide has focused on combat exposure, evidence shows that bullying, hazing, and race are understudied risk factors for military suicide. According to the interpersonal theory of suicide, thwarted belongingness, perceived burdensomeness, and acquired capability are necessary components for enacting a suicide death. In this theoretically-based interpersonal case analysis of the suicide death of Private Danny Chen, an American soldier of Chinese descent, we explore how bullying, hazing, and race may have intersected with other vulnerabilities to result in his death.

Predicting the 10-year risk of cardiovascular diseases and its relation to healthy diet indicator in Iranian military personnel

Background

Epidemiological studies indicate increased prevalence of cardiovascular disease (CVD) among military personnel. Accordingly, identification of at-risk individuals and lifestyle modification such as improving diet quality can potentially inhibits the increasing trend of CVD mortality. The aim of this study was predicting the 10-year risk of CVD and its association with healthy diet indicator (HDI) among military personnel.

Methods

In this cross-sectional study, 400 male military personnel within the age range of 30–75 years were included. HDI score was calculated based on food frequency questionnaire, and the 10-year risk of CVD was evaluated using Framingham risk score (FRS). The FRS items include age, gender, total cholesterol, high density lipoprotein cholesterol (HDL-C), systolic blood pressure, status of diabetes and smoking. Partial correlation test was employed to investigate the relationship between Framingham risk score and HDI score.

Results

The mean age and body mass index (BMI) of participants were 38.67 ± 5.3 year and 25.28 ± 3.22 kg/m², respectively. Prediction of FRS was as follows: 96.5% were low risk, 2% were moderate risk, and 1.5% were high risk. The mean HDI score of participants in this study was 5.98 ± 1.36. While HDI score did not show a significant correlation with FRS (r: − 0.009, p:0.860), increased dietary sodium intake had a significant positive correlation with FRS (r: 0.114, p:0.026).

Conclusion

The most of participants (96.5%) had in low risk of CVD development in the next 10 years. Meanwhile, the FRS showed no significant relationship with HDI score. Further researches are required to confirm the results of the present study.

American Academy of Orthopaedic Surgeons Appropriate Use Criteria: Early Screening for Psychosocial Risk and Protective Factors

The Major Extremity Trauma and Rehabilitation Consortium and the American Academy of Orthopaedic Surgeons (AAOS) have developed Appropriate Use Criteria for the Early Screening for Psychosocial Risk and Protective Factors. Evidence and clinical expertise were used to develop criteria for addressing mental and social health opportunities to help people recover from musculoskeletal injuries to the extremity, spine, and pelvis. The criteria were developed by identifying observable symptoms and results of screening that suggest mental and social health challenges among patients with lower extremity trauma in clinical practice. The 32 patient scenarios and three interventions (evaluate for psychological distress, evaluate for social health opportunities, and evaluate coping and resilience strategies) were developed by the writing panel of clinicians who are specialists in mental and social health in musculoskeletal illness. Next, a separate, multidisciplinary, voting panel made up of specialists and nonspecialists rated the appropriateness of treatment for each patient scenario using a 9-point scale to designate a treatment as "appropriate" (median rating, 7 to 9), "may be appropriate" (median rating, 4 to 6), or "rarely appropriate" (median rating, 1 to 3). Notably, with a high level of agreement, the voting panel determined that interventions to address mental and social health were appropriate in all scenarios as follows: 86% were rated appropriate, 14% were rated possibly appropriate, and none were rated rarely appropriate.

Factors associated with multiple suicide attempts in a nationally representative study of U.S. military veterans

OBJECTIVE

Veterans with a history of multiple suicide attempts are at increased risk for suicide mortality relative to those with a single attempt. However, little is known about factors that differentiate veterans who attempt suicide once compared to more than once. This study examined factors that distinguish single suicide attempters (SSA) from multiple suicide attempters (MSA) in a nationally representative sample of U.S. military 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

(a) estimated the lifetime prevalence of SSA and MSA; and (b) examined factors that differentiated veterans with a SSA from MSA.

RESULTS

The lifetime prevalences of SSA and MSA were 1.9% and 2.0%. The strongest correlates of MSA were history of lifetime depression (odds ratio [OR], 2.45; 95% confidence interval [CI], 1.43-8.35), non-suicidal self-injury (OR, 3.28; 95% CI, 1.27-8.45), drug use disorder (OR, 4.0; 95% CI, 1.67-9.54), and marital status (OR, 0.40, 95% CI, 0.18-0.87), which accounted for 15.5%-41.4% of the total explained variance in MSA.

DISCUSSION

Half of military veterans who have attempted suicide in the United States report more than one attempt, suggesting that suicide attempts are not a one-time occurrence for a substantial proportion of veterans. Veterans who attempt suicide more than once show more deliberate self-harm behavior and have greater psychiatric comorbidities relative to single attempters. Implications for future research examining risk factors for suicide attempts among veterans are discussed.

Associations of Lifetime Traumatic Brain Injury Characteristics With Prospective Suicide Attempt Among Deployed US Army Soldiers

OBJECTIVE

To estimate associations of lifetime traumatic brain injury (TBI) characteristics with prospective suicide attempt among US Army soldiers.

METHOD

The Army STARRS (Study to Assess Risk and Resilience in Servicemembers) Pre/Post Deployment Study surveyed 3 Brigade Combat Teams that were deployed to Afghanistan in 2012. Lifetime TBI and past-month postconcussive/post-TBI symptoms were evaluated at predeployment baseline. Recency and number of TBIs were quantified, and TBI severity was classified on the basis of reports of alteration/loss of consciousness and memory lapse. Suicide attempt data came from administrative records and surveys administered after return from deployment. Logistic regression models estimated associations of TBI characteristics with prospective suicide attempt among baseline respondents who were deployed (n = 7677), adjusting for other risk factors including lifetime mental disorder.

RESULTS

One hundred three soldiers made a suicide attempt over a median follow-up period of 30 months (weighted prevalence = 1.31% [0.14%]). In the final model estimating joint associations of TBI severity/recency and past-month postconcussive/post-TBI symptoms, only postconcussive/post-TBI symptoms were associated with a higher risk of suicide attempt (per standard score increase: AOR [adjusted odds ratio] = 1.31; 95% CI, 1.05-1.63; P = .012).

CONCLUSIONS

Among the lifetime TBI characteristics evaluated at predeployment baseline, only past-month postconcussive/post-TBI symptoms were prospectively associated with an increased risk of suicide attempt following deployment. Detection of postconcussive/post-TBI symptoms could facilitate targeting of Army suicide prevention programs.

Moral injury and suicidal behavior among US combat veterans: Results from the 2019-2020 National Health and Resilience in Veterans Study

BACKGROUND

Recent research suggests that exposure to potentially morally injurious experiences (PMIEs) may be associated with increased risk for suicidal behavior among US combat veterans, but population-based data on these associations are scarce. This study examined the association between PMIEs with current suicidal ideation (SI), lifetime suicide plans (SP), and suicide attempts (SA) in a contemporary, nationally representative sample of combat veterans.

METHODS

Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of US combat veterans (n = 1321). PMIEs were assessed using the Moral Injury Events Scale (MIES). Multivariable logistic regression analyses were conducted to examine associations between MIES total scores and specific types of PMIEs with suicidal behavior.

RESULTS

Thirty-six point three percent of veterans reported at least one PMIE. Perceived transgressions by self, others, and betrayal were associated with SI, SP, and SA (odds ratios [ORs] = 1.21-1.27, all p s < .05), after adjusting for sociodemographic, trauma, and psychiatric characteristics. MIES total scores were significantly, albeit weakly, associated with SP (OR = 1.03, p < .01), but not SI/SA. Depression, posttraumatic stress disorder (PTSD), and age emerged as the strongest correlates of SI/SP/SA (14.9%-38.1% of explained variance), while PMIEs accounted for a comparatively modest amount of variance (3.3%-8.9%).

CONCLUSIONS

Reports of potentially morally injurious experiences are prevalent among US combat veterans, and associated with increased risk for suicidal behavior, above and beyond severity of combat exposure, PTSD, and depression. Implications for clinical practice and future research are discussed, including the need for methodological advancements in the measurement of moral injury.

Distinguishing veterans with suicidal ideation from suicide attempt history: The role of emotion reactivity

INTRODUCTION

Growing evidence suggests emotion reactivity-sensitivity and intensity of emotional experience-may represent a diathesis for suicide risk. However, our understanding of its ability to differentiate risk for suicidal ideation (SI) from suicide attempt (SA) is limited.

METHOD

This study compares Veterans with SI (n = 81) to Veterans with SA (n = 177) history on factors relevant to emotion reactivity to determine which variable(s) best differentiate groups. Variables examined are multimodal: (a) self-report: childhood trauma, combat exposure; (b) clinician-assessed: non-suicidal self-injury (NSSI), structured diagnostic interview of psychopathology; and (c) psychophysiological: affect-modulated startle (AMS; proxy for amygdala reactivity and emotion reactivity) to unpleasant pictures was examined in a subset (n = 90).

RESULTS

SA history was independently predicted by NSSI history, MDD, PTSD, and SUD diagnosis. Childhood trauma and combat exposure did not differentiate groups. The composite risk index demonstrated good accuracy (AUC=0.71, sensitivity=0.90, specificity=0.49). Only AMS independently predicted SA history when added to the model and accuracy was improved (AUC=0.82, sensitivity=0.85, specificity=0.56).

CONCLUSION

NSSI history, MDD, PTSD, and SUD diagnosis may be salient risk factors for this population. However, emotion reactivity is a more parsimonious predictor of SA history among Veterans suggesting it is an important treatment target among Veterans with SI.

The role of oxytocin signaling in depression and suicidality in returning war veterans

Many war veterans struggle with depression and suicidality, and separation from the military is a time of particularly high risk. Based on research in non-human animals, we hypothesized that reduced oxytocin signaling would mediate symptoms of depression and suicidality in war veterans recently separated from their close comrades. We also hypothesized that veterans with more frequent contact with comrades would have fewer symptoms of depression and suicidality. In this cross-sectional study, male veterans from the Iraq and Afghanistan wars (n = 86) provided blood and urine samples for measurement of peripheral oxytocin (OT) levels, as well as saliva samples for DNA extraction followed by genotyping of oxytocin receptor gene (OXTR) Single Nucleotide Polymorphisms, and CpG-methylation assessment. Participants also completed a series of mental health questionnaires and interviews. Veterans reported feeling very close to their comrades during war, and missing them greatly upon returning home. Neither peripheral OT levels nor OXTR genotypes were related to symptoms of depression or suicidality. On the other hand, methylation at OXTR CpG -924 was negatively correlated with depressive symptomology, after controlling for possible confounds. Veterans who socialized with comrades more frequently had higher levels of urinary, but not plasma OT, as well as less depressive symptomology. Social connectedness was a strong negative predictor of symptoms of both depression and suicidality, eclipsing the predictive power of other variables such as post-deployment social support, the degree to which participants reported missing their comrades, and the frequency with which they socialized with comrades. Our results suggest that veteran mental health is more impacted by lack of social connectedness than by separation from close comrades per se. While there is some evidence that OXTR methylation relates to depressive symptomology, decreased OT signaling does not appear to mediate the relationship between social disconnectedness and depression or suicidality. Sleep quality and anxiety disorders were also significantly associated with mental health symptoms, independent of social connectedness. Our findings suggest that efforts aimed at alleviating the burden of depression and suicidality in returning war veterans should focus on re-integrating veterans into society and establishing a feeling of social connectedness, as well as on treating anxiety disorders and sleep problems.

Hill L, King A, Miller R, Latorre M, Gara M, Stanley B. Coping with Suicidal Urges: An Important Factor for Suicide Risk Assessment and Intervention

Suicide-related coping refers to strategies for adaptively managing suicidal urges and can be important an important factor for assessing risk and targeting intervention. The current study evaluated whether suicide-related coping predicted a suicidal event within 90-days, independently of other known risk factors. Veterans (N = 64) were evaluated shortly after a suicidal crisis and completed several assessments, including a measure of suicide-related coping. Multivariate analyses showed that suicide-related coping remained protective of a suicidal event (OR = 0.93; p = .047) after adjusting for suicidal ideation, previous suicide attempts, mood disorder, distress tolerance, and gender. Suicide-related coping may augment commonly assessed clinical factors in prediction of a suicidal event and is a suitable target for suicide prevention efforts.

Longitudinal courses of suicidal ideation in U.S. military veterans: a 7-year population-based, prospective cohort study

BACKGROUND

Varied longitudinal courses of suicidal ideation (SI) may be linked to unique sets of risk and protective factors.

METHOD

A national probability sample of 2291 U.S. veterans was followed over four assessments spanning 7 years to examine how a broad range of baseline risk and protective factors predict varying courses of SI.

RESULTS

Most veterans (82.6%) denied SI at baseline and all follow-ups, while 8.7% had new onset SI, 5.4% chronic SI, and 3.3% remitted SI. Compared to the no-SI group, chronic SI was associated with childhood trauma, baseline major depressive and/or posttraumatic stress disorder (MDD/PTSD), physical health difficulties, and recent traumatic stressors. Remitted veterans had the highest risk of a prior suicide attempt (SA) compared to no-SI [relative risk ratio (RRR) = 3.31] and chronic SI groups (RRR = 4.65); and high rates of MDD/PTSD (RRR = 7.62). New onset SI was associated with recent stressors and physical health difficulties. All symptomatic SI groups reported decrements in protective factors, specifically, social connectedness, trait curiosity/exploration, and purpose in life.

CONCLUSION

Nearly one-in-five veterans reported SI over a 7-year period, most of whom evidenced new onset or remitted SI courses. Chronic and remitted SI may represent particularly high-risk SI courses; the former was associated with higher rates of prospective SA, and psychiatric and physical distress, and the latter with increased likelihood of prior SA, and isolation from social and mental health supports. Physical disability, MDD/PTSD, and recent stressors may be important precipitating or maintaining factors of SI, while social connectedness may be a key target for suicide prevention efforts.

Borderline personality disorder and self-directed violence in a sample of suicidal army soldiers

There has been a sharp increase in the military suicide rates in 2004. While, borderline personality disorder (BPD) has a stronger association with suicide attempts than any other mental health disorder, there is limited evidence concerning the prevalence and scope of BPD symptoms among military personnel. This secondary data analysis compared active duty suicidal soldiers to characterize the presence-absence of BPD diagnostic criteria and lifetime history of self-directed violence in a suicidal military sample. The current study examined data of 137 active Service Members with significant suicidal ideation. Approximately one-quarter of the soldiers in this sample met full diagnostic criteria for BPD. The presence of BPD criteria was generally consistent among participants with BPD who reported past self-directed violence relative to those who did not. The number of BPD criteria was a significant predictor of the odds of reporting any nonsuicidal self-injury (NSSI) as well as the amount of NSSI, but was not associated with suicide attempt. This study demonstrated that a nontrivial proportion of suicidal soldiers meet criteria for this condition, which is strongly associated with self-directed violence. It is important to rigorously assess for the presence-absence of BPD criteria among suicidal military personnel and cultivate prevention strategies and treatment options for BPD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Association of Combat Experiences With Suicide Attempts Among Active-Duty US Service Members

Importance

There is uncertainty about the role that military deployment experiences play in suicide-related outcomes. Most previous research has defined combat experiences broadly, and a limited number of cross-sectional studies have examined the association between specific combat exposure (eg, killing) and suicide-related outcomes.

Objective

To prospectively examine combat exposures associated with suicide attempts among active-duty US service members while accounting for demographic, military-specific, and mental health factors.

Design, Setting, and Participants

This cohort study analyzed data from the Millennium Cohort Study, an ongoing prospective longitudinal study of US service members from all military branches. Participants were enrolled in 4 phases from July 1, 2001, to April 4, 2013, and completed a self-administered survey at enrollment and every 3 to 5 years thereafter. The population for the present study was restricted to active-duty service members from the first 4 enrollment phases who deployed in support of the wars in Iraq and Afghanistan. Questionnaire data were linked with medical encounter data through September 30, 2015. Data analyses were conducted from January 10, 2017, to December 14, 2020.

Exposures

Combat exposure was examined in 3 ways (any combat experience, overall combat severity, and 13 individual combat experiences) using a 13-item self-reported combat measure.

Main Outcomes and Measures

Suicide attempts were identified from military electronic hospitalization and ambulatory medical encounter data using the International Classification of Diseases, Ninth Revision codes.

Results

Among 57 841 participants, 44 062 were men (76.2%) and 42 095 were non-Hispanic White individuals (72.8%), and the mean (SD) age was 26.9 (5.3) years. During a mean (SD) follow-up period of 5.6 (4.0) years, 235 participants had a suicide attempt (0.4%). Combat exposure, defined broadly, was not associated with suicide attempts in Cox proportional hazards time-to-event regression models after adjustments for demographic and military-specific factors; high combat severity and certain individual combat experiences were associated with an increased risk for suicide attempts. However, these associations were mostly accounted for by mental disorders, especially posttraumatic stress disorder. After adjustment for mental disorders, combat experiences with significant association with suicide attempts included being attacked or ambushed (hazard ratio [HR], 1.55; 95% CI, 1.16-2.06), seeing dead bodies or human remains (HR, 1.34; 95% CI, 1.01-1.78), and being directly responsible for the death of a noncombatant (HR, 1.81; 95% CI, 1.04-3.16).

Conclusions and Relevance

This study suggests that deployed service members who experience high levels of combat or are exposed to certain types of combat experiences (involving unexpected events or those that challenge moral or ethical norms) may be at an increased risk of a suicide attempt, either directly or mediated through a mental disorder.

Burnout in Spanish Security Forces during the COVID-19 Pandemic

Since the beginning of the COVID-19 pandemic in Spain, members of the State Security Forces and the Armed Forces have been mobilized to guarantee the security and mobility of the population and to support health institutions by providing personnel for care, creating field hospitals, transferring the sick and the dead, etc. The objective of this study was to determine the levels of burnout in these professionals using the Maslach Burnout Inventory (MBI) scale, both in its different subscales and its total value. The study was developed using a quantitative methodology through a simple random sample (n = 2182). An ad hoc questionnaire was administered including variables related to: (a) socio-demographic issues, (b) subjective perceptions about their working conditions and the need for psychological and psychiatric treatment, and (c) the Death Anxiety Scale developed by Collett-Lester, and the MBI. The results show high levels of burnout (28.5%) in all its subscales: emotional exhaustion (53.8%), depersonalization (58.0%), and lack of personal development (46.3%). The logistic regression verifies a series of predictive variables that coincide in each of the subscales. These data indicate the need to implement prevention and treatment measures for workers so that their, stress, and anxiety to which they are subjected during their professional activity does not become a norm that can have negative repercussions for them, especially given the risk of new pandemic waves.

Deployment and Psychological Correlates of Suicide Ideation: A Prospective, Longitudinal Study of Risk and Resilience Among Combat Veterans

INTRODUCTION

Suicide rates among military personnel have risen in part due to war zone deployments. Yet, the degree to which deployment-related stressors, in combination with preexisting and co-occurring psychiatric symptoms and individual resilience factors, contribute to suicide ideation (SI) remains unclear. The current study leverages prospective, longitudinal data to examine both risk and protective factors associated with SI in deployed service members.

MATERIALS AND METHODS

Participants were 1,805 active duty enlisted Marines and Navy service members assessed before and after a 7-month deployment for SI, preexisting and concurrent symptoms of depression, post-traumatic stress disorder (PTSD), alcohol consumption, as well as prior and deployment-related traumatic brain injury (TBI). Current self-reported psychological resilience and social support were analyzed as potential protective factors.

RESULTS

Rates of SI were 7.3% and 3.9% before and after deployment, respectively. Of those with post-deployment SI, 68.6% were new-onset cases. Multivariate regression revealed that concurrent mild depression was the strongest risk factor (odds ratio [OR] = 10.03, 95% CI 5.28-19.07). Other significant risk factors included prior SI (OR = 3.36, 95% CI 1.60-7.05), prior subthreshold PTSD (OR = 2.10, 95% CI 1.10-3.99), and deployment TBI (OR = 1.84, 95% CI 1.03-3.28). Controlling for clinical symptoms and TBI, the risk of SI was reduced for those with moderate (OR = 0.50, 95% CI 0.27-0.93) and high psychological resilience scores (OR = 0.25, 95% CI 0.08-0.79) after deployment.

CONCLUSIONS

Results indicate that even mild symptoms of depression and PTSD may increase the risk of SI. Screening for subthreshold clinical symptoms and TBI while incorporating psychological resilience training would allow for a more multidimensional approach to suicide risk assessment.

Insomnia Symptoms and Suicide-Related Ideation in U.S. Army Service Members

Background: Insomnia has been identified as a key risk factor for suicide, though most studies have been limited to global measures of these constructs. The aim of the present study was to evaluate the link between insomnia symptoms and five different aspects of suicide-related ideation. Participants: 1,160 active U.S. Army service members (719 male; M_age = 31.2; SD_age = 8.62). Methods: As part of an archival analysis, retrospectively assessed insomnia, depression, anxiety symptoms, as well as suicide-related ideation, were evaluated. Suicide-related ideation was assessed in terms of: thoughts of death, thoughts of suicide, suicidal plan, suicidal intent, and suicidal communication. Results: Subjects with clinically significant insomnia symptoms were 3.5 times more likely to report any suicide-related ideation, and approximately 3 times more likely to report thoughts of death and thoughts of suicide. More frequent nocturnal awakenings (i.e., waking up three or more times during a single night) were associated with a greater likelihood of reporting thoughts of death or suicide, whereas greater middle insomnia (i.e., waking up and having difficulty getting back to sleep) was associated with lower odds of experiencing thoughts of suicide, suicidal plan, and suicidal intent. Conclusions: A more refined delineation of insomnia and suicide-related ideation may serve to clarify the nature of the association, and potentially offer some clues as to the underlying mechanisms. With regard to potential clinical implications, the results support that careful assessment of insomnia symptoms, suicide-related ideation, and their respective subtypes, is important and may influence how we estimate risk for suicide.

Impact of specific combat experiences on suicidal ideation and suicide attempt in U.S. military veterans: Results from the National Health and Resilience in Veterans Study

BACKGROUND

A burgeoning body of research suggests that specific types of combat experiences may be a stronger predictor of suicidality among veterans than a history of combat exposure itself. To date, however, little population-based data exist about these associations in representative samples of veterans. This study examined the association between overall severity of combat exposure and specific combat experiences with suicidal ideation and suicide attempt(s) (SI/SA) in a nationally representative sample of combat veterans.

METHODS

Data were from the National Health and Resilience in Veterans Study, a nationally representative survey of U.S. combat veterans (n = 1100). Analyses (a) compared veterans with/without current SI and lifetime SA on sociodemographic, military, and clinical characteristics; and (b) examined associations between overall combat exposure and specific combat experiences, and SI/SA.

RESULTS

Hierarchical regression analyses revealed that overall combat exposure was positively, albeit weakly, associated with SI/SA, after adjusting for sociodemographic characteristics and lifetime trauma burden [odds ratios (ORs) = 1.02-1.03]. Combat experiences involving direct exposure to death, killing, or grave injury were independently associated with SI/SA (ORs = 1.46-1.70), whereas several general combat experiences (e.g., combat patrols) were negatively associated with SI/SA (ORs = 0.44-0.65).

DISCUSSION

Results indicate that U.S. combat veterans who have witnessed others be killed or wounded in combat are at substantially higher risk for SI/SA relative to those without such histories. Collectively, findings suggest that combat exposure, when examined as an aggregate severity measure, may yield a poor prognostication of suicide risk, as it may be insufficiently sensitive to detect the effects of specific combat-related experiences.

The Association Between Sexual Functioning and Suicide Risk in U.S. Military Veteran Couples Seeking Treatment for Post-Traumatic Stress Disorder

Intimate relationship distress has been identified as one of the most common precipitants of suicidal thoughts for U.S. military populations. Sexual functioning is associated with relationship distress and has recently been identified as a predictor of suicidal ideation with female military personnel; however, no studies have examined this association among a treatment-seeking sample of male and female veterans and their partners. Couples (N = 138) completed baseline assessments of sexual functioning, relationship functioning, suicidal ideation, and mental health prior to evaluation for engagement in a couples-based PTSD treatment study. Analyses revealed that decreased sexual pleasure and decreased frequency of sexual intercourse were associated with more recent suicidal ideation for male veterans, whereas increased sexual frequency was marginally associated with increased suicidal ideation for female veterans, controlling for PTSD and depression symptoms, relationship satisfaction, and medications. These findings stress the importance of assessing sexual functioning as a risk factor for suicide and taking into consideration the possibility that sexual functioning may be protective or predictive of suicidality depending on the person and context.

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.

Suicide among university students: prevalence, risks and protective factors

Background: Research evidence on suicide in Ghana so far has focused mostly on suicide in the adult population and less work on the younger population such as university students and other vulnerable groups such as children, youth and the aged. Aims: This study was conducted to determine lifetime and current prevalence of suicidal ideation or attempts and identify the associated risks and protective factors among university students in Ghana. Methods: Using a cross-sectional design, 1003 university students (507 males and 496 females) with a mean age of 20.5 years (SD = 5.95) were administered questionnaires that measured suicide, psychological distress, self-esteem and subjective wellbeing. Results: We found the following prevalence rates of suicidal behaviours: ideations 15.2%, attempted 6.3%, death wishes 24.3% and suicidal plan 6.8%. Psychological distress was a risk factor for both suicidal ideation and suicidal attempt. Subjective wellbeing was protective of suicide attempt while self-esteem was protective of suicidal ideation. Conclusions: These findings underscore the need for school-based mental health-promoting programmes that enhance young people's self-esteem, reduce psychological distress and boost subjective wellbeing.

Suicide among Ethiopian origin soldiers in the IDF - A qualitative view of risk factors, triggers, and life circumstances

BACKGROUND

Ethiopian soldiers in the IDF comprise an at-risk group for suicide. The study investigated the unique characteristics of these soldiers, compared with other suicides in the Israel Defense Forces (IDF).

METHOD

The research group included all (n = 36) male soldiers born an Ethiopian family, who died by suicide during their compulsory military service in the years 1990-2017. The control group included all (n = 55) non-Ethiopian soldiers who died by suicide during their military service in the years 2009-2013. Socio-demographic, military-service, and suicide-related variables were examined.

RESULTS

Logistic regression analysis revealed that risk for suicide among Ethiopian soldiers were being incarcerated in a military prison, belonging to a bereaved family, seniority in the military service, and avoidance of help-seeking (explaining 87.8% of the variance).

DISCUSSION

Ethiopian suicide soldiers have endured heavy environmental pressure, such as financial problems and family bereavement. These circumstances could lead to conflict with the soldier's military service, resulting in absence from service or even imprisonment. When the Ethiopian soldier's distress goes un-expressed in words or actions with others, the psychological crisis signs remain unapparent to those around him, and the risk for eventual suicide is high.

LIMITATIONS

The case analysis did not include retrieving information from family and relatives outside the military but was derived from archived material, collected primarily for legal purposes. This limitation was addressed by assembling objective variables and information collected prior to the suicide, along with post-mortem information collected by mental health personnel in their assessments.

Co-occurring risk factors among U.S. high school students at risk for suicidal thoughts and behaviors

BACKGROUND

Suicidal thoughts and behaviors (STBs) are increasing among adolescents in the United States and are challenging to predict and prevent.  The current study identifies subtypes of youth at risk for suicidal thoughts and behaviors (STBs) in school-based settings.

METHOD

Data are from the CDC's 2015 and 2017 National Youth Risk Behavior Survey of US high school students. Among students reporting depression symptoms, latent class analysis is used to identify subtypes at risk for STBs based on personal characteristics, risk behaviors and environments.

RESULTS

Two distinct subtypes of youth were found to be at high risk for STBs: The first, larger subtype (22%) is predominately females in early high school, many of whom identify as bisexual, experienced past-year bullying, and are likely to have experienced sexual victimization.  These students have low levels of externalizing risk behaviors making them difficult to detect.  The second high-risk subtype (7%) is characterized by students with significant social integration challenges, with extremely high levels of substance abuse, fighting, physical and sexual victimization and poor academic performance.  Many of these students have low English fluency, and identify as sexual minority.

LIMITATIONS

Due to attrition or language barriers, experiences of some students at high-risk for STBs may not have been captured by this survey.

CONCLUSION

Universal screening in clinical settings, and universally focused suicide prevention programs in school-based settings are needed and should be introduced early on. Interventions should be tailored to reach high-risk students with language, cultural and social integration challenges.

An effective suicide prevention program in the Israeli Defense Forces: A cohort study

Objective

To evaluate the effectiveness of the IDF Suicide Prevention Program, implemented since 2006.

Design

Quasi-experimental (before and after) cohort study.

Participants

Two cohorts of IDF mandatory service soldiers: the first inducted prior to (1992–2005, n = 766,107) and the second subsequent to (2006–2012, n = 405,252) the launching of the intervention program.

Exposure

The IDF Suicide Prevention Program is a population-based program, incorporating: reducing weapon availability, de-stigmatizing help-seeking behavior, integrating mental health officers into service units, and training commanders and soldiers to recognize suicide risk factors and warning signs.

Main outcome measure

Suicide rate and time to suicide in cohorts before and after exposure to the Suicide Prevention Program.

Results

Trend analysis showed lower suicide rates in the cohort after intervention. The hazard ratio for the intervention effect on time to suicide was 0.44 (95% CI = 0.34–0.56, P < .001) among males. Lower risk was associated with: male gender; born in Israel; higher socio-economic status; higher intelligence score; and serving in a combat unit (HR = 0.43: 95% CI = 0.33–0.55).

Conclusions

There was a 57% decrease in the suicide rate following the administration of the IDF Suicide Prevention Program. The effect of the intervention appears to be related to use of a weapon, and being able to benefit from improved help-seeking and de-stigmatization. Future efforts should seek to extend the program's prevention reach to other demographic groups of soldiers. The success of the IDF program may inform suicide prevention in other military organizations and in the civilian sector.

Risk factors for suicide in the Israeli army between the years 1992–2012: A case-control study

Objective

Young age, availability of weapons, and stressful life events, increase the risk of suicide. The aim of the present study was to assess additional risk factors for suicide in the Israeli army.

Methods

We conducted a case-control study, to assess risk factors for suicide. The cases comprised soldiers who died by suicide during their military service (n = 462; 0.039% of all soldiers in the cohort). The control group consisted of soldiers who did not commit suicide but were in active service during the investigated period (n = 1,170,895; 99.96%). Predictor variables, including socio-demographic and psychiatric diagnoses, were considered.

Results

Using a Generalized Linear Model with a Binary Logistic dependent variable to predict suicide, while controlling the effect of intervening variables, we found the following variables enhanced the risk for committing suicide: male (RR = 6.703; P < 0.001), country of origin: Ethiopia (RR = 4.555; P = 0.014), low socioeconomic status (RR = 1.448; P = 0.016) and low adjustment difficulties (RR = 2.324; P < 0.001). In addition, we found that in males only, Cluster B Personality Disorder (RR = 2.548; P = 0.027), low (RR = 1.657; P = 0.002), to average motivation to serve in a combat unit (RR = 1.322; P = 0.046) increased the risk for suicide.

Conclusions

IDF Soldiers bearing a psychiatric diagnosis or severe adjustment difficulties remained tightly monitored through their military service, and were found to be at a lower risk for suicide. However, those enlisted with mild (low) difficulties, were found to be at greater risk for suicide, as well as soldiers whose country of origin is Ethiopia. Suicide prevention program should focus on monitoring soldiers with these risk factors, together with soldiers’ guidance regarding help seeking and de-stigmatizing suicide.

Leader provided purpose: Military leadership behavior and its association with suicidal ideation

Suicide in U.S. Army Soldiers is of major concern as it is estimated that over 100 Soldiers die by suicide each year. Examining risk and protective factors is essential to develop both an understanding of Soldier suicide as well as inform systemic interventions to reduce suicide. One potential systemic approach is to embed preventive mechanisms within the structure of the military rather than the typical administration of primary intervention through mandatory training. To examine potential mechanisms of leader-based interventions, several leadership behaviors were assessed in a cross-sectional sample of n = 1,096 active duty Soldiers. Soldiers completed self-report measures of interpersonal predictors of suicide, suicidal ideation (SI), leadership behaviors, and unit cohesion. Logistic regression was used to identify leadership behaviors related to SI. Only the leader behavior attempting to foster a sense of purpose predicted SI. Leader provided purpose (LPP) was then entered into indirect effect analyses to evaluate the mechanisms of this relationship. Analyses revealed that LPP predicted SI through unit cohesion, thwarted belongingness, and perceived burdensomeness. Results demonstrate that specific aspects of military leadership such as fostering Soldier purpose may enhance resilience and reduce risk for SI.

Unit Cohesion and Social Support as Protective Factors Against Suicide Risk and Depression Among National Guard Service Members

Introduction: Suicide and depression continue to be pervasive problems across military populations, including within the National Guard. Existing literature highlights the protective effects of social support and unit cohesion for both suicide risk and depression, yet to our knowledge, these associations have never been confirmed in National Guard populations. Thus, the aim of this study was to investigate the impacts of social support resources (i.e., general social support and unit cohesion) on depression and suicide risk among a large sample (n = 877) of National Guard service members.

Methods: Multilevel modeling was used to examine the impact of social support resources on depression and suicide ideation at both the individual and unit level.

Results: Results indicated that higher levels of perceived social support were associated with lower levels of depression and suicide ideation at both the individual and unit levels. Additionally, higher levels of perceived unit cohesion significantly predicted lower levels of depression and suicide ideation at the individual, but not unit level.

Discussion: Limitations include self-report measurement and cross-sectional nature of the data. These findings hold implications for improvement of operational climate within military units and reduction of suicide risk and depressive symptoms among National Guard service members.

Pre-deployment predictors of suicide attempt during and after combat deployment: Results from the Army Study to Assess Risk and Resilience in Servicemembers

BACKGROUND

Deployment-related experiences might be risk factors for soldier suicides, in which case identification of vulnerable soldiers before deployment could inform preventive efforts. We investigated this possibility by using pre-deployment survey and administrative data in a sample of US Army soldiers to develop a risk model for suicide attempt (SA) during and shortly after deployment.

METHODS

Data came from the Army Study to Assess Risk and Resilience in Servicemembers Pre-Post Deployment Survey (PPDS). Soldiers completed a baseline survey shortly before deploying to Afghanistan in 2011-2012. Survey measures were used to predict SAs, defined using administrative and subsequent survey data, through 30 months after deployment. Models were built using penalized regression and ensemble machine learning methods.

RESULTS

Significant pre-deployment risk factors were history of traumatic brain injury, 9 + mental health treatment visits in the 12 months before deployment, young age, female, previously married, and low relationship quality. Cross-validated AUC of the best penalized and ensemble models were .75-.77. 21.3-40.4% of SAs occurred among the 5-10% of soldiers with highest predicted risk and positive predictive value (PPV) among these high-risk soldiers was 4.4-5.7%.

CONCLUSIONS

SA can be predicted significantly from pre-deployment data, but intervention planning needs to take PPV into consideration.

Near Term Suicide Risk Assessment: A Commentary on the Clinical Relevance of Protective Factors

In this article we examine the clinical relevance of protective factors to the assessment and formulation of near-term risk of death by suicide. Contrary to current clinical belief and practice, we posit that there is no evidence base to support these factors as mitigating or buffering risk for suicide for the individual patient, especially in the near-term assessment of that suicide risk. We show that evidence-based protective factors derive from population-based studies and, applicably, have relevance to public health promotion/primary prevention and are significant in informing treatment/secondary prevention, but they lack evidence to support their often-proposed role in mitigating or buffering risk for suicide on an individual basis, especially when applied to the assessment of near-term risk of suicide. Accordingly, we argue for the need for empirical study of the role protective factors may or may not play in the formulation of a patient's risk for suicide and, in the interim, for clinical caution in assuming that protective factors have any significant buffering effect on a patient's level of near-term risk.

Intimate Relationships Buffer Suicidality in National Guard Service Members: A Longitudinal Study

OBJECTIVE

Members of the U.S. military are at a high suicide risk. While studies have examined predictors of suicide in the U.S. military, more studies are needed which examine protective factors for suicide. Informed by the interpersonal theory of suicide, this study examined the strength of the intimate relationship and its role as a buffer of suicidality in National Guard service members.

METHOD

A total of 712 National Guard residing in a Midwestern state, who had all recently returned home from a deployment, took part in this study and completed surveys at 6 and 12 months postdeployment. They were assessed on suicide risk, mental health (depression, post-traumatic stress disorder, anxiety), and relationship satisfaction.

RESULTS

Lower relationship satisfaction and more depressive symptoms at the 6-month assessment were significantly related to greater suicide risk at 12 months. Each interaction between couple satisfaction and three mental health variables (PTSD, depression, and anxiety) at the 6-month assessment was significantly associated with suicide risk at 12 months.

CONCLUSIONS

The strength of the intimate relationship serves as a buffer for suicide in National Guard service members who have PTSD, anxiety, or depression. Interventions that strengthen these intimate relationships could reduce suicide in service members.

Perceived burdensomeness, bullying, and suicidal ideation in suicidal military personnel

OBJECTIVE

Suicide is a major public health concern among military servicemembers and previous research has demonstrated an association between bullying and suicide. This study evaluated the association between workplace bullying and suicidal ideation via perceived burdensomeness and thwarted belongingness which were hypothesized to mediate this association.

METHOD

Four hundred and seventy-one suicidal Army Soldiers and U.S. Marines completed self-report measures of suicidal ideation, thwarted belongingness, perceived burdensomeness, and bullying. A series of regressions were used to test the hypothesized mediation model using the baseline data from a larger clinical trial.

RESULTS

Perceived burdensomeness was a significant mediator of the association between bullying and the level of suicidal ideation, but thwarted belongingness was not a significant mediator.

CONCLUSIONS

Perceived burdensomeness may represent a malleable target for intervention to prevent suicide among military service members, and should be evaluated further as an intervening variable with regard to suicidality in the setting of bullying victimization.

Examining the link between prior suicidality and subsequent suicidal ideation among high-risk US military service members

BACKGROUND

Research is needed to identify the factors that explain the link between prior and future suicidality. This study evaluated possible mediators of the relationship between: (1) the severity of prior suicidality and (2) suicidal ideation severity at 3-month follow-up among a sample of high-risk military personnel.

METHODS

US military service members referred to or seeking care for suicide risk (N = 624) completed self-report psychiatric domain measures and a clinician interview assessing prior suicidality severity at baseline. Three months later, participants completed a self-report measure of suicidal ideation severity. Three separate percentile bootstrap mediation models were used to examine psychiatric factors (i.e. alcohol abuse, anxiety sensitivity, hopelessness, insomnia, posttraumatic stress symptoms, suicidal ideation, and thwarted belongingness) as parallel mediators of the relationship between prior suicidality severity (specifically, suicidal ideation, suicide attempt, and overall suicidality - i.e. ideation/attempt severity combined) at baseline and suicidal ideation severity at follow-up.

RESULTS

Hopelessness, specifically, and the total effect of all mediators, each significantly accounted for the relationship between prior suicidality severity and subsequent ideation severity across models. In the models with attempt severity and overall suicidality severity as predictors, thwarted belongingness was also a significant mediator.

CONCLUSIONS

Hopelessness, thwarted belongingness, and overall severity of psychiatric indices may explain the relationship between prior suicidality severity and future suicidal ideation severity among service members at elevated suicide risk. Research is needed to replicate these findings and examine other possible mediators.

Risk factors for positive depression screening across a shipboard deployment cycle

BACKGROUND

Depression is a leading cause of healthcare use and risk for suicide among US military personnel. Depression is not well characterised over the shipboard deployment cycle, and personnel undergo less screening than with land-based deployments, making early identification less likely.

AIMS

To determine the demographic and behavioural risk factors associated with screening positive for risk of depression (ROD) across the shipboard deployment cycle.

METHOD

Active-duty ship assigned personnel completed an anonymous assessment using the Center for Epidemiologic Studies Depression Scale (CES-D) in the year prior to deployment, during deployment and in the months following deployment. Longitudinal models were used to determine risk factors.

RESULTS

In total, 598 people were included in the analysis. Over 50% of the study population screened positive for ROD (CES-D score ≥16) and over 25% screened positive for risk of major depressive disorder (CES-D score ≥22) at all time points. Lower age, female gender, alcohol use, stress and prior mental health diagnoses were all associated with greater odds of screening positive for ROD in multivariable models.

CONCLUSIONS

Although the risk factors associated with screening positive for ROD are similar to those in other military and civilian populations, the proportion screening positive exceeds previously reported prevalence. This suggests that shipboard deployment or factors associated with shipboard deployment may present particular stressors or increase the likelihood of depressive symptoms.

DECLARATION OF INTEREST

The authors are military service members (or employees of the US Government). This work was prepared as part of the authors' official duties. Title 17, U.S.C. §105 provides the 'Copyright protection under this title is not available for any work of the United States Government.' Title 17, USC, §101 defines a US Government work as work prepared by a military service member or employee of the US Government as part of that person's official duties. The views expressed in this research are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of the Army, Department of the Air Force, Department of Veterans Affairs, Department of Defense, or the US Government. Approved for public release; distribution unlimited. Material has been reviewed by the Walter Reed Army Institute of Research. There is no objection to its presentation and/or publication. The opinions or assertions contained herein are the private views of the authors, and are not to be construed as official, or as reflecting true views of the Department of the Army or the Department of Defense.

Depression and PTSD-related anhedonia mediate the association of military sexual trauma and suicidal ideation in female service members/veterans

Previous research shows a direct link between military sexual trauma and suicide risk. Little is known about mediators of this association, including posttraumatic stress disorder (PTSD) or depression severity, mental health conditions that are correlated with both suicide risk and military sexual trauma. Moreover, existing studies of military sexual trauma do not distinguish between harassment and assault, resulting in a gap in our knowledge regarding suicide risk as a function of sexual trauma type. We explored whether PTSD symptom clusters and depression mediated the association of military sexual trauma type (none, harassment-only, assault) and suicidal ideation (SI). Female service members/Veterans (n = 1190) completed a demographic inventory, military sexual trauma history and type screening, and PTSD symptom cluster severity, depression severity, and SI measures. Structural equation modeling revealed that the association of military sexual trauma, particularly assault, with SI was mediated by depression severity and PTSD-related anhedonia. Screening for SI among those endorsing a history of military sexual trauma, PTSD-related anhedonia, and depression may help identify those at risk for SI. Therapeutic interventions aimed at reducing PTSD-related anhedonia and depression symptoms may be the most efficient way to mitigate suicide risk in those with histories of assault military sexual trauma.

Personal and psychiatric characteristics among Druze soldiers attempting suicide during military service

BACKGROUND

A non-fatal suicide attempt is a strong predictor of suicide. This study aimed to examine personal characteristics and psychiatric diagnoses among Druze soldiers who attempted suicide during their military service.

METHOD

The research group (n = 180) included all Druze soldiers who had attempted suicide between the years 2008-2012 (This number encompassed 18.4% of all suicide attempts in the IDF during those years). Three control groups were examined: Jewish soldiers who had attempted suicide (n = 155), and two additional groups comprising Druze and Jewish combat soldiers who had not attempted suicide (n = 5,255 and n = 205,819, respectively).

RESULTS

While Druze soldiers were diagnosed with psychiatric conditions less frequently than their Jewish counterparts, the more prolonged time to diagnosis among Druze may account for increased severity at time of diagnosis, thus increasing the risk of suicide attempt. A multivariate analysis revealed that the odds of a suicide attempt among Druze soldiers were much higher than among Jewish soldiers (OR 20.53; p < .001). In addition, it was found that average and high socioeconomic levels, strong Hebrew language skills, and high intelligence levels were protective factors against attempted suicide (p < .001, R² = 0.217).

LIMITATIONS

The three control groups were samples, while the research group (Druze attempters) consisted of all instances of attempted suicide during the study period. Comparing only samples would have offered less statistical power; therefore, using all the records in the research group improved accuracy.

Life course well-being framework for suicide prevention in Canadian Armed Forces Veterans

Introduction: The risks of suicidality (suicidal ideation or behaviour) are higher in Canadian Armed Forces (CAF) Veterans (former members) than in the Canadian general population (CGP). Suicide prevention is everyone’s responsibility, but it can be difficult for many to see how they can help. This article proposes an evidence-based theoretical framework for discussing suicide prevention. The framework informed the 2017 joint CAF – Veterans Affairs Canada (VAC) suicide prevention strategy. Methods: Evidence for the framework was derived from participation in expert panels conducted by the CAF in 2009 and 2016, a review of findings from epidemiological studies of suicidality in CAF Veterans released since 1976, suicide prevention literature reviews conducted at VAC since 2009, and published theories of suicide. Results: Common to all suicide theories is the understanding that suicide causation is multifactorial, complex, and varies individually such that factors interact rather than lie along linear causal chains. Discussion: The proposed framework has three core concepts: a composite well-being framework, the life course view, and opportunities for prevention along the suicide pathway from ideation to behaviour. Evidence indicates that Veterans are influenced onto, along, and off the pathway by variable combinations of mental illness, stressful well-being problems and life events, individual factors including suicidal diathesis vulnerability, barriers to well-being supports, acquired lethal capability, imitation, impulsivity, and access to lethal means. The proposed framework can inform discussions about both whole-community participation in prevention, intervention and postvention activities at the individual and population levels, and the development of hypotheses for the increased risk of suicidality in CAF Veterans.

Suicide ideation severity is associated with severe suicide attempts in a military setting

BACKGROUND

There is an ongoing debate on the effectiveness of suicidal behavior prevention measures in the military. The association of three widely used tools with severe suicide attempts was assessed in this setting.

METHODS

Thirty-nine Israeli soldiers (59% males), mean age 19 yrs., who attempted suicide during military service were divided into two groups: severe (n = 14; 35.9%) and moderate suicide attempts, and were assessed using the Scale for Suicide Ideation (SSI), Suicide Intent Scale (SIS) and the Columbia Suicide Severity Rating Scale (C-SSRS).

RESULTS

Seven items from the SSI (p = 0.008), two items from SIS and one item from C-SSRS were associated with severe suicide attempts. Kendall's tau-b correlation with bootstrap demonstrated stability of these correlations.

CONCLUSION

Greater severity of suicidal ideation was associated with more severe suicide attempts. The combination of male gender, available firearms and current severe suicide ideation is high-risk danger sign in a military setting, even when reported intent to die is low.