Nonsuicidal self-injury as a prospective predictor of suicide attempts in a clinical sample of military personnel

Nonsuicidal self-injury characteristics: A mixed methods analysis of differences between veterans and civilians

Nonsuicidal self-injury (NSSI) is a well-established risk factor for suicidal behavior, with certain NSSI characteristics being associated with increased risk. In the United States (U.S.), the veteran suicide rate is elevated, though lifetime prevalence rates of NSSI appear similar between veterans and civilians. There is limited research that directly compares veterans and civilians across multiple NSSI characteristics to examine between-group differences in NSSI behavior and provide important context for the application of NSSI research with the veteran population. This study examined differences between U.S. veterans and civilians with a history of suicidal ideation across several NSSI characteristics, including method, severity, age of onset, shame, distress, and reason for initial NSSI engagement. A sample of 527 veterans and civilians completed measures of direct and indirect NSSI behaviors along with supplemental questions designed to further assess endorsed NSSI behaviors. Additionally, respondents provided written responses to an open-ended question about their reasons for initial engagement in NSSI, which were coded for post-hoc analysis. Chi-square difference tests and t-tests were conducted, revealing significant group differences between veterans and civilians in NSSI method, lifetime versatility, age of onset, age at last occurrence, and reasons for initial engagement. No significant differences were found in NSSI frequency, severity, shame, or distress. These findings provide valuable information on similarities and differences in NSSI behavior characteristics between U.S. veterans and civilians with lifetime suicidal ideation to inform future research and the assessment of NSSI in these populations.

The Prevalence of Nonsuicidal Self-Injury in Military Personnel: A Systematic Review and Meta-Analysis

Military service members and veterans (SMVs) are at risk for self-directed violence, including nonsuicidal self-injury (NSSI). While NSSI is an important construct worthy of independent study, it is understudied among SMVs and, when included in research, typically examined in the context of suicide risk. Consequently, lifetime prevalence rate estimates of NSSI among SMVs vary. This Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review and meta-analysis estimated the average lifetime NSSI prevalence among SMVs and explored demographic and methodological factors that may account for observed variability. Based on a search of Ovid MEDLINE, Embase, PsycINFO, and Web of Science, 47 samples from 42 articles across five countries met inclusion criteria. Results revealed an average NSSI lifetime prevalence rate of 15.76% among SMVs. Significantly higher prevalence rates were observed among clinical (28.14%) versus community (11.28%) samples and studies using interviews to assess NSSI (23.56%) versus self-report (13.44%) or chart review (7.84%). Lifetime prevalence increased as publication year increased and decreased as sample size increased. In contrast to prior literature, prevalence rates were comparable between active-duty SMVs, and studies collecting data anonymously versus those that did not. Lifetime prevalence was not moderated by age, gender, race, country, primary research focus, quality of NSSI operationalization, or whether NSSI methods were assessed. Findings suggest NSSI is a pervasive problem among military personnel, particularly within clinical settings, highlighting the need for systematic assessment of this important but understudied clinical phenomenon among SMVs. Further research is necessary to elucidate additional risk factors for NSSI among SMVs, including trauma exposure.

Early Adverse Family Experiences and Elevated Adrenocorticotropic Hormone Predict Non-Suicidal Self-Injury in Females with Non-Psychotic Mental Disorders and Suicidal Ideation

Nonsuicidal self-injurious behavior (NSSI), prevalent in patients with non-psychotic mental disorders (NPMD), is associated with numerous adverse outcomes. Despite active research into the clinical and psychological aspects of NSSI, the underlying biological mechanisms remain obscure. Early adverse experiences are believed to induce long-lasting changes in neuroendocrine mechanisms of stress control playing a key role in NSSI development. The aim of the study was to evaluate parameters potentially predicting development of NSSI in female patients with NPMD and suicidal ideation. Eighty female patients over 18 years with NPMD and suicidal ideation (40 with and 40 without NSSI) and 48 age matching women without evidence of mental illness (healthy controls) were enrolled. Diagnostic interviews and self-report measures were used to assess childhood maltreatment, presence, frequency, and characteristics of suicidal and self-injurious thoughts and behaviors, the Beck Depression Inventory scale to assess severity of depression. Hypothalamic-pituitary-adrenal axis markers, hormones, and neurotrophic factors were measured in blood serum. The likelihood of developing NSSI in patients with NPMD and suicidal ideation was associated with early adverse family history and elevated adrenocorticotropic hormone levels. Dysregulation of hypothalamic-pituitary-adrenal axis as a result of early chronic stress experiences may represent critical biological mechanism promoting the development of NSSI behaviors in patients with NPMD.

Nonsuicidal self-injury methods among U.S. Veterans: Latent class analysis and associations with psychosocial outcomes

Nonsuicidal self-injury (NSSI) is a debilitating concern among U.S. veterans, with wall/object-punching commonly endorsed as an NSSI method. We examined how this behavior relates to other NSSI methods and psychosocial outcomes. We conducted a latent class analysis (LCA) of NSSI methods among 1,138 Gulf War Era veterans, (77.9% male), 21.7% of whom endorsed lifetime NSSI. We categorized classes based on their associations with age, sex, combat and military sexual assault exposure, then examined the association of class membership with psychosocial indicators. LCA results supported four classes: 1) High punching/banging NSSI (2.5%); 2) Multimethod NSSI methods (6.3%); 3) High-risk, multimethod NSSI (3.1%); and 4) Low-risk NSSI (88.1%). Psychosocial indicators (suicide attempt, ideation, possible depressive or posttraumatic stress disorders, poor psychosocial functioning) were worse for members of the NSSI classes versus those in the low-risk group. A subset of U.S. veterans may engage in NSSI primarily via punching/banging methods. All patterns of NSSI engagement were associated with negative psychosocial outcomes relative to those in the low-risk class of the behavior.

Potential mechanisms of non-suicidal self-injury (NSSI) in major depressive disorder: a systematic review

Background

Non-suicidal self-injury (NSSI) is a frequent and prominent phenomenon in major depressive disorder (MDD). Even though its prevalence and risk factors are relatively well understood, the potential mechanisms of NSSI in MDD remain elusive.

Aims

To review present evidence related to the potential mechanisms of NSSI in MDD.

Methods

According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, articles for this systematic review were searched on Medline (through PubMed), Embase (through Elsevier), PsycINFO (through OVID) and Web of Science databases for English articles, as well as China National Knowledge Infrastructure (CNKI), SinoMed, Wanfang Data, and the Chongqing VIP Chinese Science and Technology Periodical (VIP) Databases for Chinese articles published from the date of inception to 2 August 2022. Two researchers (BW, HZ) independently screened studies based on inclusion and exclusion criteria and assessed their quality.

Results

A total of 25 157 studies were searched. Only 25 of them were ultimately included, containing 3336 subjects (1535 patients with MDD and NSSI, 1403 patients with MDD without NSSI and 398 HCs). Included studies were divided into 6 categories: psychosocial factors (11 studies), neuroimaging (8 studies), stress and hypothalamic-pituitary-adrenal (HPA) axis (2 studies), pain perception (1 study), electroencephalogram (EEG) (2 studies) and epigenetics (1 study).

Conclusions

This systematic review indicates that patients with MDD and NSSI might have specific psychosocial factors, aberrant brain functions and neurochemical metabolisms, HPA axis dysfunctions, abnormal pain perceptions and epigenetic alterations.

Self-harm behaviors and their intentions: a cross-cultural analysis

BACKGROUND

Self-harm behaviors (performed with either lethal and non-lethal intentions) are common, especially among individuals suffering from mood disorders, and the reasons individuals self-harm vary both by person and by the type of behavior. Understanding these variations may help clinicians determine levels of risk more accurately.

AIMS

To understand whether culture and gender are associated with the likelihood of engaging in specific self-harm behaviors and whether the intention (lethal, ambivalent, non-lethal) of these behaviors vary with culture and gender.

METHODS

2826 individuals took part in an international multilingual online depression/suicidality screening study and reported at least one instance of self-harm in the past year. Participants were grouped into six broad cultural categories (Latin America, South Asia, Russian, Western English, Chinese, Arab).

RESULTS

3-way (culture x gender x intent) interactions were observed for several self-harm behaviors (overdosing, self-burning, asphyxiating, poisoning, and jumping from heights), suggesting that individuals engage in each of these behaviors with different intentions depending on gender and culture. Cultures and genders likewise differed in the likelihood of engaging in several self-harm behaviors.

CONCLUSIONS

Clinicians should consider culture and gender when assessing for suicide risk, as similar self-harming behaviors may reflect different intentions depending on an individual's culture and gender.

Nonsuicidal self-injury among veterans is associated with psychosocial impairment, suicidal thoughts and behaviors, and underutilization of mental health services

Nonsuicidal self-injury (NSSI) is a robust predictor of suicide attempts. However, understanding of NSSI and associated treatment utilization among Veterans is limited. Although impairment may be assumed, few studies examine the association between NSSI and psychosocial functioning, a core component of the rehabilitation framework of mental health. In a national survey of Veterans, current NSSI (n = 88) was associated with higher rates of suicidal thoughts and behaviors and more severe psychosocial impairment after adjusting for demographics and probable diagnoses of posttraumatic stress disorder, major depressive disorder, and alcohol use disorder, compared to Veterans without NSSI (n = 979). Only half of Veterans with NSSI were engaged with mental health services, with few appointments attended, suggesting that these Veterans are not receiving treatment interventions. Results underscore the adverse outcomes associated with NSSI. Underutilization of mental health services highlights the importance of screening for NSSI among Veterans to improve psychosocial outcomes.

Sex-specific risk and resilience correlates of suicidal ideation in U.S. military veterans

OBJECTIVES

To estimate the prevalence and identify gender-specific risk factors associated with suicidal ideation (SI) 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 nationally representative sample of 4069 veterans. Bivariate and multivariable analyses were conducted to identify factors associated with SI in male and female veterans.

RESULTS

The prevalence of SI was significantly higher in female than male veterans (18.1 % vs. 11.2 %). In female veterans, results of a relative importance analysis revealed that the majority of explained variance in SI (Nagelkerke R² = 0.54) was accounted for by lower psychological resilience (44.4 %), and history of non-suicidal self-injury (24.4 %) and alcohol use disorder (20.6 %). In male veterans, the majority of explained variance in SI (Nagelkerke R² = 0.32) was accounted for by higher loneliness (19.5 %) and hostility (19.1 %), and lower purpose in life (16.3 %).

CONCLUSIONS

Suicidal ideation is prevalent among U.S. veterans, particularly in female veterans. Different risk factors emerged as strong correlates of SI in female and male veterans, which may be used to inform gender-specific suicide prevention and treatment efforts in this population.

Attention-deficit/hyperactivity disorder and nonsuicidal self-injury among veterans with complex psychiatric presentations

Prior research suggests a possible association between attention-deficit/hyperactivity disorder (ADHD) symptoms and nonsuicidal self-injury (NSSI) in veterans. However, this association has not yet been replicated. The present study sought to replicate and expand upon this association in a gender-balanced sample of veterans (N = 124), more than half of whom had a lifetime history of NSSI. Contrary to hypotheses, adult ADHD symptoms were not associated with NSSI history or disorder. Instead, our findings suggest that disorders characterized by negative affect may have greater utility for predicting NSSI versus those characterized by impulsivity. Further research in epidemiological samples is needed.

Comparing psychosocial functioning, suicide risk, and nonsuicidal self-injury between veterans with probable posttraumatic stress disorder and alcohol use disorder

BACKGROUND

Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) are each common among Unites States (U.S.) military veterans and frequently co-occur (i.e., PTSD+AUD). Although comorbid PTSD+AUD is generally associated with worse outcomes relative to either diagnosis alone, some studies suggest the added burden of comorbid PTSD+AUD is greater relative to AUD-alone than to PTSD-alone. Furthermore, nonsuicidal self-injury (NSSI) is more common among veterans than previously thought but rarely measured as a veteran psychiatric health outcome. This study sought to replicate and extend previous work by comparing psychosocial functioning, suicide risk, and NSSI among veterans screening positive for PTSD, AUD, comorbid PTSD+AUD, and neither disorder.

METHODS

This study analyzed data from a national sample of N = 1046 U.S. veterans who had served during the Gulf War. Participants self-reported sociodemographic, functioning, and clinical information through a mailed survey.

RESULTS

Veterans with probable PTSD+AUD reported worse psychosocial functioning across multiple domains compared to veterans with probable AUD, but only worse functioning related to controlling violent behavior when compared to veterans with probable PTSD. Veterans with probable PTSD+AUD reported greater suicidal ideation and NSSI than veterans with probable AUD, but fewer prior suicide attempts than veterans with probable PTSD.

LIMITATIONS

This study was cross-sectional, relied on self-report, did not verify clinical diagnoses, and may not generalize to veterans of other military conflicts.

CONCLUSIONS

Findings underscore the adverse psychiatric and functional outcomes associated with PTSD and comorbid PTSD+AUD, such as NSSI, and highlight the importance of delivering evidence-based treatment to this veteran population.

Does Nonsuicidal Self-Injury Predict Later Suicidal Attempts? A Review of Studies

Co-occurrence of nonsuicidal self-injury (NSSI) and suicide attempts (SA) might occur because they share common risk factors, or alternatively because one leads to the other. Using search terms salient to NSSI and SA, we screened 555 studies to identify 17 that presented temporal data about NSSI and SA. Much of the evidence indicates that NSSI predates SA, especially among females and individuals with depressive symptoms, or diagnosed with borderline personality disorder or mood disorders. However, in some studies, associated risk factors likely accounted for the effect. Greater NSSI frequency to a threshold increases risk for later SA. Findings suggest that the behaviors have common predisposing factors, but that there is also a potent gateway effect whereby NSSI precedes SA.

A meta-analysis of co-occurrence of non-suicidal self-injury and suicide attempt: Implications for clinical intervention and future diagnosis

BACKGROUND

Non-suicidal self-injury (NSSI) and suicide attempt (SA) are risk behaviors that lead to physical injury and even death in individuals, and are a very powerful risk factor when both occur together, with individuals presenting with more severe psychological and behavioral problems. Due to the different demographic characteristics of different study subjects, an overall understanding of the incidence and occurrence of this co-occurrence is lacking to clarify the focus of clinical interventions and future research directions.

METHODS

A systematic search was conducted for relevant studies in English and Chinese that reported data on co-occurring non-suicidal self-injury and suicide attempts as of May 2022. The incidence of co-occurrence of non-suicidal self-injury and suicide attempt (NSSI + SA) was calculated using Stata version 16.0 software based on a random-effects model, and the differences in incidence in different populations were compared by subgroups of age group, comorbidity, and time of occurrence. The study was written in strict accordance with PRISMA norms and registration was completed on the PROSPERO platform (CRD42022329095).

RESULTS

A total of 37 studies (139,573 individuals) were included for meta-analysis, and the combined incidence of non-suicidal self-injury and suicide attempt co-occurrence was 9.6%. Among different groups, the prevalence of NSSI + SA was 10, 11, 6, and 26% in adolescents and young adults, adults, the general population, and people with mental illness, respectively, and the co-occurrence of NSSI + SA within 12 months was 17%.

CONCLUSION

There is a significant group with a history of both non-suicidal self-injury and suicide attempts and presenting with more severe symptoms clinically. Targeted prevention and intervention are urgently needed, but the direction of intervention needs further research on the occurrence trajectory of this co-occurrence.

SYSTEMATIC REVIEW REGISTRATION

http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42022329095, identifier: CRD42022329095.

Temporal sequences of suicidal and nonsuicidal self-injurious thoughts and behaviors among inpatient and community-residing military veterans

BACKGROUND

Suicidal and nonsuicidal self-injurious thoughts and behaviors (SITBs) are major health concerns among military veterans yet little is known about the temporal relations among these outcomes. This study examined the temporal relations between suicidal and nonsuicidal SITBs among higher-risk veterans. Specifically, we identified when SITBs emerged and evaluated the role of nonsuicidal self-injury (NSSI) in the medical lethality of suicide attempts (SA), relative risk, and survival time of suicidal SITBs (i.e., suicide ideation [SI], suicide plan, SA).

METHOD

Cross-sectional data were collected from two samples examining suicide risk among veterans receiving inpatient psychiatric care (n = 157) and community-residing veterans with current depression and/or past month SI (n = 200). Participants completed an interview to assess SITBs.

RESULTS

SITBs emerged between ages 14-28 years with behaviors emerging, on average, earlier among inpatient veterans. The time lag between SITBs was not significantly different between groups. Inpatient veterans had a significantly shorter time lag from SI to SA. NSSI history predicted an increase in relative risk for all suicidal SITBs and shorter survival time. There was no association between NSSI history and medical lethality of the most serious SA for both groups.

LIMITATIONS

Limitations included use of cross-sectional, retrospective self-report with age-of-onset endorsed in years and not all SITBs were assessed (e.g., passive SI).

CONCLUSIONS

Veterans with a NSSI history are at high risk for suicidal SITBs and have a shorter survival time. Results showed thoughts (i.e., NSSI thoughts, SI) emerged before behavior (i.e., NSSI, SA) and NSSI emerged before SA.

Non-suicidal self-injury in US military veterans: Results from the National Health and Resilience in Veterans Study

BACKGROUND

To evaluate the prevalence of lifetime non-suicidal self-injury (NSSI) among US military veterans and identify sociodemographic, military, psychiatric and clinical correlates associated with NSSI.

METHODS

Data were analysed from the 2019-2020 National Health and Resilience in Veterans Study, a contemporary, nationally representative survey of 4069 US veterans. Outcomes measured included lifetime history of NSSI, trauma history, lifetime and current DSM-V mental disorders and lifetime and recent suicidal behaviours.

RESULTS

The overall prevalence of lifetime NSSI was 4.2% (95% confidence interval [3.6%, 4.9%]). Multivariable analyses revealed that veterans who endorsed lifetime NSSI were more likely to be younger, female, non-Caucasian, unmarried or unpartnered, and to have a lower annual household income. Veterans who endorsed lifetime NSSI reported more adverse childhood experiences and lifetime traumas and were more likely to have experienced military sexual trauma. They also were more likely to screen positive for lifetime posttraumatic stress disorder, major depressive disorder (MDD) and substance use disorders and to have attempted suicide. Finally, lifetime NSSI was associated with current MDD, generalized anxiety disorder, and substance use disorders, as well as past-year suicidal ideation.

CONCLUSION

Results of this study provide the first-known data on the epidemiology of NSSI in US military veterans. They suggest that certain correlates can help identify veterans who may be at greater risk for engaging in NSSI, as well as the potential prognostic utility of lifetime NSSI in predicting current psychiatric problems and suicide risk in this population.

Differentiating U.S. military veterans who think about suicide from those who attempt suicide: A population-based study

OBJECTIVE

Several vulnerability factors for suicidal behavior in U.S. veterans have been identified. However, little is known about factors that differentiate veterans who contemplate suicide from those who attempt suicide. This study examined sociodemographic and clinical characteristics that distinguish veterans who think about suicide from those who attempt suicide.

METHOD

Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a population-based sample of 4069 veterans. Analyses estimated the lifetime prevalence of suicide ideation (SI) and suicide attempts (SA); and examined differences between veterans with a history of attempt(s), and SI without a history of attempt(s).

RESULTS

A total 25.9% of U.S. veterans reported lifetime SI and 3.9% reported a SA. Several factors distinguished veterans with a history of SA from those with SI only: the strongest were younger age (odds ratio [OR] = 0.97, 95% CI = 0.95-0.98), nonsuicidal self-injury (OR = 1.81, 95% CI = 1.11-3.03), adverse childhood experiences (OR = 1.14; 95% CI = 1.06-1.23), alcohol use disorder (OR = 1.99; 95% CI = 1.28-3.12), lower household income (OR = 0.62; 95% CI = 0.40-0.95), and physical disability (OR = 1.69; 95% CI = 1.07-2.70).

CONCLUSIONS

Although a quarter of U.S. veterans contemplate suicide in their lifetimes, the majority do not attempt suicide. Specific sociodemographic and clinical features may differentiate veterans who contemplate versus attempt suicide.

Beliefs About One's Non-Suicidal Self-Injury: The Experiences of Self-Injury Questionnaire (ESIQ)

OBJECTIVE

The goal of this study was to develop and validate a measure of self-rated positive and negative beliefs about one's non-suicidal self-injury (NSSI), the Experiences of Self-Injury Questionnaire (ESIQ).

METHOD

Psychometric properties and validation against NSSI severity and shame were tested in two U.S. and two U.K. samples of individuals who endorsed a history of NSSI.

RESULTS

Exploratory and confirmatory factor analyses indicated five factors. Subscales were labeled Positive Beliefs, Personal Dislike, Interpersonal Concern, Emotional Suppression, and Emotional Expression. The Positive Beliefs Subscale covers beliefs that NSSI is valuable. Scores on this subscale were associated with endorsement of NSSI frequency, NSSI urges, and perceived likelihood of future NSSI. Other subscales showed validity in that they all showed unique effects on outcome indices of NSSI severity or shame.

CONCLUSION

The ESIQ shows promise as a brief reliable measure of beliefs about and experiences of NSSI.

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.

Association of Self-Compassion With Suicidal Thoughts and Behaviors and Non-suicidal Self Injury: A Meta-Analysis

Objectives: Self-compassion functions as a psychological buffer in the face of negative life experiences. Considering that suicidal thoughts and behaviors (STBs) and non-suicidal self-injury (NSSI) are often accompanied by intense negative feelings about the self (e.g., self-loathing, self-isolation), self-compassion may have the potential to alleviate these negative attitudes and feelings toward oneself. This meta-analysis investigated the associations of self-compassion with STBs and NSSI. Methods: A literature search finalized in August 2020 identified 18 eligible studies (13 STB effect sizes and seven NSSI effect sizes), including 8,058 participants. Two studies were longitudinal studies, and the remainder were cross-sectional studies. A random-effects meta-analysis was conducted using CMA 3.0. Subgroup analyses, meta-regression, and publication bias analyses were conducted to probe potential sources of heterogeneity. Results: With regard to STBs, a moderate effect size was found for self-compassion (r = -0.34, k = 13). Positively worded subscales exhibited statistically significant effect sizes: self-kindness (r = -0.21, k = 4), common humanity (r = -0.20, k = 4), and mindfulness (r = -0.15, k = 4). For NSSI, a small effect size was found for self-compassion (r = -0.29, k = 7). There was a large heterogeneity (I 2 = 80.92% for STBs, I 2 = 86.25% for NSSI), and publication bias was minimal. Subgroup analysis results showed that sample characteristic was a moderator, such that a larger effect size was witnessed in clinical patients than sexually/racially marginalized individuals, college students, and healthy-functioning community adolescents. Conclusions: Self-compassion was negatively associated with STBs and NSSI, and the effect size of self-compassion was larger for STBs than NSSI. More evidence is necessary to gauge a clinically significant protective role that self-compassion may play by soliciting results from future longitudinal studies or intervention studies.

How Is the Suicide Ideation in the Korean Armed Forces Affected by Mental Illness, Traumatic Events, and Social Support?

BACKGROUND

Suicide is one of the leading causes of death in the military as in the general population. To mitigate such a serious public health problem, identifying the risk or protective factors of suicide behaviors is crucial.

METHODS

We analyzed the representative data of the 2014 Korean Armed Forces to explore the relationship between past year adverse events (PAE), accumulated lifetime trauma (ALT), mental illness vulnerability, perceived social support, and suicidal ideation in the previous year.

RESULTS

Among the 6,377 subjects, 3.7% of males and 6.2% of females reported suicidal ideation in the previous year. Multivariate analytic models identified significant associations of PAE and ALT with suicidal ideation with a dose-response pattern. The mental illness vulnerability showed the most significant association with suicidal ideation even after controlling PAE or ALT. We found that perceived social support may be potentially linked with a reduced risk of suicidal ideation.

CONCLUSION

This Korean military representative data demonstrates mental illness vulnerability; PAE; and lifetime trauma as significant risk factors of suicidal ideation, while perceived social support was found as a potential protective factor. Given the importance of the prevention of suicide in the military, those risk and protective factors may be used to screen soldiers at risk of suicide and provide further support on mental health services as needed.

Identifying risk factors for suicidal ideation across a large community healthcare system

BACKGROUND

Suicide is the tenth leading cause of death in the United States. Several studies have leveraged electronic health record (EHR) data to predict suicide risk in veteran and military samples; however, few studies have investigated suicide risk factors in a large-scale community health population.

METHODS

Clinical data was queried for 9,811 patients from the Penn Medicine Health System who had completed a Patient Health Questionnaire-9 (PHQ-9) documented in the EHR between January 2017 and June 2019. Patient demographics, PHQ-9 scores, and psychiatric comorbidities were extracted from the EHR. Univariate and multivariable logistic regressions were applied to determine significant risk factors associated with suicide ideation responses from the PHQ-9.

RESULTS

One-quarter (25.8%% of patients endorsed suicide ideation. Univariate analysis found 22 risk factors of suicide ideation. Multivariable logistic regression found significant positive associations (Odds Ratio, (95% Confidence Interval)) with the following: younger ages less than 18 years: 2.1, (1.69, 2.60) and 19-24 years: 1.55, (1.29, 1.87)), single marital status (1.22, (1.08, 1.38)), African American (1.22, (1.08, 1.38)), non-commercial insurance (1.16, (1.03, 1.31)), multiple comorbidities (1 comorbidity (1.65, (1.32, 2.07); 2 comorbidities (2.07, (1.61, 2.64)), 3+ comorbidities (2.49, (1.87, 3.33))), bipolar disorders (Type I: 1.38, (1.14, 1.67) and Type II: 1.94, (1.52, 2.49)), depressive disorders (1.70, (1.49, 1.94)), obsessive compulsive disorder (OCD) (1.43, (1.08, 1.90)), and stress disorders (1.53, (1.33, 1.76)).

CONCLUSION

Community EHR information can be used to predict suicidal ideation. This information can be used to design tools for identifying patients at risk for suicide in real-time.

Expanding our understanding of the relationship between nonsuicidal self-injury and suicide attempts: The roles of emotion regulation self-efficacy and the acquired capability for suicide

OBJECTIVE

Although past literature has emphasized the role of acquired capability in the relationship between nonsuicidal self-injury (NSSI) and suicide attempts, support for the indirect relationship of NSSI to suicide attempts through acquired capability is limited. Thus, research examining other factors that may underlie this relationship is needed. Across two studies, this research examined the indirect relationships of NSSI frequency to suicide attempts through both acquired capability and emotion regulation self-efficacy (ERSE).

METHOD

Two large samples of adults (one nationwide community sample and one clinical sample of patients with substance use disorders) completed questionnaires and/or interviews.

RESULTS

Results revealed significant indirect relationships of NSSI frequency to lifetime suicide attempts through ERSE, but not acquired capability, within both samples.

CONCLUSIONS

Results highlight the relevance of ERSE to both suicide attempts and the NSSI-suicide attempt relationship, and suggest the potential utility of interventions aimed at increasing ERSE among individuals with repeated NSSI.

Characteristics of nonsuicidal self-injury among veterans

OBJECTIVE

The current study aimed to (a) assess basic nonsuicidal self-injury (NSSI) characteristics using a validated clinical interview among a sample of veterans not recruited for specific diagnostic or environmental criteria and (b) examine the relation between NSSI and medical severity of prior suicide attempts (SAs) among veterans.

DESIGN

We conducted secondary data analyses among a combined sample of veterans (N = 165) from two parent studies conducted at a large VA Medical Center that implemented identical recruitment protocols. No psychiatric criteria were utilized for inclusion or exclusion purposes.

RESULTS

Approximately 16% of participants reported NSSI history and almost 21% reported SA history. NSSI history was associated with probability of prior SA but not the medical severity of prior SA.

CONCLUSIONS

NSSI is a prevalent concern among veterans and is associated with probability of SA. It remains unclear whether prior NSSI is associated with more medically serious SA in this population.

Sex Differences in Military Sexual Trauma and Severe Self-Directed Violence

INTRODUCTION

Previous research has demonstrated an association between military sexual trauma and risk for suicide; however, risk for self-directed violence such as suicide attempt or nonsuicidal self-injury following military sexual trauma is understudied. This study examines the relationship between military sexual trauma and serious self-directed violence resulting in hospitalization, as well as whether this relationship differs by sex.

METHODS

Participants were 750,176 Operations Enduring Freedom/Iraqi Freedom/New Dawn veterans who were enrolled in Veterans Health Administration care during the period of October 1, 2001-September 30, 2014 and who were screened for military sexual trauma. Data were analyzed in 2019. Bivariate analyses and Cox proportional hazards regression models were employed.

RESULTS

Women veterans were more likely to screen positive for military sexual trauma (21.33% vs 1.63%), and women and men were equally likely to experience serious self-directed violence (1.19% women vs 1.18% men). Controlling for demographic variables and psychiatric morbidity, military sexual trauma predicted serious self-directed violence for both men and women. Further, men with military sexual trauma were 15% less likely to experience self-directed violence compared with women with military sexual trauma (hazard ratio=0.85, 95% CI=0.74, 0.98).

CONCLUSIONS

Military sexual trauma is associated with risk for serious self-directed violence for both men and women veterans, and the relationship may be pronounced among women. Results underscore the importance of incorporating military sexual trauma into treatment and preventative efforts for self-directed violence.

Non-suicidal self-injury among male service members: Descriptive information and a preliminary examination of external correlates

Previous literature has identified nonsuicidal self-injury (NSSI) as a common and noteworthy behavior, particularly given its association with psychopathology and suicide. However, the research on NSSI among males has resulted in mixed findings. Additionally, few studies have examined NSSI among service members and only one study to date has examined NSSI specifically among male service members. The present study examined descriptive statistics and clinical correlates of NSSI among male service members. Results indicated that the most common method of NSSI among this group was burning oneself with a cigarette, followed closely by cutting, and burning oneself with a lighter. NSSI engagement was associated with common correlates of NSSI such as increased emotion dysregulation, depression, impulsivity, and capability for suicide as well as decreased distress tolerance and a greatly likelihood to have experienced recent suicidal ideation. NSSI was also associated with grit, narcissism, and masculinity, some of which may be particularly important and valued in military culture. Overall, results suggest important similarities and differences among NSSI in service members relative to previously studied samples. Future research should continue to examine NSSI among male service members to ensure treatments are effectively targeting and addressing aspects of the behavior.

Non-suicidal self-injury, suicide ideation, and past suicide attempts: Comparison between transgender and gender diverse veterans and non-veterans

BACKGROUND

Transgender and gender diverse (TGD) individuals, especially veterans, experience elevated rates of non-suicidal self-injury (NSSI) and suicide related behaviors compared to gender majority individuals. Research has yet to compare TGD veterans to non-veterans or look at correlates of NSSI and related behaviors to suicide related outcomes. This study examines prevalence and suicide related correlates of NSSI among TGD veterans and TGD non-veterans.

METHOD

Data analyzed in the were part of the Trans Lifeline Mental Health Survey. Both TGD veterans (N = 313) and non-veterans (N = 3,972) completed an online, cross-sectional survey that included self-report measures of NSSI, suicidal ideation (SI), and suicidal attempt (SA) along with lifetime hospitalization and avoidance of care due to NSSI.

RESULTS

Results of this paper indicate that prevalence of NSSI, SI, and SA are elevated in both the TGD veterans and non-veteran subpopulations. Further, veterans compared to non-veterans have a lower prevalence of NSSI but higher prevalence of hospitalization when self-harm is inflicted, reflecting more healthcare utilization or increased severity of NSSI episodes. Additionally, veterans were less likely to avoid care due to NSSI. Further, veteran status seemed to be a protective factor against demographic differences that increased rates of NSSI history in non-veteran TGD individuals.

LIMITATIONS

The limitations of this study include its cross-sectional study design, one question assessing SA, and few TGD male veterans.

CONCLUSION

NSSI is an important risk factor in future suicide related outcome such as SI and SA. Further, differences in healthcare utilization among TGD veterans and non-veterans are apparent.

Putting Suicide Policy through the Wringer: Perspectives of Military Members Who Attempted to Kill Themselves

In response to the Air Force Surgeon General, Lieutenant General Mark Ediger's call for medical services to be guided by service members' values, preferences, and experiences within the medical system, we conducted an interpretive phenomenological analysis of transcripts in which service members shared their experiences of military mental health policy and practices after being identified as suicidal. Themes of their experiences underscore nuances as it relates to intersectionality of policy when faced with unique military contextual factors and power differentials; both of which were missing in available research literature. Their experiences also illuminate further the innate "Catch 22" which happens when accessing help. Catch 22 basically means if you know you need help than you are rational; but if you actually seek help, then you are crazy and not trustworthy to do your job. Themes presented center on the lack of confidentiality of Service Members in the Workplace, effects of Unit Members' Surveillance and Command Directed Evaluations, and experiences of Military Mental Health Services. Critical discussions of policy and taken for granted assumptions that often drive narrow responses to suicide, treatment, prevention, and stigma are presented. Particular attention is given to the lived experiences of service members when placed under the demands of circumstances created by policy that may inadvertently lead in some cases to further suffering. The paper closes with recommendations from participants and the authors for policy makers and future directions in research.

Non-suicidal self-injury prevalence, course, and association with suicidal thoughts and behaviors in two large, representative samples of US Army soldiers

BACKGROUND

Non-suicidal self-injury (NSSI) prospectively predicts suicidal thoughts and behaviors in civilian populations. Despite high rates of suicide among US military members, little is known about the prevalence and course of NSSI, or how NSSI relates to suicidal thoughts and behaviors, in military personnel.

METHODS

We conducted secondary analyses of two representative surveys of active-duty soldiers (N = 21 449) and newly enlisted soldiers (N = 38 507) from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).

RESULTS

The lifetime prevalence of NSSI is 6.3% (1.2% 12-month prevalence) in active-duty soldiers and 7.9% (1.3% 12-month prevalence) in new soldiers. Demographic risk factors for lifetime NSSI include female sex, younger age, non-Hispanic white ethnicity, never having married, and lower educational attainment. The association of NSSI with temporally primary internalizing and externalizing disorders varies by service history (new v. active-duty soldiers) and gender (men v. women). In both active-duty and new soldiers, NSSI is associated with increased odds of subsequent onset of suicidal ideation [adjusted odds ratio (OR) = 1.66-1.81] and suicide attempts (adjusted OR = 2.02-2.43), although not with the transition from ideation to attempt (adjusted OR = 0.92-1.36). Soldiers with a history of NSSI are more likely to have made multiple suicide attempts, compared with soldiers without NSSI.

CONCLUSIONS

NSSI is prevalent among US Army soldiers and is associated with significantly increased odds of later suicidal thoughts and behaviors, even after NSSI has resolved. Suicide risk assessments in military populations should screen for history of NSSI.

Distinguishing people with current, past, and no history of non-suicidal self-injury: Shame, social comparison, and self-concept integration

OBJECTIVE

Non-Suicidal Self-Injury (NSSI) can have a major impact on the lives of individuals and those around them. The way in which a person feels about and perceives themselves (i.e. self-concept) appears central to understanding NSSI. The current study investigates three variables linked to self-concept: shame, social comparison, and self-concept integration. We examine how well these variables differentiate people who report past NSSI, people who report current NSSI, and people who have never engaged in NSSI.

DESIGN

Cross-sectional.

METHOD

Individuals reporting NSSI in the past year (n = 51), individuals with a history of NSSI but none in the past year (n = 44), and individuals with no history of NSSI (n = 110) were compared on measures of shame, social comparison, and self-concept integration.

RESULTS

Shame was elevated in people with a history of NSSI but did not distinguish between past and current NSSI when other variables were controlled for. Self-concept integration was poorer in people reporting current NSSI than people reporting past NSSI, even when controlling for other variables.

CONCLUSIONS

The results support the role of shame as a general marker for NSSI risk, but suggest self-concept integration may fluctuate more dynamically in relation to the recency of NSSI. The study is limited by a non-matched student control group.

[Suicidality in epilepsy: epidemiology and clinical risk factors]

The results of studies on the prevalence of suicidal behavior in patients with epilepsy are discussed in the article. The reasons for the high incidence of suicides among patients with epilepsy are given, with special attention paid to social, demographic, clinical and pathopsychological risk factors. Existing gaps in our knowledge about suicidal behavior in patients with epilepsy are analyzed.

Nonsuicidal self-injury, suicide ideation and suicide attempts in the National Guard

BACKGROUND

Among members of the National Guard, suicide rates are higher than age and sex matched civilian counterparts. Across many civilian samples, nonsuicidal self-injury has emerged as a particularly strong correlate of suicide risk. The current study describes the prevalence and correlates of NSSI and suicidal thoughts and behaviors among National Guard members.

METHODS

Participants were 897 National Guard personnel recruited online who completed study measures anonymously.

RESULTS

Approximately 6% of males and 14% of females reported a history of NSSI. Almost one third of the sample reported suicide ideation and 3% of men and 11% of women reported a suicide attempt. NSSI was strongly associated with a history of suicide ideation and attempts. Characteristics of NSSI were similar across men and women.

DISCUSSION

Reliable access to effective interventions is essential for National Guard members in light of their risk for suicidal and nonsuicidal self-injurious behavior.

Wall/Object Punching: An Important but Under-Recognized Form of Nonsuicidal Self-Injury

The present research investigated wall/object punching as a form of nonsuicidal self-injury (NSSI) among 1,143 veterans seeking treatment for posttraumatic stress disorder (PTSD). Wall/object punching was remarkably common in this sample (43%), and its inclusion in the definition of NSSI increased estimated prevalence of recent NSSI by 14%. As expected, wall/object punching was strongly associated with other traditional forms of NSSI, post-NSSI relief, and suicide ideation. Male veterans and veterans with PTSD were significantly more likely to engage in wall/object punching than female veterans and veterans without PTSD. More research on this important but under-recognized form of NSSI is needed.

Incidence of suicide among military police officers in South Brazil: An 11-year retrospective cohort study

BACKGROUND

Suicide is known to be the leading cause of death among police officers (PO) worldwide. However, most studies were conducted in developed countries, with no data from Brazil. The present study aimed to evaluate the incidence and the sociodemographic profile of suicide among a military PO subpopulation in South Brazil.

METHODS

This retrospective cohort evaluated 31,110 military PO with available data on cause of death from 2006 to 2016. Participants were monitored for an average of 18.8 ± 9.6 years following the date of entry into the military police.

RESULTS

Mean age at the end of the follow up time was 41.4 ± 9.1 years, with 90.7% males. A total of 650 participants died (2.1%), with 43 suicides (6.6% of all deaths) - cumulative incidence of 138/100,000. Bivariate analysis revealed a significant association (p < 0.05) between suicide and age (HR = 0.70, 95%CI = 0.66-0.74), females (HR = 1.67, 95%CI = 1.08-2.60) and enlisted military rank (HR = 14.9, 95%CI = 2.05-108.5). Multivariate models showed an independent association between suicide and age (HR = 0.71, 95%CI = 0.67-0.74) and enlisted military rank (HR = 9.96, 95%CI = 1.30-76.3).

CONCLUSIONS

The incidence of suicide among military PO in South Brazil was high, compared to the national suicide rate. Younger age and lower military rank were independent predictors of suicide in this subpopulation.

The Impact of Cannabis Use Disorder on Suicidal and Nonsuicidal Self-Injury in Iraq/Afghanistan-Era Veterans with and without Mental Health Disorders

The objective of this study was to assess the association between cannabis use disorder (CUD) and self-injury among veterans. As expected, after adjusting for sex, age, sexual orientation, combat exposure, traumatic life events, traumatic brain injury, posttraumatic stress disorder, depression, alcohol use disorder, and noncannabis drug use disorder, CUD was significantly associated with both suicidal (OR = 3.10, p = .045) and nonsuicidal (OR = 5.12, p = .009) self-injury. CUD was the only variable significantly associated with self-injury in all three models examined. These findings are consistent with prior research among civilians and suggest that CUD may also increase veterans' risk for self-injurious behavior.

Non-suicidal self-injury and suicidal thoughts and behaviors: A study of the explanatory roles of the interpersonal theory variables among military service members and veterans

OBJECTIVE

Research has identified non-suicidal self-injury (NSSI) as a robust correlate of suicidal thoughts and behaviors; however, little is known regarding why these constructs may be related. Consistent with the interpersonal theory of suicide, this study investigated thwarted belongingness (TB), perceived burdensomeness (PB), and capability for suicide (CS) as explanatory links in the association between NSSI, ideation, and suicide attempt history.

METHOD

Military service members and veterans (N = 973; agemean = 29.9 years, 78.8% male, 63.8% Caucasian/White) completed measures of lifetime NSSI and suicide attempts; current suicidal ideation; TB, PB, and CS; and related psychiatric symptoms. Bootstrap moderated mediation analyses were employed to examine whether (a) TB moderated the mediating effect of PB on NSSI and ideation, (b) PB moderated the mediating effect of TB on NSSI and ideation, and (c) CS moderated the mediating effect of TB and PB on NSSI and attempts.

RESULTS

TB and PB significantly accounted for the relationship between lifetime NSSI and current ideation. TB did not moderate the mediating effect of PB on NSSI and ideation, and PB did not moderate the mediating effect of TB. However, CS significantly moderated the mediating effects of TB and PB on NSSI and attempt history.

CONCLUSIONS

The interpersonal theory of suicide hypotheses were partially supported. Consistent with the theory, the interaction of TB and PB only explained NSSI and attempt history among service members with high levels of CS. TB and PB only individually explained the association between lifetime NSSI and recent suicidal ideation. Prospective studies are warranted to replicate these findings across other military samples. (PsycINFO Database Record

Self-Harm, Affective Traits, and Psychosocial Functioning in Adults With Depressive and Bipolar Disorders

Self-harm refers to the purposeful destruction of bodily tissue without suicidal intention and for purposes that are not socially sanctioned. Little is known about the associations between a history of self-harm, mood symptoms, and functioning in adults with different types of mood disorders. Lifetime histories of self-harm, current mood symptoms, global functioning, and affective traits were collected on 142 adults with mood disorders. The prevalence of lifetime self-harm was higher in patients with bipolar disorder compared with patients with a unipolar depressive disorder. Self-harm was also more strongly linked to impulsivity in individuals with bipolar disorder compared with unipolar depressive disorder. Across both diagnoses, histories of self-harm were related to lower levels of current global functioning, more severe depressive symptoms, and high self-reported emotional dysregulation and neuroticism. Findings indicate that self-harm is a potent prognostic variable for symptoms, global functioning, and personality functioning in individuals with mood disorders.

Nonsuicidal Self-Injury Is Predictive of Suicide Attempts Among Individuals with Mood Disorders

Nonsuicidal self-injury (NSSI) prior to age 18 was evaluated as a risk factor for adulthood suicide attempt (SA). Archival data from 222 mood-disordered participants were analyzed using multivariate Cox proportional hazards analysis. Participants with a youth SA were excluded. The hazards of SA among adult participants with a history of youth NSSI were twice than those of mood-disordered participants without youth NSSI (hazard ratio = 2.00, 95% confidence interval = 1.16-3.44, p = .01). Moreover, participants who had both youth and adult NSSI attempted suicide significantly earlier than participants who began NSSI as an adult. Youth NSSI is associated with persistent, elevated SA risk in adulthood.

Reflections on moral care when conducting qualitative research about suicide in the United States military

Critical suicidology (White, Marsh, Kral, & Morris, 2016 ) offers a critique of positivism as the mainstream rhetoric of scientific research. In this article, the authors add a critique to the moral detachment of scientific inquiry (Wilkinson & Kleinman, 2016 ) in suicidology. They provide a discussion at the intersection of theory and research when considering moral care of all stakeholders in the implementation of suicide research toward the development of more humanitarian policies and program alternatives. The authors reflect upon their experience of conducting an Interpretative Phenomenological Analysis (Finlay, 2011 ) on suicide in the U.S. military.

Suicide in Illinois, 2005-2010: A reflection of patterns and risks by age groups and opportunities for targeted prevention

BACKGROUND

Suicide accounts for two thirds of all deaths from intentional or violence-related injury and is a leading cause of death in the United States. Patterns of suicide have been well described among high-risk groups, but few studies have compared the circumstances related to suicides across all age groups. We sought to understand the epidemiology of suicide cases in Illinois and to characterize the risks and patterns for suicide among different age groups.

METHODS

We used suicide data collected from the Illinois Violent Death Reporting System to assess demographics, method of suicide, circumstances, and mental health status among different age groups.

RESULTS

Between 2005 and 2010, 3,016 suicides were reported; 692 (23%) were female, and the median age (n = 3,013) was 45 years (range, 10-98 years). The most common method/weapon types were hanging/strangulation (33%), firearm (32%) and poisoning (21%). Hanging was more common (74%) among young people aged 10 to 19 years, while firearm use was more common among elderly persons age 65 years and older (55%). The percentage of victims within an age group experiencing a crisis within two weeks before committing suicide was highest among 10- to 14-year-olds, while the risk factor of having a family member or friend die in the past 5 years was highest among older victims.

CONCLUSION

The final analysis demonstrated age-related trends in suicide in Illinois, suggesting prevention programs should tailor services by age.

LEVEL OF EVIDENCE

Epidemiologic study, level IV.

A functional analysis of two transdiagnostic, emotion-focused interventions on nonsuicidal self-injury

OBJECTIVE

Nonsuicidal self-injury (NSSI) is prevalent and associated with clinically significant consequences. Developing time-efficient and cost-effective interventions for NSSI has proven difficult given that the critical components for NSSI treatment remain largely unknown. The aim of this study was to examine the specific effects of mindful emotion awareness training and cognitive reappraisal, 2 transdiagnostic treatment strategies that purportedly address the functional processes thought to maintain self-injurious behavior, on NSSI urges and acts.

METHOD

Using a counterbalanced, combined series (multiple baseline and data-driven phase change) aggregated single-case experimental design, the unique and combined impact of these 2 4-week interventions was evaluated among 10 diagnostically heterogeneous self-injuring adults. Ecological momentary assessment was used to provide daily ratings of NSSI urges and acts during all study phases.

RESULTS

Eight of 10 participants demonstrated clinically meaningful reductions in NSSI; 6 participants responded to 1 intervention alone, whereas 2 participants responded after the addition of the alternative intervention. Group analyses indicated statistically significant overall effects of study phase on NSSI, with fewer NSSI urges and acts occurring after the interventions were introduced. The interventions were also associated with moderate to large reductions in self-reported levels of anxiety and depression, and large improvements in mindful emotion awareness and cognitive reappraisal skills.

CONCLUSIONS

Findings suggest that brief mindful emotion awareness and cognitive reappraisal interventions can lead to reductions in NSSI urges and acts. Transdiagnostic, emotion-focused therapeutic strategies delivered in time-limited formats may serve as practical yet powerful treatment approaches, especially for lower-risk self-injuring individuals. (PsycINFO Database Record

Nonsuicidal self-injury and interpersonal violence in U.S. veterans seeking help for posttraumatic stress disorder

Nonsuicidal self-injury (NSSI) has been defined as deliberately damaging one's body tissue without conscious suicidal intent. NSSI is a robust predictor of suicidal ideation and attempts in adults. While NSSI has been associated with other-directed violence in adolescent populations, the link between NSSI and interpersonal violence in adults is less clear. The current study examined the cross-sectional relationship between NSSI and past-year interpersonal violence among 729 help-seeking veterans with posttraumatic stress disorder (PTSD). Veterans who reported a recent history of engaging in cutting, hitting, or burning themselves were significantly more likely to report making violent threats and engaging in violent acts, including the use of a knife or gun, in the past year than veterans without NSSI. NSSI was uniquely associated with interpersonal violence after controlling for a variety of dispositional, historical, contextual, and clinical risk factors for violence, including age, race, socio-economic status, marital status, employment status, combat exposure, alcohol misuse, depression, PTSD symptom severity, and reported difficulty controlling violence. These findings suggest that clinicians working with veterans with PTSD should review NSSI history when conducting a risk assessment of violence.

Suicidal ideation among young Afghanistan/Iraq War Veterans and civilians: Individual, social, and environmental risk factors and perception of unmet mental healthcare needs, United States, 2013

Suicidal Ideation among Afghanistan/Iraq War Veterans remains a health concern. As young Veterans adjust to civilian life, new risk factors might emerge and manifest differently in this group versus those in the general population. We explored these differences. With 2013 National Survey on Drug Use and Health data, we examined differences in risk of past-year suicidal ideation between Veterans of the Afghanistan/Iraq War periods aged 18-34 years (N=328) and age-comparable civilians (N=23,222). We compared groups based on individual and socio-environmental risk factors as well as perceptions of unmet mental healthcare needs. We report adjusted rate ratios (aRRs); interaction terms tested for between-group differences. PY suicidal ideation rates for Veterans and civilians did not differ (52 versus 59 per 1,000, p=0.60) and both groups shared many risk factors. However, drug problems and perceived unmet mental health care needs were vastly stronger risk factors among Veterans versus civilians (interaction terms indicated that the aRRs were 3.8-8.0 times higher for Veterans versus civilians). Other differences were discovered as well. Past-year suicidal ideation rates did not differ by Veteran status among young adults. However, different risk factors per group were detected, which can inform Veteran suicide prevention efforts.

Nonsuicidal self-injury and suicide attempts in Iraq/Afghanistan war veterans

The present study examined the association between history of nonsuicidal self-injury (NSSI) and history of suicide attempts (SA) among 292 Iraq/Afghanistan veterans, half of whom carried a lifetime diagnosis of posttraumatic stress disorder (PTSD). Consistent with hypotheses, veterans who reported a history of NSSI were significantly more likely to report a history of SA than veterans without a history of NSSI. In addition, logistic regression demonstrated that NSSI remained a significant predictor of SA even after a wide range of covariates (i.e., combat exposure, traumatic brain injury, PTSD, depression, alcohol dependence) were considered. Taken together, these findings suggest that clinicians working with veterans should include NSSI history as part of their standard risk assessment battery.

Evidence for the Propositions of the Interpersonal Theory of Suicide Among a Military Sample

OBJECTIVE

Although the interpersonal theory of suicide may explain the elevated suicide risk among military service members, past explorations have been equivocal. This study aimed to investigate the propositions of the interpersonal theory in a sample of U.S. Army recruiters.

METHOD

Participants (N = 3,428) completed self-report measures assessing the interpersonal theory's constructs (i.e., thwarted belongingness (TB), perceived burdensomeness (PB), acquired capability for suicide), current suicidal ideation, agitation, and insomnia. History of depression was obtained from medical records.

RESULTS

Hierarchical multiple regression analyses revealed that the interaction between TB and PB was associated with current suicidal ideation, controlling for depression, agitation, and insomnia. This effect was especially notable among those with high capability for suicide.

CONCLUSION

Findings provide support for the interpersonal theory in a large, diverse military sample. It may be advantageous to assess and therapeutically address TB and PB among at-risk service members.

Anxiety and its disorders as risk factors for suicidal thoughts and behaviors: A meta-analytic review

Suicidal thoughts and behaviors are highly prevalent public health problems with devastating consequences. There is an urgent need to improve our understanding of risk factors for suicide to identify effective intervention targets. The aim of this meta-analysis was to examine the magnitude and clinical utility of anxiety and its disorders as risk factors for suicide ideation, attempts, and deaths. We conducted a literature search through December 2014; of the 65 articles meeting our inclusion criteria, we extracted 180 cases in which an anxiety-specific variable was used to longitudinally predict a suicide-related outcome. Results indicated that anxiety is a statistically significant, yet weak, predictor of suicide ideation (OR=1.49, 95% CI: 1.18, 1.88) and attempts (OR=1.64, 95% CI: 1.47, 1.83), but not deaths (OR=1.01, 95% CI: 0.87, 1.18). The strongest associations were observed for PTSD. Estimates were reduced after accounting for publication bias, and diagnostic accuracy analyses indicated acceptable specificity but poor sensitivity. Overall, the extant literature suggests that anxiety and its disorders, at least when these constructs are measured in isolation and as trait-like constructs, are relatively weak predictors of suicidal thoughts and behaviors over long follow-up periods. Implications for future research priorities are discussed.