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

Subjective cognitive difficulties and posttraumatic stress disorder interact to increase suicide risk among middle-aged and older US military veterans

OBJECTIVES

To examine the role of subjective cognitive difficulties (SCD), posttraumatic stress disorder (PTSD), and their interaction in predicting suicidal ideation and current suicidal intent in middle-aged and older United States (US) military veterans.

DESIGN

Population-based cross-sectional study.

SETTING AND PARTICIPANTS

Data were analyzed from the 2019 to 2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 3602 US veterans aged 50 years and older (mean age = 69.0).

MEASUREMENTS

Questionnaires including the Medical Outcomes Study Cognitive Functioning Scale (SCD), PTSD Checklist for DSM-5 (PTSD), Patient Health Questionnaire-9 (suicidal ideation in the previous two weeks), and the Suicide Behaviors Questionnaire-Revised (current suicidal intent).

RESULTS

A total of 154 (4.4%) veterans screened positive for current PTSD, 239 (6.7%) reported past two-week suicidal ideation, and 37 (1.0%) reported current suicidal intent. The probability of suicidal ideation among veterans with both SCD and PTSD was more than six times higher than that observed in the full sample (44.5% vs. 6.7%) and more than 2.5 times higher than that observed in veterans with SCD and no PTSD (44.5% vs. 17.5%). Veterans with both subjective memory and concentration difficulties were more likely to report suicidal intent, though the interaction between SCD and PTSD was not significantly associated with suicidal intent.

CONCLUSION

Middle-aged and older U.S. veterans with subjective cognitive impairment and PTSD report higher rates of suicidal ideation than those with SCD alone. Interventions targeting SCD and PTSD may mitigate suicide risk among middle-aged and older veterans.

Suicide Characteristics of Veterans Hospitalized for Suicide Ideation or Attempt

INTRODUCTION

Veteran suicide rates continue to be unacceptably high, with the most common risk factor being a past suicide attempt (SA). However, some characteristics of suicidal ideation (SI) and behavior among Veterans hospitalized for suicide risk remain under-reported.

MATERIALS AND METHODS

One hundred and eighty-three Veterans hospitalized for either an SA or SI with intent were screened for enrollment in a treatment study to prevent suicide. Veterans completed a demographic form, the Columbia-Suicide Severity Rating Scale, and the McLean borderline personality disorder screening measure shortly after inpatient psychiatric admission. Chi-squared and t-tests were used to compare suicide characteristics (e.g., intensity, duration, deterrents, and controllability) between Veterans with and without a lifetime history of SA. Thematic analyses of the reported method of SI were conducted.

RESULTS

Sixty-seven percent of participants were hospitalized for SI and 33% were hospitalized for SA. Twenty-one percent of Veterans hospitalized for SI also endorsed a recent SA in the weeks preceding hospitalization. Most participants reported at least one lifetime SA (71%). Veterans with a lifetime history of SA reported greater frequency and duration of ideation in the week before hospitalization (t[169] =  -2.56, P = .01; t[168] =  -2.04, P = .04) while also reporting that deterrents were less likely to prevent an SA (t[107.09] =  -3.58, P = .001) compared to those with no lifetime SA.

CONCLUSION

Overall, Veterans hospitalized for SI/SA demonstrated markers of chronic suicide risk, as most participants endorsed a past attempt in their lifetime. Some Veterans admitted for SI also reported a past month's attempt, suggesting that in certain cases, hospitalization does not immediately follow an acute suicidal crisis. A past SA differentiated Veterans on average frequency and duration of SI as well as the perception of deterrents preventing suicidal behavior. Therefore, a thorough evaluation of suicide methods and intensity may be informative in treatment planning for Veterans at greatest risk of suicide.

Characteristics of Single vs. Multiple Suicide Attempters Among Adult Population: A Systematic Review and Meta-Analysis

PURPOSE OF REVIEW

We aimed to examine the factors that differentiate single and multiple suicide attempters in adult population. We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines to conduct this review and meta-analysis. The review protocol was registered in PROSPERO. We carried out a systematic literature search in three databases to identify original studies that explored the differences between single and multiple suicide attempters among adult population.

RECENT FINDINGS

There might be meaningful differences between those individuals that attempt suicide once in their lifespan and those who make multiple attempts in terms of sociodemographic and clinical characteristics. There are no previous meta-analysis addressing this topic in the adult population. A total of 75 studies were included in the review and 69 were included in the meta-analysis. Multiple attempters were more likely to present certain disorders such as mood and psychotic disorders, as well as personality or substance use disorders. Higher suicide ideation and suicide intent scores also characterized this group. Childhood trauma experiences, stressful life events, and higher rates of hopelessness were statistically significant in multiple attempters. Identifying the factors predicting multiple suicide attempts helps to delineate a high-risk suicidal profile that should be taken into account in the clinical and suicide prevention scenario.

Interpersonal stress and nonsuicidal self-injury disorder in veterans: An ecological momentary assessment study

INTRO

Nonsuicidal self-injury (NSSI) is associated with marked functional impairment and is a robust predictor of suicide attempts. Prevalence rates of NSSI, and self-directed violence more broadly, are elevated among military veterans. Despite the inclusion of interpersonal difficulty in the diagnostic criteria for NSSI disorder, the relationship between interpersonal risk factors and NSSI is not well-characterized, especially among veterans. This ecological momentary assessment (EMA) study investigated the hypothesis that interpersonal stressors and associated distress would precede and predict NSSI urge and engagement-but not vice versa-via cross-lagged multilevel modeling.

METHOD

Forty veterans with NSSI disorder completed a 28-day EMA protocol with three daily prompts assessing NSSI urges, NSSI engagement, the occurrence of interpersonal stressors, and associated subjective interpersonal distress.

RESULTS

Interpersonal stressors preceded and predicted subsequent NSSI urges, but not NSSI engagement, whereas subjective interpersonal distress preceded and predicted both NSSI urges and NSSI engagement.

CONCLUSION

Results identified interpersonal stressors as a risk factor for NSSI urges, and interpersonal distress as a risk factor for both NSSI urges and NSSI engagement. Findings highlight the importance of temporally assessing interpersonal factors related to NSSI and suggest that interpersonal distress may be a modifiable risk factor for NSSI.

Exacerbated PTSD symptoms among older U.S. military veterans during the COVID-19 pandemic: Results from the national health and resilience in veterans study

Research has demonstrated that the impact of the coronavirus 2019 (COVID-19) pandemic on the mental health of United States (U.S.) veterans was less negative than originally anticipated. However, U.S. veterans are susceptible to exacerbation of post-traumatic stress disorder (PTSD) symptomology in late life. The aims of this study were to examine the extent to which older U.S. veterans experienced an exacerbation of PTSD symptoms during the COVID-19 pandemic, and to identify pre- and peri-pandemic factors that conferred risk for symptom exacerbation. Participants were U.S. military veterans aged 60 and older who completed three waves of the 2019-2022 National Health and Resilience in Veterans Study (NHRVS) (n=1858). PTSD symptoms were measured at all waves using the PTSD Checklist for DSM-5, and a latent growth mixture model was conducted to compute latent slopes of change of PTSD symptoms over the 3-year period. 159 (8.3%) participants experienced a worsening of PTSD symptomology over the pandemic period. Factors related to PTSD exacerbation were incident trauma exposure between Waves 1 and 2, more medical conditions with onset prior to the pandemic, and peri-pandemic social restriction stress. Number of incident traumas moderated the relationship between both number of pre-pandemic medical conditions and pre-pandemic social connectedness, and exacerbated PTSD symptoms. These results suggest that the pandemic did not confer additional risk for PTSD exacerbation than would be expected over a 3-year period for older veterans. Those who experience incident trauma exposure should be monitored for symptom exacerbation.

Profiles of patients using emergency departments or hospitalized for suicidal behaviors

OBJECTIVES

This study identified profiles of patients with suicidal behaviors, their sociodemographic and clinical correlates, and assessed the risk of death within a 12-month follow-up period.

METHODS

Based on administrative databases, this 5-year study analyzed data on 5064 patients in Quebec who used emergency departments (ED) or were hospitalized for suicidal behaviors over a 2-year period. Latent class analysis was used for patient profiles, bivariate analysis for patient correlates over 2 years, and survival analysis for risk of death within a 12-month follow-up.

RESULTS

Four profiles were identified: high suicidal behaviors and high service use (Profile 1: 23%); low suicidal behaviors and moderate service use (Profile 2: 46%); low suicidal behaviors and low service use (Profile 3: 25%); and high suicidal behaviors and high acute care, but low outpatient care (Profile 4: 6%). Profiles 1 and 4 patients had more serious conditions, with a higher risk of death in Profile 1 versus Profiles 2 and 3. Profile 2 patients had relatively more common mental disorders, and Profile 3 patients had less severe conditions. Profiles 3 and 4 included more men and younger patients.

CONCLUSION

Programs better adapted to patient profiles should be deployed after ED use and hospitalization in coordination with outpatient services.

Psychological well-being in US veterans with non-fatal suicide attempts: A multi-cohort population-based study

BACKGROUND

Most people who survive suicide attempts neither re-attempt suicide nor die by suicide. Research on suicide attempt survivors has primarily focused on negative endpoints (e.g., increased suicide risk) rather than positive outcomes. One important outcome is psychological well-being (PWB), defined as positive functioning across emotional, intrapersonal, and interpersonal domains. We compared PWB among US military veterans with (i.e., attempt survivors) and without (i.e., non-attempters) a history of suicide attempt(s) using data from three nationally representative cohorts.

METHODS

Each US veteran cohort (Cohort1: N = 3148; Cohort2: N = 1474; Cohort3: N = 4042) completed measures of suicidality (e.g., attempt history), character strengths (e.g., curiosity, optimism), psychological symptoms (e.g., depression), and indicators of PWB (e.g., happiness). t-Tests were conducted to examine group differences in PWB; hierarchical regressions were conducted to examine suicide attempt status as a predictor of PWB controlling for symptoms and demographics. Multivariable regressions were conducted to identify predictors of PWB among attempt survivors.

RESULTS

In each cohort, reported PWB was markedly lower among suicide attempt survivors than non-attempters (ds = 0.9-1.2), even after adjusting for mental health symptoms. Individual differences in PWB were observed, with a subset of suicide attempt survivors reporting higher PWB levels than non-attempters (1.4-7.4 %). Curiosity and optimism were positively associated with PWB among suicide attempt survivors (rs = 0.60-0.78).

LIMITATIONS

Data were cross-sectional, limiting inferences about causation and directionality of associations.

CONCLUSIONS

Findings highlight diminished PWB as an important and understudied concern among veteran attempt survivors. Collectively, our findings underscore the importance of considering PWB in the research, assessment, and treatment of suicidality.

Post-traumatic Stress Disorder in Older U.S. Military Veterans: Prevalence, Characteristics, and Psychiatric and Functional Burden

OBJECTIVE

To characterize the prevalence, characteristics, and comorbidities of subthreshold and full post-traumatic stress disorder (PTSD) in older U.S. military veterans.

DESIGN AND SETTING

A nationally representative web-based survey of older U.S. military veterans who participated in the National Health and Resilience in Veterans Study (NHRVS) between November 18, 2019 and March 8, 2020.

PARTICIPANTS

U.S. veterans aged 60 and older (n = 3,001; mean age = 73.2, SD: 7.9, range: 60-99).

MEASUREMENTS

PTSD was assessed using the PTSD Checklist for DSM-5. Self-report measures assessed sociodemographic characteristics, trauma exposures, suicidal behaviors, psychiatric and substance use disorders, as well as mental, cognitive, and physical functioning. Multivariable analyses examined correlates of subthreshold and full PTSD.

RESULTS

The vast majority of the sample (n = 2,821; 92.7%) reported exposure to one or more potentially traumatic events. Of those exposed to such events, 262 (9.6%, 95% confidence interval [CI]: 8.4%-10.9%) and 68 (1.9%, 95% CI: 1.3%-2.6%) screened positive for subthreshold and full PTSD, respectively. The prevalence of subthreshold and full PTSD was significantly higher in female veterans and veterans who use VA as their primary healthcare. Subthreshold and full PTSD groups endorsed more adverse childhood experiences and total traumas than the no/minimal PTSD symptom group, the most common traumatic experiences endorsed were combat exposure, physical or sexual assault, and life-threatening illness or injury. Veterans with subthreshold and full PTSD were also more likely to screen positive for depression, substance use disorders, suicide attempts, nonsuicidal self-injury, and suicidal ideation, and reported lower mental, cognitive, and physical functioning.

CONCLUSION

Subthreshold PTSD and full PTSD are prevalent and associated with substantial clinical burden in older U.S. veterans. Results underscore the importance of assessing both subthreshold and full PTSD in this population.

Chronic cerebral aspects of long COVID, post-stroke syndromes and similar states share their pathogenesis and perispinal etanercept treatment logic

The chronic neurological aspects of traumatic brain injury, post-stroke syndromes, long COVID-19, persistent Lyme disease, and influenza encephalopathy having close pathophysiological parallels that warrant being investigated in an integrated manner. A mechanism, common to all, for this persistence of the range of symptoms common to these conditions is described. While TNF maintains cerebral homeostasis, its excessive production through either pathogen-associated molecular patterns or damage-associated molecular patterns activity associates with the persistence of the symptoms common across both infectious and non-infectious conditions. The case is made that this shared chronicity arises from a positive feedback loop causing the persistence of the activation of microglia by the TNF that these cells generate. Lowering this excess TNF is the logical way to reducing this persistent, TNF-maintained, microglial activation. While too large to negotiate the blood-brain barrier effectively, the specific anti-TNF biological, etanercept, shows promise when administered by the perispinal route, which allows it to bypass this obstruction.