A scoping review of military and Veteran families within international suicidality and suicide prevention research

The impacts of suicidality on families are well known, which is particularly relevant in at-risk populations, such as active duty military personnel and Veteran communities. This scoping review describes how military and Veteran families have been conceptualized within suicide prevention research. A systematic, multi-database search was conducted, and 4,835 studies were screened. All included studies underwent quality assessment. Bibliographic, participant, methodological, and family-relevant data was extracted and descriptively analyzed into Factors, Actors, and Impacts. In total, 51 studies (2007 - 2021) were included. Most studies focused on suicidality rather than suicide prevention. Factor studies described family constructs as a suicidality risk or protective factor for military personnel or Veterans. Actor studies described families' roles or responsibilities to act in relation to the suicidality of military personnel or Veterans. Impacts studies described the impacts of suicidality on military and Veteran family members. The search was limited to English language studies. There were few studies on suicide prevention interventions for or including military and Veteran family members. Family was typically considered peripheral to the military personnel or Veteran experiencing suicidality. However, there was also emerging evidence of suicidality and its consequences in military-connected family members.

Implementing a Suicide Audit in Montreal: Taking Suicide Review Further to Make Concrete Recommendations for Suicide Prevention

OBJECTIVE

A suicide audit was pilot implemented in order to generate recommendations on how to improve suicide prevention.

METHODS

Thirty-nine consecutive suicides that occurred in Montreal, Canada from January to October 2016 were audited. A retrospective analysis of their life trajectory and service utilization was conducted using the psychological autopsy method, which included interviewing suicide-bereaved survivors and examining health and social services records and the coroner's investigation file. A psychosocial and service utilization profile was drawn for each decedent. A multidisciplinary panel reviewed each case summary to identify gaps in terms of individual intervention, provincial public health and social services, and regional programs.

RESULTS

Five main suicide prevention recommendations were made to prevent similar suicides: (1) deploy mobile crisis intervention teams (short-term, high-intensity, home-based treatment) in hospital emergency departments; (2) train primary and specialized mental health care professionals to screen for and manage substance use disorders; and (3) implement public awareness campaigns to encourage help seeking for depression and substance use disorders; (4) access for all, regardless of age, to an effective psychosis treatment program; and (5) provide universal access to a general practitioner, especially for men.

CONCLUSIONS

The suicide audit procedure was implemented effectively and targeted recommendations were generated to prevent similar suicides. However, resistance from medical and hospital quality boards arose during the process, though these could be allayed if regional and provincial authorities actively endorsed the multidisciplinary and multi stakeholders suicide audit process. HighlightsA bottom-up approach to generate recommendations for suicide prevention.Implementation was challenging with resistance to our interdisciplinary approach.The audit needs the support of the regional health department to lift barriers.

Systematic Suicide Audit: An Enhanced Method to Assess System Gaps and Mobilize Leaders for Prevention

BACKGROUND AND OBJECTIVES

In Quebec, Canada, several independent processes are in place to investigate cases of death by suicide. An enhanced multidisciplinary audit process was developed to analyze these cases more thoroughly, with the aim of generating recommendations for suicide prevention. A study was undertaken to evaluate the feasibility and implementability of this process.

METHODS

The life trajectories of 14 people who died by suicide in Montreal, Canada, in 2016 were reconstructed on the basis of information retrieved by interviewing bereaved relatives and examining coroner investigation files and other records. A multidisciplinary panel that included a representative of families bereaved by suicide then reviewed case summaries to determine unmet needs and service gaps at 3 levels: individual intervention, regional programs, and the provincial health and social services system.

RESULTS

The feasibility of the audit process was demonstrated in the context of a public health care system. Thirty-one distinct recommendations were made variably across 13 of the 14 cases reviewed, whereas none had originally been made by the coroner. The recommendations that recurred most often were (1) improve training for professionals and educate the general public regarding depression and substance-related disorders; (2) deploy mobile crisis intervention teams from emergency departments; and (3) provide access to a family physician to all, especially men.

CONCLUSION

Although the audit produced novel recommendations and is implementable, there was resistance from physicians and their hospital mortality review committee against this multidisciplinary audit involving families. These concerns could be alleviated by having the process endorsed by provincial authorities.

Uncovering the heterogeneity of posttraumatic stress disorder: Towards a personalized medicine approach for military members and Veterans

Introduction: Recently, there has been substantial interest in exploring the heterogeneity of posttraumatic stress disorder (PTSD) on a neurobiological level, as individuals with PTSD, including military members and Veterans, vary in their presentation of symptoms. Methods: Critically, a dissociative subtype of PTSD (PTSD+DS) has been defined, where a large body of evidence suggests that the unique presentation of symptoms among PTSD+DS patients is associated with aberrant neurobiological underpinnings. Results: PTSD+DS is often characterized by emotion overmodulation, with increased top-down activation from emotion regulation areas, which is associated with emotional detachment, depersonalization, and derealization. This is in stark contrast to the symptoms commonly observed in individuals with PTSD, who exhibit emotion undermodulation, which involves decreased top-down regulation of hyperactive emotion generation areas and is associated with vivid re-experiencing of trauma memories and hyperarousal. Discussion: This article examines a clinical case example that clearly illustrates this heterogeneous presentation of PTSD symptomatology and psychopathology. It discusses the implications this evidence base holds for a neurobiologically-informed, personalized medicine approach to treatment for military members and Veterans.

Group identity, diffi cult adjustment to civilian life, and suicidal ideation in Canadian Armed Forces Veterans: Life After Service Studies 2016

Introduction: Suicide risk is higher in Canadian Armed Forces (CAF) Veterans than the Canadian general population (CGP). Suicidality is understood to be caused by incompletely clarified, complex interacting combinations of multiple factors. One of the precipitating factors for suicide is thought to be the social identity challenges known to occur in major life transitions. Methods: The 2016 Life After Service Studies survey representatively sampled Regular Force Veterans stratified by two release groups: earlier in 1998 to August 2012 ( n = 1,575) and more recently in September 2012 to 2015 ( n = 1,180). The linked dataset included socioeconomic and military characteristics and well-being indicators in multiple domains. Weak group identity was indicated by weak sense of local community belonging and/or not feeling part of a group with shared attitudes and beliefs. Associations were evaluated with multiple logistic regression. Results: Suicidal ideation, weak community belonging, and perceived difficult adjustment to civilian life were more prevalent in Veterans soon after release (September 2012 to 2015) than in Veterans released earlier (1998 to August 2012). Suicidal ideation and weak community belonging were more prevalent in the Veterans than in the CGP. In the more recently released Veterans, weak group identity was endorsed by the majority with suicidal ideation (93.3%). In adjusted regression models, mental health problems had the strongest association with suicidal ideation (adjusted odds ratio [AOR] = 13.4–79.3); however, weak group identity was moderately strongly associated with both difficult adjustment (AOR = 2.4–4.1) and particularly suicidal ideation (AOR = 3.8–9.0), independently of mental health problems. Discussion: Weak group identity was associated with difficult adjustment to civilian life and suicidal ideation in CAF Regular Force Veterans within 3.6 years after military release. These findings indicate the importance in suicide prevention of attending to social identity during transition to post-military life.

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.