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. Author manuscript; available in PMC: 2025 Aug 1.
Published in final edited form as: J Trauma Stress. 2024 Mar 25;37(4):594–605. doi: 10.1002/jts.23033

From posttraumatic stress symptoms to suicidal ideation among military veterans: Pathways founded on meaning in life and gratitude

Shaina A Kumar 1,2, Emily Taverna 3, Shelby Borowski 3, Brian N Smith 1,3, Dawne Vogt 1,3
PMCID: PMC11293995  NIHMSID: NIHMS1977862  PMID: 38527914

Abstract

Military veterans experience higher rates of suicidal ideation compared to nonveteran populations. Importantly, suicidal ideation often precedes and predicts fatal and nonfatal suicide attempts, and thus it is critical to better understand factors that increase risk for suicidal ideation to inform suicide prevention efforts in this population. One key predictor of suicidal ideation is exposure to traumatic experiences and their sequelae, particularly posttraumatic stress symptoms (PTSS). However, little work has explored how deficits in well-being contribute to this association among veterans. We tested two aspects of well-being—meaning in life and gratitude—as potential mechanisms underlying the pathway from PTSS to suicidal ideation among 7,388 men and women veterans who recently separated from service. A parallel mediation analysis revealed significant paths from more severe PTSS to more frequent suicidal ideation through diminished meaning in life, B = 0.005, SE = 0.001, 95% CI [0.004, 0.007], and gratitude, B = 0.001, SE = 0.001, 95% CI [< 0.001, 0.002]. Gender differences were also observed. Although the results related to meaning in life appeared to replicate across gender, pathways involving gratitude differed among men and women. Overall, our findings suggest that helping veterans build meaning and appreciation in everyday life may be a proactive and holistic approach to suicide prevention.

Suicide is a serious public health problem. Suicide rates increased approximately 36% between 2000 and 2021, claiming the lives of over 48,000 people within the United States each year (Centers for Disease Control and Prevention, 2023). Importantly, suicidal ideation often precedes and predicts fatal and nonfatal suicide attempts and was found to be the third strongest prospective predictor of death by suicide in a meta-analysis examining longitudinal risk factors for suicide over the past 50 years (Franklin et al., 2017). As such, it is critical to better understand factors that increase risk for suicidal ideation to inform prevention efforts, especially among at-risk populations.

Military veterans represent a population for whom suicide risk is especially pronounced. Adjusted suicide rates among veterans have historically outpaced rates in the general adult population (Holliday et al., 2020), and rates of suicidal ideation and attempts are relatively high in this group. Prevalence estimates suggest that approximately 1,700,000 veterans currently experience suicidal ideation, 1,300,000 have planned suicide, and over 700,000 have attempted suicide in their lifetime (Nichter et al., 2021). Notably, relative to their nonveteran peers, veteran men and women are at increased odds of experiencing lifetime suicidal ideation (i.e., 13% and 15%, respectively; Hoffmire et al., 2021). These alarming statistics have led the U.S. Department of Veterans Affairs (VA) to identify suicide prevention as a top priority.

The transition from military to civilian life is a time when veterans may be vulnerable to suicidal thoughts and behaviors. Many transitioning veterans experience a loss of self that is associated with redefining occupational, social, and recreational roles during this time, and such stressors may increase their risk for suicidal ideation and self-harm (Hoffmire et al., 2022). Indeed, this transition period has been called the “deadly gap” because transitioning veterans are at higher risk for suicide compared to the broader veteran population and the U.S. public (Sokol et al., 2021). Thus, it is important to identify pathways leading to suicidal ideation to improve identification and intervention for suicide risk among transitioning veterans.

In addition to other factors that are known to increase risk for suicidal ideation, exposure to traumatic experiences and their sequelae have been identified as particularly important predictors of suicidal thoughts (Holliday et al., 2020; Klonsky et al., 2016; Pompili et al., 2013). Individuals who have served in the military are exposed to both military and nonmilitary traumatic events at higher rates than the general population, and such exposures often precipitate symptoms of posttraumatic stress disorder (PTSD; Holliday et al., 2020). Posttraumatic stress symptoms (PTSS) are characterized by intrusive memories and reminders of the trauma, avoidance of internal and external trauma reminders, distressing cognitions and emotions, and hyperarousal symptoms (American Psychiatric Association [APA], 2013). Although the association between PTSD and suicide risk is complex (see Klonsky et al., 2016), and findings have been mixed, some prior research has revealed positive associations between PTSS and suicidality among military personnel and veterans, supporting the perspective that these symptoms may contribute to increased thoughts of suicide (see Holliday et al., 2020, and Pompili et al., 2013). It is also noteworthy that women veterans report the highest rates of lifetime PTSD compared to men veterans and nonveteran populations (Lehavot et al., 2018), and, among veterans with PTSD, men have a higher risk of dying by suicide compared to women (Ronzitti et al., 2019). Taken together, researchers have suggested that the complex relation between PTSS and suicidal ideation might be influenced by additional psychological factors (Holliday et al., 2020; Klonsky et al., 2016), and, thus, further research is warranted to better understand this association.

PTSS are thought to develop when individuals learn to associate avoidance of feared trauma-related memories and reminders (e.g., people, places, activities) with relief from distress, which then reinforces the ongoing use of avoidance to cope with distressing emotional experiences (Foa & Kozak, 1986). In turn, avoidance may contribute to reductions in overall well-being by interfering with adaptive trauma processing and impairing daily functioning across life domains (Resick et al., 2017). Although much of the literature has emphasized trauma-related avoidance of distressing emotions, a growing body of research suggests that PTSS may also contribute to difficulties engaging with positive life experiences and emotions. For example, studies have found that PTSS are associated with a fear of positive emotions, difficulties accepting and regulating positive emotions, and difficulty engaging with positive memories (Contractor et al., 2021; Weiss et al., 2018). Prior studies have also found that veterans with PTSS are more likely to suppress positive emotions and exhibit heightened physiological responses to positive stimuli (Litz et al., 2000; Roemer et al., 2001). Together, these findings suggest that individuals with PTSS may fear and avoid engaging with experiences that elicit positive emotional states.

Cognitive theories further suggest that individuals with PTSS may apply maladaptive global and situational appraisals in the context of feared trauma-related stimuli to reconcile discrepant experiences with their beliefs, which may exacerbate distressing emotional experiences and avoidance behaviors (Ehlers & Clark, 2000; Resick et al., 2017). The nature of these cognitive attributions may directly relate to what it means to engage with positive life experiences and emotions. For example, veterans may hold trauma-related beliefs such as, “I do not deserve to experience good things in life because it will dishonor those who lost their lives,” or, “If I let myself feel positive emotions, something bad will happen.” These beliefs may reinforce ongoing perceptions of threat and associated distress in the context of positive life experiences, and the avoidance of such experiences may interfere with developing more balanced beliefs.

General difficulties engaging with positive life experiences and emotions may be reflected in perceptions of meaning in life and gratitude, two indicators of positive psychological health that may be especially salient for veterans navigating the transition from military to civilian life. Meaning in life refers to the “sense made of, and significance felt regarding, the nature of one’s being and existence” (Steger et al., 2006). In the context of the current study, PTSS may disrupt the meaning-making process following veterans’ traumatic experiences (see C. L. Park, 2010), leading to difficulties finding purpose in the aftermath of these events. Indeed, prior empirical work has revealed a significant negative association between PTSS and meaning in life (Fischer et al., 2020) as well as between meaning in life and suicidal ideation (Fischer et al., 2023).

Along with challenges in meaning-making following trauma exposure, veterans with more severe PTSS might also have difficulty maintaining a sense of gratitude. Gratitude is an experience of thankfulness that involves valuing and appreciating positive experiences in daily life (Rashid & Seligman, 2018). For veterans, the same PTSS that disrupt their sense of meaning might discourage their disposition toward gratitude. Supporting this assertion, previous research suggests that PTSS are associated with lower levels of gratitude (Kashdan et al., 2006), and lower levels of gratitude are linked to suicidal ideation (McGuire et al., 2022).

Yet, to our knowledge, no study has examined meaning in life and gratitude as potential mechanisms underlying the pathway from PTSS to suicidal ideation. Understanding how and when aspects of well-being matter to functioning is critical for advancing psychological science (King & Hicks, 2021), and here we chose to focus on meaning in life and gratitude for several reasons. First, these constructs are commonly viewed as critical components of well-being above and beyond other positive psychological constructs (N. Park & Peterson, 2009; Steger et al., 2013), serving as essential ingredients of flourishing (see Fredrickson, 2001, and C. L. Park, 2010 for theoretical discussions). As such, experiencing trauma-related deficits in meaning and gratitude might distinctly impact one’s risk for PTSD and other negative mental health sequelae. Second, although meaning in life and gratitude are often relatively stable across time, evidence suggests these constructs might evolve as individuals encounter different life circumstances (Kumar et al., 2023; N. Park & Peterson, 2009). Studies in this area can, therefore, shed light on ways that changes in meaning in life and gratitude unfold during times of transition and provide insight regarding for whom (e.g., men and women veterans) and under what circumstances (e.g., following trauma exposure and related sequelae) meaning in life and gratitude might be particularly challenged.

The present study

The present study was designed to build on prior research in several ways. First, whereas most work related to trauma and its sequelae focuses exclusively on ill-being, this study examined whether and how well-being underlies the pathway from PTSS to suicidal ideation. Second, the prospective design of the study stands in contrast to most available work on trauma and well-being. Whereas many prior cross-sectional studies of trauma and well-being have assessed predictors and outcomes concurrently, the present study examined how PTSS prospectively predicts suicidal ideation in the context of lower meaning in life and gratitude across 1 year. Third, the current study sample was composed of veterans who served in support of military operations in Afghanistan and Iraq following the September 11, 2001, terrorist attacks (9/11) and recently separated from military service, a population with unique challenges and experiences that might impact well-being. Finally, to our knowledge, no study has examined gender-stratified models of the associations among PTSS, meaning in life and gratitude, and suicidal ideation. This is an important consideration given that researchers have found gender differences among men and women regarding PTSS and suicidal ideation (e.g., Hoffmire et al., 2021; Lehavot et al., 2018) as well as meaning in life and gratitude (e.g., Kashdan et al., 2009; Steger et al., 2009).

Drawing on theory and prior research, we predicted that more severe PTSS would be associated with more subsequent suicidal ideation in our sample of veterans. Extending prior research, we also hypothesized that lower levels of meaning in life and gratitude would each underlie the pathway from PTSS to suicidal ideation over time. Given the lack of related research, we had no specific hypotheses regarding gender-stratified models.

METHOD

Participants and procedure

Data were drawn from the Veteran Metrics Initiative Study, a prospective cohort study that assessed post-9/11 veterans’ well-being throughout the first 3 years of their transition from military to civilian life. A detailed description of recruitment methods is provided in Vogt et al. (2018). Data were collected at six time points that occurred within approximately 3 months of separation and again at approximately 9, 15, 21, 27, and 33 months postseparation. The current study used data from the 21, 27, and 33-month postseparation assessments (i.e., Time 1 [T1] at Month 21; Time 2 [T2] at Month 27; Time 3 [T3] at Month 33) because suicide risk might be particularly high during this time, and many initiatives in place to monitor and address suicide risk and enhance the well-being of newly transitioned veterans have ended by this point (Hoffmire et al., 2022). This choice was also based on prior research indicating that veterans may experience the largest changes in well-being during this timeframe (Vogt et al., 2022). Overall, 6,480 participants (n = 5,307 men, n = 1,173 women) responded at T1, 5,844 responded at T2, and 5,249 responded at T3. Providing evidence that nonresponse bias was not a large concern for this study, respondents were similar to the sampling frame on many characteristics (e.g., gender, race and ethnicity, branch of service; see Vogt et al., 2018). Institutional Review Board approval was obtained from VA Boston Healthcare System and the survey firm that administered the survey, and informed consent was obtained from participants.

Of veterans in this sample (i.e., those who completed at least one measure of interest at any of the three time points; N = 7,388), most identified as men (81.6%, n = 6,029) and ranged in age from 18 to 64 years old (M = 34.03 years SD = 9.42). Veterans identified as White (78.2%, n = 5,780); Black or African American (12.3%, n = 909); Asian (5.0%, n = 368); Native American or Alaska Native (3.4%; n = 249), other Pacific Islander (1.5%, n = 113); West Asian, Middle Eastern, or North African (0.4%, n = 30); Native Hawaiian (0.4%, n = 26); and “other” (6.3%, n = 463); more than one race could be selected). In addition, 14.0% (n = 1,035) of participants identified as Hispanic. Approximately 12.2% (n = 897) of the sample continued to serve in the National Guard/Reserves, whereas the remainder reported separating from the Army (33.1%, n = 2,441), Navy (19.5%, n = 1,441), Air Force (19.0%, n = 1,405), or Marine Corps (16.2%, n = 1,192). Participants reported a range of paygrades, including E1–E4 junior enlisted (29.3%, n = 2,168), E5–E6 midgrade enlisted (30.2%, n = 2,230), E7–E9 senior enlisted (17.0%, n = 1,258), W1–W5 warrant officers or O1–O3 junior officers (10.1%; n = 747), and O4–O10 senior officers (13.3%, n = 985). Most veterans in the sample (70.5%, n = 5,205) reported at least one war deployment, and 85.4% (n = 6,309) indicated honorable separation.

Measures

PTSS

The PTSD Checklist for DSM-5 (PCL-5; Weathers et al., 2013) is a 20-item self-report measure used to assess symptoms of posttraumatic stress as outlined in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013). Participants who reported a prior traumatic experience completed an abbreviated version of the PCL-5 (Price et al., 2016) to examine PTSS at T1. The abbreviated PCL-5 has comparable diagnostic utility to the full PCL-5 (Price et al., 2016) and consists of eight items that are rated on a scale of 0 (not at all) to 4 (extremely). Responses were summed (possible range: 0–32), with higher scores indicating more severe PTSS. Veterans who did not endorse a traumatic event received a score of 0, consistent with related literature (Prins et al., 2016). Past work has supported the validity of this measure (e.g., Geier et al., 2020), and internal consistency in the current sample was excellent at T1, Cronbach’s α = .95.

Meaning in life

Veterans completed the Purpose in Life Test–Short Form (PIL-SF; Schulenberg et al., 2011) to examine meaning in life at T2 (controlling for T1 PIL-SF score; see Data Analysis section for information regarding model covariates). The PIL-SF is a four-item self-report measure in which each item is anchored to a question and rated on a scale of 1 to 7. For example, the second item reads, “My personal existence is…,” with response options ranging from 1 (utterly meaningless without purpose) to 7 (very purposeful and meaningful). A sum score was created (possible range: 4–28), with higher scores indicating greater levels of meaning in life. Past work has supported the validity of this measure (e.g., Schulenberg et al., 2011), and internal consistency in the current sample excellent at both T1, Cronbach’s α = .90, and T2, Cronbach’s α = .90.

Gratitude

The Gratitude Questionnaire (GQ-6; McCullough et al., 2002) is a six-item self-report measure of gratitude. Veterans reported on their experience of gratitude at T2 (controlling for T1) by completing the first item on the GQ-6, “I have so much in life to be thankful for.” Respondents rated the item on a scale ranging from 1 (strongly disagree) to 7 (strongly agree), with higher scores indicating higher levels of gratitude. Past work has supported the validity of the GQ-6 (e.g., McCullough et al., 2002), and this item has been used in previous work examining gratitude (e.g., Robustelli & Whisman, 2018) and is consistent with the definition of gratitude used in the current study (Rashid & Seligman, 2018).

Suicidal ideation

We assessed suicidal ideation at T3 (controlling for T1 and T2) using Item 9 (i.e., “How often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?”) of the Patient Health Questionnaire–9 (PHQ-9; Kroenke et al., 2001). Respondents rated the item on a scale of 0 (not at all) to 3 (nearly every day), with higher scores indicating a higher frequency of suicidal ideation over the previous 2 weeks (possible range: 0–3). Past work has supported the validity of the PHQ-9 (e.g., Kroenke et al., 2001) and the use of a single-item measure of suicidal ideation (Desseilles et al., 2012). Notably, this item has been used as a screen for suicidality in the VA’s suicide risk identification program (Gujral et al., 2023) and in previous work assessing suicidal ideation among veterans (e.g., Elbogen et al., 2020; Hoffmire et al., 2022).

Data analysis

First, we examined descriptive characteristics and correlations among study variables. Second, using Mplus (Version 8.8; Muthén & Muthén, 1998–2017), we conducted a path analysis to test our first hypothesis that more severe PTSS would be associated with more suicidal ideation. Third, we tested our hypotheses focused on meaning in life and gratitude as mechanisms in the link between PTSS and suicidal ideation. Path models were first analyzed with the total sample and then separately by gender using the weighted least squares estimation method (WLSMV) to address nonnormality in our study variables, and suicidal ideation was treated as an ordered categorical variable. Here, we employed Hayes’ (2022) mediation criteria such that indirect effects were based on the product of Paths a and b. A bias-corrected bootstrap technique with 5,000 resamples was used to derive 95% confidence intervals (CI) for direct and indirect effects.

All exogenous variables were correlated, as were variables related to the mediation, to account for associations among these effects and retain participants with missing data (Enders, 2010). For each mediator (T2 meaning in life, T2 gratitude) and outcome (T3 suicidal ideation) variable, we controlled for prior scores (T1 meaning in life, T1 gratitude, and T1 and T2 suicidal ideation, respectively) to prevent inflated estimates (Cole & Maxwell, 2003). To assess global model fit, we evaluated the chi-square test of model fit, comparative fit index (CFI), root mean square error of approximation (RMSEA), and standard root mean residual (SRMR; Kline, 2015). To facilitate interpretation of model parameters in our tests of mediation, each mediator variable was mean-centered to create meaningful values at which main effects could be interpreted. Finally, because the sample size was determined from the larger study, a priori power analyses for the parallel mediation models could not be conducted. A sensitivity analysis suggested we were powered to detect an r effect size as small as .03 (N = 7,388, power = .80, two-tailed α = .05) for a regression path with seven predictors (i.e., T1 PTSS, T1 and T2 meaning in life, T1 and T2 gratitude, and T1 and T2 suicidal ideation as predictors of T3 suicidal ideation). The proportion of variance explained in endogenous variables (R2) and unstandardized parameter estimates are reported.

RESULTS

Descriptive and bivariate statistics

Descriptive and bivariate statistics among study variables are displayed in Table 1. With regard to the endorsement of suicidal ideation at T3, approximately 10% (n = 529) of the sample endorsed some degree of suicidal ideation, with 7.2% (n = 379) scoring their response as 1 (several days over the last two weeks), 1.5% (n = 80) as 2 (more than half the days), and 1.3% (n = 70) as 3 (nearly every day). There was no significant difference in proportions of suicidal ideation among men and women, χ(3, N = 5,298) = 1.24, p = .745. At each time point, PTSS were positively correlated with suicidal ideation, rs = .34–.43, ps < .001, and negatively correlated with meaning in life and gratitude, rs = −.33–−.45, ps < .001. Meaning in life and gratitude were also negatively correlated with suicidal ideation at each time point, rs = −.28–−.38, ps < .001. All variables were sufficiently distinct, rs = −.28–.69, suggesting multicollinearity was not a concern.

TABLE 1.

Descriptive and bivariate statistics

Variable 2. 3. 4. 5. 6. 7. 8. N M SD Observed range
1. T1 PTSS −.45 −.42 −.35 −.33 .43 .39 .34 6,424 5.36 7.70 0.00–32.00
2. T1 Meaning in life – .69 .63 .50 −.37 −.32 −.30 6,478 21.25 4.84 4.00–28.00
3. T2 Meaning in life – .50 .63 −.33 −.38 −.32 5,833 21.22 4.87 4.00–28.00
4. T1 Gratitude – .59 −.33 −.30 −.28 6,485 6.16 1.24 1.00–7.00
5. T2 Gratitude – −.29 −.35 −.28 5,842 6.13 1.25 1.00–7.00
6. T1 Suicidal ideation – .53 .48 6,510 0.13 0.48 0.00–3.00
7. T2 Suicidal ideation – .50 5,892 0.15 0.49 0.00–3.00
8. T3 Suicidal ideation – 5,298 0.14 0.48 0.00–3.00
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Note: PTSS = posttraumatic stress symptoms; T1 = Time 1; T2 = Time 2; T3 = Time 3. All correlations were significant at p < .001.

Pathways from PTSS to suicidal ideation in the total sample

First, we examined whether more severe PTSS were associated with more subsequent suicidal ideation in the total sample. Consistent with our first hypothesis, T1 PTSS were positively related to T3 suicidal ideation, controlling for T1 and T2 ideation, B = 0.034, SE = 0.002, 95% CI [0.029, 0.038].

Second, we examined whether meaning in life and gratitude were significant mediators of the pathway from PTSS to suicidal ideation in the total sample. The parallel mediation model demonstrated good model fit, χ2(6, N = 7,388) = 159.30, p < .001, CFI = .989, RMSEA = .059, 90% CI [0.051, 0.067], SRMR = .017, and explained a significant proportion of variance in meaning in life (54.6%), p < .001; gratitude (43.0%), p < .001; and suicidal ideation (34.3%), p < .001. As shown in Figure 1, the results reflected a significant direct path from T1 PTSS to T3 suicidal ideation, B = 0.020, SE = 0.003, 95% CI [0.015, 0.026]. Further, the a paths from T1 PTSS to both T2 meaning in life, B = −0.087, SE = 0.011, 95% CI [−0.108, −0.067], and T2 gratitude, B = −0.025, SE = 0.003, 95% CI [−0.031, −0.019], were significant and in the expected direction. The b paths from T2 meaning in life to T3 suicidal ideation, B = −0.060, SE = 0.006, 95% CI [−0.071, −0.048], and from T2 gratitude to T3 suicidal ideation, B = −0.050, SE = 0.021, 95% CI [−0.091, −0.011], were also significant and in the expected direction. Finally, as predicted, T1 PTSS were indirectly related to T3 suicidal ideation through both lower T2 meaning in life, B = 0.005, SE = 0.001, 95% CI [0.004, 0.007], and T2 gratitude, B = 0.001, SE = 0.001, 95% CI [< 0.001, 0.002]. These findings support our second and third hypotheses for the total sample.

FIGURE 1. Parallel mediation model for the total sample.

FIGURE 1

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Note: The figure depicts the first parallel mediation model reflecting associations in the total sample. Unstandardized coefficients and 95% confidence intervals (CI) are reported. All effects were significant (i.e., the 95% CIs do not contain zero). The model explained 54.6% of the variance in meaning, 43.0% in gratitude, and 34.3% in suicidal ideation.

Pathways from PTSS to suicidal ideation in gender-stratified samples

Next, we examined whether more severe PTSS were associated with more subsequent suicidal ideation in the gender-stratified samples. For men veterans, T1 PTSS were positively related to T3 suicidal ideation, controlling for T1 and T2 ideation, B = 0.034, SE = 0.003, 95% CI [0.029, 0.040]. Similarly, for women veterans, T1 PTSS were positively related to T3 suicidal ideation, controlling for T1 and T2 ideation, B = 0.032, SE = 0.005, 95% CI [0.022, 0.042].

Finally, we examined whether meaning in life and gratitude were significant mechanisms of the pathway from PTSS to suicidal ideation over time in the gender-stratified samples. The parallel mediation model estimated with the men sample demonstrated good model fit, χ2(6, N = 6,029) = 141.75, p < .001, CFI = .988, RMSEA = .061, 90% CI [0.053, 0.070], SRMR = .018, and explained a significant proportion of variance in meaning in life (54.5%), p < .001; gratitude (43.8%), p < .001; and suicidal ideation (34.8%), p < .001. As shown in Figure 2, the results reflected a significant direct path from T1 PTSS to T3 suicidal ideation, B = 0.020, SE = 0.003, 95% CI [0.013, 0.026]. Further, the a paths from T1 PTSS to both T2 meaning in life, B = −0.087, SE = 0.012, 95% CI [−0.112, −0.063], and T2 gratitude, B = −0.023, SE = 0.004, 95% CI [−0.030, −0.016], were significant and in the expected direction. The b paths from T2 meaning in life to T3 suicidal ideation, B = −0.063, SE = 0.007, 95% CI [−0.076, −0.050], and from T2 gratitude to T3 suicidal ideation, B = −0.059, SE = 0.023, 95% CI [−0.104, −0.013], were also significant and in the expected direction. Finally, T1 PTSS were indirectly related to T3 suicidal ideation through both lower T2 meaning in life, B = 0.005, SE = 0.001, 95% CI [0.004, 0.008], and lower T2 gratitude, = 0.001, SE = 0.001, 95% CI [< 0.001, 0.003]. Collectively, the results in the men veteran subsample largely mirrored the findings from the total sample.

FIGURE 2. Parallel mediation model for the men sample.

FIGURE 2

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Note: The figure depicts the second parallel mediation model reflecting associations among men in the sample. Unstandardized coefficients and 95% confidence intervals (CI) are reported. All effects were significant (i.e., the 95% CIs do not contain zero). The model explained 54.5% of the variance in meaning, 43.8% in gratitude, and 34.8% in suicidal ideation.

The parallel mediation model estimated with the women veteran subsample also demonstrated good model fit, χ2(6, N = 1,359) = 26.14, p < .001, CFI = .991, RMSEA = .050, 90% CI [0.031, 0.070], SRMR = .015, and explained a significant proportion of variance in meaning in life (54.7%), p < .001; gratitude (39.1%), p < .001; and suicidal ideation (33.3%), p < .001. As shown in Figure 3, the results reflected a significant direct path from T1 PTSS to T3 suicidal ideation, B = 0.023, SE = 0.006, 95% CI [0.011, 0.036]. Further, the a paths from T1 PTSS to both T2 meaning in life, B = −0.092, SE = 0.022, 95% CI [−0.135, −0.048], and T2 gratitude, B = −0.034, SE = 0.006, 95% CI [−0.046, −0.021], were significant and in the expected direction, as was the b path from T2 meaning in life to T3 suicidal ideation, B = −0.047, SE = 0.013, 95% CI [−0.070, −0.021]. However, the b path from T2 gratitude to T3 suicidal ideation, B = −0.004, SE = 0.050, 95% CI [−0.102, 0.095], was not significant. Finally, there was a significant indirect effect from T1 PTSS to T3 suicidal ideation through T2 meaning in life, B = 0.004, SE = 0.002, 95% CI [0.002, 0.008], but not T2 gratitude, B < 0.001, SE = 0.002, 95% CI [−0.003, 0.004]. Overall, the results in the subsample of veteran women appeared to differ from the men sample.

FIGURE 3. Parallel mediation model for the women sample.

FIGURE 3

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Note: The figure depicts the third parallel mediation model reflecting associations among women in the sample. Unstandardized coefficients and 95% confidence intervals (CI) are reported. Dashed lines represent nonsignificant effects, and solid lines represent significant effects. The model explained 54.7% of the variance in meaning, 39.1% in gratitude, and 33.3% in suicidal ideation.

DISCUSSION

The current study provides several important insights about suicidal ideation during veterans’ transition from military to civilian life. Notably, the rates of suicidal ideation were relatively high in this group: Nearly 3 years after separation from service, one in every 10 veterans endorsed some degree of suicidal ideation. This finding is consistent with research among other nationally representative samples of veterans (Nichter et al., 2021) and underscores the importance of connecting veterans to suicide prevention services to prevent a progression of suicidal ideation to behaviors. This necessitates prioritizing connections to providers even for veterans who might not appear to need support immediately following separation (Hoffmire et al., 2022).

Our findings also provide critical insight regarding longitudinal predictors of suicidal ideation. The finding that veterans who endorsed more severe levels of PTSS also reported more suicidal ideation 1 year later is consistent with some prior research (Holliday et al., 2020; Pompili et al., 2013), and we add to work in this area by highlighting that veterans experiencing PTSS in the context of major life transitions are likely among those at risk for suicide-related sequelae. Further, we extend posttraumatic stress and suicide research by introducing novel aspects of well-being as mechanisms that appear to underlie the relation between PTSS and suicidal ideation. Here, we found a pathway from more severe PTSS to lessened meaning in life and gratitude and, in turn, more experiences of suicidal ideation in the total sample. To our knowledge, no previous studies have examined deficits in meaning in life and gratitude as mechanisms of this association among veterans transitioning from military to civilian life despite research showing that each of these factors is negatively associated with PTSS and suicidal ideation in this group (e.g., Fischer et al., 2020, 2023; Kashdan et al., 2006; McGuire et al., 2022). Indeed, these findings align with research suggesting that positive emotional experiences may be feared and avoided among individuals with PTSS (Contractor et al., 2021; Litz et al., 2000; Roemer et al., 2001; Weiss et al., 2018).

Lastly, some nuanced differences were observed when examining pathways from PTSS to suicidal ideation in the gender-stratified models. It appeared that the a path associations from PTSS to meaning in life and gratitude were robust—both men and women experienced decreases in meaning and gratitude due to greater PTSS. The b path association from meaning in life to suicidal ideation also appeared to replicate across genders; however, the b path association from gratitude to suicidal ideation differed among men and women. Although estimates on this pathway were nearly identical to the total sample among men, the b path and respective indirect effect were not significant among women. In other words, lower levels of gratitude were not associated with suicidal ideation nor did gratitude function as an underlying mechanism of the link between posttraumatic stress and suicidal ideation in women.

Prior work has identified a positive association between PTSS and the avoidance of negative emotions among men and women; however, an association between PTSS and the avoidance of positive emotions has previously only been observed in men (Schick et al., 2020). In contrast, the direct effects on our a path suggest that both men and women may have difficulty managing positive emotional experiences in the context of more severe PTSS. Relatedly, the robust b path and indirect effects involving meaning in life align with research suggesting that a lack of meaning may contribute to highly deleterious outcomes, including suicidal ideation and attempts (King & Hicks, 2021). That said, the b path and indirect effects involving gratitude differed among men and women. As a concept, gratitude is generally framed in an external context, encapsulating broader positive aspects of one’s life (e.g., as measured here with the item “I have so much in life to be thankful for”). A sense of gratitude—or lack thereof—likely shapes both men’s and women’s responses to trauma, but this influence might be particularly salient for men, who have been found to be more likely than women to construct external narratives that focus on the limitations they perceive in the world when they experience suicidal ideation (Denneson et al., 2020). In comparison, women tend to form internal narratives and contemplate their own limitations in response to life’s challenges. In this way, a deficit in gratitude may emerge as a significant catalyst for suicidal ideation among men, who may be less likely to emphasize appreciation in everyday life following trauma exposure, a hypothesis that warrants attention in future research.

Although the current study has important implications for suicide prevention, there are several limitations worth noting. First, this sample lacked elements of diversity that might impact the generalizability of the results. Specifically, although we were able to examine effects separately by gender, most participants identified as White. Future researchers should sample veterans with minoritized identities, as well as other subsets of veterans, to assess whether our findings replicate. Second, our assessments were based on self-report instruments, and we utilized abbreviated measures. This decision was made to minimize participant burden over the course of the longitudinal study. That said, veterans are in the best position to report on their own level of functioning, and we administered items from self-report measures with strong psychometric properties. To expand upon our findings, future research could include more comprehensive self-report and clinician-administered measures of functioning. Finally, it should be noted that we limited our analyses to the second and third years following separation. We view this as a strength in comparison to other related studies of veterans that have utilized a more limited follow-up period or assessed predictors and outcomes concurrently, precluding conclusions about temporality. That said, we did not administer the measures of meaning in life or gratitude before the 15-month assessment and, therefore, could not have examined our research questions at prior time points. Researchers should consider examining these constructs in closer proximity to this life transition in future studies.

The present findings underscore the value of prioritizing interventions that cultivate a sense of meaning in life and gratitude to reduce suicidal ideation. Indeed, meaning in life and gratitude are modifiable intervention targets (Rashid & Seligman, 2018), and activities that bolster these factors could supplement existing trauma-focused treatments such as prolonged exposure (PE; Foa et al., 2019) and cognitive processing therapy (CPT; Resick et al., 2017). In the context of PE, clinicians might help veterans identify, prioritize, and enhance motivation for in vivo exposures that would facilitate engagement with personally meaningful activities (e.g., mentoring other veterans through the transition experience). Similarly, clinicians could identify and help veterans challenge trauma-related “stuck points” that interfere with gratitude in daily life and develop alternative beliefs that foster gratitude during CPT (e.g., “Sometimes bad things will happen, but I have a strong support network to help me cope”). Further, veterans might be encouraged to access freely available evidence-based resources focused on strengthening meaning in life and gratitude that help promote healthy coping (e.g., the “Life Crafting” and “Three Good Things” activities from the Greater Good Science Center [2023a, 2023b]). These low-cost, high-reward practices might be a critical point of intervention that can provide a sense of hope and interrupt a lethal progression from suicidal ideation to attempts.

In sum, suicidal ideation often arises from a profound sense of emotional pain and hopelessness, making the enhancement of well-being a valuable strategy for suicide prevention. Indeed, a strong sense of purpose may function as a psychological anchor, providing veterans with meaning in their lives and reason to persevere. Similarly, gratitude may encourage veterans to focus on their blessings rather than burdens, thereby bolstering their capacity to cope with life’s challenges. Together, helping veterans build meaning and an attitude of appreciation in everyday life may be a proactive and holistic approach to suicide prevention.

OPEN PRACTICES STATEMENT.

This study was not preregistered. Neither the data nor the materials have been made available on a permanent third-party archive. Deidentified data specific to the current paper are available from the last author upon reasonable request, pending approval from the U.S. Department of Veterans Affairs.

Acknowledgments

This research drew from data collected as part of a previously funded project managed by the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. (HJF), and collaboratively sponsored by the Bob Woodruff Foundation, Health Net Federal Services, The Heinz Endowments, HJF, Lockheed Martin Corporation, May and Stanley Smith Charitable Trust, National Endowment for the Humanities, Northrop Grumman, Philip and Marge Odeen, Prudential, Robert R. McCormick Foundation, Rumsfeld Foundation, Schultz Family Foundation, Walmart Foundation, Wounded Warrior Project, Inc., and the Veterans Health Administration Health Services Research and Development Service (FOP-15-462-4). Shaina Kumar was supported by a T32 award from the National Institute of Mental Health (T32MH019836).

Footnotes

The views expressed are those of the authors and do not necessarily represent the views or policy of the U.S. Department of Veterans Affairs or the National Institute of Mental Health.

REFERENCES

  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). 10.1176/appi.books.9780890425596 [DOI] [Google Scholar]
  2. Centers for Disease Control and Prevention. (2023). Facts about suicide. https://www.cdc.gov/suicide/facts/
  3. Cole DA, & Maxwell SE (2003). Testing mediational models with longitudinal data: Questions and tips in the use of structural equation modeling. Journal of Abnormal Psychology, 112(4), 558–577. 10.1037/0021-843X.112.4.558 [DOI] [PubMed] [Google Scholar]
  4. Contractor AA, Weiss NH, & Forkus SR (2021). Moderating effects of dysregulation and fear of positive emotions on the relationship between posttraumatic stress disorder symptoms and positive memory count. Journal of Clinical Psychology, 77(3), 701–721. 10.1002/jclp.23046 [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Denneson LM, Tompkins KJ, McDonald KL, Hoffmire CA, Britton PC, Carlson KF, Smolenski DJ, & Dobscha SK (2020). Gender differences in the development of suicidal behavior among United States military veterans: A national qualitative study. Social Science & Medicine, 260, Article 113178. 10.1016/j.socscimed.2020.113178 [DOI] [PubMed] [Google Scholar]
  6. Desseilles M, Perroud N, Guillaume S, Jaussent I, Genty C, Malafosse A, & Courtet P (2012). Is it valid to measure suicidal ideation by depression rating scales? Journal of Affective Disorders, 136(3), 398–404. 10.1016/j.jad.2011.11.013 [DOI] [PubMed] [Google Scholar]
  7. Ehlers A, & Clark DM (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38(4), 319–345. 10.1016/s0005-7967(99)00123-0 [DOI] [PubMed] [Google Scholar]
  8. Elbogen EB, Molloy K, Wagner HR, Kimbrel NA, Beckham JC, Van Male L, Leinbach J, & Bradford DW (2020). Psychosocial protective factors and suicidal ideation: Results from a national longitudinal study of veterans. Journal of Affective Disorders, 260, 703–709. 10.1016/j.jad.2019.09.062 [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Enders CK (2010). Applied missing data analysis. Guilford Press. [Google Scholar]
  10. Fischer IC, Nichter B, Feldman DB, Na PJ, Tsai J, Harpaz-Rotem I, Schulenberg SE, & Pietrzak RH (2023). Purpose in life protects against the development of suicidal thoughts and behaviors in U.S. veterans without a history of suicidality: A 10-year, nationally representative, longitudinal study. Journal of Affective Disorders, 340, 551–554. 10.1016/j.jad.2023.08.040 [DOI] [PubMed] [Google Scholar]
  11. Fischer IC, Shanahan ML, Hirsh AT, Stewart JC, & Rand KL (2020). The relationship between meaning in life and post-traumatic stress symptoms in U.S. military personnel: A meta-analysis. Journal of Affective Disorders, 277, 658–670. 10.1016/j.jad.2020.08.063 [DOI] [PubMed] [Google Scholar]
  12. Foa EB, Hembree EA, Rothbaum BO, & Rauch SAM (2019). Prolonged exposure therapy for PTSD: Therapist guide (2nd ed.). Oxford University Press. [Google Scholar]
  13. Foa EB, & Kozak MJ (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99(1), 20–35. 10.1037/0033-2909.99.1.20 [DOI] [PubMed] [Google Scholar]
  14. Franklin JC, Ribeiro JD, Fox KR, Bentley KH, Kleiman EM, Huang X, Musacchio KM, Jaroszewski AC, Chang BP, & Nock MK (2017). Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychological Bulletin, 143(2), 187–232. 10.1037/bul0000084 [DOI] [PubMed] [Google Scholar]
  15. Fredrickson BL (2001). The role of positive emotions in positive psychology: The broaden- and-build theory of positive emotions. American Psychologist, 56(3), 218–226. 10.1037/0003-066X.56.3.218 [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Geier TJ, Hunt JC, Hanson JL, Heyrman K, Larsen SE, Brasel KJ, & deRoon-Cassini TA (2020). Validation of abbreviated four- and eight-item versions of the PTSD Checklist for DSM-5 in a traumatically injured sample. Journal of Traumatic Stress, 33(3), 218–226. 10.1002/jts.22478 [DOI] [PubMed] [Google Scholar]
  17. Greater Good Science Center. (2023a). Life crafting. https://ggia.berkeley.edu/practice/life_crafting
  18. Greater Good Science Center. (2023b). Three good things. https://ggia.berkeley.edu/practice/three-good-things
  19. Gujral K, Bahraini N, Brenner LA, Van Campen J, Zulman DM, Illarmo S, & Wagner TH (2023). VA’s implementation of universal screening and evaluation for the suicide risk identification program in November 2020—Implications for veterans with prior mental health needs. PLoS One, 18(4), 1–16. 10.1371/journal.pone.0283633 [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Hayes AF (2022). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach (3rd ed.). Guilford Press. [Google Scholar]
  21. Hoffmire CA, Borowski S, Griffin BJ, Maguen S, & Vogt D (2022). Trajectories of suicidal ideation following separation from military service: Overall trends and group differences. Suicide and Life-Threatening Behavior, 52(3), 413–426. 10.1111/sltb.12831 [DOI] [PubMed] [Google Scholar]
  22. Hoffmire CA, Monteith LL, Forster JE, Bernhard PA, Blosnich JR, Vogt D, Maguen S, Smith AA, & Schneiderman AI (2021). Gender differences in lifetime prevalence and onset timing of suicidal ideation and suicide attempt among post-9/11 veterans and nonveterans. Medical Care, 59, S84–S91. 10.1097/MLR.0000000000001431 [DOI] [PubMed] [Google Scholar]
  23. Holliday R, Borges LM, Stearns-Yoder KA, Hoffberg AS, Brenner LA, & Monteith LL (2020). Posttraumatic stress disorder, suicidal ideation, and suicidal self-directed violence among U.S. military personnel and veterans: A systematic review of the literature from 2010 to 2018. Frontiers in Psychology, 11, Article 1998. 10.3389/fpsyg.2020.01998 [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Kashdan TB, Mishra A, Breen WE, & Froh JJ (2009). Gender differences in gratitude: Examining appraisals, narratives, the willingness to express emotions, and changes in psychological needs. Journal of Personality, 77(3), 691–730. 10.1111/j.1467-6494.2009.00562.x [DOI] [PubMed] [Google Scholar]
  25. Kashdan TB, Uswatte G, & Julian T (2006). Gratitude and hedonic and eudaimonic well-being in Vietnam War veterans. Behaviour Research and Therapy, 44(2), 177–199. 10.1016/j.brat.2005.01.005 [DOI] [PubMed] [Google Scholar]
  26. King LA, & Hicks JA (2021). The science of meaning in life. Annual Review of Psychology, 72, 561–584. 10.1146/annurev-psych-072420-122921 [DOI] [PubMed] [Google Scholar]
  27. Kline RB (2015). Principles and practice of structural equation modeling (4th ed.). Guilford Press. [Google Scholar]
  28. Klonsky ED, May AM, & Saffer BY (2016). Suicide, suicide attempts, and suicidal ideation. Annual Review of Clinical Psychology, 12, 307–330. 10.1146/annurev-clinpsy-021815-093204 [DOI] [PubMed] [Google Scholar]
  29. Kroenke K, Spitzer RL, & Williams JBW (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613. 10.1046/j.1525-1497.2001.016009606.x [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Kumar SA, Borowski S, & Vogt D (2023). Meaning in life following service among post-9/11 military veterans: A latent growth mixture model analysis. Applied Psychology: Health and Well-Being. Advance online publication. 10.1111/aphw.12513 [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Lehavot K, Katon JG, Chen JA, Fortney JC, & Simpson TL (2018). Post-traumatic stress disorder by gender and veteran status. American Journal of Preventive Medicine, 54(1), e1–e9. 10.1016/j.amepre.2017.09.008 [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Litz BT, Orsillo SM, Kaloupek D, & Weathers F (2000). Emotional processing in posttraumatic stress disorder. Journal of Abnormal Psychology, 109(1), 26–39. 10.1037/0021-843X.109.1.26 [DOI] [PubMed] [Google Scholar]
  33. McCullough ME, Emmons RA, & Tsang J (2002). The grateful disposition: A conceptual and empirical topography. Journal of Personality and Social Psychology, 82(1), 112–127. 10.1037/0022-3514.82.1.112 [DOI] [PubMed] [Google Scholar]
  34. McGuire AP, Fagan JG, Tsai J, Merians AN, Nichter B, Norman SB, Southwick SM, & Pietrzak RH (2022). Dispositional gratitude predicts the development of psychopathology and suicidal behaviors: Results from a 7-year population-based study of U.S. military veterans. Journal of Psychiatric Research, 149, 168–176. 10.1016/j.jpsychires.2022.02.028 [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Muthén LK, & Muthén BO (1998–2017). Mplus user’s guide (8th ed.). Muthén & Muthén. [Google Scholar]
  36. Nichter B, Stein MB, Norman SB, Hill ML, Straus E, Haller M, & Pietrzak RH (2021). Prevalence, correlates, and treatment of suicidal behavior in U.S. military veterans: Results from the 2019–2020 National Health and Resilience in Veterans Study. The Journal of Clinical Psychiatry, 82(5), Article 20m13714. 10.4088/JCP.20m13714 [DOI] [PubMed] [Google Scholar]
  37. Park CL (2010). Making sense of the meaning literature: An integrative review of meaning making and its effects on adjustment to stressful life events. Psychological Bulletin, 136(2), 257–301. 10.1037/a0018301 [DOI] [PubMed] [Google Scholar]
  38. Park N, & Peterson C (2009). Character strengths: Research and practice. Journal of College and Character, 10(4). 10.2202/1940-1639.1042 [DOI] [Google Scholar]
  39. Pompili M, Sher L, Serafini G, Forte A, Innamorati M, Dominici G, Lester D, Amore M, & Girardi P (2013). Posttraumatic stress disorder and suicide risk among veterans: A literature review. Journal of Nervous and Mental Disease, 201(9), 802–812. 10.1097/NMD.0b013e3182a21458 [DOI] [PubMed] [Google Scholar]
  40. Price M, Szafranski DD, van Stolk-Cooke K, & Gros DF (2016). Investigation of abbreviated 4- and 8-item versions of the PTSD Checklist 5. Psychiatry Research, 239, 124–130. 10.1016/j.psychres.2016.03.014 [DOI] [PubMed] [Google Scholar]
  41. Prins A, Bovin MJ, Smolenski DJ, Marx BP, Kimerling R, Jenkins-Guarnieri MA, Kaloupek DG, Schnurr PP, Kaiser AP, Leyva YE, & Tiet QQ (2016). The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5): Development and evaluation within a veteran primary care sample. Journal of General Internal Medicine, 31(10), 1206–1211. 10.1007/s11606-016-3703-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Rashid T & Seligman M (2018). Positive psychotherapy: Clinician manual. Oxford University Press. [Google Scholar]
  43. Resick PA, Monson CM, & Chard KM (2017). Cognitive processing therapy for PTSD: A comprehensive manual. Guilford Press. [Google Scholar]
  44. Robustelli BL, & Whisman MA (2018). Gratitude and life satisfaction in the United States and Japan. Journal of Happiness Studies, 19(1), 41–55. 10.1007/s10902-016-9802-5 [DOI] [Google Scholar]
  45. Roemer L, Litz BT, Orsillo SM, & Wagner AW (2001). A preliminary investigation of the role of strategic withholding of emotions in PTSD. Journal of Traumatic Stress, 14(1), 149–156. 10.1023/A:1007895817502 [DOI] [Google Scholar]
  46. Ronzitti S, Loree AM, Potenza MN, Decker SE, Wilson SM, Abel EA, Haskell SG, Brandt CA, & Goulet JL (2019). Gender differences in suicide and self-directed violence risk among veterans with post-traumatic stress and substance use disorders. Women’s Health Issues, 29(Suppl 1), S94–S102. 10.1016/j.whi.2019.04.010 [DOI] [PubMed] [Google Scholar]
  47. Schick MR, Weiss NH, Contractor AA, Suazo NC, & Spillane NS (2020). Post-traumatic stress disorder’s relation with positive and negative emotional avoidance: The moderating role of gender. Stress and Health, 36(2), 172–178. 10.1002/smi.2920 [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Schulenberg SE, Schnetzer LW, & Buchanan EM (2011). The Purpose in Life Test–Short Form: Development and psychometric support. Journal of Happiness Studies, 12(5), 861–876. 10.1007/s10902-010-9231-9 [DOI] [Google Scholar]
  49. Sokol Y, Gromatsky M, Edwards ER, Greene AL, Geraci JC, Harris RE, & Goodman M (2021). The deadly gap: Understanding suicide among veterans transitioning out of the military. Psychiatry Research, 300, Article 113875. 10.1016/j.psychres.2021.113875 [DOI] [PubMed] [Google Scholar]
  50. Steger MF, Frazier P, Oishi S, & Kaler M (2006). The Meaning in Life Questionnaire: Assessing the presence of and search for meaning in life. Journal of Counseling Psychology, 53(1), 80–93. 10.1037/0022-0167.53.1.80 [DOI] [Google Scholar]
  51. Steger MF, Oishi S, & Kashdan TB (2009). Meaning in life across the life span: Levels and correlates of meaning in life from emerging adulthood to older adulthood. Journal of Positive Psychology, 4(1), 43–52. 10.1080/17439760802303127 [DOI] [Google Scholar]
  52. Steger MF, Shin JY, Shim Y, & Fitch-Martin A (2013). Is meaning in life a flagship indicator of well-being? In Waterman AS (Ed.), The best within us: Positive psychology perspectives on eudaimonia (pp. 159–182). American Psychological Association. [Google Scholar]
  53. Vogt D, Borowski SC, Godier-McBard LR, Fossey MJ, Copeland LA, Perkins DF, & Finley EP (2022). Changes in the health and broader well-being of U.S. veterans in the first three years after leaving military service: Overall trends and group differences. Social Science & Medicine, 294, Article 114702. 10.1016/j.socscimed.2022.114702 [DOI] [PubMed] [Google Scholar]
  54. Vogt D, Perkins DF, Copeland LA, Finley EP, Jamieson CS, Booth B, Lederer S, & Gilman CL (2018). The Veterans Metrics Initiative study of US veterans’ experiences during their transition from military service. British Medical Journal Open, 8(6), Article e020734. 10.1136/bmjopen-2017-020734 [DOI] [PMC free article] [PubMed] [Google Scholar]
  55. Weathers FW, Litz BT, Keane TM, Palmier PA, Marx BP, & Schnurr PP (2013). The PTSD Checklist for DSM-5 (PCL-5). https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp
  56. Weiss NH, Dixon-Gordon KL, Peasant C, & Sullivan TP (2018). An examination of the role of difficulties regulating positive emotions in posttraumatic stress disorder. Journal of Traumatic Stress, 31(5), 775–780. 10.1002/jts.22330 [DOI] [PMC free article] [PubMed] [Google Scholar]

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