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World Psychiatry logoLink to World Psychiatry
letter
. 2017 Sep 21;16(3):326–327. doi: 10.1002/wps.20467

Factors protecting against the development of suicidal ideation in military veterans

Robert H Pietrzak 1,2, Barbara L Pitts 3, Ilan Harpaz‐Rotem 1,2, Steven M Southwick 1,2, Julia M Whealin 3,4
PMCID: PMC5608823  PMID: 28941099

The growing rate of suicide among military veterans is a critical public health concern1, 2. Accordingly, there is an urgent need to better identify at‐risk veterans and provide early targeted interventions3. Numerous studies have examined risk factors for suicide in veterans, which have generally focused on mental and physical health problems4, 5. Surprisingly scarce research has sought to identify modifiable protective factors, despite emerging theoretical frameworks of suicide risk emphasizing such factors, including psychological resilience (i.e., psychological qualities that allow one to better manage adversity, such as self‐efficacy and cognitive flexibility), acceptance‐based coping (i.e., acceptance that a traumatic or stressful life event is real and must be addressed), social support, optimism, and curiosity6, 7, 8.

Characterization of risk and protective factors linked to early indicators of suicide risk, such as suicidal ideation, is critical to informing targeted suicide prevention efforts3. Prospective cohort studies that follow population‐based, non‐psychiatric samples prior to the development of suicidal ideation are an ideal context within which to identify such factors. We explored the risk and protective factors associated with the development of suicidal ideation over a 4‐year period in a nationally representative sample of military veterans.

We analyzed data from the National Health and Resilience in Veterans Study, a nationally representative, prospective cohort study of US veterans. The sample was drawn from a survey panel of 50,000 US adults maintained by GfK Knowledge Networks Inc. The baseline survey was conducted in September‐October 2011, and follow‐up surveys were carried out in September‐October 2013 and 2015. In the current study, we analyzed data from 2,093 veterans who did not endorse suicidal ideation at baseline and who completed at least one follow‐up assessment over the 4‐year follow‐up period. The study was approved by the Human Subjects Subcommittee of the VA Connecticut Healthcare System.

Suicidal ideation was assessed using a two‐part question from the Patient Health Questionnaire‐9: “Over the last 2 weeks, how often have you been bothered by the following problems: thoughts you might be better off dead, and thoughts of hurting yourself in some way?”. Items were coded 0 (“not at all”), 1 (“several days”), 2 (“more than half the days”), or 3 (“nearly every day”). Incident suicidal ideation was operationalized as endorsement of “1” or higher on either question over the 4‐year follow‐up period. A comprehensive range of socio‐demographic, military, health and psychosocial (perceived resilience, optimism, purpose in life, social support, coping strategies, and religiosity/spirituality) characteristics were assessed9.

A hierarchical multivariate binary logistic regression analysis was conducted to evaluate baseline predictors of incident suicidal ideation over the 4‐year period. Socio‐demographic (e.g., age) and military (e.g., combat veteran status) variables were entered in step 1; potential risk factors (e.g., depression, post‐traumatic stress disorder (PTSD), somatic problems) in step 2; and potential protective factors (e.g., scores on measures of psychosocial characteristics and social connectedness) in step 3. Incident suicidal ideation (no/yes) was the dependent variable. The analysis was weighted post‐stratification based on the demographic distribution from the most contemporaneous current population survey of the US Census Bureau, to permit generalizability to the US veteran population.

The mean age of the sample was 62.4 ± 13.8 years (range 22‐93) and included predominantly male (92.0%), white (78.5%) and non‐combat‐exposed (68.4%) veterans. One hundred forty‐three (weighted 7.5%) veterans developed suicidal ideation over the 4‐year follow‐up period.

Increased risk of incident suicidal ideation was associated with loneliness (i.e., score on Short Loneliness Scale; relative risk ratio, RRR=1.22, p=0.002; relative variance explained, RVE=16.5%); disability in instrumental activities of daily living (i.e., endorsement of needing help with activities such as doing housework and taking medication properly; RRR=3.46, p<0.001; RVE=14.8%); PTSD symptoms (score on PTSD Checklist; RRR=1.05, p<0.001; RVE=7.9%); somatic problems (i.e., score on somatization subscale of Brief Symptom Inventory‐18; RRR=1.09, p<0.001; RVE=7.0%); alcohol use problems (i.e., score on Alcohol Use Disorders Identification Test‐Consumption; RRR=1.10, p=0.001; RVE=5.7%); denial‐based coping (i.e., endorsing use of denial to cope with trauma on the Brief COPE; RRR=3.36, p=0.002; RVE=4.3%); and higher age (RRR=1.02, p=0.015; RVE=2.0%).

Decreased risk of incident suicidal ideation was independently associated with greater social support (score on Medical Outcomes Study Social Support Scale‐5; RRR=0.94, p=0.002; RVE=20.3%); curiosity (score on “I frequently find myself looking for new opportunities to grow as a person (e.g., information, people, resources)” item from the Curiosity and Exploration Inventory; RRR=0.85, p<0.001; RVE=9.3%); resilience (score on Connor‐Davidson Resilience Scale‐10; RRR=0.96, p=0.009; RVE=8.0%); and acceptance‐based coping (endorsement of use of acceptance‐based coping on the Brief COPE; RRR=0.60, p=0.014; RVE=4.2%).

This study provides one of the most comprehensive assessments to date of risk and protective factors for developing suicidal ideation in a nationally representative sample of military veterans. They replicate prior work implicating mental and physical health problems as risk factors for suicidality in veterans4, 5 and extend these findings to suggest that loneliness, disability in instrumental activities of daily living, and denial‐based coping may additionally contribute to suicidal ideation risk in this population.

Greater perceived social support, curiosity, resilience, and acceptance‐based coping accounted for more than 40% of the total variance in predicting suicidal ideation risk. These protective factors are modifiable and addressed in contemporary cognitive‐behavioral psychotherapies6, 7, 8, and thus may be promising targets in prevention efforts designed to mitigate suicide risk in veterans.

Taken together, the results of this study underscore the importance of comprehensive and multi‐modal assessment, monitoring, prevention, and treatment approaches that target a broad range of risk and protective factors for suicidal ideation10.

Robert H. Pietrzak1,2, Barbara L. Pitts3, Ilan Harpaz‐Rotem1,2, Steven M. Southwick1,2, Julia M. Whealin3,4
1US Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, West Haven, CT, USA; 2Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA; 3US Department of Veterans Affairs VA Pacific Islands Healthcare System, Honolulu, HI, USA; 4University of Hawaii School of Medicine, Manoa, HI, USA

References


Articles from World Psychiatry are provided here courtesy of The World Psychiatric Association

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