Those left behind: A scoping review of the effects of suicide exposure on veterans, service members, and military families

Abstract

Veteran and service member suicide remains a significant public health concern. One factor that may impact suicide risk is suicide exposure—knowing someone who has died by suicide or attempted suicide. However, the majority of the extant literature has focused on nonmilitary samples, which may not generalize to military veterans and service members. The current review synthesizes findings regarding suicide exposure in military veterans, service members, their families, and military systems. Our review suggests that the relationship between suicide exposure, suicide risk, and mental health outcomes remains inconsistent. Future research should further explore this important area.

Over the last decade, U.S. military active duty service member and veteran suicide rates have been on the rise (Psychological Health Center of Excellence, 2018; U.S. Department of Veterans Affairs, 2019). According to the most recent data from the Department of Defense, service member suicide rates have been increasing linearly since 2011 (18.0 per 100,000 to 24.8 per 100,000; Psychological Health Center of Excellence, 2018). In addition, service member suicide rates are elevated compared with that of the general population (18.2 per 100,000; Psychological Health Center of Excellence, 2018). Veterans are 1.5 times more likely to die by suicide than the general population with roughly 17 veterans dying by suicide per day (U.S. Department of Veterans Affairs, 2019). These numbers highlight the emergent need for more knowledge regarding suicide risk in these populations.

Much of the current empirical literature has primarily focused on identifying suicide risk factors among military/service members. However, little is known regarding how a death by suicide impacts the mental health of their families and surviving veterans/service members. Among civilian populations, suicide exposure, or experiencing another’s death by suicide, is associated with myriad concerning outcomes, including feelings of rejection and shame, anxiety, depression, posttraumatic stress disorder (PTSD), prolonged grief, and suicidal ideation and attempts (Cerel et al., 2016, 2017; Pitman et al., 2016). Although risk associated with suicide exposure has begun to receive empirical attention broadly, far more research is needed in samples of military veterans, service members, and their families. These populations may face unique challenges and cultural factors (e.g. access to firearms, profound stress, separation from families, etc.) that can further exacerbate the impact of suicide exposure. Consequently, understanding the impact of service member/veteran suicide can have far reaching implications for interventions tailored to bereaved family members and others within the individual’s military system.

Our primary aim is to review the existing literature on suicide survivorship in veterans, active duty military members, and their families. Specifically, we will synthesize findings from the extant literature regarding the current prevalence of suicide exposure among military populations. We will then evaluate current research on the association between suicide exposure and suicide risk, risk for mental illness, and views of mental healthcare and treatment-seeking behaviors within military populations. We will also review the effects of suicide exposure on military-related groups, including military families, providers, and systems. We conclude by identifying gaps in the current literature to inform future research directions on suicide survivorship in military members, veterans, and their families.

Effects of suicide exposure among veterans and service members

A handful of studies have examined the prevalence of suicide exposure in military populations (Table 1). Suicide exposure rates for veterans and service members appear to range from 47.1% (Cerel et al., 2015) to 65.4% (Bryan et al., 2017; Hom et al., 2017). Across studies, exposed individuals reported knowing, on average, three people who died by suicide (Bryan et al., 2017; Cerel et al., 2015; Hom et al., 2017). Unfortunately, service members and veterans most commonly report losing a friend by suicide (52.1–54.5%; Bryan et al., 2017; Hom et al., 2017), with a smaller percentage endorsing losing a coworker/fellow service member (10.6–28.7%; Bryan et al., 2017; Hom et al., 2017) or a family member (16.7–30.1%; Bryan et al., 2017; Cerel et al., 2015; Hom et al., 2017). Given the significant percentage of service members and veterans who know at least one person who has died by suicide, it is likely that rates of suicide exposure are also high for military and veteran families. However, we did not identify any studies that examined the prevalence of suicide exposure among military or veteran families. Three main themes emerged regarding the effects of suicide exposure among veterans/service members: suicide risk, risk for mental illness, and views of mental healthcare and treatment-seeking behaviors.

Table 1.

Suicide exposure in military members.

Study	n	Participants	Study design	Exposure variables	Outcome variables
Bryan et al., 2017	971	Active duty National Guard personnel	Cross-sectional	Lifetime exposure; Closeness to decedent	PTSD symptoms; Depression symptoms; Hazardous drinking; Lifetime/most recent SI and SA; Lifetime trauma exposure
Cerel et al., 2019		N/A	N/A	N/A	N/A
Cerel et al., 2015	931	Veterans of Army, Navy, Air Force, Marines, and Coast Guard	Cross-sectional	Number of lifetime exposures; Closeness to decedent; Recency of deaths; Familial relation to decedent; Exposure during military career; Exposure to traumatic death non-suicide related	Depression symptoms; Anxiety symptoms; PTSD symptoms; Prolonged grief
Harrington-LaMorie et al., 2018	N/A	N/A	N/A	N/A	N/A
Hom et al., 2017	1753	Active-duty U.S. military members and veterans	Cross-sectional	Lifetime exposure; Closeness to decedent; Relation to decedent; Exposure during military career; Perceived impact of suicide	SI, SA, and NSSI; Thwarted belongingness
Weisenhorn et al., 2017	434	Veterans of Army, Navy, Air Force, Marines, and Cost Guard exposed to suicide	Cross-sectional	Perceived impact of suicide	PTSD symptoms
Chen et al., 2019	71	Student service members/veterans	Cross-sectional	Lifetime exposure; Relation to decedent; Suicide exposure attempt	SI, SA, and NSSI; Stigma toward mental health help-seeking; Attitudes toward suicide prevention; Formal/informal help-seeking behavior
Carr, 2011	1	Active-duty U.S. Army Soldier	Case Study	N/A	N/A
Lubens & Silver, 2019	206	Combat veterans	Cross-sectional/qualitative	Lifetime exposure to military death by suicide; lifetime exposure to combat death	Grief, unit cohesion, combat exposure, PTSD symptoms, anger, past diagnoses of PTSD/depression
Ursano et al., 2017	9512	Active-duty US Army soldiers	Longitudinal	Suicide attempts in soldier’s units	SA
LaCroix et al., 2018	66	Family members exposed to military suicide	Cross-sectional	N/A	Perspectives on various suicide prevention activities for veterans/service members

Suicide risk

A small but growing body of literature has linked suicide exposure with suicide risk. Cross-sectional studies among veterans and service members have consistently linked suicide exposure with current and lifetime suicidal ideation (small effects; Bryan et al., 2017; Cerel et al., 2015; Hom et al., 2017), but yielded mixed findings pertaining to suicide-related behaviors. Among active military personnel and veterans, suicide exposure was associated with greater self-reported likelihood of a future suicide attempt, and lifetime suicidal planning, attempts, and nonsuicidal self-injury, albeit with small effects (Hom et al., 2017). Similarly, in a sample of transgender and gender-diverse veterans, Tucker et al. (2019) found that exposure to suicide attempts and deaths were independently related to a history of at least one lifetime suicide attempt. In contrast, in a sample of National Guard service members, Bryan et al. (2017) found no association between suicide exposure and lifetime suicide attempt history. It is possible that sample-specific factors (e.g. service length, unit cohesion, active versus reserve status) provide some explanation for these discrepant cross-sectional findings, but research is needed to investigate this relationship further.

Critically, we identified only one longitudinal study in Army service members that examined associations between suicide attempt exposure and subsequent suicidal behavior. Ursano et al. (2017) found that past-year suicide attempts in a soldier’s unit predicted later suicide attempts, even after controlling for sociodemographic variables, service-related characteristics (e.g. deployment status, time in service), mental health diagnoses, and unit variables (e.g. unit size, suicide deaths, combat deaths). Notably, the risk of suicide attempts increased for soldiers with a combat arms occupation, and who were stationed in smaller units, especially those in units with five or more past-year suicide attempts. These findings underscore the importance of considering contextual and temporal aspects of suicide exposure to identify exposed service members who are at particularly elevated risk of suicidal thoughts and behaviors. More longitudinal studies in a range of military and veteran samples are needed to confirm these findings and identify factors that may intensify negative impacts of suicide exposure.

In addition to the need for greater longitudinal research, more studies will be needed to clarify if, and how, the effects of suicide exposure vary between military and civilian samples. Suicide exposure has been linked with suicide risk among both civilians (Cerel et al., 2016, 2017; Pitman et al., 2016) and service members/veterans (e.g. Ursano et al., 2017), but whether the impacts of suicide exposure vary across these groups remains an open question. We identified only one study that compared associations between suicide exposure and suicidal thoughts and behaviors across service member/veterans versus civilians. Interestingly, Chen et al. (2019) found that rates of lifetime ideation and attempts did not vary across student veterans who had been exposed to suicide versus student veterans without this history. Moreover, rates of lifetime suicidal thoughts and behaviors did not vary across student veterans or civilians with a history of suicide exposure. Although additional research is needed to examine these relationships across military/veteran versus civilian samples, it is certainly possible that suicide exposure confers higher risk of suicidal thoughts and behaviors, irrespective of the sample.

Emerging evidence suggests some aspects of being exposed to suicide are linked with suicide risk as well. One aspect is number of known decedents and closeness to the decedent. However, some of these relationships appear to be accounted for by third variables that broadly index distress and potential predisposing suicide risk factors. Specifically, one study found that a small relationship between number of known decedents and lifetime ideation (Bryan et al., 2017) became insignificant after controlling for sociodemographic factors, deployment history, trauma exposure, and mental health diagnoses. Two studies found that greater closeness to a suicide decedent was linked with greater risk of suicide attempts and current and lifetime suicidal ideation (Bryan et al., 2017; Hom et al., 2017). Similar to results regarding number of suicide decedents, these small effects became insignificant (Bryan et al., 2017) or reversed in direction (Hom et al., 2017) after controlling for relevant mental health and/or suicide history variables. Interestingly, however, closeness to the decedent was associated with greater self-reported likelihood of making a future suicide attempt, even after accounting for lifetime and current suicidality (Hom et al., 2017). Moreover, veterans and service members who reported being more negatively impacted by a suicide endorsed worse recent suicidal ideation, and greater risk of attempting suicide in the future, as well as increased lifetime ideation, planning, attempts, and non-suicidal self-injury (Hom et al., 2017). Thus, factors that may be indicative of greater emotional impacts of the suicide loss may be particularly useful indicators of increased suicide risk. However, all of these studies were cross-sectional, precluding interpretations about temporal ordering of effects.

Another aspect is timing. Two studies examined whether the timing of suicide exposure was associated with suicidality. Among veterans who had been exposed to both suicide and traumatic deaths (Cerel et al., 2015), being exposed to suicide first was linked with increased risk of lifetime ideation (OR = 3.56). Bryan et al. (2017) examined the timing of first onset of suicidal ideation and attempts in relation to suicide exposure. They found that approximately 37% of service members who attempted suicide for the first time postexposure did so within a year of the suicide. They also found that suicidal ideation was more common after suicide exposure among service members who had previously had thoughts of suicide (OR = 11.73), or attempted suicide (OR = 8.40). In addition, service members who had previously attempted suicide were more likely to make another attempt following suicide exposure (OR = 7.09). These findings suggest potential critical risk periods following suicide exposure.

However, more temporally detailed research (e.g. over the months following the exposure) is needed to better understand temporal trajectories of risk following exposure among both service members and veterans. Research in this vein has the potential to inform the timing and implementation of suicide postvention efforts.

Mental illness

Suicide exposure has been linked with a myriad of mental health disorders for veterans and servicemembers (Bryan et al., 2017; Cerel et al., 2015; Weisenhorn et al., 2017). Suicide exposed veterans are approximately twice as likely to have clinical depression (OR = 1.94) or an anxiety disorder (OR = 2.39; Cerel et al., 2015) compared to nonexposed veterans. In another study, after controlling for demographics and service-related variables, suicide exposure accounted for 37% of the variance in PTSD symptoms in non-married veterans and 20% of the variance for married veterans (Weisenhorn et al., 2017). Although not comprehensive, this research suggests suicide exposure increases risk of mental illness in general among both veterans and service members.

Specific aspects of suicide exposure may be associated with risk for developing psychiatric symptoms as well. Bryan et al. (2017) found that a greater number of known suicide decedents and perceived closeness to the decedent were both significantly related to a greater likelihood of having PTSD (OR = 1.18 and 1.54, respectively) and depression (OR = 1.19 and 1.36, respectively). However, when covariates (i.e. gender, age, number of deployments, lifetime trauma) were included in analyses, only perceived closeness to the decedent significantly predicted a PTSD/depression diagnosis. Cerel et al. (2015) found similar effects, whereby greater perceived closeness was associated with incrementally greater risk for depression, anxiety, PTSD, and prolonged grief.

Similarly, impact and perceptions of suicide have been linked with risk of mental health symptoms. In Weisenhorn et al. (2017), veterans exposed to suicide rated the impact of the event on their lives. Veterans who endorsed a high impact of the suicide were 10.4 times more likely to have PTSD symptoms compared to low-impact veterans. Moreover, it is possible that the nature of suicide versus other kinds of death may contribute to risk of developing psychiatric symptoms. For example, service members who were exposed to either a death in combat or to a death by suicide reported feeling as if the suicide deaths were unexpected compared to death in combat, and also reported more difficulty accepting suicide deaths (Lubens & Silver, 2019). These data signify that service members may process and think about suicide deaths differently compared to other types of deaths, which could in turn explain the association of suicide exposure and poor mental health outcomes. Longitudinal research is needed to investigate this possibility.

Views of mental healthcare and treatment-seeking behavior

Researchers rarely investigate impacts of suicide exposure on views of mental healthcare among veterans and service members. In fact, we only found one study that examined the effect of suicide exposure on mental health treatment (Chen et al., 2019), conducted in a university sample. Interestingly, student service members, veterans, and civilians exposed to suicide endorsed more positive mental health and suicide prevention beliefs than those without this history (Chen et al., 2019). Specifically, individuals who had been exposed to suicide reported feeling greater responsibility to speak openly about suicide with at-risk peers and endorsed more adaptive attitudes about the utility of treatment. These results suggest that suicide exposure, regardless of civilian or service member/veteran status, may increase receptiveness to mental health treatment. However, suicide exposed service members/veterans and civilians also endorsed that individuals seeking mental health treatment would be perceived more negatively by others (Chen et al., 2019). Additional research is needed to understand why this may be the case (e.g. responses of others to those bereaved by suicide, public stigma regarding treatment-seeking), and to clarify potential differential effects of suicide exposure on personal, relative to public, stigma.

Interestingly, Chen et al. (2019) also indicated that patterns of treatment-seeking differed as a function of suicide exposure and civilian status. Suicide exposed service members, veterans, and civilians endorsed greater utilization of psychiatric treatment versus nonexposed individuals. Further, service members and veterans were more likely than civilians to endorse utilization of psychotherapy, regardless of history of suicide exposure (Chen et al., 2019); this may reflect cultural effects, greater accessibility of mental health services (e.g. access to Veterans Affairs healthcare systems), greater perceived need for treatment, or other factors, all of which may play a role in treatment utilization more broadly.

Nevertheless, these areas represent a significant gap in the literature. Future research should examine whether aspects of suicide exposure and/or its after-math uniquely affect views of mental health care and treatment utilization, information that could inform postvention strategies.

Effects of suicide exposure in related groups

A single suicide can impact a number of people, including peers, family members, friends, providers of the deceased, and military systems as a whole (Pak et al., 2019; Pitman et al., 2014). These individuals often form part of the veteran/service member’s support structure, and at times may mitigate maladaptive outcomes (e.g. Levi-Belz, 2015). Therefore, understanding how suicide exposure impacts these individuals and systems is necessary to more comprehensively understand effects of suicide exposure on veterans and service members and to potentially inform postvention strategies. Accordingly, we review current research in this important area below.

Family members

Effects of suicide exposure on families of veterans and service members may be particularly profound, especially for those related to the deceased. With regards to service members in particular, research indicates that suicides overwhelmingly occur in the individual’s residence (Defense Suicide Prevention Office [DSPO], 2014). As a result, family members are especially likely to find the decedent’s body, an overwhelmingly traumatizing experience (Harrington-LaMorie et al., 2018). Complicating matters further, bereaved family members also undergo military death investigations, which can be highly distressing, but unavoidable due to implications for benefits (Harrington-LaMorie et al., 2018).

Moreover, one study suggests that family members bereaved by a military suicide may face greater shame, isolation, or distress than civilian families (Harrington-LaMorie et al., 2018). Harrington-LaMorie et al. (2018) discuss how, given the military cultural perception of suicide as a dishonorable death, this stigma in turn may negatively affect military community support. Young military families may be particularly vulnerable to this withdrawal of social support, as new in-laws or family relations may assign blame to bereaved spouses. Spouses and immediate family members may also blame themselves, believing that they did not do enough to connect the decedent to mental health treatment. Even among families in which stigma and blame do not present as significant concerns, social support may be limited by a general lack of knowledge in how best to help families after a death by suicide.

Suicide exposure in military families may be associated with more positive views of mental health treatment, which may be protective during this time of grief. In one study (LaCroix et al., 2018), family members of service members who had died by suicide rated the following action steps most integral for prevention of military suicides: reducing mental health stigma, increasing care and support from military leadership, provision of confidential mental health and crisis management services, and recognition of warning signs. Although respondents rated these steps as highly important, it is unclear if ratings were directly related to suicide exposure given lack of a comparison group.

To this end, future research will need to compare families with and without suicide exposure (including military families facing bereavement from other causes of death) to determine the unique effect of suicide exposure on attitudes toward mental health treatment. In addition, the work of Harrington-LaMorie et al. (2018) provides a strong foundation, yet far more research is needed on the unique challenges faced by military families exposed to suicide. For instance, it is unclear if the effects on spouses or partners differ from the effects on children; similarly, it is unclear how different family structures (e.g. same-sex partnership, unmarried/cohabitating couples, biological children relative to stepchildren, etc.) may affect the consequences of suicide exposure. Future research should also examine factors associated with adaptive responses to suicide exposure in military families (e.g. positive views of mental health treatment), and how these factors may be developed or enhanced.

Military systems/treatment providers

Perhaps unsurprisingly, research on the effects of suicide exposure on military systems (peers, overall unit cohesion, military personnel, and treatment providers) remains severely under-studied (Pak et al., 2019). A case study (Carr, 2011) describes both acute and long-term effects of suicide exposure on the decedent’s unit, the on-base medical unit, and the mental health providers on base. These acute effects included shock, disbelief, guilt, acute stress reactions (e.g. dissociation, hypervigilance, insomnia), and subsequent mental health concerns among fellow service members, severe enough to necessitate evacuation. Long-term effects included continued guilt, intensified mental health difficulties, and increased mental health treatment referrals. Further, on-base mental health treatment providers reported increased burden and strain. Consistent with this, Pak et al. (2019) suggest that individuals in units exposed to suicide may perceive having failed both the decedent and the bereaved family and, as a result, blame themselves for the individual’s death. Indeed, higher grief following a suicide death has been linked with lower unit cohesion, whereas the opposite effect has been found for combat-related deaths (Lubens & Silver, 2019). In addition to collective grieving, military units may further face poor morale, as members of the unit may begin to lack confidence in peers and leadership (Pak et al., 2019). Pak et al. (2019) proposed that how the military unit responds to a suicide exposure (including leadership responsiveness, unit cohesion, and unit social support) will affect subsequent survivor responses; however, this remains largely untested.

Although this research provides valuable preliminary insight, greater empirical work will need to be done documenting the effects of suicide exposure on broader military systems. Tests of Pak et al.’s (2019) proposed model may reveal factors that mitigate risks associated with suicide exposure in military units. Future research will also need to include large, diverse samples of different entities within one’s military system (peers, leaders, treatment providers, etc.) and determine how results compare to those of Carr’s case study (2011). Additionally, research is needed on how specific aspects of suicide exposure may uniquely affect these outcomes. Finally, researchers may wish to assess how subjective norms and attitudes (e.g. the unit’s stigma around mental health difficulties and treatment) affect the consequences of suicide exposure.

Summary and future directions

Overall, studies suggest that half or more veterans experience suicide exposure (47.1–65.4%). This prevalence appears elevated compared with meta-analytical research showing a 21.8% lifetime prevalence (Andriessen et al., 2017). Elevated suicide exposure rates among service members and military veterans is unsurprising considering the high suicide rates within this population (Psychological Health Center of Excellence, 2018; U.S. Department of Veterans Affairs, 2019). However, a meta-analysis (Andriessen et al., 2017) noted significant heterogeneity across samples. Thus, it is possible that prevalence rates for suicide exposure among military veterans may be in part biased by limited sample sizes. Notably, there were no studies we could identify evaluating suicide exposure prevalence among military families. Future research is sorely needed to establish the prevalence of suicide exposure in family members and peers of veterans/service members. Through an understanding of how greatly these individuals are impacted by suicide exposure, researchers can establish the importance of studying exposure for future grants in these samples. This could be accomplished through cross-sectional research involving survey administration to military families/peers.

Additionally, studies generally showed significant associations between suicide exposure and suicidal ideation and attempts. However, these effects tended to be small and appeared to be variable across populations (e.g. National Guard, student veterans). Specific features of suicide exposure (e.g. closeness, perceived impact) may contribute to the degree to which military veterans experience increased risk. It is possible such features impact heterogeneity of findings across samples. In addition, the reviewed studies did not consistently measure the features necessary to allow for replication of findings across studies. Similarly, researchers evaluated no specific mechanisms of risk. Past studies of first responders, who experience frequent suicide exposure, show that suicide exposure is positively associated with elevated acquired capability for suicide, a known suicide risk factor (Hom et al., 2018). Further exploration of potential mechanisms of suicide risk associated with suicide exposure may help better disentangle these relationships. For example, perceived burdensomeness, thwarted belongingness, psychological pain, and hopelessness are all risk factors that have not been looked at in suicide-exposed veterans/service members. Additionally, future researchers may wish to explore the possibility that the effects of suicide exposure on risk mechanisms (e.g. acquired capability) differ between military and civilian samples.

When considering research on protective factors and views on mental health care, there were very few articles studying these variables within military veteran populations. Only one study was identified that examined a protective factor in suicide-exposed veterans. Weisenhorn et al.’s (2017) work suggests that married veterans are less likely to report that suicide exposure highly impacted their lives compared to non-married veterans. This lack of research on protective factors is a major gap in the literature, as past research in nonexposed veteran samples shows protective factors, such as reasons for living, are associated with decreased suicide risk among military veterans (Chen et al., 2020). As such, future work looking at other factors that may reduce suicide risk in exposed veterans/service members is sorely needed. Similarly, past studies have found that negative mental health beliefs, such as stigmatizing beliefs toward treatment and individuals with mental illness, are associated with decreased help-seeking; an important avenue of support for mitigating suicide risk (Schnyder et al., 2017). Additional research is needed to better understand how suicide exposure impacts protective factors and mental health views to inform future suicide prevention efforts.

Interestingly, there were few articles on the impact of suicide exposure on service members/veteran peers and military family members. Cerel et al (2019) note that approximately 135 individuals are impacted by each suicide death. The limited research on these different military systems shows challenges to gaining support following suicide exposure as the result of stigma and other barriers. Indeed, the small number of identified studies and the small sample sizes may indicate the role of stigma in constraining some of these research efforts. Thus, supporting family members and friends is an important avenue for mitigating future risk. Use of methodologies, such as social networks analysis, may help to identify risk and protective factors within a social circle to inform tailored prevention efforts (e.g. Santini et al., 2015). Furthermore, given the high degree of distress experienced following suicide exposure among peers and family members, research is needed on the optimal postvention strategies for decreasing risk of suicide contagion (Hoge et al., 2017).

Suicide exposure among military veterans, their family members, and other affected military personnel is an important, prevalent risk factor for suicide. The extant literature shows some support for the assertion that suicide exposure may lead to increased suicide risk and other mental health outcomes. However, methodological issues including but not limited to predominantly cross-sectional designs, lack of measurement of mechanisms of risk, and small sample sizes preclude definitive conclusions regarding the relationship between suicide exposure and mental health outcomes within this population. These short-comings could be addressed in future research by employing longitudinal studies examining veterans’, service members’, and their families’ experiences with suicide exposure and their own mental health across a multitude of timepoints. Through this type of study design, stronger assertions can be made regarding the association between suicide exposure and subsequent mental health risk. Additionally, through longitudinal designs, mechanisms of risk could be better established.

In considering future research directions as a whole, there is a significant dearth in research on suicide exposure among military family members, peers, and friends. Considering the potential impact of suicide exposure, this research gap may impact not only military family members and other loved ones but also veterans and service members in their social circles. At present, the scope of suicide exposure within this population remains unknown, greatly limiting outreach and intervention efforts. As much remains unknown about the experiences, preferences, and needs of this group, mixed-method studies evaluating qualitative experiences with suicide exposure and their association with suicide and other mental health outcomes may inform future interventions.

Similarly, shared and unique suicide risk mechanisms following suicide exposure for military veterans and service members within the context of military systems remain understudied. Current studies, as described above, have sought to translate existing theoretical constructs to veteran and service member populations but have had limited consideration for potential risk mechanisms specific to each group. For example, help seeking processes by military service members are generally different from veterans served within the VA health care system. Understanding mechanisms of suicide exposure is important for identifying potential targets for intervention with special attention to modifiable risk factors. For example, while specific historical suicide exposure contexts associated with suicide risk (e.g. closeness with the decedent) could be informative for targeted outreach efforts, they would have limited utility for intervention development. One framework which may inform efforts is Fluid Vulnerability Theory, which posits that specific stressors can activate cognitive, affective, and motivational responses that increase suicide risk (Rudd, 2006). These responses may become activated again when presented with similar life stressors, thus leading individuals to have a “fluid” vulnerability to suicide risk. In addition, as aforementioned, suicide exposure is associated with mental health symptoms among military veteran populations that may contribute to suicide risk. For example, trauma-related cognitions among veterans with posttraumatic stress disorder are associated with suicidal ideation (Horwitz et al., 2018). Within the context of Fluid Vulnerability Theory, if a veteran has existing trauma-related cognitions due to military-related loss, similar life events, such as suicide exposure, may activate these cognitions and increase suicide risk. Further research is needed to identify specific mechanisms of suicide risk to inform intervention and prevention efforts.

Methodologically, future studies should also consider using more advanced forms of measurement, such as ecological momentary assessment (EMA). EMA is a research strategy whereby participants’ behaviors and experiences can be measured in real-time, thereby reducing bias that may be associated with memory recall (Shiffman et al., 2008). EMA studies could be utilized with veterans/service members who were recently exposed to suicide to better capture the specific sequence of events that suicide exposed persons may experience. Additionally, patterns of risk could potentially be identified through EMA that could alert doctors or mental health professionals that suicide-exposed veterans and service members may be at risk for suicide.

With regards to mental health treatment and help-seeking, much remains unknown regarding the specific preferences and needs for mental health treatment among military veterans and service members following suicide exposure. Although our review found that mental health treatment is common within this population, it remains unclear if the services received were effective for mitigating suicide risk following suicide exposure or if the services were deemed satisfactory. In addition, the reviewed studies showed a sizeable proportion of individuals have no history of mental health treatment. As the majority of military veterans who die by suicide are not currently engaged in care (Office of Mental Health and Suicide Prevention, 2019), learning more about their preferences and needs for treatment within the context of suicide exposure is important for reaching at-risk individuals.

Additionally, this review only included studies of United States military members/veterans, so these findings may not generalize to military members of other countries. This could be addressed through collaboration with researchers in various countries to collect data on military suicide exposure and mental health across a variety of different cultural backgrounds. Through more substantive research efforts, such as the ones suggested, intervention and prevention efforts can be greatly improved to mitigate the impact of suicide exposure on military populations and their families.