Hostname: page-component-848d4c4894-ttngx Total loading time: 0 Render date: 2024-05-21T04:40:12.836Z Has data issue: false hasContentIssue false
  • English
  • Français

Longitudinal courses of suicidal ideation in U.S. military veterans: a 7-year population-based, prospective cohort study

Published online by Cambridge University Press:  19 February 2021

Sarah Herzog Open the ORCID record for Sarah Herzog [Opens in a new window] ,
Jack Tsai ,
Brandon Nichter Open the ORCID record for Brandon Nichter [Opens in a new window] ,
Lorig Kachadourian ,
Ilan Harpaz-Rotem Open the ORCID record for Ilan Harpaz-Rotem [Opens in a new window]  and
Robert H. Pietrzak
Sarah Herzog*
Affiliation:
Department of Psychiatry, Columbia University Irving Medical Center, Columbia University, New York, NY, USA Division of Molecular Imaging and Neuropathology, New York State Psychiatric Institute, New York, NY, USA
Jack Tsai
Affiliation:
VA National Center on Homelessness Among Veterans, Tampa, FL, USA School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
Brandon Nichter
Affiliation:
Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
Lorig Kachadourian
Affiliation:
U.S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, West Haven, CT, USA Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
Ilan Harpaz-Rotem
Affiliation:
U.S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, West Haven, CT, USA Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
Robert H. Pietrzak
Affiliation:
U.S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, West Haven, CT, USA Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA
*
Author for correspondence: Sarah Herzog, E-mail: sarah.herzog@nyspi.columbia.edu
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

Varied longitudinal courses of suicidal ideation (SI) may be linked to unique sets of risk and protective factors.

Method

A national probability sample of 2291 U.S. veterans was followed over four assessments spanning 7 years to examine how a broad range of baseline risk and protective factors predict varying courses of SI.

Results

Most veterans (82.6%) denied SI at baseline and all follow-ups, while 8.7% had new onset SI, 5.4% chronic SI, and 3.3% remitted SI. Compared to the no-SI group, chronic SI was associated with childhood trauma, baseline major depressive and/or posttraumatic stress disorder (MDD/PTSD), physical health difficulties, and recent traumatic stressors. Remitted veterans had the highest risk of a prior suicide attempt (SA) compared to no-SI [relative risk ratio (RRR) = 3.31] and chronic SI groups (RRR = 4.65); and high rates of MDD/PTSD (RRR = 7.62). New onset SI was associated with recent stressors and physical health difficulties. All symptomatic SI groups reported decrements in protective factors, specifically, social connectedness, trait curiosity/exploration, and purpose in life.

Conclusion

Nearly one-in-five veterans reported SI over a 7-year period, most of whom evidenced new onset or remitted SI courses. Chronic and remitted SI may represent particularly high-risk SI courses; the former was associated with higher rates of prospective SA, and psychiatric and physical distress, and the latter with increased likelihood of prior SA, and isolation from social and mental health supports. Physical disability, MDD/PTSD, and recent stressors may be important precipitating or maintaining factors of SI, while social connectedness may be a key target for suicide prevention efforts.

Keywords

Longitudinalrisk and protective factorssuicidal ideationsuicide attemptveterans
Type
Original Article
Information
Psychological Medicine , Volume 52 , Issue 15 , November 2022 , pp. 3570 - 3579
Check for updates
Copyright
Copyright © The Author(s) 2021. Published by Cambridge University Press

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Afifi, T. O., Taillieu, T., Zamorski, M. A., Turner, S., Cheung, K., & Sareen, J. (2016). Association of child abuse exposure with suicidal ideation, suicide plans, and suicide attempts in military personnel and the general population in Canada. JAMA Psychiatry, 73(3), 229–238.CrossRefGoogle ScholarPubMed
Allan, N. P., Gros, D. F., Lancaster, C. L., Saulnier, K. G., & Stecker, T. (2019). Heterogeneity in short-term suicidal ideation trajectories: Predictors of and projections to suicidal behavior. Suicide and Life-Threatening Behavior, 49(3), 826–837.CrossRefGoogle ScholarPubMed
Baca-Garcia, E., Perez-Rodriguez, M. M., Oquendo, M. A., Keyes, K. M., Hasin, D. S., Grant, B. F., & Blanco, C. (2011). Estimating risk for suicide attempt: Are we asking the right questions?: Passive suicidal ideation as a marker for suicidal behavior. Journal of Affective Disorders, 134(1–3), 327–332.CrossRefGoogle ScholarPubMed
Bomyea, J., Stout, D., & Simmons, A. (2019). Attenuated prefrontal and temporal neural activity during working memory as a potential biomarker of suicidal ideation in veterans with PTSD. Journal of Affective Disorders, 257, 607–614.CrossRefGoogle ScholarPubMed
Borges, G., Angst, J., Nock, M. K., Ruscio, A. M., & Kessler, R. C. (2008). Risk factors for the incidence and persistence of suicide-related outcomes: A 10-year follow-up study using the National Comorbidity Surveys. Journal of Affective Disorders, 105(1–3), 25–33.CrossRefGoogle ScholarPubMed
Bruffaerts, R., Demyttenaere, K., Borges, G., Haro, J. M., Chiu, W. T., Hwang, I., … Alonso, J. (2010). Childhood adversities as risk factors for onset and persistence of suicidal behaviour. The British Journal of Psychiatry, 197(1), 20–27.CrossRefGoogle ScholarPubMed
Bush, K., Kivlahan, D. R., McDonell, M. B., Fihn, S. D., & Bradley, K. A. (1998). The AUDIT alcohol consumption questions (AUDIT-C): An effective brief screening test for problem drinking. Archives of Internal Medicine, 158(16), 1789–1795.CrossRefGoogle ScholarPubMed
Campbell-Sills, L., & Stein, M. B. (2007). Psychometric analysis and refinement of the Connor–Davidson Resilience Scale (CD-RISC): Validation of a 10-item measure of resilience. Journal of Traumatic Stress, 20(6), 1019–1028.CrossRefGoogle ScholarPubMed
Carlson, E. B., Smith, S. R., Palmieri, P. A., Dalenberg, C., Ruzek, J. I., Kimerling, R., … Spain, D. A. (2011). Development and validation of a brief self-report measure of trauma exposure: The trauma history screen. Psychological Assessment, 23(2), 463.CrossRefGoogle ScholarPubMed
Corona, C. D., Van Orden, K. A., Wisco, B. E., & Pietrzak, R. H. (2019). Meaning in life moderates the association between morally injurious experiences and suicide ideation among US combat veterans: Results from the National Health and Resilience in Veterans Study. Psychological Trauma: Theory, Research, Practice, and Policy, 11(6), 614.CrossRefGoogle ScholarPubMed
Derogatis, L. R., & Spencer, P. (1993). Brief Symptom Inventory: BSI (Vol. 18). Upper Saddle River, NJ, USA: Pearson.Google Scholar
Desai, S., Arias, I., Thompson, M. P., & Basile, K. C. (2002). Childhood victimization and subsequent adult revictimization assessed in a nationally representative sample of women and men. Violence and Victims, 17(6), 639. Retrieved from https://search.proquest.com/docview/208556395/fulltextPDF/2EDFDA903AA544B5PQ/1?accountid=12261.CrossRefGoogle Scholar
Fanning, J. R., & Pietrzak, R. H. (2013). Suicidality among older male veterans in the United States: Results from the national health and resilience in veterans study. Journal of Psychiatric Research, 47(11), 1766–1775.CrossRefGoogle ScholarPubMed
Franklin, J. C., Ribeiro, J. D., Fox, K. R., Bentley, K. H., Kleiman, E. M., Huang, X., … Nock, M. K. (2017). Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychological Bulletin, 143(2), 187.CrossRefGoogle ScholarPubMed
Fuehrlein, B. S., Mota, N., Arias, A. J., Trevisan, L. A., Kachadourian, L. K., Krystal, J. H., … Pietrzak, R. H. (2016). The burden of alcohol use disorders in US military veterans: Results from the National Health and Resilience in Veterans Study. Addiction, 111(10), 1786–1794.CrossRefGoogle ScholarPubMed
Glaesmer, H., Rief, W., Martin, A., Mewes, R., Brähler, E., Zenger, M., & Hinz, A. (2012). Psychometric properties and population-based norms of the Life Orientation Test Revised (LOT-R). British Journal of Health Psychology, 17(2), 432–445.CrossRefGoogle ScholarPubMed
Grasso, D. J., Ford, J. D., & Briggs-Gowan, M. J. (2013). Early life trauma exposure and stress sensitivity in young children. Journal of Pediatric Psychology, 38(1), 94–103.CrossRefGoogle ScholarPubMed
Groves, R. M., Fowler, F. J. Jr., Couper, M., Lepkowski, J., Singer, E., & Tourangeau, R. (2009). Survey Methodology (2nd ed.). New York: John Wiley & Sons.Google Scholar
Hardy, S. E., & Gill, T. M. (2004). Recovery from disability among community-dwelling older persons. JAMA, 291(13), 1596–1602.CrossRefGoogle ScholarPubMed
Have, M. T., de Graaf, R., Van Dorsselaer, S., Verdurmen, J., van't Land, H., Vollebergh, W., & Beekman, A. (2009). Incidence and course of suicidal ideation and suicide attempts in the general population. The Canadian Journal of Psychiatry, 54(12), 824–833.CrossRefGoogle ScholarPubMed
Hazan, C., & Shaver, P. R. (1990). Love and work: An attachment-theoretical perspective. Journal of Personality and Social Psychology, 59(2), 270.CrossRefGoogle Scholar
Hedegaard, H., Curtin, S. C., & Warner, M. (2020). Increase in suicide mortality in the United States, 1999–2018. National Center for Health Statistics, Data Brief No. 362, April 2020.Google Scholar
Herzog, S., Fogle, B., Harpaz-Rotem, I., Tsai, J., & Pietrzak, R. H. (2019). Dissociative symptoms in a nationally representative sample of trauma-exposed U.S. military veterans: Prevalence, comorbidities, and suicidality. Journal of Affective Disorders, 272, 138–145.CrossRefGoogle Scholar
Joiner, T. E. Jr, Conwell, Y., Fitzpatrick, K. K., Witte, T. K., Schmidt, N. B., Berlim, M. T., … Rudd, M. D. (2005). Four studies on how past and current suicidality relate even when ‘everything but the kitchen sink’ is covaried. Journal of Abnormal Psychology, 114(2), 291.CrossRefGoogle ScholarPubMed
Kang, H. K., Bullman, T. A., Smolenski, D. J., Skopp, N. A., Gahm, G. A., & Reger, M. A. (2015). Suicide risk among 1.3 million veterans who were on active duty during the Iraq and Afghanistan wars. Annals of Epidemiology, 25(2), 96–100.CrossRefGoogle ScholarPubMed
Kashdan, T. B., Gallagher, M. W., Silvia, P. J., Winterstein, B. P., Breen, W. E., Terhar, D., & Steger, M. F. (2009). The curiosity and exploration inventory-II: Development, factor structure, and psychometrics. Journal of Research in Personality, 43(6), 987–998.CrossRefGoogle ScholarPubMed
Kleiman, E. M., & Beaver, J. K. (2013). A meaningful life is worth living: Meaning in life as a suicide resiliency factor. Psychiatry Research, 210(3), 934–939.CrossRefGoogle ScholarPubMed
Koenig, H. G., & Büssing, A. (2010). The Duke University Religion Index (DUREL): A five-item measure for use in epidemological studies. Religions, 1(1), 78–85.CrossRefGoogle Scholar
Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613.CrossRefGoogle ScholarPubMed
Kuwert, P., Knaevelsrud, C., & Pietrzak, R. H. (2014). Loneliness among older veterans in the United States: results from the National Health and Resilience in Veterans Study. The American Journal of Geriatric Psychiatry, 22(6), 564–569.CrossRefGoogle ScholarPubMed
Löwe, B., Kroenke, K., & Gräfe, K. (2005). Detecting and monitoring depression with a two-item questionnaire (PHQ-2). Journal of Psychosomatic Research, 58(2), 163–171.CrossRefGoogle ScholarPubMed
Madsen, T., Karstoft, K.-I., Bertelsen, M., & Andersen, S. B. (2014). Postdeployment suicidal ideations and trajectories of posttraumatic stress disorder in Danish soldiers: A 3-year follow-up of the USPER study. Journal of Clinical Psychiatry, 74(9), 994–1000.CrossRefGoogle Scholar
Maguen, S., Metzler, T. J., Bosch, J., Marmar, C. R., Knight, S. J., & Neylan, T. C. (2012). Killing in combat may be independently associated with suicidal ideation. Depression and Anxiety, 29(11), 918–923.CrossRefGoogle ScholarPubMed
McCullough, M. E., Emmons, R. A., & Tsang, J.-A. (2001). The gratitude questionnaire-six item form (GQ-6). Retrieved April, 16, 2010.Google Scholar
Molnar, B. E., Berkman, L. F., & Buka, S. L. (2001). Psychopathology, childhood sexual abuse and other childhood adversities: Relative links to subsequent suicidal behaviour in the US. Psychological Medicine, 31(6), 965.CrossRefGoogle ScholarPubMed
Mościcki, E. K. (1997). Identification of suicide risk factors using epidemiologic studies. Psychiatric Clinics of North America, 20(3), 499–517.CrossRefGoogle ScholarPubMed
Mościcki, E. K. (2001). Epidemiology of completed and attempted suicide: Toward a framework for prevention. Clinical Neuroscience Research, 1(5), 310–323.CrossRefGoogle Scholar
Nichter, B., Hill, M., Norman, S., Haller, M., & Pietrzak, R. H. (2020a). Associations of childhood abuse and combat exposure with suicidal ideation and suicide attempt in US military veterans: A nationally representative study. Journal of Affective Disorders, 276, 1102–1108.CrossRefGoogle ScholarPubMed
Nichter, B., Hill, M., Norman, S., Haller, M., & Pietrzak, R. H. (2020b). Mental health treatment utilization among US military veterans with suicidal ideation: Results from the national health and resilience in veterans study. Journal of Psychiatric Research, 130, 61–67.CrossRefGoogle ScholarPubMed
Nock, M. K., Borges, G., Bromet, E. J., Alonso, J., Angermeyer, M., Beautrais, A., … Gluzman, S. (2008a). Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. The British Journal of Psychiatry, 192(2), 98–105.CrossRefGoogle ScholarPubMed
Nock, M. K., Borges, G., Bromet, E. J., Cha, C. B., Kessler, R. C., & Lee, S. (2008b). Suicide and suicidal behavior. Epidemiologic Reviews, 30(1), 133–154.CrossRefGoogle ScholarPubMed
Nock, M. K., Deming, C. A., Fullerton, C. S., Gilman, S. E., Goldenberg, M., Kessler, R. C., … Schoenbaum, M. (2013). Suicide among soldiers: A review of psychosocial risk and protective factors. Psychiatry: Interpersonal & Biological Processes, 76(2), 97–125.CrossRefGoogle ScholarPubMed
Nock, M. K., Millner, A. J., Joiner, T. E., Gutierrez, P. M., Han, G., Hwang, I., … Zaslavsky, A. M. (2018). Risk factors for the transition from suicide ideation to suicide attempt: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Journal of Abnormal Psychology, 127(2), 139.CrossRefGoogle ScholarPubMed
Nock, M. K., Stein, M. B., Heeringa, S. G., Ursano, R. J., Colpe, L. J., Fullerton, C. S., … Schoenbaum, M. (2014). Prevalence and correlates of suicidal behavior among soldiers: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry, 71(5), 514–522.CrossRefGoogle ScholarPubMed
Pagura, J., Cox, B. J., Sareen, J., & Enns, M. W. (2008). Factors associated with multiple versus single episode suicide attempts in the 1990–1992 and 2001–2003 United States national comorbidity surveys. The Journal of Nervous and Mental Disease, 196(11), 806–813.CrossRefGoogle ScholarPubMed
Pietrzak, R. H., & Cook, J. M. (2013). Psychological resilience in older US veterans: Results from the national health and resilience in veterans study. Depression and Anxiety, 30(5), 432–443.CrossRefGoogle ScholarPubMed
Pietrzak, R. H., Goldstein, M. B., Malley, J. C., Rivers, A. J., Johnson, D. C., & Southwick, S. M. (2010). Risk and protective factors associated with suicidal ideation in veterans of operations enduring freedom and Iraqi freedom. Journal of Affective Disorders, 123(1–3), 102–107.CrossRefGoogle ScholarPubMed
Pietrzak, R. H., Pitts, B. L., Harpaz-Rotem, I., Southwick, S. M., & Whealin, J. M. (2017). Factors protecting against the development of suicidal ideation in military veterans. World Psychiatry, 16(3), 326.CrossRefGoogle ScholarPubMed
Ribeiro, J., Franklin, J., Fox, K. R., Bentley, K., Kleiman, E. M., Chang, B., & Nock, M. K. (2016). Self-injurious thoughts and behaviors as risk factors for future suicide ideation, attempts, and death: A meta-analysis of longitudinal studies. Psychological Medicine, 46(2), 225–236.CrossRefGoogle Scholar
Russell, D., Turner, R. J., & Joiner, T. E. (2009). Physical disability and suicidal ideation: A community-based study of risk/protective factors for suicidal thoughts. Suicide and Life-Threatening Behavior, 39(4), 440–451.CrossRefGoogle ScholarPubMed
Sareen, J., Cox, B. J., Afifi, T. O., de Graaf, R., Asmundson, G. J., Ten Have, M., & Stein, M. B. (2005). Anxiety disorders and risk for suicidal ideation and suicide attempts: A population-based longitudinal study of adults. Archives of General Psychiatry, 62(11), 1249–1257.CrossRefGoogle ScholarPubMed
Schulenberg, S. E., Schnetzer, L. W., & Buchanan, E. M. (2011). The purpose in life test-short form: Development and psychometric support. Journal of Happiness Studies, 12(5), 861–876.CrossRefGoogle Scholar
Sherbourne, C. D., & Stewart, A. L. (1991). The MOS social support survey. Social Science & Medicine, 32(6), 705–714.CrossRefGoogle ScholarPubMed
Smith, N. B., Mota, N., Tsai, J., Monteith, L., Harpaz-Rotem, I., Southwick, S. M., & Pietrzak, R. H. (2016). Nature and determinants of suicidal ideation among US veterans: Results from the national health and resilience in veterans study. Journal of Affective Disorders, 197, 66–73.CrossRefGoogle ScholarPubMed
Stewart, A. L., & Ware, J. E. (1992). Measuring Functioning and Well-Being: The Medical Outcomes Study Approach. Durham and London: Duke University Press.Google Scholar
Teo, A. R., Marsh, H. E., Forsberg, C. W., Nicolaidis, C., Chen, J. I., Newsom, J., … Dobscha, S. K. (2018). Loneliness is closely associated with depression outcomes and suicidal ideation among military veterans in primary care. Journal of Affective Disorders, 230, 42–49.CrossRefGoogle ScholarPubMed
Terhakopian, A., Sinaii, N., Engel, C. C., Schnurr, P. P., & Hoge, C. W. (2008). Estimating population prevalence of posttraumatic stress disorder: An example using the PTSD checklist. Journal of Traumatic Stress, 21(3), 290–300.CrossRefGoogle ScholarPubMed
Thompson, J. M., Zamorski, M. A., Sweet, J., VanTil, L., Sareen, J., Pietrzak, R. H., … Pedlar, D. (2014). Roles of physical and mental health in suicidal ideation in Canadian Armed Forces Regular Force veterans. Canadian Journal of Public Health, 105(2), e109–e115.CrossRefGoogle ScholarPubMed
U.S. Census Bureau (2011). Current Population Survey. Washington, D.C: National Processing Center (NCP).Google Scholar
U.S. Department of Health and Human Services. (2010). Mental health and mental disorders objectives. Healthy People 2020. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/mental-health-and-mental-disorders/objectives.Google Scholar
U.S. Department of Veterans Affairs. (2019). 2019 National Veteran Suicide Prevention Annual Report.Google Scholar
Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S. R., Selby, E. A., & Joiner, T. E Jr. (2010). The interpersonal theory of suicide. Psychological Review, 117(2), 575.CrossRefGoogle ScholarPubMed
Wang, J., Ursano, R. J., Gonzalez, O. I., Russell, D. W., Dinh, H., Hernandez, L., … Galea, S. (2018). Association of suicidal ideation with trajectories of deployment-related PTSD symptoms. Psychiatry Research, 267, 455–460.CrossRefGoogle ScholarPubMed
Weathers, F. W., Huska, J. A., & Keane, T. M. (1991). PCL-C for DSM-IV. Boston: National Center for PTSD-Behavioral Science Division.Google Scholar
Weathers, F. W., Litz, B. T., Herman, D. S., Huska, J. A., & Keane, T. M. (1993). The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. Paper presented at the annual convention of the international society for traumatic stress studies, San Antonio, TX.Google Scholar
Witte, T. K., Fitzpatrick, K. K., Warren, K. L., Schatschneider, C., & Schmidt, N. B. (2006). Naturalistic evaluation of suicidal ideation: Variability and relation to attempt status. Behaviour Research and Therapy, 44(7), 1029–1040.CrossRefGoogle ScholarPubMed
World Health Organization (WHO). (2019). Suicide: Key Facts. Retrieved from https://www.who.int/news-room/fact-sheets/detail/suicide.Google Scholar
Yarlas, A., White, M., & Bjorner, J. (2013). The development and validation of a revised version of the Medical Outcomes Study Cognitive Functioning Scale (Mos-Cog-R). Value in Health, 16(3), A33–A34.CrossRefGoogle Scholar
Zerach, G., Levi-Belz, Y., & Solomon, Z. (2014). Trajectories of suicidal ideation and posttraumatic stress symptoms among former prisoners of war: A 17-year longitudinal study. Journal of Psychiatric Research, 49, 83–89.CrossRefGoogle ScholarPubMed