Changes in guilt cognitions mediate the effect of trauma-informed guilt reduction therapy on PTSD and depression outcomes.

OBJECTIVE: Trauma-informed guilt reduction therapy (TrIGR), a six-session cognitive behavioral therapy targeting trauma-related guilt and distress, reduces guilt and symptoms of posttraumatic stress disorder (PTSD) and depression, yet little is known regarding how and why TrIGR may be effective. METHOD: This study examined treatment-related changes in avoidant coping and trauma-related guilt cognitions as possible mediators of treatment effects on PTSD and depression outcomes at 3- and 6-month follow-up. Data were from a randomized controlled trial for treatment of trauma-related guilt comparing TrIGR and supportive care therapy among 145 post-9/11 US veterans (Mage = 39.2 [8.1], 93.8% male). RESULTS: At pretreatment, most (86%) met PTSD criteria. Intent to treat analyses using parallel mediation models indicated changes in guilt cognitions, but not avoidant coping, mediated the effect of TrIGR on reducing PTSD severity at 3-month (a × b = -0.15, p < 0.01, 95% CI: [-0.24 to -0.06], p = 0.001) and 6-month (a × b = -0.17, 95% CI: [-0.26 to -0.07], p = 0.001) follow-up. Similarly, changes in guilt cognitions, but not avoidant coping, mediated the effect of TrIGR on reducing depression severity at 3-month (a × b = -0.10, 95% CI: [-0.18 to -0.02], p = 0.02) and 6-month (a × b = -0.11, 95% CI: [-0.20 to -0.03], p = 0.01) follow-up. CONCLUSIONS: Compared to guilt cognitions, changes in avoidant coping were less integral to downstream PTSD and depression symptom reduction. Guilt cognition change may be a salient active ingredient of PTSD and depression treatment for those with trauma-related guilt and a key therapy element to which providers should be attuned.

Prevalence, correlates, and mental health burden associated with homelessness in U.S. military veterans.

BACKGROUND: Homelessness is a major public health problem among U.S. military veterans. However, contemporary, population-based data on the prevalence, correlates, and mental health burden of homelessness among veterans are lacking. METHODS: Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, a nationally representative survey of veterans (n = 4069). Analyses examined the prevalence and correlates of homelessness, as well as the independent associations between homelessness and current probable psychiatric conditions, suicidality, and functioning. RESULTS: The lifetime prevalence of homelessness was 10.2% (95% confidence interval 9.3-11.2). More than 8-of-10 veterans reported experiencing their first episode of homelessness following military service, with a mean of 10.6 years post-discharge until onset (s.d. = 12.6). Adverse childhood experiences (ACEs), cumulative trauma burden, current household income, younger age, and drug use disorder emerged as the strongest correlates of homelessness (49% of total explained variance). Veterans with a history of homelessness had elevated odds of lifetime suicide attempt, attempting suicide two or more times, and past-year suicide ideation [odd ratios (ORs) 1.3-3.1]. They also had higher rates of current probable posttraumatic stress disorder, major depressive, generalized anxiety, and drug use disorders (ORs 1.7-2.4); and scored lower on measures of mental, physical, cognitive, psychosocial functioning (d = 0.11-0.15). CONCLUSIONS: One in ten U.S. veterans has experienced homelessness, and these veterans represent a subpopulation at substantially heightened risk for poor mental health and suicide. ACEs were the strongest factor associated with homelessness, thus underscoring the importance of targeting early childhood adversities and their mental health consequences in prevention efforts for homelessness in this population.

Moral injury and substance use disorders among US combat veterans: results from the 2019-2020 National Health and Resilience in Veterans Study.

BACKGROUND: Exposure to potentially morally injurious events (PMIEs) is associated with increased risk for substance use disorders (SUDs), although population-based studies remain limited. The goal of this study was to better understand the relationships between PMIE exposure and lifetime and past-year alcohol use disorder (AUD), drug use disorder (DUD), and SUD. METHODS: Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 1321 combat veterans. Multivariable analyses examined associations between three types of PMIE exposure (perpetration, witnessing, and betrayal), and lifetime and past-year AUD, DUD, and SUD, adjusting for sociodemographic variables, combat exposure severity, prior trauma, and lifetime posttraumatic stress disorder and major depressive disorder. RESULTS: Perpetration was associated with increased odds of lifetime AUD (OR 1.15; 95% CI 1.01-1.31) and lifetime SUD (OR 1.18; 95% CI 1.03-1.35). Witnessing was associated with greater odds of past-year DUD (OR 1.20; 95% CI 1.04-1.38) and past-year SUD (OR 1.14; 95% CI 1.02-1.28). Betrayal was associated with past-year AUD (OR 1.20; 95% CI 1.03-1.39). A large proportion of the variance in past-year AUD was accounted for by betrayal (38.7%), while witnessing accounted for 25.8% of the variance in past-year DUD. CONCLUSIONS: Exposure to PMIEs may be a stronger contributor to SUDs among veterans than previously known. These findings highlight the importance of targeted assessment and treatment of moral injury among veterans with SUDs, as well as attending to specific types of morally injurious experiences when conceptualizing and planning care.

Mental health impact of the COVID-19 pandemic in U.S. military veterans: a population-based, prospective cohort study.

BACKGROUND: The coronavirus disease-2019 (COVID-19) pandemic has caused myriad health, social, and economic stressors. To date, however, no known study has examined changes in mental health during the pandemic in the U.S. military veteran population. METHODS: Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, a nationally representative, prospective cohort survey of 3078 veterans. Pre-to-peri-pandemic changes in psychiatric symptoms were evaluated, as well as pre-pandemic risk and protective factors and pandemic-related correlates of increased psychiatric distress. RESULTS: The prevalence of generalized anxiety disorder (GAD) positive screens increased from pre- to peri-pandemic (7.1% to 9.4%; p < 0.001) and was driven by an increase among veterans aged 45-64 years (8.2% to 13.5%; p < 0.001), but the prevalence of major depressive disorder and posttraumatic stress disorder positive screens remained stable. Using a continuous measure of psychiatric distress, an estimated 13.2% of veterans reported a clinically meaningful pre-to-peri-pandemic increase in distress (mean = 1.1 standard deviation). Veterans with a larger pre-pandemic social network size and secure attachment style were less likely to experience increased distress, whereas veterans reporting more pre-pandemic loneliness were more likely to experience increased distress. Concerns about pandemic-related social losses, mental health COVID-19 effects, and housing stability during the pandemic were associated with increased distress, over-and-above pre-pandemic factors. CONCLUSIONS: Although most U.S. veterans showed resilience to mental health problems nearly 1 year into the pandemic, the prevalence of GAD positive screens increased, particularly among middle-aged veterans, and one of seven veterans experienced increased distress. Clinical implications of these findings are discussed.

Genetic liability to suicidal thoughts and behaviors and risk of suicide attempt in US military veterans: moderating effects of cumulative trauma burden.

BACKGROUND: Little is known about environmental factors that may influence associations between genetic liability to suicidality and suicidal behavior. METHODS: This study examined whether a suicidality polygenic risk score (PRS) derived from a large genome-wide association study (N = 122,935) was associated with suicide attempts in a population-based sample of European-American US military veterans (N = 1664; 92.5% male), and whether cumulative lifetime trauma exposure moderated this association. RESULTS: Eighty-five veterans (weighted 6.3%) reported a history of suicide attempt. After adjusting for sociodemographic and psychiatric characteristics, suicidality PRS was associated with lifetime suicide attempt (odds ratio 2.65; 95% CI 1.37-5.11). A significant suicidality PRS-by-trauma exposure interaction emerged, such that veterans with higher levels of suicidality PRS and greater trauma burden had the highest probability of lifetime suicide attempt (16.6%), whereas the probability of attempts was substantially lower among those with high suicidality PRS and low trauma exposure (1.4%). The PRS-by-trauma interaction effect was enriched for genes implicated in cellular and developmental processes, and nervous system development, with variants annotated to the DAB2 and SPNS2 genes, which are implicated in inflammatory processes. Drug repurposing analyses revealed upregulation of suicide gene-sets in the context of medrysone, a drug targeting chronic inflammation, and clofibrate, a triacylglyceride level lowering agent. CONCLUSION: Results suggest that genetic liability to suicidality is associated with increased risk of suicide attempt among veterans, particularly in the presence of high levels of cumulative trauma exposure. Additional research is warranted to investigate whether incorporation of genomic information may improve suicide prediction models.

Psychosocial moderators of polygenic risk for suicidal ideation: Results from a 7-year population-based, prospective cohort study of U.S. veterans.

Polygenic risk scores (PRS) may help inform the etiology of suicidal thoughts and behaviors. In this study, we evaluated whether a suicidality PRS derived from a large genome-wide association study (GWAS) of suicidality from the UK Biobank (N = 122,935) predicted suicidal ideation (SI) in a 7-year population-based, prospective cohort of European-American US veterans (N = 1326). Results revealed that 8.8% (n = 115) of veterans developed new-onset SI, 4.0% (n = 52) had chronic SI, 3.4% (n = 31) had remitted SI, and 83.8% (n = 1128) denied SI over the study period. Suicidality PRSstandardized was positively associated with chronic SI (relative risk ratio [RRR] = 4.54, 95% confidence interval [CI] = 1.01-20.48) and new-onset SI (RRR = 2.97, 95%CI = 1.22-7.23), and negatively associated with remitted SI (RRR = 0.12, 95% CI = 0.02-0.60). Among veterans with higher suicidality PRS, those with higher baseline dispositional optimism had a lower likelihood of chronic SI (RRR = 0.67, 95% CI = 0.49-0.91) and higher likelihood of remitted SI (RRR = 1.98, 95% CI = 1.18-3.31). Among veterans with higher suicidality PRS, those with higher baseline levels of social support were less likely to develop new-onset SI (RRR = 0.95, 95% CI = 0.92-0.99). These interaction effects were enriched for genes implicated in neuron recognition and development, while the PRS main effect was enriched for genes involved in mannosylation. Collectively, results of this study suggest that suicidality PRS is linked prospectively to symptomatic courses of SI, and that dispositional optimism and social support moderate these associations. Interventions targeting these modifiable psychosocial factors may help mitigate risk of SI in veterans with high polygenic risk for suicidality.

Suicidal Thoughts and Behaviors in Older U.S. Military Veterans: Results From the National Health and Resilience in Veterans Study.

OBJECTIVE: To identify the prevalence and correlates associated with suicidal thoughts and behaviors (STBs) in a nationally representative sample of older (55+) US military veterans. METHODS: Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study (N = 3,356; mean age = 70.6). Self-report measures of past-year suicidal ideation (SI), lifetime suicide plan, lifetime suicide attempt(s), and future suicide intent were examined in relation to sociodemographic, neuropsychiatric, trauma, physical health, and protective factors. RESULTS: A total of 6.6% (95% CI = 5.7%-7.8%) of the sample endorsed past-year SI, 4.1% (CI = 3.3%-5.1%) a lifetime suicide plan, 1.8% (CI = 1.4%-2.3%) a lifetime suicide attempt, and 0.9% (CI = 0.5%-1.3%) future suicide intent. Higher levels of loneliness and lower levels of purpose in life were most strongly associated with past-year SI; lifetime history of major depressive disorder with suicide plan and suicide attempt; and frequency of past-year SI and more negative expectations regarding emotional aging with future suicide intent. CONCLUSION: These findings provide the most up-to-date nationally representative prevalence estimates of STBs among older military veterans in the United States. Several modifiable vulnerability factors were found to be associated with suicide risk in older US military veterans, suggesting that these factors may be targets for intervention in this population.

Subjective cognitive difficulties and posttraumatic stress disorder interact to increase suicide risk among middle-aged and older US military veterans.

OBJECTIVES: To examine the role of subjective cognitive difficulties (SCD), posttraumatic stress disorder (PTSD), and their interaction in predicting suicidal ideation and current suicidal intent in middle-aged and older United States (US) military veterans. DESIGN: Population-based cross-sectional study. SETTING AND PARTICIPANTS: Data were analyzed from the 2019 to 2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 3602 US veterans aged 50 years and older (mean age = 69.0). MEASUREMENTS: Questionnaires including the Medical Outcomes Study Cognitive Functioning Scale (SCD), PTSD Checklist for DSM-5 (PTSD), Patient Health Questionnaire-9 (suicidal ideation in the previous two weeks), and the Suicide Behaviors Questionnaire-Revised (current suicidal intent). RESULTS: A total of 154 (4.4%) veterans screened positive for current PTSD, 239 (6.7%) reported past two-week suicidal ideation, and 37 (1.0%) reported current suicidal intent. The probability of suicidal ideation among veterans with both SCD and PTSD was more than six times higher than that observed in the full sample (44.5% vs. 6.7%) and more than 2.5 times higher than that observed in veterans with SCD and no PTSD (44.5% vs. 17.5%). Veterans with both subjective memory and concentration difficulties were more likely to report suicidal intent, though the interaction between SCD and PTSD was not significantly associated with suicidal intent. CONCLUSION: Middle-aged and older U.S. veterans with subjective cognitive impairment and PTSD report higher rates of suicidal ideation than those with SCD alone. Interventions targeting SCD and PTSD may mitigate suicide risk among middle-aged and older veterans.

Cannabis use among U.S. military veterans with subthreshold or threshold posttraumatic stress disorder: Psychiatric comorbidities, functioning, and strategies for coping with posttraumatic stress symptoms.

Cannabis use is common among individuals with posttraumatic stress disorder (PTSD) symptoms, but its impact on psychiatric symptoms and functioning in this population is unclear. To clarify the clinical and functional correlates of cannabis use in individuals with PTSD symptoms, we analyzed data from the 2019-2020 National Health and Resilience in Veterans Study, a nationally representative survey of U.S. military veterans. Participants with current subthreshold or full PTSD (N = 608) reported on their past-6-month cannabis use and current psychiatric symptoms, functioning, treatment utilization, and PTSD symptom management strategies. Veterans with subthreshold/full PTSD who used cannabis more than weekly were more likely to screen positive for co-occurring depression, anxiety, and suicidal ideation than those who did not use cannabis, ORs = 3.4-3.8, or used cannabis less than weekly, ORs = 2.7-3.7. Veterans who used cannabis more than weekly also scored lower in cognitive functioning than veterans with no use, d = 0.25, or infrequent use, d = 0.71, and were substantially more likely to endorse avoidance coping strategies, ORs = 8.2-12.2, including substance use, OR = 4.4, and behavioral disengagement, ORs = 2.7-9.1, to manage PTSD symptoms. Despite more psychiatric and functional problems, veterans with frequent cannabis use were not more likely to engage in mental health treatment, ORs = 0.87-0.99. The results suggest enhanced cannabis use screening, interventions targeting risky use, and strategies promoting treatment engagement may help ameliorate more severe clinical presentations associated with frequent cannabis use among veterans with subthreshold/full PTSD.

Non-suicidal self-injury in US military veterans: Results from the National Health and Resilience in Veterans Study.

BACKGROUND: To evaluate the prevalence of lifetime non-suicidal self-injury (NSSI) among US military veterans and identify sociodemographic, military, psychiatric and clinical correlates associated with NSSI. METHODS: Data were analysed from the 2019-2020 National Health and Resilience in Veterans Study, a contemporary, nationally representative survey of 4069 US veterans. Outcomes measured included lifetime history of NSSI, trauma history, lifetime and current DSM-V mental disorders and lifetime and recent suicidal behaviours. RESULTS: The overall prevalence of lifetime NSSI was 4.2% (95% confidence interval [3.6%, 4.9%]). Multivariable analyses revealed that veterans who endorsed lifetime NSSI were more likely to be younger, female, non-Caucasian, unmarried or unpartnered, and to have a lower annual household income. Veterans who endorsed lifetime NSSI reported more adverse childhood experiences and lifetime traumas and were more likely to have experienced military sexual trauma. They also were more likely to screen positive for lifetime posttraumatic stress disorder, major depressive disorder (MDD) and substance use disorders and to have attempted suicide. Finally, lifetime NSSI was associated with current MDD, generalized anxiety disorder, and substance use disorders, as well as past-year suicidal ideation. CONCLUSION: Results of this study provide the first-known data on the epidemiology of NSSI in US military veterans. They suggest that certain correlates can help identify veterans who may be at greater risk for engaging in NSSI, as well as the potential prognostic utility of lifetime NSSI in predicting current psychiatric problems and suicide risk in this population.

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

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.

Moral injury and suicidal behavior among US combat veterans: Results from the 2019-2020 National Health and Resilience in Veterans Study.

BACKGROUND: Recent research suggests that exposure to potentially morally injurious experiences (PMIEs) may be associated with increased risk for suicidal behavior among US combat veterans, but population-based data on these associations are scarce. This study examined the association between PMIEs with current suicidal ideation (SI), lifetime suicide plans (SP), and suicide attempts (SA) in a contemporary, nationally representative sample of combat veterans. METHODS: Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of US combat veterans (n = 1321). PMIEs were assessed using the Moral Injury Events Scale (MIES). Multivariable logistic regression analyses were conducted to examine associations between MIES total scores and specific types of PMIEs with suicidal behavior. RESULTS: Thirty-six point three percent of veterans reported at least one PMIE. Perceived transgressions by self, others, and betrayal were associated with SI, SP, and SA (odds ratios [ORs] = 1.21-1.27, all p s < .05), after adjusting for sociodemographic, trauma, and psychiatric characteristics. MIES total scores were significantly, albeit weakly, associated with SP (OR = 1.03, p < .01), but not SI/SA. Depression, posttraumatic stress disorder (PTSD), and age emerged as the strongest correlates of SI/SP/SA (14.9%-38.1% of explained variance), while PMIEs accounted for a comparatively modest amount of variance (3.3%-8.9%). CONCLUSIONS: Reports of potentially morally injurious experiences are prevalent among US combat veterans, and associated with increased risk for suicidal behavior, above and beyond severity of combat exposure, PTSD, and depression. Implications for clinical practice and future research are discussed, including the need for methodological advancements in the measurement of moral injury.

Suicide-Specific Cognitions and Suicidal Behavior in U.S. Military Veterans.

BACKGROUND: U.S. military veterans may be reluctant to disclose suicidal thoughts and behaviors. Suicide-specific cognitions, which generally avoid direct mention of suicide, may be reliable indicators of risk among those reluctant to disclose such thoughts and behaviors. METHODS: Data from a population-based, cross-sectional study of 2,430 U.S. military veterans were analyzed to examine the associations between the Brief Suicide Cognitions Scale (B-SCS), suicidal ideation, and suicide planning. RESULTS: After adjusting for age, sex, number of adverse childhood experiences, cumulative trauma burden, depressive symptom severity, and lifetime history of suicide attempt, total scores on the B-SCS (excluding the item mentioning suicide) were uniquely associated with suicidal ideation (odds ratio [OR] = 1.23, 95% confidence interval [CI] = 1.15-1.32) and suicide planning (OR = 1.27, 95%CI = 1.18-1.37). Exploratory post-hoc analyses revealed that difficulties with solving and coping with one's problems were uniquely linked to these outcomes. CONCLUSIONS: Assessment of suicide-specific cognitions may help to enhance suicide detection and prevention in veterans, especially in those who may not directly disclose thoughts of suicide. Intervention efforts to bolster perceived deficits in coping and problem-solving may help mitigate suicide risk in this population.

Health and psychiatric impairment associated with moral injury, military sexual trauma, and their co-occurrence in U.S. combat veterans.

BACKGROUND: Military sexual trauma (MST) and moral injury (MI) are associated with adverse psychiatric and health outcomes among military veterans. However, no known population-based studies have examined the incremental burden associated with the co-occurrence of these experiences relative to either alone. METHOD: Cross-sectional data were analyzed from the National Health and Resilience in Veterans Study, a nationally representative sample of 1330 U.S. combat veterans. Veterans reported on history of exposure to MST and potentially morally injurious events (PMIEs). Analyses estimated the lifetime prevalence of MST only, PMIEs only, and co-occurring MST and PMIEs; and examined associations between MST/PMIEs status and psychiatric and physical health comorbidities, functioning, and suicidality. RESULTS: The lifetime weighted prevalence of exposure to MST only, PMIEs only, and co-occurring MST and PMIEs were 2.7%, 32.3%, and 4.5%, respectively. Compared with all other groups, the co-occurring MST + PMIEs group reported greater severity of posttraumatic stress, depression, generalized anxiety, and insomnia symptoms. They also scored lower on measures of physical, mental, and psychosocial functioning, and reported a greater number of chronic medical conditions and somatic complaints. Veterans with co-occurring MST + PMIEs were more than twice as likely as those with MST only to report past-year suicidal ideation. CONCLUSIONS: The co-occurrence of MST and MI is associated with a greater psychiatric and health burden among combat veterans than either experience alone. Results underscore the importance of assessing and treating MST and MI in this population. Findings underscore the importance for future work to parse overlap between morally salient aspects of MST and the concept of moral injury.

Firearm storage practices among military veterans in the United States: Findings from a nationally representative survey.

BACKGROUND: Unsafe storage of firearms is associated with increased risk of suicide.. However, contemporary population-based data on the prevalence and correlates of firearm storage practices among veterans are limited. METHODS: Data were from the 2022 National Health and Resilience in Veterans Study, a nationally representative sample of 2441 veterans. Analyses examined: (1) the prevalence of firearm storage practices; (2) sociodemographic, psychiatric, and clinical characteristics associated with storing firearms loaded and/or in non-secure location; and (3) associations between types of potentially traumatic events and storage practices. RESULTS: More than half of veterans reported owning one or more personal firearms (50.9%). Among firearm owners, 52.9% reported some form of unsafe firearm storage practice (i.e., loaded and/or non-secure location), with 39.9% reporting that they stored one or more firearms loaded. After adjusting for sociodemographic characteristics, major depressive, alcohol and drug use disorders, direct trauma exposures, future suicidal intent, and traumatic brain injury were associated with storing firearms loaded and/or in a non-secure location (ORs = 1.09-7.16). Veterans with a history of specific forms of direct trauma exposure (e.g., physical assault) were more likely to store firearms unsafely. LIMITATIONS: Cross-sectional design precludes causal inference. CONCLUSIONS: Half of U.S. veterans who own firearms store at least one personal firearm loaded and/or in a non-secure location, with approximately four-in-ten keeping a loaded firearm in the home. These high rates underscore the importance of nationwide training initiatives to promote safe firearm storage for all service members and veterans, regardless of risk status, as well as for healthcare professionals working with veterans.

Sex-specific risk and resilience correlates of suicidal ideation in U.S. military veterans.

OBJECTIVES: To estimate the prevalence and identify gender-specific risk factors associated with suicidal ideation (SI) in a nationally representative sample of U.S. military veterans. METHODS: Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 4069 veterans. Bivariate and multivariable analyses were conducted to identify factors associated with SI in male and female veterans. RESULTS: The prevalence of SI was significantly higher in female than male veterans (18.1 % vs. 11.2 %). In female veterans, results of a relative importance analysis revealed that the majority of explained variance in SI (Nagelkerke R2 = 0.54) was accounted for by lower psychological resilience (44.4 %), and history of non-suicidal self-injury (24.4 %) and alcohol use disorder (20.6 %). In male veterans, the majority of explained variance in SI (Nagelkerke R2 = 0.32) was accounted for by higher loneliness (19.5 %) and hostility (19.1 %), and lower purpose in life (16.3 %). CONCLUSIONS: Suicidal ideation is prevalent among U.S. veterans, particularly in female veterans. Different risk factors emerged as strong correlates of SI in female and male veterans, which may be used to inform gender-specific suicide prevention and treatment efforts in this population.

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.

OBJECTIVES: To determine the incidence of suicidal ideation and suicide attempts (STBs) in veterans without an endorsed history of STBs and identify baseline predictors of these outcomes over a 10-year period. METHODS: Population-based prospective cohort study of 2307 US military veterans using five waves of the 2011-2021 National Health and Resilience in Veterans Study. Baseline data were collected in 2011, with follow-up assessments conducted 2-(2013), 4-(2015), 7-(2018), and 10-years (2021) later. RESULTS: In total, 10.1 % (N = 203) of veterans endorsed incident suicidal ideation (SI) over the 10-year period and 3.0 % (N = 55) endorsed an incident suicide attempt (SA). Multivariable regression analyses revealed the following baseline predictors of incident SI: lower annual household income, current posttraumatic stress disorder, current alcohol use disorder (AUD), disability with activities of daily living (i.e., ADLs) or instrumental activities of daily living (i.e., IADLs), lower perceived social support, lower community integration, and lower purpose in life. Current AUD, greater cumulative trauma burden, and lower purpose in life at baseline were predictive of incident SA. Relative importance analyses revealed that lower purpose in life was the strongest predictor of both incident SI and SA. CONCLUSIONS: Psychosocial determinants of health, such as purpose in life, may be more reliable predictors of incident suicidal thoughts and behaviors than traditional risk factors (e.g., psychiatric distress; history of SA) in those without a history of STBs. Evidence-based interventions that facilitate purpose in life and feelings of connectedness and belonging should be examined as possible treatments for STBs.

Childhood Sexual Abuse and Military Sexual Trauma Interact to Increase Suicide Risk: Results from a Nationally Representative Veteran Sample.

Childhood sexual abuse (CSA) and military sexual trauma (MST) are prevalent among veterans. Such exposures are associated with adverse mental-health sequelae, including elevated risk for suicidal thoughts and behaviors. Nonetheless, prior studies have largely focused upon discrete experiences of CSA or MST in circumscribed samples. In the current study, we analyzed data from a large, nationally representative sample of 4,069 US military veterans to examine main and interactive effects of CSA and MST in relation to suicidal thoughts and behaviors. After accounting for sociodemographics, psychiatric comorbidity, and trauma-related characteristics, we detected a significant interaction between MST and CSA as it related to report of past-year suicidal ideation, lifetime suicide attempt, and risk for future suicide attempt. These findings underscore the impact of sexual trauma throughout the lifespan, highlighting the continued importance of screening for trauma exposure and connecting veterans to appropriate, evidence-based treatment to decrease their risk for suicidal thoughts and behaviors.

Longitudinal Trends in Suicidal Thoughts and Behaviors Among US Military Veterans During the COVID-19 Pandemic.

Importance: Concerns have been raised since the onset of the COVID-19 pandemic that vulnerable populations, such as military veterans, may be at increased risk of suicidal thoughts and behaviors (STBs). Objective: To examine longitudinal trends in STBs in US military veterans during the first 3 years of the COVID-19 pandemic. Design, Setting, and Participants: This cohort study is a population-based longitudinal study including US military veterans that used 3 surveys from the National Health and Resilience in Veterans Study. Median dates of data collection were November 21, 2019 (prepandemic); November 14, 2020; and August 18, 2022. Main Outcomes and Measures: Lifetime and past-year suicidal ideation, suicide planning, and suicide attempt. Results: In this longitudinal study including 2441 veterans (mean [SD] age, 63.2 years [14.0]; 2182 [92.1%] male), past-year suicidal ideation decreased from 9.3% prepandemic (95% CI, 8.2%-10.6%) to 6.8% a year later (95% CI%, 5.8-7.9%) and then slightly increased to 7.7% (95% CI, 6.7%-8.9%) 2 years later. In total, 9 veterans (0.4%) reported attempting suicide at least once during the follow-up period, while 100 (3.8%) developed new-onset suicidal ideation and 28 (1.2%) developed new-onset suicide planning. After adjusting for sociodemographic and military characteristics, factors strongly associated with new-onset suicidal ideation included higher education (odds ratio [OR], 3.27; 95% CI, 1.95-5.46), lifetime substance use disorder (OR, 2.07; 95% CI, 1.23-3.46), prepandemic loneliness (OR, 1.28; 95% CI, 1.09-1.49), and lower prepandemic purpose in life (OR, 0.92; 95% CI, 0.86-0.97). Factors associated with new-onset suicide planning included lifetime substance use disorder (OR, 3.03; 95% CI, 1.22-7.55), higher prepandemic psychiatric distress (OR, 1.52; 95% CI, 1.06-2.18), and lower prepandemic purpose in life (OR, 0.88; 95% CI, 0.81-0.95). Conclusions and Relevance: Contrary to expectations, the prevalence of STBs did not increase for most US veterans during the COVID-19 pandemic. However, veterans with preexisting loneliness, psychiatric distress, and lower purpose in life were at heightened risk of developing new-onset suicidal ideation and suicide planning during the pandemic. Evidence-based prevention and intervention efforts that target these factors may help mitigate suicide risk in this population.

Firearm Ownership Among a Nationally Representative Sample of U.S. Veterans.

INTRODUCTION: This study aimed to identify the prevalence and correlates of firearm ownership in a large, contemporary, nationally representative sample of U.S. military veterans. METHODS: Data were analyzed from the 2022 National Health and Resilience in Veterans Study (N=2,326; mean age=60.2 years). Weighted independent-sample t-tests and chi-square analyses were conducted to compare veterans who did with those who did not report firearm ownership on sociodemographic, military, and psychiatric variables. A multivariable logistic regression analysis using backward elimination was conducted to identify the characteristics independently associated with firearm ownership, and a relative importance analysis was conducted to quantify the relative variance in firearm ownership that was explained by each of the statistically significant main effects. RESULTS: Of the total 2,326 veterans, 1,217 (weighted 50.9%, 95% CI=48.0%, 53.9%) reported owning any firearms. Male sex, conservative political ideology, living in rural area, home ownership, cumulative trauma burden, and lifetime history of alcohol use disorder were most strongly associated with firearm ownership. CONCLUSIONS: This study provides an updated characterization of the prevalence and correlates of firearm ownership among the U.S. veterans. Results of this nationally representative study suggest that firearm ownership in this group may be higher than previously reported and underscore the importance of targeted suicide prevention efforts promoting firearm safety among vulnerable segments of this population.