How well can U.S. military veterans' suicidal ideation be predicted from static and change-based indicators of their psychosocial well-being as they adapt to civilian life?

BACKGROUND: Identifying predictors of suicidal ideation (SI) is important to inform suicide prevention efforts, particularly among high-risk populations like military veterans. Although many studies have examined the contribution of psychopathology to veterans' SI, fewer studies have examined whether experiencing good psychosocial well-being with regard to multiple aspects of life can protect veterans from SI or evaluated whether SI risk prediction can be enhanced by considering change in life circumstances along with static factors. METHODS: The study drew from a longitudinal population-based sample of 7141 U.S. veterans assessed throughout the first three years after leaving military service. Machine learning methods (cross-validated random forests) were applied to examine the predictive utility of static and change-based well-being indicators to veterans' SI, as compared to psychopathology predictors. RESULTS: Although psychopathology models performed better, the full set of well-being predictors demonstrated acceptable discrimination in predicting new-onset SI and accounted for approximately two-thirds of cases of SI in the top strata (quintile) of predicted risk. Greater engagement in health promoting behavior and social well-being were most important in predicting reduced SI risk, with several change-based predictors of SI identified but stronger associations observed for static as compared to change-based indicator sets as a whole. CONCLUSIONS: Findings support the value of considering veterans' broader well-being in identifying individuals at risk for suicidal ideation and suggest the possibility that well-being promotion efforts may be useful in reducing suicide risk. Findings also highlight the need for additional attention to change-based predictors to better understand their potential value in identifying individuals at risk for SI.

State of the Knowledge of VA Military Sexual Trauma Research.

Despite substantial efforts to counter sexual assault and harassment in the military, both remain persistent in the Armed Services. In February 2021, President Biden directed the U.S. Department of Defense to establish a 90-day Independent Review Commission on Sexual Assault in the Military (IRC) to assess the department's efforts and make actionable recommendations. As servicemembers discharge from the military, effects of military sexual trauma (MST) are often seen in the Veterans Health Administration (VA). In response to an IRC inquiry about VA MST research, we organized an overview on prevalence, adverse consequences, and evidence-based treatments targeting the sequelae of MST. Women are significantly more likely to experience MST than their male counterparts. Other groups with low societal and institutional power (e.g., lower rank) are also at increased risk. Although not all MST survivors experience long-term adverse consequences, for many, they can be significant, chronic, and enduring and span mental and physical health outcomes, as well as cumulative impairments in functioning. Adverse consequences of MST come with commonalities shared with sexual trauma in other settings (e.g., interpersonal betrayal, victim-blaming) as well as unique aspects of the military context, where experiences of interpersonal betrayal may be compounded by perceptions of institutional betrayal (e.g., fear of reprisal or ostracism, having to work/live alongside a perpetrator). MST's most common mental health impact is posttraumatic stress disorder, which rarely occurs in isolation, and may coincide with major depression, anxiety, eating disorders, substance use disorders, and increased suicidality. Physical health impacts include greater chronic disease burden (e.g., hypertension), and impaired reproductive health and sexual functioning. Advances in treatment include evidence-based psychotherapies and novel approaches relying on mind-body interventions and peer support. Nonetheless, much work is needed to enhance detection, access, care, and support or even the best interventions will not be effective.

Predicting Sex-Specific Nonfatal Suicide Attempt Risk Using Machine Learning and Data From Danish National Registries.

Suicide attempts are a leading cause of injury globally. Accurate prediction of suicide attempts might offer opportunities for prevention. This case-cohort study used machine learning to examine sex-specific risk profiles for suicide attempts in Danish nationwide registry data. Cases were all persons who made a nonfatal suicide attempt between 1995 and 2015 (n = 22,974); the subcohort was a 5% random sample of the population at risk on January 1, 1995 (n = 265,183). We developed sex-stratified classification trees and random forests using 1,458 predictors, including demographic factors, family histories, psychiatric and physical health diagnoses, surgery, and prescribed medications. We found that substance use disorders/treatment, prescribed psychiatric medications, previous poisoning diagnoses, and stress disorders were important factors for predicting suicide attempts among men and women. Individuals in the top 5% of predicted risk accounted for 44.7% of all suicide attempts among men and 43.2% of all attempts among women. Our findings illuminate novel risk factors and interactions that are most predictive of nonfatal suicide attempts, while consistency between our findings and previous work in this area adds to the call to move machine learning suicide research toward the examination of high-risk subpopulations.

Using machine learning to predict suicide in the 30 days after discharge from psychiatric hospital in Denmark.

BACKGROUND: Suicide risk is high in the 30 days after discharge from psychiatric hospital, but knowledge of the profiles of high-risk patients remains limited. AIMS: To examine sex-specific risk profiles for suicide in the 30 days after discharge from psychiatric hospital, using machine learning and Danish registry data. METHOD: We conducted a case-cohort study capturing all suicide cases occurring in the 30 days after psychiatric hospital discharge in Denmark from 1 January 1995 to 31 December 2015 (n = 1205). The comparison subcohort was a 5% random sample of all persons born or residing in Denmark on 1 January 1995, and who had a first psychiatric hospital admission between 1995 and 2015 (n = 24 559). Predictors included diagnoses, surgeries, prescribed medications and demographic information. The outcome was suicide death recorded in the Danish Cause of Death Registry. RESULTS: For men, prescriptions for anxiolytics and drugs used in addictive disorders interacted with other characteristics in the risk profiles (e.g. alcohol-related disorders, hypnotics and sedatives) that led to higher risk of postdischarge suicide. In women, there was interaction between recurrent major depression and other characteristics (e.g. poisoning, low income) that led to increased risk of suicide. Random forests identified important suicide predictors: alcohol-related disorders and nicotine dependence in men and poisoning in women. CONCLUSIONS: Our findings suggest that accurate prediction of suicide during the high-risk period immediately after psychiatric hospital discharge may require a complex evaluation of multiple factors for men and women.

Stress Disorders and the Risk of Nonfatal Suicide Attempts in the Danish Population.

Accurate documentation of the associations between stress disorders and suicide attempts provides important information about a high-risk population and target group for preventative interventions. In this case-cohort study, cases were all individuals born or residing in Denmark who made a nonfatal suicide attempt during 1995-2015 (n = 22,974). The comparison subcohort included a 5% random sample of the Danish population on January 1, 1995 (n = 265,183). Stress disorder diagnoses and suicide attempts were identified using ICD-10 codes from national medical registries. The presence of any stress disorder substantially increased the rate of suicide attempts versus the comparison subcohort, rate per 100,000 person-years (PYs) = 604 vs. 13. We observed associations between each type of stress disorder and suicide attempts, hazard ratios (HRs) = 10.1-37.6, even after adjustment for potential confounders, adjusted HRs = 1.8-8.3, with the strongest associations for adjustment disorder relative to other diagnoses. After adjusting for demographic and health variables, the rate of suicide attempts among individuals with any stress disorder diagnosis was nearly 13 times the suicide attempt rate in the comparison cohort. A bias analysis demonstrated that associations remained robust despite potential differential misclassification of suicide attempts. Study strengths included the use of individual-level data linked across administrative and medical registries in the setting of universal health care and the use of longitudinal analyses capturing data over 20 years. The study demonstrated associations between the full range of stress disorders and suicide attempts, extending research specific to posttraumatic stress disorder.

Pre-marital predictors of marital violence in the WHO World Mental Health (WMH) Surveys.

PURPOSE: Intimate partner violence (IPV) is a pervasive public health problem. Existing research has focused on reports from victims and few studies have considered pre-marital factors. The main objective of this study was to identify pre-marital predictors of IPV in the current marriage using information obtained from husbands and wives. METHODS: Data from were obtained from married heterosexual couples in six countries. Potential predictors included demographic and relationship characteristics, adverse childhood experiences, dating violence, and psychiatric disorders. Reports of IPV and other characteristics from husbands and wives were considered independently and in relation to spousal reports. RESULTS: Overall, 14.4% of women were victims of IPV in the current marriage. Analyses identified ten significant variables including age at first marriage (husband), education, relative number of previous marriages (wife), history of one or more categories of childhood adversity (husband or wife), history of dating violence (husband or wife), early initiation of sexual intercourse (husband or wife), and four combinations of internalizing and externalizing disorders. The final model was moderately predictive of marital violence, with the 5% of women accounting for 18.6% of all cases of marital IPV. CONCLUSIONS: Results from this study advance understanding of pre-marital predictors of IPV within current marriages, including the importance of considering differences in the experiences of partners prior to marriage and may provide a foundation for more targeted primary prevention efforts.

Predeployment predictors of psychiatric disorder-symptoms and interpersonal violence during combat deployment.

BACKGROUND: Preventing suicides, mental disorders, and noncombat-related interpersonal violence during deployment are priorities of the US Army. We used predeployment survey and administrative data to develop actuarial models to identify soldiers at high risk of these outcomes during combat deployment. METHODS: The models were developed in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) Pre-Post Deployment Study, a panel study of soldiers deployed to Afghanistan in 2012-2013. Soldiers completed self-administered questionnaires before deployment and one (T1), three (T2), and nine months (T3) after deployment, and consented to administrative data linkage. Seven during-deployment outcomes were operationalized using the postdeployment surveys. Two overlapping samples were used because some outcomes were assessed at T1 (n = 7,048) and others at T2-T3 (n = 7,081). Ensemble machine learning was used to develop a model for each outcome from 273 predeployment predictors, which were compared to simple logistic regression models. RESULTS: The relative improvement in area under the receiver operating characteristic curve (AUC) obtained by machine learning compared to the logistic models ranged from 1.11 (major depression) to 1.83 (suicidality).The best-performing machine learning models were for major depression (AUC = 0.88), suicidality (0.86), and generalized anxiety disorder (0.85). Roughly 40% of these outcomes occurred among the 5% of soldiers with highest predicted risk. CONCLUSIONS: Actuarial models could be used to identify high risk soldiers either for exclusion from deployment or preventive interventions. However, the ultimate value of this approach depends on the associated costs, competing risks (e.g. stigma), and the effectiveness to-be-determined interventions.

Sexual Assault Victimization and Mental Health Treatment, Suicide Attempts, and Career Outcomes Among Women in the US Army.

OBJECTIVES: To examine associations of administratively recorded sexual assault victimization during military service with subsequent mental health and negative career outcomes among US Army women controlling for nonrandom victimization exposure. METHODS: We used data from the Army Study to Assess Risk and Resilience in Servicemembers to apply propensity score methods to match all 4238 female Regular Army soldiers with administratively recorded sexual assault victimization during 2004 to 2009 to 5 controls per case with similar composite victimization risk. We examined associations of this victimization measure with administratively recorded mental health treatment, suicide attempt, and Army career outcomes over the subsequent 12 months by using survival analysis for dichotomous outcomes and conditional generalized linear models for continuous outcomes. RESULTS: Women with administratively recorded sexual assault had significantly elevated odds ratios (ORs) of subsequent mental health treatment (any, OR = 2.5; 95% confidence interval [CI] = 2.4, 2.6; specialty, OR = 3.1; 95% CI = 2.9, 3.3; inpatient, OR = 2.8; 95% CI = 2.5, 3.1), posttraumatic stress disorder treatment (any, OR = 6.3; 95% CI = 5.7, 6.9; specialty, OR = 7.7; 95% CI = 6.8, 8.6; inpatient, OR = 6.8; 95% CI = 5.4, 8.6), suicide attempt (OR = 3.0; 95% CI = 2.5, 3.6), demotion (OR = 2.1; 95% CI = 1.9, 2.3), and attrition (OR = 1.2; 95% CI = 1.1, 1.2). CONCLUSIONS: Sexual assault victimization is associated with considerable suffering and likely decreased force readiness.

Gender Differences in Machine Learning Models of Trauma and Suicidal Ideation in Veterans of the Iraq and Afghanistan Wars.

Suicide rates among recent veterans have led to interest in risk identification. Evidence of gender-and trauma-specific predictors of suicidal ideation necessitates the use of advanced computational methods capable of elucidating these important and complex associations. In this study, we used machine learning to examine gender-specific associations between predeployment and military factors, traumatic deployment experiences, and psychopathology and suicidal ideation (SI) in a national sample of veterans deployed during the Iraq and Afghanistan conflicts (n = 2,244). Classification, regression tree analyses, and random forests were used to identify associations with SI and determine their classification accuracy. Findings converged on several associations for men that included depression, posttraumatic stress disorder (PTSD), and somatic complaints. Sexual harassment during deployment emerged as a key factor that interacted with PTSD and depression and demonstrated a stronger association with SI among women. Classification accuracy for SI presence or absence was good based on the receiver operating characteristic area under the curve, men = .91, women = .92. The risk for SI was classifiable with good accuracy, with associations that varied by gender. The use of machine learning analyses allowed for the discovery of rich, nuanced results that should be replicated in other samples and may eventually be a basis for the development of gender-specific actuarial tools to assess SI risk among veterans.

Patterns of Smoking and Unhealthy Alcohol Use Following Sexual Trauma Among U.S. Service Members.

In the first known longitudinal study of the topic, we examined whether experiencing sexual assault or sexual harassment while in the military was associated with increased risk for subsequent unhealthy alcohol use and smoking among U.S. service members in the Millennium Cohort Study (2001-2012). Adjusted complementary log-log models were fit to estimate the relative risk of (a) smoking relapse among former smokers (men: n = 4,610; women: n = 1,453); (b) initiation of unhealthy alcohol use (problem drinking and/or drinking over recommended limits) among those with no known history of unhealthy alcohol use (men: n = 8,459; women: n = 4,816); and (c) relapse among those previously reporting unhealthy alcohol use (men: n = 3,487; women: n = 1,318). Men who reported experiencing sexual assault while in the military had sixfold higher risk for smoking relapse: relative risk (RR) = 6.62; 95% confidence interval (CI) [2.34, 18.73], than men who did not. Women who reported experiencing sexual assault while in the military had almost twice the risk for alcohol relapse: RR = 1.73; 95% CI [1.06, 2.83]. There were no other significant associations. These findings suggest that men and women may respond differently following sexual trauma, and support future concerted policy efforts by military leadership to prevent, detect, and intervene on sexual assault.

Sexual Trauma and Adverse Health and Occupational Outcomes Among Men Serving in the U.S. Military.

Although absolute counts of U.S. service men who experience sexual trauma are comparable to service women, little is known about the impact of sexual trauma on men. The association of recent sexual trauma (last 3 years) with health and occupational outcomes was investigated using longitudinal data (2004-2013) from the Millennium Cohort Study. Of 37,711 service men, 391 (1.0%) reported recent sexual harassment and 76 (0.2%) sexual assault. In multivariable models, sexual harassment or assault, respectively, was associated with poorer mental health: AOR = 1.60, 95% CI [1.22, 2.12], AOR = 4.39, 95% CI [2.40, 8.05]; posttraumatic stress disorder: AOR = 2.50, 95% CI [1.87, 3.33], AOR = 6.63, 95% CI [3.65, 12.06]; depression: AOR = 2.37, 95% CI [1.69, 3.33], AOR = 5.60, 95% CI [2.83, 11.09]; and multiple physical symptoms: AOR = 2.22, 95% CI [1.69, 2.92]; AOR = 3.57, 95% CI [1.98, 6.42], after adjustment for relevant covariates. Sexual harassment was also associated with poorer physical health: AOR = 1.68, 95% CI [1.27, 2.22]. Men who reported sexual trauma were more likely to have left military service: AOR = 1.60, 95% CI [1.14, 2.24], and be disabled/unemployed postservice: AOR = 1.76, 95% CI [1.02, 3.02]. Results suggest that sexual trauma was significantly associated with adverse health and functionality extending to postmilitary life. Findings support the need for developing better prevention strategies and services to reduce the burden of sexual trauma on service men.

Traumatic Brain Injury and Suicidal Ideation Among U.S. Operation Enduring Freedom and Operation Iraqi Freedom Veterans.

Traumatic brain injury (TBI) is associated with suicidal behavior among veterans, and gender differences in the strength of associations may exist. Almost all research has been limited to Veterans Health Administration (VHA) patients, and it is unclear if findings generalize to veterans who do not use VHA services. We examined gender- and VHA-user-specific associations between TBI related to deployment and postdeployment suicidal ideation in a U.S. national sample of 1,041 female and 880 male Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans. Path analysis was used to estimate TBI and suicidal ideation association, and examine PTSD and depression symptomatology in these associations. TBI was associated with suicidal ideation among male VHA users, OR = 3.64, 95% CI [2.21, 6.01]; and male and female nonusers, OR = 2.24, 95% CI [1.14, 4.44] and OR = 2.65, 95% CI [1.26, 5.58], respectively, in unadjusted analyses. This association was explained by depression symptoms among male and female nonusers. Among male VHA users an association between TBI and suicidal ideation remained when accounting for depression symptoms, OR = 2.50, 95% CI [1.33, 4.71]. Our findings offered evidence of an association between TBI and suicidal ideation among male OEF/OIF VHA users.

Recent Sexual Trauma and Adverse Health and Occupational Outcomes Among U.S. Service Women.

Sexual trauma is prevalent among military women, but data on potential effects are needed. The association of sexual trauma with health and occupational outcomes was investigated using longitudinal data from the Millennium Cohort Study. Of 13,001 U.S. service women, 1,364 (10.5%) reported recent sexual harassment and 374 (2.9%) recent sexual assault. Women reporting recent sexual harassment or assault were more likely to report poorer mental health: OR = 1.96, 95% CI [1.71, 2.25], and OR = 3.45, 95% CI [2.67, 4.44], respectively. They reported poorer physical health: OR = 1.39, 95% CI [1.20, 1.62], and OR = 1.39, 95% CI [1.04, 1.85], respectively. They reported difficulties in work/activities due to emotional health: OR = 1.80, 95% CI [1.59, 2.04], and OR = 2.70, 95% CI [2.12, 3.44], respectively. They also reported difficulties with physical health: OR = 1.55, 95% CI [1.37, 1.75], and OR = 1.52 95% CI [1.20, 1.91], respectively, after adjustment for demographic, military, health, and prior sexual trauma characteristics. Recent sexual harassment was associated with demotion, OR = 1.47, 95% CI [1.12, 1.93]. Findings demonstrated that sexual trauma represents a potential threat to military operational readiness and draws attention to the importance of prevention strategies and services to reduce the burden of sexual trauma on military victims.

Accuracy of an intimate partner violence screening tool for female VHA patients: a replication and extension.

The 4-item Hurt/Insult/Threaten/Scream (HITS) tool accurately detects past-year intimate partner violence (IPV) among female Veterans Health Administration (VHA) patients; however, it lacks a sexual IPV item. This study evaluated the accuracy of an extended HITS (E-HITS), which adds a sexual IPV item, in female VHA patients. A sample of 80 female U.S. veteran VHA patients in New England completed a mail survey (50.0% response rate) that included the 5-item E-HITS and the Revised Conflict Tactics Scales (CTS-2). Women were included if they were in an intimate relationship in the past year. The women averaged 49 years of age and 86.0% of the sample was White. Accuracy of the 4-item HITS was compared to the 5-item E-HITS, using the CTS-2 as the reference. There were 20 women (25.0%) who reported past-year IPV on the CTS-2. The receiver operator characteristic curves demonstrated that the HITS and E-HITS performed nearly identically at their optimal cutoff scores of 6 and 7, respectively. At these cutoff scores, the sensitivity of both tools was .75, 95% CI [.55, .95]. The specificities were similar; .83 for the HITS, 95% CI [.73, .92], and .82 for the E-HITS, 95% CI [.72, .90]. Including a sexual IPV item may be clinically beneficial; it also attains the same accuracy of case identification as the HITS.

A pilot study of a randomized controlled trial of yoga as an intervention for PTSD symptoms in women.

Posttraumatic stress disorder (PTSD) is a debilitating condition that affects approximately 10% of women in the United States. Although effective psychotherapeutic treatments for PTSD exist, clients with PTSD report additional benefits of complementary and alternative approaches such as yoga. In particular, yoga may downregulate the stress response and positively impact PTSD and comorbid depression and anxiety symptoms. We conducted a pilot study of a randomized controlled trial comparing a 12-session Kripalu-based yoga intervention with an assessment control group. Participants included 38 women with current full or subthreshold PTSD symptoms. During the intervention, yoga participants showed decreases in reexperiencing and hyperarousal symptoms. The assessment control group, however, showed decreases in reexperiencing and anxiety symptoms as well, which may be a result of the positive effect of self-monitoring on PTSD and associated symptoms. Between-groups effect sizes were small to moderate (0.08-0.31). Although more research is needed, yoga may be an effective adjunctive treatment for PTSD. Participants responded positively to the intervention, suggesting that it was tolerable for this sample. Findings underscore the need for future research investigating mechanisms by which yoga may impact mental health symptoms, gender comparisons, and the long-term effects of yoga practice.

Examining mechanisms of change in a yoga intervention for women: the influence of mindfulness, psychological flexibility, and emotion regulation on PTSD symptoms.

OBJECTIVE: This study explored possible mechanisms through which symptoms of posttraumatic stress disorder (PTSD) were reduced in a randomized controlled trial comparing the effect of a yoga intervention with an assessment control. METHOD: We examined whether changes in psychological flexibility, mindfulness, and emotion regulation strategies (expressive suppression and reappraisal) were associated with posttreatment PTSD symptoms for 38 women with Diagnostic and Statistical Manual of Mental Disorders Fourth Edition full or subthreshold PTSD. RESULTS: Hierarchical linear regression models revealed that expressive suppression significantly decreased for the yoga group relative to the assessment control. Psychological flexibility increased significantly for the control but not yoga group. However, increases in psychological flexibility were associated with decreases in PTSD symptoms for the yoga but not control group. CONCLUSION: Preliminary findings suggest that yoga may reduce expressive suppression and may improve PTSD symptoms by increasing psychological flexibility. More research is needed to replicate and extend these findings.

Victims' psychosocial well-being after reporting sexual harassment in the military.

Given the importance of reporting to sexual harassment prevention and intervention efforts, it is not surprising that an extensive scientific literature has developed on predictors of victims' decisions about making a formal report to authorities about their experiences. In contrast, little empirical work has focused on how reporting affects victims, particularly their psychosocial well-being. This study used a national sample of 1,562 former military Reservists who had experienced sexual harassment during their service to examine the relationship between reporting; experiences reporting; and psychosocial well-being, as indicated by post-harassment functioning, worst symptoms of posttraumatic stress disorder (PTSD) following the harassment, and current symptoms of depression. Making a formal report was not associated with well-being, but among those who did report, perceiving that the report had resulted in the harassment being addressed by authorities was associated with better post-harassment functioning and fewer symptoms of PTSD. Satisfaction with the reporting process showed the strongest association with well-being, demonstrating small but meaningful associations with depression and medium-to-large and medium associations with post-harassment functioning and PTSD, respectively. Although findings did not vary by gender, predictors accounted for more variance in well-being for men than women. In the whole sample, satisfaction with the reporting process mediated the relationship between victims' perceptions of system responsiveness to the report and post-harassment functioning and PTSD. Findings suggest that a victim's perceptions of and satisfaction with the reporting process may impact well-being more strongly than whether the victim made a report to authorities. Men may be even more strongly impacted by their experiences with the reporting process than women.

In Their Own Words: Women Veterans Identify the Personal Consequences of Military Sexual Trauma Victimization.

This qualitative study provides a platform for women veterans to inform our perspective of their experienced impacts following military sexual trauma (MST). We engaged 23 women veterans in semistructured interviews and used a grounded theory-informed thematic analytic approach, to interpret women's experiences. Women described negative impacts of their MST experiences across psychological, behavioral, and occupational domains. Less frequently, women discussed experiences of posttraumatic growth. These results aid our understanding of the complexities of women's posttrauma experiences and suggest that holistic intervention frameworks focused on a range of potential intervention targets are warranted in helping women veterans recover from MST.