Suicide Risk Among US Veterans With Military Service During the Vietnam War.

Importance: There are persistent questions about suicide deaths among US veterans who served in the Vietnam War. It has been believed that Vietnam War veterans may be at an increased risk for suicide. Objective: To determine whether military service in the Vietnam War was associated with an increased risk of suicide, and to enumerate the number of suicides and analyze patterns in suicides among Vietnam War theater veterans compared with the US population. Design, Setting, and Participants: This cohort study compiled a roster of all Vietnam War-era veterans and Vietnam War theater veterans who served between February 28, 1961, and May 7, 1975. The 2 cohorts included theater veterans, defined as those who were deployed to the Vietnam War, and nontheater veterans, defined as those who served during the Vietnam War era but were not deployed to the Vietnam War. Mortality in these 2 cohorts was monitored from 1979 (beginning of follow-up) through 2019 (end of follow-up). Data analysis was performed between January 2022 and July 2023. Main Outcomes and Measures: The outcome of interest was death by suicide occurring between January 1, 1979, and December 31, 2019. Suicide mortality was ascertained from the National Death Index. Hazard ratios (HRs) that reflected adjusted associations between suicide risk and theater status were estimated with Cox proportional hazards regression models. Standardized mortality rates (SMRs) were calculated to compare the number of suicides among theater and nontheater veterans with the expected number of suicides among the US population. Results: This study identified 2 465 343 theater veterans (2 450 025 males [99.4%]; mean [SD] age at year of entry, 33.8 [6.7] years) and 7 122 976 nontheater veterans (6 874 606 males [96.5%]; mean [SD] age at year of entry, 33.3 [8.2] years). There were 22 736 suicides (24.1%) among theater veterans and 71 761 (75.9%) among nontheater veterans. After adjustments for covariates, Vietnam War deployment was not associated with an increased risk of suicide (HR, 0.94; 95% CI, 0.93-0.96). There was no increased risk of suicide among either theater (SMR, 0.97; 95% CI, 0.96-0.99) or nontheater (SMR, 0.97; 95% CI, 0.97-0.98) veterans compared with the US population. Conclusions and Relevance: This cohort study found no association between Vietnam War-era military service and increased risk of suicide between 1979 and 2019. Nonetheless, the 94 497 suicides among all Vietnam War-era veterans during this period are noteworthy and merit the ongoing attention of health policymakers and mental health professionals.

Moral injury and peri- and post-military suicide attempts among post-9/11 veterans.

BACKGROUND: Our goal was to examine the association between moral injury, mental health, and suicide attempts during military service and after separation by gender in post-9/11 veterans. METHODS: A nationally representative sample of 14057 veterans completed a cross-sectional survey. To examine associations of exposure to potentially morally injurious events (PMIEs; witnessing, perpetrating, and betrayal) and suicidal self-directed violence, we estimated two series of multivariable logistic regressions stratified by gender, with peri- and post-military suicide attempt as the dependent variables. RESULTS: PMIE exposure accounted for additional risk of suicide attempt during and after military service after controlling for demographic and military characteristics, current mental health status, and pre-military history of suicidal ideation and attempt. Men who endorsed PMIE exposure by perpetration were 50% more likely to attempt suicide during service and twice as likely to attempt suicide after separating from service. Men who endorsed betrayal were nearly twice as likely to attempt suicide during service; however, this association attenuated to non-significance after separation in the fully adjusted models. In contrast, women who endorsed betrayal were over 50% more likely to attempt suicide during service and after separation; PMIE exposure by perpetration did not significantly predict suicide attempts before or after service among women in the fully adjusted models. CONCLUSIONS: Our findings indicate that suicide assessment and prevention programs should consider the impact of moral injury and attend to gender differences in this risk factor in order to provide the most comprehensive care.

The mental health of Vietnam theater veterans-the lasting effects of the war: 2016-2017 Vietnam Era Health Retrospective Observational Study.

Mental health data from the 2016-2017 Vietnam Era Health Retrospective Observational Study (VE-HEROeS) were analyzed by cohort, represented by United States Vietnam theater veterans (VTs) who served in Vietnam, Cambodia, and Laos; nontheater veterans (NTs) without theater service; and age- and sex-matched nonveterans (NVs) without military service. The exposure of interest was Vietnam theater service. Surveys mailed to random samples of veterans (n = 42,393) and nonveterans (n = 6,885) resulted in response rates of 45.0% for veterans (n = 6,735 VTs, Mage = 70.09, SE = 0.04; n = 12,131 NTs) and 67.0% for NVs (n = 4,530). We examined self-report data on four mental health outcomes: probable posttraumatic stress disorder (PTSD), depression, psychological distress, and overall mental health functioning. Weighted adjusted odds ratios (aORs) between each outcome and cohort were estimated, controlling for covariates in four models: cohort plus sociodemographic variables (Model 1), Model 1 plus physical health variables (Model 2), Model 2 plus potentially traumatic events (PTEs; Model 3), and Model 3 plus other military service variables (Model 4). Mental health outcome prevalence was highest for VTs versus other cohorts, with the largest aOR, 2.88, for PTSD, 95% CI [2.46, 3.37], p < .001 (Model 4, VT:NT). Physical health and PTEs contributed most to observed effects; other service variables contributed least to aORs overall. Mental health dysfunction persists among VTs years after the war's end. The present results reaffirm previous findings and highlight the need for continued mental health surveillance in VTs.

Potentially traumatic events and health among lesbian, gay, bisexual and heterosexual Vietnam veterans: Results from the Vietnam Era Health Retrospective Observational study.

Objectives: To examine differences in potentially traumatic events (PTEs), probable PTSD, and health-related quality of life (HRQoL) between lesbian, gay, and bisexual (LGB) and heterosexual Vietnam Era veterans. Method: Data are from the 2016-2017 Vietnam Era Health Retrospective Observational study survey (n = 18,866; 45% response rate). PTEs were defined using the 10-item Brief Trauma Questionnaire and a dichotomous item about whether respondents witnessed sexual assault during military service. Current probable PTSD was measured with the Primary Care PTSD Screen, and mental and physical HRQoL was assessed with the SF-8™. Multivariable regression analyses were first adjusted for sociodemographic and military-related characteristics, and then with PTEs as a count variable ranging from 0-11. Survey weights accounted for the complex sampling design and nonresponse. Results: Approximately 1.5% of veterans were LGB. Compared to heterosexual veterans, LGB veterans were more likely to report exposure to natural disasters, childhood physical abuse, adulthood physical assault, and sexual assault, and they were less likely to report combat exposure, witnessing someone being seriously injured or killed, or witnessing sexual assault while in the military. Compared to heterosexual veterans, LGB veterans had greater odds of current probable PTSD (adjusted odds ratio [aOR] = 1.50, 95% CI [1.04, 2.16]) and poorer mental HRQoL (B = -1.70, SE = .72, p = .018). PTEs attenuated sexual orientation differences in probable PTSD (aOR = 1.27, 95% CI [.82, 1.97]) and poorer mental HRQoL (B = -1.22, SE = .67, p = .067). Conclusions: Among Vietnam Era veterans, PTEs differ based on sexual orientation, and contribute to LGB veterans' greater prevalence of current probable PTSD and poorer mental HRQoL relative to heterosexual veterans. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Hospital admissions related to mental disorders in U.S. Army soldiers in Iraq and Afghanistan.

We conducted a retrospective study of 473,964 U.S. Army soldiers deployed to Iraq and Afghanistan through December 2004 using deployment and admission records. We categorized mental disorder diagnoses using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and identified attempted suicide/ self-inflicted injuries using ICD-9-CM diagnosis codes E950-E959. We estimated and evaluated relative risks (RR) using Poisson regression models. Analysis found 1,948 psychiatric hospitalizations of deployed soldiers. The most common mental problems were mood, adjustment, and anxiety disorders (including post-traumatic stress disorder [PTSD]). RR of mental disorders ranged from 1.6 to 3 for females and 2 to 6 for enlisted soldiers compared to their counterparts. Younger soldiers had 30-60% higher substance abuse disorders. Combat units in Iraq demonstrated higher risk of any mental disorder and anxiety problems compared to combat support units. Younger women had the highest incidence of attempted suicide/ self-inflicted injuries. Further mental disorders surveillance is recommended.

Use of oral topiramate to promote smoking abstinence among alcohol-dependent smokers: a randomized controlled trial.

BACKGROUND: Previously, our group has shown that topiramate, a sulfamate-substituted fructopyranose derivative, is an effective treatment for alcohol dependence. Herein, we extend that proof-of-concept study by determining whether cigarette-smoking, alcohol-dependent individuals from the earlier study also experienced improved smoking outcomes. METHODS: As a subgroup analysis of a larger double-blind, randomized, controlled, 12-week study comparing topiramate vs placebo as treatment for alcohol dependence, a 12-week clinical trial compared topiramate vs placebo in 94 cigarette-smoking, alcohol-dependent individuals. Of these, 45 were assigned to receive topiramate (escalating dose from 25 to 300 mg/d) and the remaining 49 had placebo as an adjunct to weekly standardized medication compliance management. The primary outcome was smoking cessation ascertained by self-report and confirmed by the level of serum cotinine (nicotine's major metabolite). RESULTS: Topiramate recipients were significantly more likely than placebo recipients to abstain from smoking (odds ratio, 4.46; 95% confidence interval, 1.08-18.39; P = .04). Using a serum cotinine level of 28 ng/mL or lower to segregate nonsmokers from smokers, we found that the topiramate group had 4.97 times the odds of being nonsmokers (95% confidence interval, 1.1-23.4;P = .04). Smoking cessation rates for topiramate recipients were 19.4% and 16.7% at weeks 9 and 12, respectively, compared with 6.9% at both time points for placebo recipients. CONCLUSION: In this trial, topiramate (up to 300 mg/d) showed potential as a safe and promising medication for the treatment of cigarette smoking in alcohol-dependent individuals.

Did TCDD exposure or service in Southeast Asia increase the risk of cancer in air force Vietnam veterans who did not spray agent orange?

OBJECTIVE: We sought to examine cancer incidence in 1482 Air Force veterans who served in Southeast Asia (SEA) and who were not occupationally exposed to herbicides. METHODS: Cancer incidence between 1982 and 2003 was determined by record review and Cox proportional hazards models were used to estimate risk ratios across serum 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) and years served in SEA categories. RESULTS: All sites cancer risk increased with TCDD (relative risk = 1.6, 95% confidence interval = 1.2-2.2). The risk of prostate cancer increased with years of SEA service but not with TCDD. TCDD and years of SEA service interacted with all sites cancer; the risk was greatest in those with the highest TCDD levels and the longest time served in SEA. CONCLUSIONS: These results suggest nonoccupational exposures to TCDD or other factors while in SEA may contribute to cancer risk in these veterans.

Platelet serotonin uptake and paroxetine binding among allelic genotypes of the serotonin transporter in alcoholics.

Expression rates of long (L) and short (S) alleles of the serotonin (5-HT) transporter (5-HTT) gene have been shown to differ under various circumstances. We compared 5-HTT uptake (function) level and paroxetine binding (density) in platelets of alcoholics as indices of 5-HTT expression rate among LL, LS, and SS genotypes. Concentration curves of [3H]5-HT and [3H]paroxetine were used to quantify the equilibrium constant (Km) and maximum 5-HT uptake rate (Vmax) for 5-HTT uptake into intact platelets and the dissociation constant (Kd) and maximum specific binding density (Bmax) for paroxetine binding to platelet membranes, respectively. Genotypes were determined using electrophoresis with fluorescent markers. Vmax for 5-HTT uptake did not correlate with Bmax for paroxetine binding (r=-0.095, P=0.415). Means of Vmax and Bmax did not differ in a statistically significant manner among LL, LS, and SS genotypes in these alcoholic subjects. However, Vmax for LL and SS appeared to have a bimodal distribution, so the percentage of subjects with Vmax <200 fmol/min-10(7) platelets was statistically significantly higher in LL than in SS (51.5% vs. 22.7%, respectively), with an odds ratio of 3.6 (P<0.05). The percentage of Vmax <200 fmol/min-10(7) platelets for LS was 39.3% (not significant vs. LL or SS). Previous studies of healthy human controls have shown that 5-HTT density in raphe nuclei and 5-HTT uptake in platelets are higher in the LL genotype than in S carriers. Our findings in currently drinking alcoholics support the hypothesis that those with the LL genotype of the 5'-HTTLPR region of the 5-HTT gene have reduced 5-HTT function.

Oral topiramate reduces the consequences of drinking and improves the quality of life of alcohol-dependent individuals: a randomized controlled trial.

BACKGROUND: Topiramate, a fructopyranose derivative, was superior to placebo at improving the drinking outcomes of alcohol-dependent individuals. OBJECTIVES: To determine whether topiramate, compared with placebo, improves psychosocial functioning in alcohol-dependent individuals and to discover how this improvement is related to heavy drinking behavior. DESIGN: Double-blind, randomized, controlled, 12-week clinical trial comparing topiramate vs placebo for treating alcohol dependence (1998-2001). PARTICIPANTS: One hundred fifty alcohol-dependent individuals, diagnosed using the DSM-IV. INTERVENTIONS: Seventy-five participants received topiramate (escalating dose of 25 mg/d to 300 mg/d), and 75 had placebo and weekly standardized medication compliance management. MAIN OUTCOME MEASURES: Three elements of psychosocial functioning were measured: clinical ratings of overall well-being and alcohol-dependence severity, quality of life, and harmful drinking consequences. Overall well-being and dependence severity and quality of life were analyzed as binary responses with a generalized estimating equation approach; harmful drinking consequences were analyzed as a continuous response using a mixed-effects, repeated-measures model. RESULTS: Averaged over the course of double-blind treatment, topiramate, compared with placebo, improved the odds of overall well-being (odds ratio [OR] = 2.17; 95% confidence interval [CI], 1.16-2.60; P =.01); reported abstinence and not seeking alcohol (OR = 2.63; 95% CI, 1.52-4.53; P =.001); overall life satisfaction (OR = 2.28; 95% CI, 1.21-4.29; P =.01); and reduced harmful drinking consequences (OR = -0.07; 95% CI, -0.12 to -0.02, P =.01). There was a significant shift from higher to lower drinking quartiles on percentage of heavy drinking days, which was associated with improvements on all measures of psychosocial functioning. CONCLUSIONS: As an adjunct to medication compliance enhancement treatment, topiramate (up to 300 mg/d) was superior to placebo at not only improving drinking outcomes but increasing overall well-being and quality of life and lessening dependence severity and its harmful consequences.

Cancer in US Air Force veterans of the Vietnam War.

Cancer incidence and mortality were summarized in Air Force veterans of the Vietnam War. The index subjects were Operation Ranch Hand veterans who sprayed 2,3,7,8 tetrachlorodibenzo-p-dioxin (dioxin)-contaminated herbicides in Vietnam. Comparisons served in Southeast Asia during the same period but did not spray herbicides. We assessed cancer incidence and mortality using national rates and contrasted cancer risk in each of three Ranch Hand dioxin exposure categories relative to comparisons. The incidence of melanoma and prostate cancer was increased among white Ranch Hand veterans relative to national rates. Among veterans who spent at most 2 years in Southeast Asia, the risk of cancer at any site, of prostate cancer and of melanoma was increased in the highest dioxin exposure category. These results appear consistent with an association between cancer and dioxin exposure.

Serum 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) levels and thyroid function in Air Force veterans of the Vietnam War.

PURPOSE: We assessed potential health effects of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) concentration in serum on thyroid function in US Air Force veterans involved in Operation Ranch Hand, the unit responsible for the aerial spraying of herbicides, including TCDD-contaminated Agent Orange, during the Vietnam War from 1962 to 1971. Other Air Force veterans who were not involved with spraying herbicides were included as Comparisons. METHODS: We analyzed thyroxine (total T4), thyroid stimulating hormone (TSH), triiodothyronin percent uptake (T3% uptake), the free thyroxine index (FTI), and thyroid diseases against serum TCDD levels. Data was available for 1,009 Ranch Hand and 1,429 Comparison veterans compliant to any of five examinations in 1982, 1985, 1987, 1992, and 1997. Each veteran was assigned to one of four exposure categories based on serum TCDD levels, named Comparison, Ranch Hand Background, Ranch Hand Low Elevated, and Ranch Hand High Elevated. RESULTS: Cross-sectional analyses found statistically significantly increased TSH means at the 1985 and 1987 examinations in the High category and a significant increasing trend across the three Ranch Hand TCDD categories in 1982, 1985, 1987 and 1992. A repeated-measures analysis found significantly increased TSH means in the High TCDD category. We found no significant relation between the occurrence of thyroid disease and TCDD category. CONCLUSIONS: These findings suggest that TCDD affects thyroid hormone metabolism and function in Ranch Hand veterans. Further follow-up will be necessary to understand the relation, if any, between thyroid disease and TCDD levels.