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Re: PTSD and Suicide Ideation in Veterans

Posted: Fri Oct 02, 2020 7:09 pm
by trader32176
PTSD and Death from Suicide

Understanding the causes of death from suicide has been the subject of scientific research for decades. In recent years, the increasing suicide rates among Veterans and active duty military members has brought predictors of suicide with specific relevance to these populations to the forefront of the research in this area (e.g., PTSD). Most of this work has focused on PTSD and suicidal ideation or suicide attempt, and provided evidence for these associations (see Additional Citations for a brief summary of some well-done studies in this area). Research on predictors of suicidal behavior like ideation and attempts is critical; however, it does not necessarily provide information about the association between PTSD and death from suicide. This distinction is important because only about 15% of people who survive a suicide attempt go on to eventually die by suicide and, further, there are well-known differences in the risk factors for these events (e.g., gender). The more limited body of work on death from suicide is in part a result of challenges inherent to studying suicide in general (e.g., rarity of the event on a population level, difficulty in predicting who will die by suicide even in a high-risk sample, need for data collected prior to death) and, accordingly, a large portion of our knowledge in this area has come from epidemiologic studies using registry-based data. Interestingly, while some studies provide clear evidence that PTSD increases risk for death from suicide several studies have found evidence of a protective effect (i.e., PTSD decreases risk of death from suicide), thus resulting in a debate regarding the true magnitude and direction of this association. Further complicating this issue is the effect of comorbid psychopathology (e.g., depression) on this association, which has been inconsistently considered across studies. Depression in particular is known to be highly comorbid with PTSD and is also a strong risk factor for death from suicide and thus may act as a confounder, mediator, or modifier of this association, or any combination of the three. In this overview, we will summarize the state of the literature on the association between PTSD and death from suicide across civilian, active duty, and Veteran populations.

This guide to the literature focuses exclusively on risk factors for death from suicide and will not discuss the voluminous literature on risk factors for suicidal ideation, plans, or unsuccessful attempts. In the final sections, we discuss possible etiologic and methodologic causes of the disparate findings to date, and present possibilities for future research which may help elucidate this complex association.

Point: PTSD increases risk for death from suicide

Although few studies have examined the association between PTSD and suicide among civilian samples, the work that has been done has documented consistent evidence of a strong association, even while accounting for pre-existing psychiatric comorbidity (Gradus et al., 2010; Gradus et al., 2015). One study examined all suicide deaths from 1994–2006 using the Danish national healthcare and social registries, and found that persons with PTSD had 5.3 times the rate of death from suicide than persons without PTSD, after adjustment for gender, age, marital status, income, and pre-existing depression diagnoses (n = 208,918). A subsequent study examined death from suicide among all persons diagnosed with PTSD in Denmark from 1995–2011 and found that after adjustment for demographics and pre-existing comorbid psychiatric diagnoses, persons with PTSD had 13 times the rate of suicide than persons without PTSD (n = 22,716). The association between PTSD and suicide is particularly relevant to military members and Veterans, and given the availability of registry-based data on these populations most of the research in this area has been conducted within these populations. A handful of studies have documented an association between PTSD and suicide in active duty military members, but these studies did not examine comorbid psychopathology. In the entire active duty military population in 2005 (n = 2,064,183) and 2007 (n = 1,981,810) evidence of an association between PTSD and suicide was found in Army and Air Force members in both years, with effects ranging in magnitude from 1.9 to over 10. Sample sizes were too small to calculate an association for service members in the Marines or Navy (Hyman, Ireland, Frost, & Cottrell, 2012). Among US Army service members from 2001–2009 those who died by suicide (n = 874) were almost 13 times more likely to have received a diagnosis of PTSD compared to all Army service members in the same time period (Black, Gallaway, Bell, & Ritchie, 2011). These findings were corroborated in a smaller study of risk factors for suicide in the US Army from 2007–2008 (n = 255) in which persons with PTSD had 6 times the rate of suicide than those without PTSD (Bachynski et al., 2012). Using data from the Millennium Cohort Study (n = 151,560) that included current and former military personnel, LeardMann and colleagues (2013) found a sex- and age-adjusted association for PTSD and suicide of 1.8. Despite this evidence of an 80% increase in suicide risk among people with PTSD, this association was not statistically significant, likely due to sample size, and thus PTSD was not further examined in multivariate models.Some of the earliest and most expansive epidemiologic studies on PTSD and death from suicide have been conducted among Veterans, and these have used varying methods to examine comorbid psychopathology. Among Vietnam-era Veterans included in the Department of Veterans Affairs (VA) Agent Orange Registry (Bullman & Kang, 1994), Veterans with PTSD (n = 4,247) had an approximately 4 times higher suicide rate than Veterans without PTSD (n = 12,010), adjusting only for age and race. This study did not adjust for other psychiatric disorders analytically, but, in a separate analysis, did examine the association between PTSD and suicide among 3,246 Veterans who had no comorbid diagnoses, thus, controlling for comorbidity through restriction. Among these Veterans the suicide rate was almost 6 times as high as the expected rate in general population US males. Since this early study, several other epidemiologic studies have documented an association between PTSD and suicide in Veteran samples, primarily Veterans who use VA services, but with varying methods to assess comorbid psychopathology. Ilgen et al. (2010) examined the rate of suicide from fiscal year (FY) 1999 to FY 2006 among all Veterans who used VA care in FY 1999 (n = 3,291,891). Adjusting for age, male Veterans with PTSD had 1.8 times the rate of suicide than male Veterans without PTSD, while female Veterans with PTSD had 3.5 times the rate of suicide than female Veterans without PTSD. A subsequent study by Ilgen and colleagues (2012), examined all Veterans who received Veterans Health Administration (VHA) services during FY 2007 or FY 2008 (n = 5,772,282) and found a main effect for the association between PTSD and suicide among these Veterans, adjusting for sex, age, and VISN. Despite the contribution of this work to our understanding of this association, neither study examined the effect of comorbid psychiatric diagnoses on these associations. Further, it is unclear how this work might generalize to Veterans who do not use VA services. These studies were followed by work from Conner et al. (2013) that explicitly examined psychiatric disorder comorbidity and suicide in all male patients who used VA services in FY 1999 (n = 2,962,810). Patients with PTSD and any psychiatric comorbidity had 2.6 times the rate of suicide than those with no psychiatric diagnoses. Similar to the previous work by Bullman and Kang (1994), the authors then conducted analyses which were restricted to patients with PTSD diagnosis and no comorbidity and, thus, controlled for potential confounding by psychiatric comorbidity through restriction.

Those with PTSD and no other psychiatric disorders had 1.6 times the rate of suicide than male Veterans without any psychiatric diagnoses. Subsequently, in the largest study to date focused specifically on PTSD and suicide, Conner and colleagues (2014) examined VHA patients from FY 2007–2008 (n = 5,913,648). In unadjusted analyses and demographically-adjusted analyses PTSD was associated with suicide with odds ratios that were all approximately 1.3. However, after adjustment for comorbid psychiatric diagnoses this association was reduced to 0.77, indicating a protective effect of PTSD on suicide. Counterpoint: PTSD is protective against death from suicide Given what we know about the potential negative, long-term consequences of PTSD and evidence of an association between PTSD and suicide, a study demonstrating a protective effect for the association between PTSD and suicide may seem counterintuitive or perhaps like a spurious finding. However, the 2014 study by Conner and colleagues is not the only one that has documented this association in this direction. A study of all US military personnel from 2001–2011 (n = 3,795,823) examined suicide during military service or post-separation and found a protective effect of PTSD across a range of time periods between diagnosis and death (effect estimates ranged from 0.63 to 0.82) compared to persons with no PTSD diagnoses (Shen, Cunha, & Williams, 2016). These estimates were adjusted for demographics, military variables, and comorbid psychopathology. In the Army STARRS study, the largest and most sophisticated study of risk factors for suicide among military members to date, a protective effect was found for the association between PTSD diagnosis during hospitalization and suicide after psychiatric hospitalization in 53,769 soldiers between 2004–2009 using novel machine learning methods that incorporated predictors from multiple domains including various forms of psychopathology (Kessler et al., 2015). The authors of the study do caution, however, that when building their models they prioritized the accuracy of the overall model, rather than the accurate estimation of each individual association, so the associations should be interpreted with caution. Among Veterans, Desai, Dausey, and Rosenheck (2008) found that among VA patients who were discharged from an inpatient unit between 1994–1998 (n = 1,057) PTSD was protective against death from suicide when adjusting for demographics and psychiatric comorbidity (adjusted risk ratio = 0.62). Similarly, in a study of all male Veterans discharged from VA inpatient units from FY 2005 to FY 2010 (n = 346,662) the association between PTSD and suicide was 0.66 for the year following discharge, after adjustment for demographics and psychiatric comorbidity (Britton et al., 2017). Zivin and colleagues (2007) examined PTSD and suicide among VA patients receiving treatment for depression from 1999–2004 (n = 807,694) and also found the association between PTSD and suicide to be protective (adjusted hazard ratio = 0.77).

Understanding disparate findings

Although most studies have documented that PTSD is associated with an increased risk for suicide, more than a few well-done studies have found a protective association. Why this is remains an open and important question. Potential explanations span etiologic and methodologic reasoning. A large and obvious discrepancy between the studies in each category has to do with the assessment of psychiatric comorbidity. Most of the studies that provide evidence of an association did not adjust for comorbidity, with the exception of the civilian research and the Veteran studies that adjusted through restriction. Studies that document an association without accounting for psychiatric comorbidity may report estimates that are inflated away from the null (due to lack of adjustment for these potential confounders); however, studies that did adjust for other psychopathology, particularly depression, provide compelling evidence of an association.Conversely, studies that documented a protective effect either adjusted for psychiatric comorbidity statistically or examined study populations with high levels of psychopathology. While it is hard to imagine that PTSD actually protects individuals from death from suicide, it is possible that such findings were the result of methodological choices or biases. For example, depression and its symptoms frequently co-occur with PTSD. In samples with high levels of comorbid PTSD and depression statistical adjustment for depression would obscure the part of the effect of PTSD on suicide that is due to this comorbidity. This adjustment would drive observed associations towards the null (e.g., that PTSD has no effect on death by suicide) and perhaps beyond it to demonstrate a protective effect. In fact, when strictly adhering to traditional epidemiologic methods, adjustment for a variable that is on the “causal pathway” between a predictor of interest and an outcome (i.e., PTSD -> Depression -> Suicide) is not recommended because these variables are thought to play an etiologically important role that is worthy of description rather than adjustment. In addition, in studies conducted entirely among samples with psychopathology (e.g., patients with depression or patients discharged from inpatient units), numerically smaller effects may be observed due to the use of a very high-risk study population. In these studies, the risk of suicide conferred by PTSD may not be enough to demonstrate an increased association, when compared to the very elevated suicide risk among a reference group with depression and/or other forms of psychopathology. The use of a high-risk reference group could make ratio measures of effect appear null or even protective if the predictor of interest has a weaker association with the outcome than the other risk factors that characterizes the study sample. Perhaps all results are evidence of different pieces of truth – that there are cross-population differences in the magnitude and direction of the association between PTSD and suicide. For that matter, there are likely within population differences in this association due to individual factors (e.g., gender or race/ethnicity – interestingly, the civilian studies which provide evidence for an association included a larger proportion of women than the active duty and Veteran studies). Epidemiologic research is critical for understanding the health of populations and documenting the need for resources. Yet, it is important to remember that one observed effect is an aggregation of likely varying effects that differ by people, places, and time included in one study. An important focus of future research will be to examine for whom PTSD is a risk factor for suicide and under what circumstances risk is potentiated. Further, future work will need to include rigorous and advanced methods to examine the many simultaneous and complicated roles of comorbid psychopathology can play in this association (e.g., marginal structural modeling, which allows for variables to be examined as confounders and modifiers simultaneously). Current novel applications of machine learning methods to understanding suicide risk are also a step in this direction (McCarthy et al., 2015).

Other data-driven methods that allow for the visualization of subpopulations for whom specific associations are particularly important (e.g., regression trees) may also result in a deeper understanding of the nuances of this association. In sum, there is conflicting evidence regarding the direction of the association between PTSD and death from suicide. While the majority of studies point to an increased risk of suicide associated with PTSD, the studies that do not corroborate these findings are too many to be discounted. Further research is needed to understand this potentially critical association.

Re: PTSD and Suicide Ideation in Veterans

Posted: Sat Oct 03, 2020 3:32 am
by trader32176
What Are the Treatments for PTSD? ... disorder#1

Posttraumatic stress disorder (PTSD), a type of anxiety disorder, can happen after a deeply threatening or scary event. Even if you weren't directly involved, the shock of what happened can be so great that you have a hard time living a normal life.

People with PTSD can have insomnia, flashbacks, low self-esteem, and a lot of painful or unpleasant emotions. You might constantly relive the event -- or lose your memory of it altogether.

When you have PTSD, it might feel like you'll never get your life back. But it can be treated. Short- and long-term psychotherapy and medications can work very well. Often, the two kinds of treatment are more effective together.

PTSD therapy has three main goals:

Improve your symptoms
Teach you skills to deal with it
Restore your self-esteem

Most PTSD therapies fall under the umbrella of cognitive behavioral therapy (CBT). The idea is to change the thought patterns that are disturbing your life. This might happen through talking about your trauma or concentrating on where your fears come from.

Depending on your situation, group or family therapy might be a good choice for you instead of individual sessions.

Cognitive Processing Therapy

CPT is a 12-week course of treatment, with weekly sessions of 60-90 minutes.

At first, you'll talk about the traumatic event with your therapist and how your thoughts related to it have affected your life. Then you'll write in detail about what happened. This process helps you examine how you think about your trauma and figure out new ways to live with it.

For example, maybe you've been blaming yourself for something. Your therapist will help you take into account all the things that were beyond your control, so you can move forward, understanding and accepting that, deep down, it wasn't your fault, despite things you did or didn't do.
Prolonged Exposure Therapy

If you've been avoiding things that remind you of the traumatic event, PE will help you confront them. It involves eight to 15 sessions, usually 90 minutes each.

Early on in treatment, your therapist will teach you breathing techniques to ease your anxiety when you think about what happened. Later, you'll make a list of the things you've been avoiding and learn how to face them, one by one. In another session, you'll recount the traumatic experience to your therapist, then go home and listen to a recording of yourself.

Doing this as "homework" over time may help ease your symptoms.

Eye Movement Desensitization and Reprocessing

With EMDR, you might not have to tell your therapist about your experience. Instead, you concentrate on it while you watch or listen to something they're doing -- maybe moving a hand, flashing a light, or making a sound.

The goal is to be able to think about something positive while you remember your trauma. It takes about 3 months of weekly sessions.
Stress Inoculation Training

SIT is a type of CBT. You can do it by yourself or in a group. You won't have to go into detail about what happened. The focus is more on changing how you deal with the stress from the event.

You might learn massage and breathing techniques and other ways to stop negative thoughts by relaxing your mind and body. After about 3 months, you should have the skills to release the added stress from your life.

The brains of people with PTSD process "threats" differently, in part because the balance of chemicals called neurotransmitters is out of whack. They have an easily triggered "fight or flight" response, which is what makes you jumpy and on-edge. Constantly trying to shut that down could lead to feeling emotionally cold and removed.

Medications help you stop thinking about and reacting to what happened, including having nightmares and flashbacks. They can also help you have a more positive outlook on life and feel more "normal" again.

Several types of drugs affect the chemistry in your brain related to fear and anxiety. Doctors will usually start with medications that affect the neurotransmitters serotonin or norepinephrine (SSRIs and SNRIs), including:

Fluoxetine (Prozac)
Paroxetine (Paxil)
Sertraline (Zoloft)
Venlafaxine (Effexor)

The FDA has approved only paroxetine and sertraline for treating PTSD.

Because people respond differently to medications, and not everyone's PTSD is the same, your doctor may prescribe other medicines "off label," too. (That means the manufacturer didn't ask the FDA to review studies of the drug showing that it's effective specifically for PTSD.) These may include:

Monoamine oxidase inhibitors (MAOIs)
Antipsychotics or second generation antipsychotics (SGAs)

It's OK for you to use a medicine off-label if your doctor thinks there's a reason to.

Medications might help you with specific symptoms or related issues, such as prazosin (Minipress) for insomnia and nightmares.

Which one or combination of meds is likely to work best for you depends in part on the kinds of trouble you're having in your life, what the side effects are like, and whether you also have anxiety, depression, bipolar disorder, or substance abuse problems.

It takes time to get the dosage of some medications right. With certain medications, you might need to have regular tests -- for example, to see how your liver is working -- or check in with your doctor because of possible side effects.

Medications probably won't get rid of your symptoms, but they can make them less intense and more manageable.

Disclaimer : This info is for educational / informational purposes only . See your doctor before making decisions on any treatments, or therapies.

Re: PTSD and Suicide Ideation in Veterans

Posted: Wed Oct 07, 2020 5:41 am
by trader32176
"Brain fog" after COVID -19 recovery may indicate post-traumatic stress disorder

10/7/20 ... order.aspx

A new report suggests that lingering "brain fog" and other neurological symptoms after COVID-19 recovery may be due to post-traumatic stress disorder (PTSD), an effect observed in past human coronavirus outbreaks such as SARS and MERS.

People who have recovered from COVID-19 sometimes experience lingering difficulties in concentration, as well as headaches, anxiety, fatigue or sleep disruptions. Patients may fear that the infection has permanently damaged their brains, but researchers say that's not necessarily the case.

A paper co-authored by clinical professor and neuropsychologist Andrew Levine, MD, of the David Geffen School of Medicine at UCLA, and graduate student Erin Kaseda, of Rosalind Franklin University of Medicine and Science, in Chicago, explores the historical data on survivors of previous coronaviruses, which caused severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS).

The paper was published in The Clinical Neuropsychologist.

"The idea is to raise awareness among neuropsychologists that PTSD is something you might want to consider when evaluating persistent cognitive and emotional difficulties among COVID-19 survivors," said Dr. Levine.

"When we see someone for neuropsychological testing, we expect them to be at their best, relatively speaking," Dr. Levine said. "If we identify a psychiatric illness during our evaluation, and if we believe that condition's symptoms are interfering with their ability to perform at their best, we would want that treated first, and then retest them once it's under control."

If the symptoms are due, even partially, to a psychiatric condition such as PTSD, treatment will help manage those symptoms, and provide a clearer view of any underlying brain issues.

" Once they have treatment, and hopefully have some remission of their psychiatric symptoms, if the cognitive complaints and the deficits on neuropsychological tests are still there, then that's more evidence that something else is going on."

- Erin Kaseda, Graduate Student, Rosalind Franklin University of Medicine and Science

"It's going to be important for clinicians across the board to be keeping up with the literature that's coming out, to make sure they have the most up to date information as these survivors are starting to present for neuropsychological testing."

Kaseda began pursuing this question based on her experience working with patients with mild traumatic brain injury, such as concussion. "When these symptoms persist for months or years after the original injury, it's much more likely to be due to the presence of a psychiatric disorder," she said.

A review of data from the SARS and MERS outbreaks showed that those survivors had heightened risk for PTSD.

In the case of COVID-19, the symptoms of PTSD may arise in response to the invasive measures needed to treat the patients, including intubation and ventilation, which can be traumatic for fearful patients. Other times, delirium causes patients with COVID-19 to suffer hallucinations, and the memory of these terrifying sensations continues to plague the recovered patient.

In addition to patients who have been hospitalized, frontline health-care providers can be similarly affected due to the constant stress and fear they face at work. And for some people, the anxiety of living through a pandemic, being isolated from friends, and battling the constant fear of an invisible threat can deliver a similar blow to thinking and memory skills.

While a PTSD diagnosis might not sound like good news, there are many available treatments for the disorder, including psychotherapy and medications. By comparison, researchers are still working to understand the direct neurological effects of COVID-19. "Treatment options (for COVID) are still quite a way's out, because it's still an evolving situation," Kaseda said.

"We don't actually know anything yet from survivors of COVID-19," Kaseda said. "Until we have that data, it's very hard to say what actual percentage of patients are going to have cognitive complaints because of direct effects of the virus, because of medical intervention, or because of psychiatric concerns."

Re: PTSD and Suicide Ideation in Veterans

Posted: Sun Oct 11, 2020 3:42 am
by trader32176
Post traumatic stress disorder as a risk factor for suicidal ideation in Iraq and Afghanistan War veterans

Post traumatic stress disorder (PTSD) was examined as a risk factor for suicidal ideation in Iraq and Afghanistan War veterans (N = 407) referred to Veterans Affairs mental health care. The authors also examined if risk for suicidal ideation was increased by the presence of comorbid mental disorders in veterans with PTSD. Veterans who screened positive for PTSD were more than 4 times as likely to endorse suicidal ideation relative to non-PTSD veterans. Among veterans who screened positive for PTSD (n = 202), the risk for suicidal ideation was 5.7 times greater in veterans who screened positive for two or more comorbid disorders relative to veterans with PTSD only. Findings are relevant to identifying risk for suicide behaviors in Iraq and Afghanistan War veterans.

Re: PTSD and Suicide Ideation in Veterans

Posted: Fri Oct 16, 2020 4:41 am
by trader32176
Study aims to understand the impact of COVID-19 pandemic on Canadian veterans and their spouses

10/15/20 ... ouses.aspx

Lawson Health Research Institute and the Centre of Excellence on Post-Traumatic Stress Disorder (PTSD) are partnering with a population at high risk of mental illness - Canadian Veterans and spouses of Canadian Veterans - to study how they have been impacted by the COVID-19 pandemic. Through online surveys, the project will hear directly from Veterans and their spouses to assess the pandemic's effects on their wellbeing over time. The team hopes results can be used by health care workers and policymakers to support Veterans and their families during both the current pandemic and future public health emergencies.

" With concerns about COVID-19 infection and drastic changes to everyday life, the pandemic is taking a toll on the health of Canadians. And it may be particularly distressing for those vulnerable to mental illness."

- Dr. Don Richardson, Lawson Associate Scientist and Director of the MacDonald Franklin Operational Stress Injury (OSI) Research Centre

Population studies show that Canadian Veterans are at double the risk of mental illness when compared to the rest of the population. They experience higher rates of depression, anxiety and loneliness. Spouses of Canadian Veterans are also at higher risk of distress, sometimes undertaking significant caregiving responsibilities that lead to less independence.

"It's currently unknown how the pandemic will impact Veterans and their spouses, but it could result in particularly serious outcomes," says Dr. Anthony Nazarov, Associate Scientist at Lawson and the MacDonald Franklin OSI Research Centre. "We want to hear from all Canadian Veterans and their spouses, whether they're doing well or not and whether they're seeking care or not."

The study aims to recruit 1,000 Canadian Veterans and 250 spouses of Canadian Veterans. Participants will complete online surveys, available in both English and French, once every three months for a total of 18 months. They will be asked questions about their psychological, social, family-related and physical wellbeing, and any relevant changes to their lifestyle and health care treatment.

"Veterans who regularly access health care services could encounter significant changes, including a move to virtual care appointments. This could lead to increased caregiving responsibilities for spouses," says Dr. Nazarov. "Given the uncertainty surrounding the pandemic, these changes may persist well into the future, mandating a thorough assessment of patient satisfaction and treatment outcomes."

The team hopes results can be used to support the wellness of Veterans and their families during public health emergencies. This includes providing health care professionals and policymakers with information to guide emergency preparedness policies and health care delivery models. They hope results can also be used to recognize early signs of distress in order to target with early interventions.

"We are seeking to understand the impact of COVID-19 on Veterans and their families to identify if this global pandemic is leading to psychological distress or triggering historical traumas," says Dr. Patrick Smith, CEO of the Centre of Excellence on Post-Traumatic Stress Disorder. "The Centre's primary goal is to increase Canadian expertise related to military and Veteran mental health, suicide prevention and substance use disorders. This study can help us understand if the pandemic is having debilitating and life-altering effects, and help us address a potential mental health crisis."


Lawson Health Research Institute

Re: PTSD and Suicide Ideation in Veterans

Posted: Sat Oct 17, 2020 3:09 pm
by trader32176
➤ Risk factors for suicide among Veterans

Sexual dysfunction linked to suicidal thoughts—Sexual dysfunction is common in people with posttraumatic stress disorder (PTSD). In a 2020 study led by researchers with the San Diego VA Health Care System, a team assessed 138 Veterans and their partners before they began couples-based PTSD treatment. The assessment showed that, in male Veterans, decreased sexual pleasure and decreased frequency of sexual intercourse were linked with more recent suicidal thoughts.

In female Veterans, increased sexual frequency was marginally linked with increased suicidal thoughts. The researchers stressed the importance of assessing sexual function as a risk factor for suicide, and suggested therapists should consider the possibility that sexual functioning may be protective or predictive of suicidality depending on the person being treated and the context of the treatment.

Post-TBI symptoms linked to suicide attempts—Having traumatic brain injury (TBI) symptoms before deployment is associated with an increased risk of suicide attempt following deployment, according to a study published in 2020 that included a VA San Diego Healthcare System researcher.

The research team studied data on 7,677 soldiers deployed to Afghanistan in 2012. Of these, 103 attempted suicide. The team found that soldiers who had had post-concussive or TBI symptoms prior to deployment had a higher risk of suicide attempt than those without TBI symptoms. Therefore, detecting TBI symptoms could help target Veterans who would benefit from suicide prevention programs.

In a 2019 study of the effects of TBI on suicide attempts, a team of researchers funded by VA’s Mid-Atlantic MIRECC found that post-9/11 Veterans with a history of repeated TBIs were about twice as likely to report suicidal thoughts over the week before being surveyed, compared with Veterans who had had one TBI or none at all.

The findings were developed from interviews with more than 800 Veterans who had combat roles in Iraq and Afghanistan. About half of the interviewees reported at least one TBI. Nearly 20% of those with a history of multiple TBIs said they had recent suicidal ideation—thoughts of suicide—compared with 11% of Veterans with one TBI and 9% with no history of a TBI.

PTSD, however, was not consistently associated with suicidal ideation in Veterans with TBI.

Social determinants of health and suicide—Social determinants of health are economic and social conditions that can influence an individual's or group's health status. In a 2019 study, researchers at the VA Pittsburgh Healthcare System’s Center for Health Equity Research and Promotion used VA electronic health data to learn that seven adverse social determinants of health were strongly associated with thoughts of suicide and suicide attempts in Veterans, even after adjusting for mental health diagnoses.

The seven adverse social determinants of health were violence, housing instability, financial or employment problems, legal problems, familial or social problems, lack of access to health care and transportation, and nonspecific psychosocial needs. The team concluded that integrating social determinants of health into the electronic health record, using ICD-10 codes, could improve suicide prevention efforts.

Suicide risk common in patients with anxiety—In a 2019 study, a team of researchers with the Syracuse VA Medical Center found that 40% of surveyed Veterans with anxiety had at least one risk factor for suicide. The team surveyed 182 primary care patients who had anxiety symptoms but were not in psychotherapy specialty care.

The researchers found that suicide risk was more common in Veterans who also screened positive for depression than in those who had anxiety alone. The severity of anxiety symptoms did not affect Veterans’ suicide risk. The researchers believe primary care providers should assess suicide risk in patients with anxiety even when those patients are not seeking mental health treatment or when their anxiety symptoms do not rise to the level of a disorder.

Two genes may be linked to suicide attempts—Researchers with the Durham VA Medical Center and Duke University conducted a genome-wide association study, published in 2018, in which they examined the genomes of a large sample of Veterans to look for genetic variations that could be associated with a history of suicidal behavior. (A genome is the complete set of genetic information in a person or organism.)

The team found an association between suicide attempts and a gene called KCNMB2, which plays an important role in neuronal excitability. They also found evidence that may link another gene, ABI3BP, to both suicide attempts and suicidal thoughts. The researchers cautioned that additional work to replicate and extend their findings is needed.

Possible link between low cholesterol and suicide—Researchers at the Coatesville VA Medical Center in Pennsylvania found that lower cholesterol levels may be a biomarker for suicidal behavior. The 2017 study results indicated that Veterans with total cholesterol levels below 168 mg/dL appeared to be at higher risk of suicide than those with higher cholesterol levels. The researchers examined the medical records of 128 Veterans who received care at the Coatesville VA and who were included in a suicide prevention database.

Veterans in the study who experienced suicidal thoughts or attempts had cholesterol levels that were significantly lower than those who did not. Further analysis found that Veterans with suicidal behaviors were younger; leaner; and had more anxiety, more sleep problems, and higher education than those who were being seen for a health issue unrelated to suicide. The researchers cautioned against making a definitive link between low cholesterol and suicide risk.

➤ Predictors of suicidal behavior

Suicidal thoughts and behaviors, including suicide attempts and death by suicide, are commonly found at higher rates among people with psychiatric disorders. VA researchers have studied warning signs in hopes of being able to prevent suicide in Veterans and others.

Benzodiazepines may increase suicide risk—Benzodiazepines are sedative drugs commonly prescribed for conditions such as insomnia, anxiety, and dementia. They are also prescribed to people with PTSD and are often given to patients with chronic obstructive pulmonary disorder (COPD) to treat symptoms.

In a 2019 study, researchers from VA Puget Sound Health Care System in Seattle and the University of Washington found long-term use of benzodiazepines in COPD patients who also had PTSD more than doubled their risk of suicide. The researchers looked at the medical records of 44,555 Veterans who received VA care between 2010 and 2012. Of these, 23.6% received benzodiazepines for 90 days or longer. The researchers found that these patients had higher rates of psychiatric admissions. However, long-term use of benzodiazepines in this patient group did not increase the risk of death from all causes or from respiratory events.

Opioids are a key contributor to suicides and drug overdoses—Researchers from the VA Center for Clinical Management Research and the University of Michigan published a 2019 review article that found American adults died by suicide or drug overdose at more than twice the rate they did 17 years ago. The researchers also found that use of opioid medications was a key contributor to that rise in deaths. Opioids are a class of drugs used to treat moderate to severe pain.

Using data from the Centers for Disease Control and Prevention, the researchers showed that the number of deaths from suicide and unintentional overdoses rose from 41,364 in 2000 to 110,749 in 2017. Suicides and overdoses from opioids accounted for more than 41% of such deaths in 2017, up from 17% in 2000. Opioids were implicated in more than two-thirds of all unintentional overdose deaths in 2017 and one-third of all overdose-related suicides.

The researchers believe addressing the problem will take investments in proven treatments for opioid addiction and additional research to identify and better treat Veterans at risk for opioid overdoses.

Suicidal thinking among Veterans—As part of the National Health and Resilience in Veterans study, more than 2,000 Veterans were surveyed on their prevalence of suicidal thinking. The study participants were asked twice, in 2011 and 2013, whether they had experienced suicidal thoughts in the two weeks prior to the survey. A minority, nearly 14%, reported they had.

The results of the 2016 study, led by VA's National Center for PTSD, determined that higher levels of psychiatric distress, physical health problems, and a history of substance misuse predicted chronic suicidal thinking in the study population.

In addition, because many Veterans reported having had suicidal thoughts in one survey but not the other, the researchers determined thoughts of suicide can come and go over time. The study authors said this finding underscored the need for ongoing monitoring of Veterans for suicidal thoughts, not just a one-time screening. Study researchers also found that being connected to others socially could keep some Veterans from thinking about suicide.

Substance use disorders and suicide risk—A team of researchers led by the VA Center for Clinical Management Research in Ann Arbor, Michigan, found in 2017 that Veterans with substance use problems have a higher risk of suicide than those without. They looked at health data for than 4.8 million Veterans and found drug and alcohol problems affected 8% of males and 3% of females in the study population. Veterans with a substance use disorder had more than twice the risk of suicide compared to those who did not.

The suicide rate was especially high among women Veterans with drug or alcohol problems. These women had greater than five times the rate of suicide than women Veterans who did not have substance abuse problems.

Exposure to suicide increases risk—Veterans and active-duty service members who have been bereaved by suicide may be at elevated risk of suicide, according to a 2017 study by researchers at the VA Eastern Colorado Health Care System and the University of Florida. The study's authors found that individuals who were particularly close to a person who died by suicide were at greater risk for future suicidal behaviors themselves.

The authors did not look at how service members and Veterans compared to the civilian population, nor did they study the degree to which service members or Veterans were exposed to suicide.

Insomnia and suicide
—A 2012 chart review study of 423 Veterans who died by suicide found that nearly half (173) of those Veterans had a sleep disturbance, such as insomnia, documented by a clinician. The study found that Veterans with a sleep disturbance died sooner after their final visit to a VA facility than those who did not. Researchers with the New York/New Jersey VA Health Care Network Center of Excellence for Suicide Prevention concluded that the presence of a sleep disturbance might pose a near-term risk of suicide. They suggested interventions to address sleep disturbances might be an important way to reduce suicide risk.

In 2016, researchers with the Center of Excellence for Suicide Prevention in Canandaigua, New York, found that cognitive behavioral therapy for insomnia and imagery rehearsal therapy were useful in treating nightmares in combat Veterans with PTSD. The researchers found that combining the two therapies was successful in reducing insomnia, nightmares, depression, and PTSD severity. The researchers said the combination of CBT-I and IRT was a promising treatment for Veterans with combat-related trauma and psychiatric morbidity.

Biomarkers of suicide—VA researchers at the Durham VA Medical Center and the Mid-Atlantic MIRECC found, in a 2014 study, that changes in the levels of certain amino acids in the body may contribute to suicide risk. The amino acids in question are important in regulating people's mood and behavior, although understanding their exact relationships to suicide will require further study.

In 2016, VA researchers at the Rocky Mountain MIRECC for Suicide Prevention in Denver, along with researchers in three other countries, found reduced activity in the enzyme ACMSD in people who have attempted suicide.

The enzyme is part of a chain of biochemical reactions called the kynurenine pathway, which is activated by inflammation. When it behaves sluggishly, it causes abnormal levels of two acids in the body, which could be measured in blood tests to help identify patients at high risk of suicide.

➤ Responding to suicide risk

While the studies described above and others help clinicians identify patients who are at risk of harming themselves, VA researchers are also considering ways to decrease that risk.

Uridine study—Uridine is a naturally occurring dietary supplement that shares similar brain mechanisms and neural effects with ketamine and lithium, two treatments commonly used to reduce suicidal thoughts. A team of VA researchers led by investigators at the Salt Lake City VA Medical Center is conducting a study to determine whether four weeks of taking uridine is an effective treatment for suicide compared to a group taking a placebo. They are recruiting 90 participants for this study, which is scheduled to be completed in 2023.

Firearms and older Veterans—Among U.S. Veterans, male Veterans aged 55 to 74 account for a disproportionate number of suicide deaths. For all Veterans, a majority of suicides are related to firearms. In a 2020 study, a team led by researchers at the Rocky Mountain MIRECC for Suicide Prevention interviewed 17 Veterans, aged 50 to 70, who were current or former firearm owners or users in order to learn about their experiences and beliefs about firearms.

The researchers identified six themes that could be used to develop safety interventions among older male Veterans. They learned the interviewees’ firearm experiences were usually facilitated by family members and took place at an early age; firearms serve an important social function; these Veterans believe not everyone should have access to firearms; they have preferences for who is involved in firearm safety discussions; and they perceive firearms as useful for protection.

The team hopes these findings may be useful in developing a personalized, effective intervention for Veterans in this age group.

WHO develops promising strategy—The World Health Organization (WHO), a United Nations body, has made suicide prevention a top priority on the global public-health agenda. WHO has developed a program called "brief intervention and contact," providing people who go to an emergency room following a suicide attempt with a one-hour educational session and regular contact with a health care professional after they are discharged.

A team of researchers with the White River Junction VA Medical Center in Vermont and Dartmouth College found in 2017 that this program was linked to significantly lower odds of suicide, based on a literature search. No other suicide prevention technique produced significant effects in reducing suicide, according to the research team. The team recommended additional research into this strategy.

Health-promoting behaviors may reduce suicidal thoughts in Veterans with PTSD
—Researchers with the VA Center of Excellence for Research on Returning War Veterans in Waco, Texas, published a 2016 survey of more than 100 Iraq and Afghanistan Veterans with PTSD. They found that Veterans who routinely engaged in activities to foster good nutrition, physical activity, stress management, spiritual growth, health responsibility, and positive interpersonal relationships have a less pronounced link to suicidal thoughts.

The researchers believe that promoting these activities in Veterans with PTSD could help lower their suicide risk.