Prevalence, Correlates, and Treatment of Suicidal Behavior in US Military Veterans: Results From the 2019–2020 National Health and Resilience in Veterans Study

Brandon Nichter, PhD; Murray B. Stein, MD, MPH; Sonya B. Norman, PhD; Melanie L. Hill, PhD; Elizabeth Straus, PhD; Moira Haller, PhD; Robert H. Pietrzak, PhD, MPH

J Clin Psychiatry 2021;82(5):20m13714

ABSTRACT

Objective: US military veterans have high rates of suicide relative to civilians. However, little is known about the prevalence and correlates of suicidal behaviors in the general US veteran population.

Methods: Data were from the National Health and Resilience in Veterans Study, a representative survey of US veterans conducted in 2019–2020 (n = 4,069). Analyses (1) estimated the prevalence of current suicidal ideation, lifetime suicide plans, and lifetime suicide attempts; (2) identified associated sociodemographic, military, DSM-5 psychiatric, and other risk correlates; and (3) examined mental health treatment utilization among veterans with suicidal ideation, suicide plans, or suicide attempts.

Results: The prevalence of current suicidal ideation, lifetime suicide plans, and lifetime suicide attempts was 9.0%, 7.3%, and 3.9%, respectively. Suicidal behaviors were most prevalent among veterans aged 18–44 years, with 18.2%, 19.3%, and 11.1%, respectively, endorsing suicidal ideation, suicide plans, and suicide attempts. Major depressive disorder (MDD), age, posttraumatic stress disorder, and adverse childhood experiences (ACEs) emerged as the strongest correlates of suicidal ideation and suicide plans, while MDD, age, alcohol use disorder, and ACEs were the strongest correlates of suicide attempts. Only 35.5% of veterans with current suicidal ideation were engaged in mental health treatment, with veterans who used the US Veterans Administration (VA) as their primary source of health care more than twice as likely as VA non-users to be engaged in such treatment (54.7% vs 23.8%).

Conclusions: Suicidal behaviors are highly prevalent among US veterans, particularly among young veterans. Results suggest that nearly two-thirds of veterans with current suicidal ideation are not engaged in mental health treatment, signaling the need for enhanced suicide prevention and outreach efforts.

Continue Reading...

Did you know members enjoy unlimited free PDF downloads as part of their subscription? Subscribe today for instant access to this article and our entire library in your preferred format. Alternatively, you can purchase the PDF of this article individually.

Subscribe Now

Already a member? Login

Purchase PDF for $40

Members enjoy free PDF downloads on all articles. Join today

References (54)

United States Department of Veterans Affairs. 2019 National Veteran Suicide Prevention Annual Report. Washington, DC: US Dept of Health and Human Services; 2020.
Corson K, Denneson LM, Bair MJ, et al. Prevalence and correlates of suicidal ideation among Operation Enduring Freedom and Operation Iraqi Freedom veterans. J Affect Disord. 2013;149(1–3):291–298. PubMed CrossRef
Arenson MB, Whooley MA, Neylan TC, et al. Posttraumatic stress disorder, depression, and suicidal ideation in veterans: results from the mind your heart study. Psychiatry Res. 2018;265(4):224–230. PubMed CrossRef
Smith NB, Mota N, Tsai J, et al. Nature and determinants of suicidal ideation among U.S. veterans: results from the national health and resilience in veterans study. J Affect Disord. 2016;197:66–73. PubMed CrossRef
Fanning JR, Pietrzak RH. Suicidality among older male veterans in the United States: results from the National Health and Resilience in Veterans Study. J Psychiatr Res. 2013;47(11):1766–1775. PubMed CrossRef
Maguen S, Madden E, Cohen BE, et al. Suicide risk in Iraq and Afghanistan veterans with mental health problems in VA care. J Psychiatr Res. 2015;68:120–124. PubMed CrossRef
Nock MK, Stein MB, Heeringa SG, et al; Army STARRS Collaborators. Prevalence and correlates of suicidal behavior among soldiers: results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry. 2014;71(5):514–522. PubMed CrossRef
Bryan CJ, Bryan AO. Sociodemographic correlates of suicidal thoughts and behaviors among college student service members/veterans. J Am Coll Health. 2015;63(7):502–507. PubMed CrossRef
Blosnich JR, Brenner LA, Bossarte RM. Population mental health among U.S. military veterans: results of the Veterans Health Module of the Behavioral Risk Factor Surveillance System, 2011–2012. Ann Epidemiol. 2016;26(8):592–596. PubMed CrossRef
Kimbrel NA, Newins AR, Dedert EA, et al; VA Mid-Atlantic MIRECC Workgroup. Cannabis use disorder and suicide attempts in Iraq/Afghanistan-era veterans. J Psychiatr Res. 2017;89:1–5. PubMed CrossRef
Lemaire CM, Graham DP. Factors associated with suicidal ideation in OEF/OIF veterans. J Affect Disord. 2011;130(1–2):231–238. PubMed CrossRef
Nichter B, Hill M, Norman S, et al. Impact of specific combat experiences on suicidal ideation and suicide attempt in U.S. military veterans: results from the National Health and Resilience in Veterans Study. J Psychiatr Res. 2020;130:231–239. PubMed CrossRef
Bryan CJ, Griffith JE, Pace BT, et al. Combat exposure and risk for suicidal thoughts and behaviors among military personnel and veterans: a systematic review and meta-analysis. Suicide Life Threat Behav. 2015;45(5):633–649. PubMed CrossRef
Bell JB, Nye EC. Specific symptoms predict suicidal ideation in Vietnam combat veterans with chronic post-traumatic stress disorder. Mil Med. 2007;172(11):1144–1147. PubMed CrossRef
Guerra VS, Calhoun PS; Mid-Atlantic Mental Illness Research, Education and Clinical Center Workgroup. Examining the relation between posttraumatic stress disorder and suicidal ideation in an OEF/OIF veteran sample. J Anxiety Disord. 2011;25(1):12–18. PubMed CrossRef
Maguen S, Luxton DD, Skopp NA, et al. Killing in combat, mental health symptoms, and suicidal ideation in Iraq war veterans. J Anxiety Disord. 2011;25(4):563–567. PubMed CrossRef
Nichter B, Norman S, Haller M, et al. Psychological burden of PTSD, depression, and their comorbidity in the U.S. veteran population: suicidality, functioning, and service utilization. J Affect Disord. 2019;256:633–640. PubMed CrossRef
Norman SB, Haller M, Hamblen JL, et al. The burden of co-occurring alcohol use disorder and PTSD in U.S. Military veterans: comorbidities, functioning, and suicidality. Psychol Addict Behav. 2018;32(2):224–229. PubMed CrossRef
Stein MB, Campbell-Sills L, Ursano RJ, et al; Army STARRS Collaborators. Childhood maltreatment and lifetime suicidal behaviors among new Soldiers in the US Army: results from the Army Study to Assess Risk and resilience in servicemembers (Army STARRS). J Clin Psychiatry. 2018;79(2):70–77. PubMed CrossRef
Carroll TD, Currier JM, McCormick WH, et al. Adverse childhood experiences and risk for suicidal behavior in male Iraq and Afghanistan veterans seeking PTSD treatment. Psychol Trauma. 2017;9(5):583–586. PubMed CrossRef
Fralick M, Sy E, Hassan A, et al. Association of concussion with the risk of suicide: a systematic review and meta-analysis. JAMA Neurol. 2019;76(2):144–151. PubMed CrossRef
Meffert BN, Morabito DM, Sawicki DA, et al. US Veterans who do and do not utilize veterans affairs health care services: demographic, military, medical, and psychosocial characteristics. Prim Care Companion CNS Disord. 2019;21(1):18m02350. PubMed CrossRef
Tsai J, Mota NP, Pietrzak RHUS. U.S. female veterans who do and do not rely on VA health care: needs and barriers to mental health treatment. Psychiatr Serv. 2015;66(11):1200–1206. PubMed CrossRef
Nichter B, Hill M, Norman S, et al. Mental health treatment utilization among U.S. military veterans with suicidal ideation: results from the National Health and Resilience in Veterans Study. J Psychiatr Res. 2020;130:61–67. PubMed CrossRef
Nichter B, Norman SB, Maguen S, et al. Moral injury and suicidal behavior among US combat veterans: Results from the 2019–2020 National Health and Resilience in Veterans Study. Depress Anxiety. 2021;38(6):606–614. PubMed CrossRef
Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–613. PubMed CrossRef
Pietrzak RH, Russo AR, Ling Q, et al. Suicidal ideation in treatment-seeking Veterans of Operations Enduring Freedom and Iraqi Freedom: the role of coping strategies, resilience, and social support. J Psychiatr Res. 2011;45(6):720–726. PubMed CrossRef
Altura KC, Patten SB, Fiest KM, et al. Suicidal ideation in persons with neurological conditions: prevalence, associations and validation of the PHQ-9 for suicidal ideation. Gen Hosp Psychiatry. 2016;42:22–26. PubMed CrossRef
Blevins CA, Weathers FW, Davis MT, et al. The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): development and initial psychometric evaluation. J Trauma Stress. 2015;28(6):489–498. PubMed CrossRef
Bovin MJ, Marx BP, Weathers FW, et al. Psychometric properties of the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (PCL-5) in veterans. Psychol Assess. 2016;28(11):1379–1391. PubMed CrossRef
Sheehan D. The Mini-International Neuropsychiatric Interview (Version 7.0. 2) for DSM-5. 2016.
Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14(4):245–258. PubMed CrossRef
Weathers F, Blake D, Schnurr P, et al. The Life Events Checklist for DSM-5 (LEC-5). National Center for PTSD. https://www.ptsd.va.gov/professional/assessment/documents/LEC5_Standard_Self-report.pdf
Donnelly KT, Donnelly JP, Dunnam M, et al. Reliability, sensitivity, and specificity of the VA traumatic brain injury screening tool. J Head Trauma Rehabil. 2011;26(6):439–453. PubMed CrossRef
Tonidandel S, LeBreton JM. Relative importance analysis: a useful supplement to regression analysis. J Bus Psychol. 2011;26(1):1–9. CrossRef
R: A Language and Environment for Statistical Computing. Version 3.6. Vienna, Austria: R Foundation for Statistical Computing; 2019.
Nock MK, Deming CA, Fullerton CS, et al. Suicide among soldiers: a review of psychosocial risk and protective factors. Psychiatry. 2013;76(2):97–125. PubMed CrossRef
Steinberg L, Albert D, Cauffman E, et al. Age differences in sensation seeking and impulsivity as indexed by behavior and self-report: evidence for a dual systems model. Dev Psychol. 2008;44(6):1764–1778. PubMed CrossRef
Fuehrlein BS, Mota N, Arias AJ, et al. The burden of alcohol use disorders in US military veterans: results from the National Health and Resilience in Veterans Study. Addiction. 2016;111(10):1786–1794. PubMed CrossRef
Arnett JJ, Žukauskienė R, Sugimura K. The new life stage of emerging adulthood at ages 18–29 years: implications for mental health. Lancet Psychiatry. 2014;1(7):569–576. PubMed CrossRef
Klonsky ED, Saffer BY, Bryan CJ. Ideation-to-action theories of suicide: a conceptual and empirical update. Curr Opin Psychol. 2018;22:38–43. PubMed CrossRef
Nock MK, Millner AJ, Joiner TE, et al. Risk factors for the transition from suicide ideation to suicide attempt: results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). J Abnorm Psychol. 2018;127(2):139–149. PubMed CrossRef
Teicher MH, Samson JA. Annual research review: enduring neurobiological effects of childhood abuse and neglect. J Child Psychol Psychiatry. 2016;57(3):241–266. PubMed CrossRef
Turner HA, Butler MJ. Direct and indirect effects of childhood adversity on depressive symptoms in young adults. J Youth Adolesc. 2003;32(2):89–103. CrossRef
Nichter B, Hill M, Norman S, et al. Associations of childhood abuse and combat exposure with suicidal ideation and suicide attempt in U.S. military veterans: a nationally representative study. J Affect Disord. 2020;276:1102–1108. PubMed CrossRef
Vandemortal TF. Faking it: social desirability response bias in self-report research. Aust J Adv Nurs. 2008;4:40–48.
Tsai J, Link B, Rosenheck RA, et al. Homelessness among a nationally representative sample of US veterans: prevalence, service utilization, and correlates. Soc Psychiatry Psychiatr Epidemiol. 2016;51(6):907–916. PubMed CrossRef
Brown LA, Belli G, Suzuki N, et al. Reduction in suicidal ideation from prolonged exposure therapy for adolescents. J Clin Child Adolesc Psychol. 2020;49(5):651–659. PubMed CrossRef
Norr AM, Smolenski DJ, Reger GM. Effects of prolonged exposure and virtual reality exposure on suicidal ideation in active duty soldiers: an examination of potential mechanisms. J Psychiatr Res. 2018;103:69–74. PubMed CrossRef
Rudd MD, Bryan CJ, Wertenberger EG, et al. Brief cognitive-behavioral therapy effects on post-treatment suicide attempts in a military sample: results of a randomized clinical trial with 2-year follow-up. Am J Psychiatry. 2015;172(5):441–449. PubMed CrossRef
Bedard-Gilligan M, Garcia N, Zoellner LA, et al. Alcohol, cannabis, and other drug use: Engagement and outcome in PTSD treatment. Psychol Addict Behav. 2018;32(3):277–288. PubMed CrossRef
Nichter B, Haller M, Norman S, et al. Risk and protective factors associated with comorbid PTSD and depression in U.S. military veterans: results from the National Health and Resilience in Veterans Study. J Psychiatr Res. 2020;121:56–61. PubMed CrossRef
Kehle-Forbes SM, Meis LA, Spoont MR, et al. Treatment initiation and dropout from prolonged exposure and cognitive processing therapy in a VA outpatient clinic. Psychol Trauma. 2016;8(1):107–114. PubMed CrossRef
Bryan CJ, Mintz J, Clemans TA, et al. Effect of crisis response planning vs contracts for safety on suicide risk in U.S. Army Soldiers: a randomized clinical trial. J Affect Disord. 2017;212:64–72. PubMed CrossRef