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Patients with posttraumatic stress disorder (PTSD) are at an elevated risk of suicide. For patients hospitalized for suicide risk, psychosocial treatment and stabilization are routinely offered; however, the availability of evidence-based, manualized therapeutic interventions for PTSD is sparse. Typically, the short duration of hospitalization makes it difficult to accommodate evidence-based, trauma-focused treatments. This article presents the clinical course of four active-duty service members with PTSD who were hospitalized in a psychiatric inpatient unit for acute suicide risk and treated with Written Exposure Therapy for Suicide (WET-S). WET-S is a brief, five-session therapy based upon Written Exposure Therapy and augmented with Crisis Response Planning for Suicide Prevention. Both posttraumatic stress symptoms and suicidal ideation were reduced from pre- to posttreatment for three of the four patients treated. WET-S shows promise as a manualized therapeutic intervention that can be delivered on an inpatient psychiatric unit.

Preliminary data suggest cognitive processing therapy (CPT) significantly reduces posttraumatic stress disorder (PTSD) symptom severity among military personnel and veterans when delivered over 12 days and combined with daily recreational activities (Bryan et al., 2018). The present study aimed to examine how therapy pace (i.e., daily vs. weekly sessions) and setting (i.e., clinic vs. recreational) impacts change in PTSD symptom severity. Forty-five military personnel and veterans diagnosed with PTSD chose to receive CPT (a) daily at a recreational facility with recreational programming, (b) daily on a university campus without recreational programming, and (c) weekly on a university campus without recreational programming. PTSD symptom severity was assessed with the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) and the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5). Reductions in CAPS-5 and PCL-5 scores were large and statistically significant across all three settings (Cohen's ds2.1). As compared to reductions in CAPS-5 and PCL-5 scores in daily therapy at a recreational facility (CAPS-5: d = 1.63-2.40; PCL-5: d = 1.99-2.17), reductions in CAPS-5 and PCL-5 scores were significantly larger in daily therapy on campus, CAPS-5: t(80) = -2.9, p = .005, d = 2.23-2.69; PCL-5: t(78) = 2.6, p = .010, d = 2.54-4.43, but not weekly therapy on campus, CAPS-5: t(80) = 0.2, p = .883, d = 1.04-2.47; PCL-5: t(78) = 1.0, p = .310, d = 1.77-3.44. Participants receiving daily therapy on campus and weekly therapy on campus also had higher rates of clinically significant improvement and good end-state functioning. Results support the effectiveness of CPT across multiple treatment settings and formats and suggest that daily CPT may be less effective when delivered in combination with recreational activities.

Research has largely not identified processes contributing to the relationship between physical disability and suicide risk. This cross-sectional research is aimed at examining the associations among felt stigma, perceived burdensomeness, disability severity, and perceptions about future suicidal ideation and attempts. Adults (N = 127) with physical disabilities recruited through online and printed advertisements completed self-report measures and semi-structured interviews. We anticipated that felt stigma would be associated with individuals’ perceived likelihood of future suicidal ideation and attempts indirectly through perceived burdensomeness, and that these relationships would be moderated by the impact of disability on three important life domains. Results from a series of moderated mediation analyses partially supported study hypotheses and indicated indirect relationships of stigma to suicide-related perceptions. However, disability severity in the three examined domains did not moderate these indirect relationships. Felt stigma and perceived burdensomeness may contribute to self-perceptions of suicide risk among individuals with physical disabilities.

Introduction Given the increase in firearm purchases during the COVID-19 pandemic, this study seeks to determine the extent to which COVID-19 firearm purchasers differ in terms of suicide risk from nonfirearm owners and firearm owners who did not make a purchase during COVID-19. Methods Participants (N=3,500) were recruited through Qualtrics Panels to participate in an online survey examining methods for self-protection. ANCOVAs were utilized to assess suicidal ideation. Multivariate ANCOVAs were used to examine firearm storage practices and storage changes during COVID-19. Data were collected in late June and early July 2020, and analyses were conducted in July 2020. Results Individuals who purchased a firearm during COVID-19 more frequently reported lifetime, past-year, and past-month suicidal ideation than nonfirearm owners and firearm owners who did not make a purchase during COVID-19. COVID-19 purchasers with lifetime ideation were less likely to hide loaded firearms in a closet than those without lifetime ideation. COVID-19 purchasers with past-year or past-month ideation were more likely to use locking devices than COVID-19 purchasers without past-month ideation. Conclusions In contrast to firearm owners more generally, COVID-19 firearm purchasers appear far more likely to have experienced suicidal ideation and appear less likely to use certain unsafe firearm storage methods but also report a greater number of storage changes during COVID-19 that made firearms less secure. Future research should seek to further understand those who purchased a firearm during COVID-19 and determine ways to increase secure storage among firearm owners.

Firearm sales have surged during COVID-19, raising concerns about a coming wave of suicide deaths. Little is known, however, about the individuals considering acquiring firearms during the pandemic. Recent research has highlighted that individuals considering acquiring firearms may be motivated by exaggerated threat expectancies. In a sample of 3,500 Americans matched to 2010 United States Census data, we compared individuals intending to buy firearms in the coming 12 months (assessed in late June and early July 2020) to those undecided or not planning to acquire firearms on a range of demographic, anxiety, and firearm ownership variables. Our results indicated that those intending to acquire a firearm in the next twelve months are less tolerant of uncertainty, endorse exaggerated threat expectancies, and are experiencing more severe COVID-19 specific fears. Individuals intending to purchase firearms were also more likely to have experienced suicidal ideation in the past year, to have worked in law enforcement, and to have been considered essential workers during COVID-19. Furthermore, such individuals were more likely to already own firearms and to have purchased firearms during the opening months of the COVID-19 pandemic. Those intending to purchase firearms did not endorse lower perceived neighborhood safety, however, indicating that their intent to purchase firearms is unlikely to be driven by tangible threats in their immediate environment. These findings highlight that exaggerated fears may be motivating individuals to purchase firearms to diminish anxiety and that this trend may be particularly common among individuals who already own firearms.

The aim of this paper is to develop understandings of how meaning-making processes apply to moral injury in military populations. Moral injury is an emerging clinical construct recognized as a source of mental health morbidity. Meaning-making processes, especially following highly stressful events, have far-reaching applicability to ensuring favorable mental health outcomes. This paper examines meaning-making processes in the context of moral injury: meaning and morality in times of war, morally injurious experiences, moral emotions and cognitions, the importance of meaning-making in general mental health, and how meaning-making plays into the expressions and/or symptoms of MI. We apply these understandings in a case vignette of a Veteran affected by moral injury. We end by offering suggestions on how meaning-making can be applied in the development of clinical support strategies in cases of moral injury.

The efficacy of prolonged exposure (PE) on suicide ideation (SI) as a secondary outcome among individuals with posttraumatic stress disorder (PTSD) is unclear. The purpose of this study was to compare the efficacy of PE in two formats (spaced, S-PE, 10 sessions over 8 weeks, and massed, M-PE, 10 sessions over 2 weeks) to Present Centered Therapy (PCT) and minimal contact control (MCC) on SI exacerbation among patients without suicide intent or plans. Active duty military personnel (n = 335) were randomized to: (1) S-PE vs. PCT and (2) M-PE vs. MCC. All participants completed the Beck Scale for Suicide Ideation and the Beck Depression Inventory (Suicide item) at baseline, posttreatment, and follow-ups. S-PE and PCT had significant and comparable reductions in SI during treatment. M-PE had significantly steeper reductions in SI during treatment compared to MCC. Specifically, more participants in M-PE compared to MCC had reliable improvement versus reliable exacerbation. Reduction in PTSD symptoms was significantly associated with reduction of SI. PE was associated with significant reductions in SI over time that were comparable to PCT and superior to MCC. These findings suggest that both trauma- and non-trauma-focused treatments are associated with reductions in SI, and that trauma-focused treatments improve SI relative to waitlist.

Although veterans living in remote/rural areas are at elevated risk for suicide, there is very little research specific to treating suicidal veterans who present with barriers to in-person care. The current study aims to examine the delivery of brief cognitive-behavioral therapy for suicide prevention (BCBT-SP) via Clinical Video Telehealth (CVT) to the home of a veteran discharged from the psychiatric inpatient unit after a recent suicide attempt. Preliminary data on acceptability, feasibility, and changes in symptoms were gathered. The veteran received treatment during the 2020 COVID-19 outbreak and additional adaptations were made accordingly. The veteran did not engage in any suicidal behavior during the course of treatment, and suicidal ideation, depression, and anxiety decreased as treatment progressed. The results provide initial support for the feasibility of BCBT-SP via CVT to the home.

Background Associative learning undergirds the development of addiction, such that drug-related cues serve as conditioned stimuli to elicit drug-seeking responses. Plausibly, among opioid misusing chronic pain patients, pain-related information may serve as a conditioned stimulus to magnify opioid cue-elicited autonomic and craving responses through a process of second-order conditioning. Methods We utilized a novel psychophysiological probe of pain-opioid conditioned associations, the Cue-Primed Reactivity (CPR) task. In this task, participants were presented with images as primes (200 ms) and cues (6000 ms) in pairs organized in four task blocks: “control-opioid,” “pain-opioid,” “control-pain,” and “opioid-pain.” Opioid-treated chronic pain patients (N = 30) recruited from an Army base in the Western United States were classified as opioid misusers (n = 17) or non-misusers (n = 13) via a validated cutpoint on the Prescription Drug Use Questionnaire (PDUQ; Compton et al., 2008). Opioid misuse status was examined as a predictor of HRV, craving, and mood responses on the CPR task. Results HRV increased to a greater extent during the pain-opioid block compared to the control-opioid block for non-misusers compared to misusers (p = .003, η2partial = 0.27). In contrast, craving increased to a greater extent from baseline to the pain-opioid block for misusers than for non-misusers (p = .03, η2partial = .16). Conclusions Findings suggest that opioid-treated chronic pain patients exhibit Pavlovian conditioned responses to opioid cues strengthened by an associative learning process of second-order conditioning when primed by pain-related images. This pain-opioid contingency appears to become disrupted among individuals who engage in opioid misuse, such that opioid-related stimuli elicit motivational responses irrespective of pain-related contextual stimuli.

Studies of active duty service members have shown that military personnel who screen positive for posttraumatic stress disorder (PTSD) are more than twice as likely to make a suicide attempt. Evidence-based PTSD treatments can reduce suicidal ideation; however, it can be challenging to provide evidence-based, trauma-focused, PTSD treatment to high-risk patients on an acute psychiatric inpatient unit because the priority of care is stabilization. Treatment for PTSD requires more time and resources than are typically afforded during inpatient hospitalizations. Written Exposure Therapy is an evidence-based, five-session, trauma-focused treatment for PTSD that may overcome the implementation challenges of providing PTSD treatment in an acute inpatient psychiatric treatment setting. This paper describes the design, methodology, and protocol of a randomized clinical trial. The goal of the study is to determine if five 60-min sessions of Written Exposure Therapy enhanced with Crisis Response Planning for suicide risk reduces the presence, frequency, and severity of suicidal ideation, suicidal behavior, rehospitalization, and non-suicidal, self-injurious behaviors. The study also will determine if Written Exposure Therapy for Suicide reduces posttraumatic stress symptom severity among military service members, veterans, and other adult military beneficiaries admitted to an acute psychiatric inpatient unit for comorbid suicide ideation or attempt and PTSD symptoms compared with Treatment as Usual. The study is designed to enhance the delivery of care for those in acute suicidal crisis with comorbid PTSD symptoms.

The STRONG STAR Consortium (South Texas Research Organizational Network Guiding Studies on Trauma and Resilience) and the Consortium to Alleviate PTSD are interdisciplinary and multi-institutional research consortia focused on the detection, diagnosis, prevention, and treatment of combat-related posttraumatic stress disorder (PTSD) and comorbid conditions in military personnel and veterans. This manuscript outlines the consortia's state-of-the-science collaborative research model and how this can be used as a roadmap for future trauma-related research. STRONG STAR was initially funded for 5 years in 2008 by the U.S. Department of Defense's (DoD) Psychological Health and Traumatic Brain Injury Research Program. Since the initial funding of STRONG STAR, almost 50 additional peer-reviewed STRONG STAR-affiliated projects have been funded through the DoD, the U.S. Department of Veterans Affairs (VA), the National Institutes of Health, and private organizations. In 2013, STRONG STAR investigators partnered with the VA's National Center for PTSD and were selected for joint DoD/VA funding to establish the Consortium to Alleviate PTSD. STRONG STAR and the Consortium to Alleviate PTSD have assembled a critical mass of investigators and institutions with the synergy required to make major scientific and public health advances in the prevention and treatment of combat PTSD and related conditions. This manuscript provides an overview of the establishment of these two research consortia, including their history, vision, mission, goals, and accomplishments. Comprehensive tables provide descriptions of over 70 projects supported by the consortia. Examples are provided of collaborations among over 50 worldwide academic research institutions and over 150 investigators.

Background: Research suggests that individuals who know someone who died by suicide are at increased risk for posttraumatic stress disorder (PTSD), depression, and recent suicidal thoughts. Studies have not yet investigated the association of suicide exposure with suicide attempts, however, especially among high-risk subgroups of military personnel such as the National Guard. Procedures: An anonymous online survey was completed by 971 military personnel assigned to the National Guard in Utah and Idaho. Weighted analyses were conducted to ensure demographic matching to the full population. Univariate and multivariate logistic regression was used to test the association of suicide exposure with psychiatric condition, suicide ideation, and suicide attempts. Main findings: 65.4% of National Guard personnel reported knowing someone who had died by suicide. On average, participants knew 3.0 (SD = 2.0) suicide decedents. Total number of known suicide decedents was associated with significantly increased risk for PTSD (OR = 1.18, p = .008), depression (OR = 1.19, p = .003), and suicide ideation (OR = 2.48, p

Objective To evaluate the effectiveness of crisis response planning for the prevention of suicide attempts. Method Randomized clinical trial of active duty Army Soldiers (N=97) at Fort Carson, Colorado, presenting for an emergency behavioral health appointment. Participants were randomly assigned to receive a contract for safety, a standard crisis response plan, or an enhanced crisis response plan. Incidence of suicide attempts during follow-up was assessed with the Suicide Attempt Self-Injury Interview. Inclusion criteria were the presence of suicidal ideation during the past week and/or a lifetime history of suicide attempt. Exclusion criteria were the presence of a medical condition that precluded informed consent (e.g., active psychosis, mania). Survival curve analyses were used to determine efficacy on time to first suicide attempt. Longitudinal mixed effects models were used to determine efficacy on severity of suicide ideation and follow-up mental health care utilization. Results From baseline to the 6-month follow-up, 3 participants receiving a crisis response plan (estimated proportion: 5%) and 5 participants receiving a contract for safety (estimated proportion: 19%) attempted suicide (log-rank χ2(1)=4.85, p=0.028; hazard ratio=0.24, 95% CI=0.06–0.96), suggesting a 76% reduction in suicide attempts. Crisis response planning was associated with significantly faster decline in suicide ideation (F(3,195)=18.64, p Conclusion Crisis response planning was more effective than a contract for safety in preventing suicide attempts, resolving suicide ideation, and reducing inpatient hospitalization among high-risk active duty Soldiers.

Research has demonstrated a robust link between traumatic brain injuries (TBIs) and suicide risk. Yet, few studies have investigated factors that account for this link. Utilizing a clinical sample of deployed military personnel, this study aimed to examine a serial meditation model of anger and depression in the association of mild TBI and suicide risk. A total of 149 military service members referred for evaluation/treatment of a suspected head injury at a military hospital participated in the present study (92.6% male; Mage = 27.9y). Self-report measures included the Suicidal Behaviors Questionnaire-Revised (SBQ-R), Automated Neuropsychological Assessment Metrics (ANAM) anger and depression subscales, and Behavioral Health Measure-20 depression subscale. A current mild TBI diagnosis was confirmed by a licensed clinical psychologist/physician. Overall, 84.6% (126/149) of participants met diagnostic criteria for a current mild TBI. Bootstrapped serial mediation analyses indicated that the association of mild TBI and suicide risk is serially mediated by anger and depression symptoms (bias-corrected 95% confidence interval [CI] for the indirect effect = 0.044, 0.576). An alternate serial mediation model in which depression symptoms precede anger was not statistically significant (bias-corrected 95% CI for the indirect effect = -0.405, 0.050). Among a clinical sample of military personnel, increased anger and depression statistically mediated the association of mild TBI and suicide risk, and anger appears to precede depression in this pathway. Findings suggest that therapeutically targeting anger may serve to thwart the trajectory to suicide risk among military personnel who experience a mild TBI. Future research should investigate this conjecture within a prospective design to establish temporality.

This study sought to determine differences in preferred messengers on the topic of safe firearm storage and suicide prevention between firearm owners and non-firearm owners, and among firearm owners of different racial groups and sexes. Participants were 6200 United States residents recruited via Qualtrics Panels to complete an online survey. Data were collected during March 2020. The total sample and all subsamples ranked law enforcement, current military personnel, and military veterans as the top three most credible sources to discuss firearm safety for suicide prevention. Significant differences existed among the mean ranking of sources between firearm owners and non-firearm owners as well as between several subgroups of firearm owners. The identical ranking of the top three sources indicates that these groups agree on the relative credibility of multiple sources, although the average level of credibility for particular sources may vary. These findings highlight that the effectiveness of messaging on safe firearm storage may hinge on the identity of the individual delivering the message and provide an initial roadmap for how to consider packaging specific messages.

Suicides within the U.S. Armed Forces remain elevated. Brief cognitive behavioral therapy for suicide prevention (BCBT) has demonstrated preliminary efficacy as a psychotherapeutic intervention that reduces suicide attempts among U.S. Army Soldiers. The generalizability of BCBT's effects in other military groups and its underlying mechanisms of action remain unknown, however. The Marine Suicide Prevention and Intervention REsearch (M-SPIRE) study is designed to test the efficacy of BCBT for the prevention of suicide attempts among active duty U.S. Marines with recent suicidal ideation or attempts and to identify potential mechanisms of change contributing to BCBT's effects. In this protocol paper, we describe M-SPIRE's rationale and methods with a particular emphasis on measuring treatment fidelity and BCBT's hypothesized mechanisms of action.

BACKGROUND: The relative balance between the wish to live and the wish to die (i.e., suicidal ambivalence) is a robust predictor of suicidal behavior and may be a mechanism underlying the effectiveness of treatments that reduce suicidal behaviors. To date, however, few studies have explored possible mechanisms of action in these treatments. METHOD: Active duty Soldiers (N=152) with a recent suicide attempt and/or active suicide ideation were randomized to receive brief cognitive behavioral therapy (BCBT) or treatment as usual (TAU). The Suicide Attempt Self-Injury Inventory (Linehan et al., 2006a) was used to assess the incidence of suicide attempts during the 2-year follow-up. The wish to live and the wish to die were assessed with items 1 and 2, respectively, of the Beck Scale for Suicide Ideation (Beck and Steer, 1991). RESULTS: Across both treatments, the wish to live was significantly weaker among patients who attempted suicide but the wish to die was stronger only among patients who attempted suicide in TAU. Among nonattempters, the wish to die stabilized the wish to live, but among attempters the wish to live and the wish to die were not associated with each other. In BCBT the wish to live destabilized the wish to die among nonattempters. LIMITATIONS: Self-report methodology, predominantly male sample. CONCLUSIONS: The emergence of suicidal behavior is driven primarily by the absence of the wish to live. BCBT is associated with a unique coupling of an ambivalent wish to live and wish to die, which may suggest an underlying mechanism of action.Copyright © 2016. Published by Elsevier B.V. Language: en

Objective Alcohol use is associated with unplanned or impulsive suicide attempts. Although unplanned suicide attempts assume a rapid transition for suicidal impulse to action, many studies do not quantify the time elapsed from suicidal impulse to action. The current study was designed to clarify how alcohol use facilitates the transition from suicidal impulse to action among U.S. Army personnel. We hypothesized that alcohol consumption during the 24 h preceding a suicide attempt would be associated with significantly faster transition from suicidal impulse to action but would be unrelated to medical lethality. Method A total of 119 active duty U.S. Army Soldiers who made a total of 175 suicide attempts during military service, 121 of which occurred during the preceding year, completed clinician-administered structured interviews focused on psychiatric diagnosis and the contextual characteristics of their suicide attempts. Results Alcohol use during the 24 h prior to a suicide attempt was associated with significantly faster transition from suicidal impulse to action. Among suicide attempts in the past year, lethality significantly increased as the length of time since the last alcoholic drink increased. Drug use during the 24 h prior to a suicide attempt was unrelated to speed of transition or attempt lethality. Conclusions Soldiers acted upon their suicidal impulses more quickly when they had been drinking on the day of their suicide attempts. This rapid transition may contribute to the selection of less lethal suicide methods during periods of active drinking as compared to methods selected after the discontinuation of alcohol consumption.

The restriction of potentially lethal means during periods of high risk has been identified as one of the more promising suicide prevention strategies. The purpose of this paper is to introduce clinicians to means restriction counseling and to describe a Motivational Interviewing (MI) based approach for use with ambivalent or challenging patients. This paper examines empirical support behind legislative efforts for means restriction along with the limitations. It explains the need for means restriction counseling with adults and requisite challenges. For patients who are reluctant, it describes an MI-based approach to means restriction counseling and provides a case example. By the end of the paper, readers should be aware of the potential importance of means restriction counseling and the possible use of an MI-based approach with challenging patients. Means restriction counseling is a promising clinical intervention for suicidal patients and research on MI-based and other approaches is sorely needed.

Moral injury represents an emerging clinical construct recognized as a source of morbidity in current and former military personnel. Finding effective ways to support those affected by moral injury remains a challenge for both biomedical and complementary and alternative medicine. This paper introduces the concept of moral injury and suggests two complementary and alternative medicine, pastoral care and mindfulness, which may prove useful in supporting military personnel thought to be dealing with moral injury. Research strategies for developing an evidence-base for applying these, and other, complementary and alternative medicine modalities to moral injury are discussed.

Identifying predictors of suicide attempts is critical in intervention and prevention efforts, yet finding predictors has proven difficult due to the low base rate and underpowered statistical approaches. The objective of the current study was to use machine learning to examine predictors of suicidal behaviors among high-risk suicidal Soldiers who received outpatient mental health services in a randomized controlled trial of Brief Cognitive Behavioral Therapy for Suicide Prevention (BCBT) compared to treatment as usual (TAU). Self-report measures of clinical and demographic variables, administered prior to the start of outpatient treatment to 152 participants with recent suicidal thoughts and/or behaviors were analyzed using machine learning software to identify the best combination of variables for predicting suicide attempts during or after treatment. Worst-point suicidal ideation, history of multiple suicide attempts, treatment group (i.e., BCBT or TAU), suicidogenic cognitions, and male sex were found, in combination, correctly classified 30.8% of patients who attempted suicide during the two-year follow-up period. This combination has higher sensitivity than many models that have previously been used to predict suicidal behavior. Overall, this study provides a combination of variables that can be assessed clinical to help identify high-risk suicidal individuals.

Research among adolescent samples has suggested patterns of change in suicidal ideation (SI) following psychiatric hospitalization discharge are heterogenous and predictive of subsequent suicide attempts. However, no studies have examined SI trajectories following discharge among adult samples or the effect of treatment on trajectories. We used growth mixture modeling to examine trajectories of SI among 152 active duty military personnel in a randomized controlled trial comparing brief cognitive-behavioral therapy (CBT) for suicide prevention to treatment as usual following discharge from inpatient psychiatric hospitalization for a suicide risk. Analyses of SI at baseline, 3-, 6-, and 12-months post-discharge among the full sample randomized to both conditions revealed two trajectories: rapid improvers (59.21%) and gradual improvers (40.79%). Gradual improvers were more than twice as likely to attempt suicide in the two years following discharge. Exploratory analyses suggested that, relative to those in the treatment as usual condition, those randomized to brief CBT in both trajectories may be less likely to make a suicide attempt during the follow-up period. Results replicate and extend prior research in identifying distinct ideation trajectories following psychiatric inpatient hospitalization for suicide risk to active-duty personnel in a treatment trial and linking these trajectories to suicide attempts during follow-up.

Although ideation-to-action theories of suicide aim to explain the emergence of suicidal behaviors, researchers have primarily focused on the content of underlying mechanisms (i.e., who dies by suicide). Much less attention has focused on the temporal dynamics of suicide risk (i.e., when suicide occurs). The fluid vulnerability theory conceptualizes suicide as an inherently dynamic construct that follows a nonlinear time course. Newer research implicates the existence of multiple nonlinear change processes among suicidal individuals, some of which appear to be associated with the emergence of suicidal behavior. The cusp catastrophe model provides a useful model for conceptualizing these change processes and provides a foundation for explaining a number of poorly understood phenomena including sudden emergence of suicidal behavior without prior suicidal planning. The implications of temporal dynamics for suicide-focused theory, practice, and research are discussed.

Rates of psychological disorders and suicide have increased dramatically among military personnel since the onset of combat operations in Iraq and Afghanistan. To date, few studies have identified psychological factors that insulate service members from emotional distress and suicide risk following combat. The current study investigates the protective effects of psychological flexibility on emotional distress and suicidal ideation in 168 active duty Air Force convoy operators. Self-report data were collected before deployment and at 1, 3, 6, and 12 months postdeployment. Robust generalized estimating equations with repeated measurements indicated that, over time, service members with greater psychological flexibility reported less severe posttraumatic stress ( B =−.039, SE =.011, p =.001) and depression ( B =−.053, SE =.009, p B =−.035, SE =.010, p B =.115, SE =.044, p =.008). Results suggest that psychological flexibility guards against emotional distress among service members and buffers the effects of depression on suicide risk.

Background Nonsuicidal self-injury (NSSI) is a risk factor for suicide attempts, but it has received little attention in military populations, for whom suicide rates have doubled over the past decade. In the current study, the relationship of NSSI with future suicide attempts was prospectively examined in a sample of active duty Soldiers receiving outpatient psychiatric treatment for suicide ideation and/or a recent suicide attempt. Methods Data were collected as part of a two-year prospective study of 152 active duty Soldiers (87% male, 71% Caucasian, mean age = 27.53) in outpatient mental health care who reported current suicide ideation and/or a suicide attempt during the month preceding intake. Suicide attempts and NSSI were assessed using the Suicide Attempt Self Injury Interview. Results Forty percent of Soldiers with a history of nonsuicidal self-injury and 25% of Soldiers with a history of suicide attempt made a suicide attempt during the 2-year follow-up. Soldiers with a history of nonsuicidal self-injury were more than twice as likely to make a subsequent suicide attempt (hazard ratio [HR] = 2.25, P = .045). Soldiers with a history of suicide attempt were no more likely to make a subsequent suicide attempt than Soldiers without a previous suicide attempt (HR = .88, P = .787). Thirty percent of Soldiers with a history of suicide attempt had also engaged in nonsuicidal self-injury. Forty-two percent of Soldiers with histories of both nonsuicidal self-injury and suicide attempt made a subsequent suicide attempt and were more likely to make a suicide attempt during follow-up than Soldiers with a history of suicide attempt only. Number of NSSI episodes, but not number of suicide attempts, was significantly associated with increased risk for future suicide attempt. Results were unchanged when adjusting for baseline symptom severity. Limitations Predominantly male, active duty Army sample. Conclusions Among Soldiers in outpatient mental health care, a history of NSSI is a stronger predictor of future suicide attempts than a history of suicide attempts. Soldiers with a history of both NSSI and suicide attempt are at especially increased risk.

Primary care is a critical setting for suicide prevention because it is often the first and only source of mental health care for the U.S. general population. It is also important because suicidal patients report a greater number of somatic complaints and make more frequent medical visits compared to nonsuicidal patients. Models for managing suicide within primary care have recently arisen, yet no models have been proposed for use within the patient-centered medical home (PCMH), a primary care model that integrates behavioral health into its practice. The authors suggest a chronic disease model for the management of suicide risk in the PCMH along with collaborative strategies that may include suicide screening and targeted assessment, warm hand-offs, cognitive-behavioral interventions, routine collaborative medication management, and means restriction counseling. The current paper advises how those within the PCMH can adapt and implement evidence-based practices to manage suicide. Finally, the authors discuss a case example illustrating these evidence-based and collaborative methods.

Objective Past self-injurious thoughts and behaviors (SITB) are robust predictors of future suicide risk, but no studies have explored the prevalence of SITB occurring prior to military service among military personnel and veterans, or the association of premilitary SITB with suicidal ideation and suicide attempts during or after military service. The current study explores these issues in two separate samples. Method Self-report data were collected from 374 college student veterans via anonymous only survey (Study 1) and from 151 military personnel receiving outpatient mental health treatment (Study 2). Results Across both studies, premilitary suicide attempts were among the most prominent predictor of subsequent suicide attempts that occurred after joining the military, even when controlling for demographics and more recent emotional distress. Among military personnel who made a suicide attempt during or after military service, approximately 50% across both samples experienced suicidal ideation and up to 25% made a suicide attempt prior to joining the military. Military personnel and veterans who made suicide attempts prior to joining the military were over six times more likely to make a later suicide attempt after joining the military. In Study 2, significantly more severe current suicidal ideation was reported by participants with histories of premilitary suicide risk, even when controlling for SITB occurring while in the military. Conclusions Military personnel and veterans who experienced SITB, especially suicide attempts, prior to joining the military are more likely to attempt suicide while in the military and/or as a veteran, and experience more severe suicidal crises.

Background: Newer approaches for understanding suicidal behavior suggest the assessment of suicidespecific beliefs and cognitions may improve the detection and prediction of suicidal thoughts and behaviors. The Suicide Cognitions Scale (SCS) was developed to measure suicide-specific beliefs, but it has not been tested in a military setting. Methods: Data were analyzed from two separate studies conducted at three military mental health clinics (one U.S. Army, two U.S. Air Force). Participants included 175 active duty Army personnel with acute suicidal ideation and/or a recent suicide attempt referred for a treatment study (Sample 1) and 151 active duty Air Force personnel receiving routine outpatient mental health care (Sample 2). In both samples, participants completed self-report measures and clinician-administered interviews. Follow-up suicide attempts were assessed via clinician-administered interview for Sample 1. Statistical analyses included confirmatory factor analysis, between-group comparisons by history of suicidality, and generalized regression modeling. Results: Two latent factors were confirmed for the SCS: Unloveability and Unbearability. Each demonstrated good internal consistency, convergent validity, and divergent validity. Both scales significantly predicted current suicidal ideation ( βs 40.316, ps o0.002) and significantly differentiated suicide attempts from nonsuicidal self-injury and control groups (F(6, 286) ¼9.801, po0.001). Both scales significantly predicted future suicide attempts (AORs41.07, ps o0.050) better than other risk factors. Limitations: Self-report methodology, small sample sizes, predominantly male samples. Conclusions: The SCS is a reliable and valid measure that predicts suicidal ideation and suicide attempts among military personnel better than other well-established risk factors.

Suicide ideation is an inherently dynamic construct. Previous research implicates different temporal patterns in suicide ideation among individuals who have made multiple suicide attempts as compared to individuals who have not. Temporal patterns among first-time attempters might therefore distinguish those who eventually make a second suicide attempt. To test this possibility, the present study used a dynamical systems approach to model change patterns in suicide ideation over the course of brief cognitive behavioral therapy for suicide prevention (12 sessions total) among 33 treatment-seeking active duty Soldiers with one prior suicide attempt. Variable-centered models were constructed to determine if change patterns differed between those with and without a follow-up suicide whereas person-centered models were constructed to determine if within-person change patterns were associated with eventual suicide attempts. Severity of suicide ideation was not associated with the occurrence of suicide attempts during follow-up, but person-centered temporal patterns were. Among those who made an attempt during follow-up, suicide ideation demonstrated greater within-person variability across treatment. Results suggest certain change processes in suicide ideation may characterize vulnerability to recurrent suicide attempt among first-time attempters receiving outpatient behavioral treatment. Nonlinear dynamic models may provide advantages for suicide risk assessment and treatment monitoring in clinical settings.

Suicide risk among U.S. military personnel has been increasing over the past decade. Fluid vulnerability theory (FVT; Rudd, 2006) posits that acute suicidal episodes increase in severity when trait-based (e.g., shame) and state-based (e.g., hopelessness) risk factors interact, especially among individuals who have been previously suicidal. In contrast, trait-based protective factors (e.g., pride) should buffer the deleterious effects of risk factors.77 active duty military personnel (95% Air Force; 58.4% male, 39.0% female; 67.5% Caucasian, 19.5% African-American, 1.3% Native American, 1.3% Native Hawaiian/Pacific Islander, 1.3% Asian, and 5.2% other) engaged in outpatient mental health treatment completed self-report surveys of shame, hopelessness, pride, and suicidal ideation. Multiple generalized regression was utilized to test the associations and interactive effects of shame, hopelessness, and worst-point past suicidal ideation on severity of current suicidal ideation.Shame significantly interacted with hopelessness (B=-0.013, SE=0.004, p0.001) and worst-point suicidal ideation (B=0.027, SE=0.010, p=0.010), augmenting each variable's effect on severity of current suicidal ideation. A significant three-way interaction among shame, worst-point suicidal ideation, and pride was also observed (B=-0.010, SE=0.0043, p=0.021), indicating that pride buffered the interactive effects of shame with worst-point suicidal ideation.Small sample size, cross-sectional design, and primarily Air Force sample.Among military outpatients with histories of severe suicidal episodes, pride buffers the effects of hopelessness on current suicidal ideation. Results are consistent with FVT.

BACKGROUND: Suicide rates in the U.S. military have been rising rapidly in the past decade. Research suggests guilt is a significant predictor of suicidal ideation among military personnel, and may be especially pronounced among those who have been exposure to combat-related traumas. The current study explored the interactive effect of direct combat exposure and guilt on suicidal ideation in a clinical sample of military personnel. METHODS: Ninety-seven active duty U.S. Air Force personnel receiving outpatient mental health treatment at two military clinics completed self-report symptom measures of guilt, depression, hopelessness, perceived burdensomeness, posttraumatic stress disorder, and suicidal ideation. RESULTS: Generalized multiple regression analyses indicated a significant interaction of guilt and direct combat exposure (B=.124, SE=.053, p=.020), suggesting a stronger relationship of guilt with suicidal ideation among participants who had direct combat exposure as compared to those who had not. The interactions of direct combat exposure with depression (B=.004, SE=.040, p=.926), PTSD symptoms (B=.016, SE=.018, p=.382), perceived burdensomeness (B=.159, SE=.152, p=.300) and hopelessness (B=.069, SE=.036, p=.057) were nonsignificant. CONCLUSIONS: Although guilt is associated with more severe suicidal ideation in general among military personnel, it is especially pronounced among those who have had direct combat exposure. Language: en

Self-reported reasons for suicide attempts were examined in a sample of active duty soldiers who had attempted suicide using a functional approach that classifies suicidal behaviors into four primary functions of reinforcement: automatic negative (AN-R; to reduce aversive internal experiences), automatic positive (AP-R; to generate desired internal experiences), social negative (SN-R; to avoid aversive contextual demands), and social positive (SP-R; to generate desired environmental contexts). Based on previous theory and research, the authors hypothesized that soldiers would attempt suicide primarily to reduce aversive internal experiences (i.e., AN-R).72 soldiers (66 male, 6 female; 65.3% Caucasian, 9.7% African-American, 2.8% Asian, 2.8% Pacific Islander, 4.2% Native American, and 9.7% "other"; age M=27.34, SD=6.50) were interviewed using the Suicide Attempt Self Injury Interview to assess suicidal intent, method, lethality, and reasons for attempting suicide.Soldiers endorsed attempting suicide for both automatic and social reasons, with multiple functions being endorsed in 95% of attempts. AN-R was endorsed in 100% of suicide attempts, and was primary to other functions. Suicidal intent was weakly correlated with AN-R, AP-R, and SN-R functions (rs.22), and medical lethality was very weakly correlated with only the SP-R function (r=.18).Small sample size and retrospective self-report methodology.Soldiers attempt suicide primarily to alleviate emotional distress. Reasons for attempting suicide do not correlate strongly with suicidal intent or medical lethality.

External life events and internal experiences (i.e., emotional distress and trauma-related thoughts) occurring in the 24 h preceding suicide attempts were examined in a sample of active duty U.S. Soldiers. Seventy-two Soldiers (66 male, 6 female; 65.3% Caucasian, 9.7% African-American, 2.8% Asian, 2.8% Pacific Islander, 4.2% Native American, and 9.7% "other"; age M = 27.34, SD = 6.50) were interviewed using the Suicide Attempt Self Injury Interview to assess the occurrence of external events and internal experiences on the day of their suicide attempts, and to determine their associations with several dimensions of suicide risk: suicidal intent, lethality, and deliberation about attempting. Multiple external stressors and internal states were experienced by Soldiers in the 24 h preceding their suicide attempts, with emotional distress being the most common. Trauma-related thoughts were much less frequently reported in the 24 h preceding suicide attempts. Emotional experiences were directly associated with suicidal intent, and explained the relationship between external events and suicidal intent. Lethality was unrelated to any external events, emotional experiences, or trauma-related thoughts. Greater emotional distress and trauma-related thoughts were associated with shorter deliberation about whether or not to attempt suicide. Soldiers experience multiple sources of distress in the period immediately preceding their suicide attempts. Soldiers who experience more negative emotional experiences have a stronger desire for suicide and spend less time deliberating before an attempt. Language: en

The interpersonal-psychological theory of suicide posits that the interaction of three elements is required for lethal suicidal behaviors: the perception that one is a burden on others, the perception that one does not belong, and fearlessness about death combined with high pain tolerance (termed “acquired capability” for suicide). Although an ever expanding research base supports the theory, very limited data exist supporting the theory among military personnel, a group that has experienced a rapid increase in suicides during the past several years. The current study tests the interpersonal-psychological theory in two clinical samples of military personnel while deployed to Iraq: those seeking treatment for mild traumatic brain injury, and those seeking outpatient mental health treatment. In both samples, perceived burdensomeness and acquired capability were significantly associated with suicidality, as was their interaction term. Results partially support the interpersonal-psychological theory of suicide, and indicate that perceptions of burdensomeness combined with fearlessness about death are associated with increased suicidality among deployed military personnel.

Suicide rates have been increasing in military personnel since the start of Operation Enduring Freedom and Operation Iraqi Freedom, and it is vital that efforts be made to advance suicide risk assessment techniques and treatment for members of the military who may be experiencing suicidal symptoms. One potential way to advance the understanding of suicide in the military is through the use of the Interpersonal-Psychological Theory of Suicide. This theory proposes that three necessary factors are needed to complete suicide: feelings that one does not belong with other people, feelings that one is a burden on others or society, and an acquired capability to overcome the fear and pain associated with suicide. This review analyzes the various ways that military service may influence suicidal behavior and integrates these findings into an overall framework with relevant practical implications. Findings suggest that although there are many important factors in military suicide, the acquired capability may be the most impacted by military experience because combat exposure and training may cause habituation to fear of painful experiences, including suicide. Future research directions, ways to enhance risk assessment, and treatment implications are also discussed.

Suicide in the military is a growing concern. The interpersonal-psychological theory of suicidal behavior proposes that an individual will not die by suicide unless he or she experiences a combined disconnection from others, feelings that one is a burden on others, and the ability to do so, but this theory has not yet been rigorously tested with military samples. The current study tested the theory’s hypotheses in predicting history of suicide in a sample of 88 active duty US Air Force personnel, which was compared to a non-military undergraduate sample (n = 309) and a non-military clinical sample (n = 228). Active duty personnel demonstrated higher acquired capability when compared to a clinical non-military sample. As compared to non-military undergraduates, active duty personnel demonstrated less perceived burdensomeness, but did not differ in terms of thwarted belongingness. The interaction of burdensomeness and acquired capability significantly predicted suicidal history, but the three-way interaction between burdensomeness, belongingness, and acquired capability did not, providing partial support for the theory in a military sample.