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The U.S. DoD has identified firearm suicide prevention as a key operational priority. One vital approach to addressing firearm suicides is through promoting lethal means safety, which involves the voluntary use of secure storage for personally owned firearms and/or temporarily moving firearms out of the home during risk periods. Despite promising approaches to lethal means safety, critical gaps remain in research, programming, and communication among and across scientists, DoD programmatic leaders, front-line commanders, and service members. To address these gaps, the first-ever national “Firearm Suicide Prevention in the Military: Messaging and Interventions Summit” was convened in June 2022, bringing together DoD personnel and researchers with expertise in firearm suicide prevention and lethal means safety. The Summit identified 10 recommendations to enhance firearm suicide prevention messaging and interventions in the U.S. military, including (1) repeal or amend prohibitions on questioning service members about personal firearms; (2) develop, examine, and use common language for firearm injury prevention; (3) implement a universal approach to training on comprehensive firearm injury prevention; (4) encourage leadership across disciplines and levels; (5) aim for broad culture change; (6) support innovative research; (7) consider various outcome measures; (8) promote “cultural competence” for better communication; (9) reduce territorialism; and (10) develop creative partnerships. Ultimately, these recommendations can facilitate productive partnerships with a shared goal: to develop, test, and implement strategies that standardize lethal means safety and reduce firearm suicides and other firearm injuries or harm among service members.

Abnormal reward processing is an important yet understudied risk factor for suicide. Recent neuroimaging studies have found that suicidality is associated with abnormal reward-related neural reactivity and connectivity across a wide range of brain regions and circuits. The varying, and oftentimes discrepant, findings have hindered progress in elucidating the neurobiological link between reward processing dysfunction and suicide risk. Some of this variability is likely related to different reward-related paradigms that are utilized across studies. The primary aim of the current study was to address these issues by comparing neural reactivity between youth with and without a history of suicidal ideation during direct manipulation of reward parameters. A total of 108 unmedicated youth, ages 17-19, were classified into two groups: 1) history of suicidal ideation (n = 39) and 2) no history of suicidal ideation (n = 69). All participants completed a novel reward anticipation task probing anticipation of predictable (P-reward) and unpredictable (U-reward) monetary reward. Results revealed that compared with controls, youth with a history of suicidal ideation exhibited increased neural activation in the dorsal anterior cingulate cortex (dACC) and right anterior insula (aINS) during anticipation of U-reward. There were no group differences during anticipation of P-reward. These findings suggest that propensity for suicidal ideation may be related to specific abnormalities during anticipation of U-reward, but not P-reward.

The US Air Force remote warrior community comprises several career fields including remotely piloted aircraft pilots and intelligence, cyber, and sensor operators. The crews are responsible for working seamlessly together to provide 24/7 real-time intelligence, surveillance, and reconnaissance and precision-strike weapons capabilities for a wide range of global combat operations. Due to the rapid increase in global demands and operational tempo, there is growing concern from military leadership about the impact of operational stress on the health and psychological well-being of remote warriors. Previous assessments from 2011 and 2015 have demonstrated a significant increase in the reported rates of operators experiencing suicide ideation. The current study examined two protective factors expected to reduce the risk of suicide ideation – team member social support and leader social support. A total of 905 active duty remote warriors participated in occupational health assessments conducted in 2018. Risk factors for suicide ideation included being unmarried, worsening relationship problems, occupational burnout, and increased operational stress. Results indicated that team member and leader social support were significant protective factors for shift workers and those who reported being less likely to seek mental healthcare. Implications of the findings, intervention recommendations, and directions for future research are discussed.

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.

Objectives Duration, frequency, and intensity of nature exposure link to different physical and psychological benefits. The present study aimed to determine how time outdoors affected military veterans' posttraumatic stress disorder (PTSD) symptomology during PTSD treatment. Method Hypotheses regarding time outdoors and the effect of program duration on PTSD symptoms were examined using multilevel models. The authors hypothesized that hours outdoors, both within- and between-persons, would predict reduced PTSD symptomology, program duration would predict reduced PTSD symptomology, and that hours outdoors and program duration would be significant when accounting for the other. Results The present study found that time outdoors correlated with participants' decreased PTSD symptomology: the more time participants spent outdoors, the greater the reduction in their PTSD symptoms. Conclusion The effect of time outdoors was significant within-person, not between persons, suggesting that nature exposure may be used as an adjunct to traditional mental health treatment where exposure or dosage should be person-specific.

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.

Objective Suicide risk is a nonlinear temporal process, but the ways in which suicide-focused interventions have statistically examined risk effects have ignored these nonlinearities. This paper highlights the potential benefits of using data analytic methods that account for nonlinear change patterns. Method Using a dynamical systems perspective, interventions are framed in terms of attractor dynamics. An attractor has three primary qualities where an intervention can have an effect. These correspond to contextual differences, shifts in the underlying temporal patterns, and changes in the stability of the temporal pattern. Results/conclusions It is argued that the ideal effect is one in which there is both an observed change in stability and a shift in the underlying temporal pattern toward less risk. Other types of intervention effects can have alternate explanations that are less desirable. Mean, variance, and growth differences are discussed within a systems context, and an example model is provided using Latent Change Score Modeling (McArdle, Annual Review of Psychology, 60, 2009, 577-605).

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.

Posttraumatic stress disorder (PTSD) and alcohol use (AU) are highly prevalent and comorbid among post-9/11 U.S. military veterans. Both issues are associated with working memory (WM) deficits, but have rarely been studied concurrently in cognitive studies of post-9/11 veterans. They also have been measured inconsistently, with variable outcomes, in prior veteran studies despite their relevance to new intervention paradigms involving WM.The present study evaluated 52 post-9/11 veterans [predominantly male (94.2%); White (44.2%) or Black (36.5%); 50% being diagnosed with PTSD based on CAPS-5 results] with objectively verified valid neuropsychological test performance on measures of PTSD, AU, combat exposure, and verbal and visual WM.PTSD was not associated with verbal or visual WM performances, whereas AU and combat exposure were significantly associated with poorer visual WM performances.AU and prior combat exposure may influence visual WM performances in post-9/11 veterans, which is relevant to novel PTSD treatment paradigms. This sample was limited to mostly male and White or Black participants, and future studies should focus on sampling more heterogeneous groups of veterans with regard to sex and ethnicity. Improvements in specification/multimodal WM assessment are important for future research, as these may directly impact developing intervention efforts. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

An issue of major policy interest in the U.S. military has been interpersonal violence (IPV), especially relative to the frequent and lengthy deployments of U.S. service members to Iraq and Afghanistan. Lacking, however, are estimates of perpetrators of IPV, in particular, for reservists who have been 30% of the ground combat force. In the present study, Army National Guard soldiers (N = 4,567 in 50 company-sized units) responded to questions about deployment and combat, IPV, and suicidal behaviors. Over a tenth (12.2%) of the soldiers reported having done any aggressive behaviors toward significant others or children during postdeployment. More lengthy and repeated deployments were associated with perpetration of IPV. Having killed or wounded someone and having experienced some form of combat trauma were much more strongly associated with IPV perpetration. Suicidal behaviors were associated with having committed IPV, with the greatest risk associated with suicide attempts. Findings are discussed in terms of underlying mechanisms of both IPV perpetration and suicidal behaviors.

Introduction: To examine positive and negative affective processes associated with firearm acquisition and firearm ownership. Methods: An online cross-sectional survey assessing firearm ownership, reasons for firearm ownership, intentions to acquire a firearm in the next 12 months, and positive and negative affective states was administered to 6,200 U.S. adults (49.0% male, 51.0% female). Results: Mean negative and positive affect were significantly elevated among protective firearm owners (i.e., those who kept firearms for the primary purpose of self-protection) and participants intending to acquire a firearm. Protective firearm owners intending to acquire another firearm reported significantly higher negative affect than all other subgroups. Within this subgroup, negative affect and positive affect were positively correlated. Among all other subgroups, negative and positive affect were either negatively correlated or uncorrelated. Discussion: The intention to acquire firearms and protective firearm ownership are associated with both positive and negative affectivity. Typical cognitive-affective processes may be disrupted among protective firearm owners intending to acquire another firearm.

Firearm availability is correlated with increased suicide mortality. Some firearm owners may be more vulnerable to suicide than others, but heterogeneity among firearm owners has received little empirical attention. The present study used latent class analysis (LCA) to identify subgroups of firearm owners who keep firearms primarily for protection (i.e.

Objective Military veterans who interpret their own or others' actions as moral transgressions are theorized to experience moral distress. The purpose of this study was to explore patterns of moral distress and associated psychological, social, and religious or spiritual problems among student veterans. Method Student veterans (N = 498) retrospectively reported experiences of moral distress associated with deployment-related events in which they felt (a) troubled by what they witnessed, (b) troubled by what they did, (c) troubled by what they failed to do, (d) betrayed by military leaders, or (e) betrayed by fellow service members. Results Latent profile analysis revealed 5 response patterns: No Moral Distress (42%), Witnessing-Only (16%), Moral Distress-Other (19%; encompassing distress mostly from being betrayed by others), Moral Distress-Self (8%; encompassing distress mostly from one's own actions or inactions), and Moral Distress-Self and Other (15%). We compared scores on measures of posttraumatic stress, familial or social functioning, and religious or spiritual struggles between profiles and observed moderate to large differences. Conclusions Whereas participants reported some problems (e.g., interpersonal conflict) regardless of whether they were exposed to a morally injurious event by witnessing, perpetrating, or being betrayed, in comparison to those reporting no moral distress, those who felt responsible for the event reported greater guilt and lack of purpose and those who held others responsible for the event reported greater posttraumatic stress. Participants who endorsed feeling betrayed by others' and troubled by their own actions reported multiple problems including posttraumatic stress, interpersonal difficulties, and religious or spiritual struggles. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Insomnia is the most commonly reported symptom of posttraumatic stress disorder (PTSD), with at least 70% of patients with PTSD reporting disturbed sleep. Although posttraumatic insomnia has traditionally been conceptualized as a consequence of PTSD, it is the most likely symptom to not remit following otherwise successful PTSD treatment. This suggests that the relationship between PTSD and insomnia is more complex, such that they likely share underlying pathological mechanisms and that factors non-specific to PTSD maintain chronic trauma-induced insomnia. Although several theories and hypotheses have been presented to explain the relationship between PTSD and insomnia, neurobiological and psychological models have not been integrated, thereby limiting their comprehensiveness and abilities to inform effective intervention. Further, existing models have not addressed how acute trauma-induced insomnia becomes chronic. The present review examined models of PTSD and insomnia separately, as well as existing theorized mechanisms of their co-morbidity. The distinct characteristics of trauma-induced insomnia were also reviewed and presented to describe the unique clinical presentation of trauma-induced insomnia. Review and integration of the literature were used to propose an integrated model of chronic trauma-induced insomnia informed by a neuropsychobiological framework. Clinical implications and future research directions are presented and discussed.

The aim of the present study was to evaluate the unique associations between self-report history of mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) symptoms on functiona...

Objective To evaluate the psychometric and predictive performance of the Columbia-Suicide Severity Rating Scale (C-SSRS) in emergency department (ED) patients with suicidal ideation or attempts (SI/SA). Methods Participants (n = 1,376, mean age 36.8, 55% female, 76.8% white) completed the C-SSRS during the ED visit and were followed for one year. Reliability analyses, exploratory structural equation modeling, and prediction of future SA were explored. Results Reliability of the Suicidal Ideation subscale was adequate, but was poor for the Intensity of Ideation and Suicidal Behavior subscales. Three empirically derived factors characterized the C-SSRS. Only Factor 1 (Suicidal Ideation and Attempts) was a reliable predictor of subsequent SA, though odds ratios were small (ORs: 1.09-1.10, CI95% : 1.04, 1.15). The original C-SSRS Suicidal Ideation and Suicidal Behavior subscales and the C-SSRS ED screen predicted subsequent SA, again with small odds ratios (ORs: 1.07-1.19, CI95% : 1.01, 1.29). In participants without a SA history, no C-SSRS subscale predicted subsequent SA. History of any SA (OR: 1.98, CI95% : 1.43, 2.75) was the strongest predictor of subsequent SA. Conclusions The psychometric evidence for the C-SSRS was mixed. History of a prior SA, as measured by the C-SSRS, provided the most parsimonious and powerful assessment for predicting future SA.

Military service poses stressors for many service members (SMs). Accordingly, support programs exist to address these demands, but these services are often underused. This article uses data from a ...

The present study examined Preferences in Information Processing (PIP), an emerging model of understanding suicidal thoughts and behaviors (STBs), in a clinical military sample for the first time. Constructs of need for affect (NFA; i.e., extent to which one engages or avoids emotional content) and need for cognition (NFC; i.e., extent of preference for and enjoyment of cognitive effort) are central individual differences of the PIP model hypothesized to be associated with STBs. Data (

Suicide risk screening assumes that suicidal thoughts and behaviors exist on a continuous, hierarchical spectrum with some suicidal thoughts implicated with greater risk for suicidal behaviors. However, screening measures based on the hierarchical model may not capture the suicide risk construct. This study assessed psychometric properties of the Columbia Suicide Severity Rating Scale (CSSRS) for (a) between- and within-person measurement dimensions, (b) item utility in capturing the suicide risk construct, and (c) tenability of a hierarchical risk model. We found that the CSSRS functions differentially between and within individuals, CSSRS items capture more suicide risk construct, and that CSSRS items in current practice likely appear in the correct order. The current CSSRS reasonably represents within-person suicide risk, but not between-person risk. Scale norms or alternate scoring could facilitate functional equivalence and utility for between- and within-person CSSRS dimensions.

Objective The fluid vulnerability theory of suicide posits that each person has a baseline risk for suicide, which is comprised of both stable and dynamic factors. The current study investigated the unique involvement of suicide-specific cognitions and attentional fixation on recent suicidal ideation (SI) and SI at its worst. Method Data were analyzed from a sample of N = 126 undergraduate students with a history of SI. Path analyses were used to analyze the relationship between suicide-specific cognitions, attentional fixation, and SI (current and worst point). Results Results revealed that suicide-specific cognitions were directly related to both recent SI and worst-point SI. Suicide-specific cognitions had a significant, indirect effect with worst-point SI through attentional fixation, but this effect was not significant when using recent SI. Conclusion These data support the need for interventions to target cognitive contents and contexts (e.g., fixation) to reduce escalation of SI. Future work would benefit from replicating and extending results in studies that include prospective designs and the assessment of suicidal behaviors.

Approximately half of patients who attempt or die by suicide screened negative for suicidal ideation during their most recent medical visit. Maladaptive beliefs and schemas can increase cognitive vulnerability to suicidal behavior, even among patients without recent or past suicidal thoughts and behaviors. Assessing these beliefs could improve the detection of patients who will engage in suicidal behavior after screening negative for elevated suicide risk.Primary care patients who completed the Patient Health Questionnaire-9 and the Suicide Cognitions Scale-Revised (SCS-R) during routine clinic visits and denied suicidal ideation at baseline (N = 2417) were included in the study sample. Suicidal behaviors during the 12 months after baseline were assessed. Logistic regression analyses examined the association of baseline SCS-R scores with later suicidal behavior.In both univariate and multivariate analyses, SCS-R total scores were associated with significantly increased risk of suicidal behavior within 90, 180, and 365 days post-baseline. Results were unchanged when patients who reported prior suicidal behavior were excluded (N = 2178). In item-level analyses, all 16 SCS-R items significantly differentiated patients with and without follow-up suicidal behavior.Study limitations included missing follow-up data, restriction of sample to U.S. military medical beneficiaries, and inability to assess representativeness of the sample relative to the full primary care population.SCS-R scores are elevated among patients who attempt suicide after denying both suicidal ideation and prior suicide attempts, suggesting the scale may reflect enduring suicide risk. The SCS-R could enhance suicide risk screening and assessment.

Studies have examined burnout and its impact on health, to include its influence on sleep. While many studies report a significant relationship between burnout and insomnia in civilian populations, no studies have examined this relationship in a military population. The United States Air Force (USAF) Pararescue personnel are an elite combat force who are specially trained to conduct both first-line combat and full spectrum personnel recovery and may be at high risk of burnout and insomnia. The current study investigated the association between dimensions of burnout and insomnia, and also examined potential moderators of the associations. A cross-sectional survey was administered to 203 Pararescue personnel (Mean Age = 32.1 years; 100% Male; 90.1% Caucasian) recruited from six US bases. The survey included measures of three dimensions of burnout (emotional exhaustion, depersonalization, personal achievement), insomnia, psychological flexibility, and social support. Emotional exhaustion was significantly associated with insomnia with a moderate to large effect size, when controlling for covariates. Depersonalization, but not personal achievement, was also significantly associated with insomnia. There was no evidence that associations between burnout and insomnia were moderated by psychological flexibility or social support. These findings help to identify individuals at risk of insomnia and may ultimately be useful in developing interventions for insomnia in this population.

ImportanceSecure firearm storage may help reduce firearm injury and death. Broad implementation requires more granular assessments of firearm storage practices and greater clarity on circumstances that may prevent or promote the use of locking devices.ObjectiveTo develop a more thorough understanding of firearm storage practices, obstacles to using locking devices, and circumstances in which firearm owners would consider locking unsecured firearms.Design, Setting, and ParticipantsA cross-sectional, nationally representative survey of adults residing in 5 US states who owned firearms was administered online between July 28 and August 8, 2022. Participants were recruited via probability-based sampling.Main Outcomes and MeasuresFirearm storage practices were assessed via a matrix provided to participants in which firearm-locking devices were described both via text and images. Locking mechanisms (key/personal identification number [PIN]/dial vs biometric) were specified for each type of device. Obstacles to the use of locking devices and circumstances in which firearm owners would consider locking unsecured firearms were assessed via self-report items developed by the study team.ResultsThe final weighted sample included 2152 adult (aged ≥18 years), English-speaking firearm owners residing in the US; the sample was predominantly male (66.7%). Among the 2152 firearm owners, 58.3% (95% CI, 55.9%-60.6%) reported storing at least 1 firearm unlocked and hidden, with 17.9% (95% CI, 16.2%-19.8%) reporting storing at least 1 firearm unlocked and unhidden. Gun safes were the most frequently used device both among participants who use keyed/PIN/dial locking mechanisms (32.4%; 95% CI, 30.2%-34.7%) and those who use biometric locking mechanisms (15.6%; 95% CI, 13.9%-17.5%). Those who do not store firearms locked most frequently noted a belief that locks are unnecessary (49.3%; 95% CI, 45.5%-53.1%) and a fear that locks would prevent quick access in an emergency (44.8%; 95% CI, 41.1%-48.7%) as obstacles to lock usage. Preventing access by children was the most often reported circumstance in which firearm owners would consider locking unsecured firearms (48.5%; 95% CI, 45.6%-51.4%).Conclusions and RelevanceIn this survey study of 2152 firearm owners, consistent with prior research, unsecure firearm storage was common. Firearm owners appeared to prefer gun safes relative to cable locks and trigger locks, indicating that locking device distribution programs may not match firearm owners’ preferences. Broad implementation of secure firearm storage may require addressing disproportionate fears of home intruders and increasing awareness of the risks associated with household firearm access. Furthermore, implementation efforts may hinge on broader awareness of the risks of ready firearm access beyond unauthorized access by children.

Previous research has linked unsafe firearm storage practices and other ownership-related characteristics to key factors that facilitate the transition from suicidal thoughts to suicidal behaviors (i.e., acquired capability for suicide). This research has not investigated the extent to which firearm owners store firearms in their vehicles, a factor that increases ready access to the most lethal means of suicide.This cross-sectional study investigated the prevalence of occasional and permanent vehicle firearm storage as well as demographic and psychological correlates of this practice in a sample ofParticipants completed an online survey for monetary compensation.Over 40% of participants indicated at least occasionally storing firearms in their vehicles with over 15% indicating storage of firearms unlocked and loaded. Elevated scores on measures of negative affect, worry, intolerance of uncertainty, and historical suicidal thoughts and behaviors were seen in those who endorsed vehicle firearm storage compared to those who did not.Individual and public health firearm safety strategies would benefit from an explicit focus on the transition of firearms to and from one's vehicle.HIGHLIGHTSOver 40% of male firearm owners at least occasionally store a firearm in a vehicle.15% of those who store a firearm in a vehicle do so unlocked and loaded.Suicidal thought severity was related to storing a firearm in a vehicle.Historical suicidal behaviors were related to storing a firearm in a vehicle.

Objective Patients with posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) are often not offered exposure therapy for PTSD due to concerns that symptoms may worsen. This study examined whether initiating exposure would cause exacerbation of PTSD, alcohol use, depression, or suicidal ideation (SI) among patients with PTSD/AUD participating in exposure therapy for PTSD. Method Veterans were randomized to either concurrent treatment of PTSD and substance use disorders using prolonged exposure (COPE) or seeking safety, a nonexposure intervention, and were included in this study if they had data to at least Session 5 available (n = 81). They completed measures of PTSD, alcohol use, and depression/SI symptom severity throughout treatment and posttreatment. The reliable exacerbation method examined the number of participants who demonstrated clinically meaningful symptom exacerbation from Sessions 3 to 5 (capturing the prepost window for the start of exposure in COPE). Hierarchical/logistic regressions examined whether treatment condition predicted exacerbation of symptoms. T tests/chi-square analyses examined whether clinical exacerbation led to worse posttreatment outcomes. Results Few participants endorsed exacerbation in symptoms of PTSD (15.8%), alcohol use (5.1%), depression (10.2%), or SI (12.8%). No significant treatment condition differences existed. Participants who experienced symptom exacerbation had higher rates of depression posttreatment compared to those who did not experience symptom exacerbation, but there were no differences in PTSD, alcohol use, or SI. Conclusions Exposure therapy did not lead to more clinical exacerbation than nonexposure therapy during the course of treatment, providing support that exposure therapy should not be withheld from patients with PTSD/AUD. This was a secondary analysis. and future studies that are sufficiently powered may demonstrate different results. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The Suicide Cognitions Scale (SCS) measures suicide-related beliefs proposed by the Fluid Vulnerability Theory. A recent investigation of a revised version of the SCS (i.e., SCS-R) which omits items explicitly referencing suicide has indicated that the measure is highly influenced by a general factor and may be useful for distinguishing severity levels of suicidal thoughts and behaviors; however, limited concurrent validity studies with a range of suicide-related experiences have been conducted. As such, this study replicated and extended previous psychometric research on the SCS-R in an online survey study with a community sample of N = 10,625 U.S. adults. Results confirmed the unidimensional structure of the SCS-R. Logistic regression analyses indicated that the total score of the SCS-R is useful in distinguishing varying levels of suicidal thoughts and behaviors such as past-month planning for suicide without attempt versus past-month suicide attempt. Implications and limitations are discussed.

OBJECTIVE: Failing to account for temporal dynamics can hinder our understanding of suicidal ideation and the potential mechanisms underlying increased risk for suicide death and suicide attempts associated with posttraumatic stress disorder (PTSD). To address these limitations, this study used an analytic approach based on Dynamical Systems Theory to describe temporal patterns associated with multiple dimensions of suicidal ideation in a treatment-seeking sample of military personnel diagnosed with PTSD. METHOD: We performed a secondary analysis of archived data from 742 active duty military personnel (90% male, 57% white, mean age = 33 ± 7.4 years) enrolled in three clinical trials to examine the dimensional measurement properties of the first 5 items of the Scale for Suicidal Ideation (SSI). RESULTS: Findings indicated two change dynamics for suicidal ideation: homeostatic (i.e., the tendency for suicidal ideation to return to a stable point) and cyclical (i.e., the tendency for suicidal ideation to switch back and forth between higher and lower values). Cycling was the dominant dynamic, and was related to variables other from suicidal ideation. CONCLUSION: The cyclic nature of suicidal ideation suggests that assessment timing and context could influence observed associations with other variables. Analytic approaches and clinical methods that do not account for the temporal dynamics of suicide risk could miss these properties, thereby hindering efforts to identify mechanisms underlying the relationship between PTSD and suicidal thoughts and behaviors, and limiting opportunities for proactive and timely intervention. CLINICAL IMPACT STATEMENT: Suicidal ideation is multidimensional, with each dimension following different time courses. Cycling of suicidal ideation is pronounced among military personnel receiving treatment for PTSD. Recognizing these patterns could improve assessment and treatment by identifying critical periods of time during treatment that warrant suicide-focused interventions.

This editorial overview provides an introduction to the Suicide and Life-Threatening Behaviors Special Issue: "Analytic and Methodological Innovations for Suicide-Focused Research." We outline several challenges faced by modern suicidologists, such as the need to integrate different analytical and methodological techniques from other fields with the unique data problems in suicide research. Therefore, the overall aim of this issue was to provide up-to-date methodological and analytical guidelines, recommendations, and considerations when conducting suicide-focused research. The articles herein present this information in an accessible way for researchers/clinicians and do not require a comprehensive background in quantitative methods. We introduce the topics covered in this special issue, which include how to conduct power analyses using simulations, work with large data sets, use experimental therapeutics, and choose covariates, as well as open science considerations, decision-making models, ordinal regression, machine learning, network analysis, and measurement considerations. Many of the topics covered in this issue provide step-by-step walkthroughs using worked examples with the accompanied code in free statistical programs (i.e., R). It is our hope that these articles provide suicidologists with valuable information and strategies that can help overcome some of the past limitations of suicide research, and improve the methodological rigor of our field.

Suicide is a persistent issue in the United States and across the globe. A large body of published research shows that posttraumatic stress disorder (PTSD) increases the risk of suicidal ideation, suicidal behaviors, and death by suicide. However, the existing literature examining why that association might pertain is widely dispersed across disciplines (e.g., psychology, nursing) and lacks an integrative theoretical framework, making it difficult to conceptualize the current state of science in this area. Therefore, the primary aims of this narrative review were to (a) provide a comprehensive and interdisciplinary critique of the current state of knowledge regarding mechanisms that underlie the association between PTSD and suicide and (b) organize that knowledge according to a specified theoretical framework. The framework guiding this review is "fluid vulnerability theory," a diathesis-stress model of suicide that emphasizes the dynamic nature of suicide risk across cognitive, emotional, behavioral, and physiological domains. A summary of the findings, including patterns that emerged, gaps that remain, and recommendations for the advancement of science and practice in this area are addressed in this narrative review.

The study explored the development of the Brief Suicide Cognitions Scale (B-SCS), a simple and brief measure of suicide risk. The B-SCS provides a brief measure that captures critical aspects of suicide risk embedded in core beliefs about the self as unlovable, one's emotional experience as unbearable, and life problems as unsolvable (i.e., the suicidal belief system), resulting in chronic or enduring suicide risk and heightened vulnerability for acute episodes secondary to internal and external triggers. Data were analyzed from three diverse samples, including a student sample (N = 349), an inpatient psychiatric sample (N = 160), and a sample of emergency department (ED) patients presenting secondary to a suicidal crisis (N = 94). Those in the student and inpatient samples completed additional symptom measures (hopelessness, anxiety, depression) and the ED sample provided 6-month follow-up data for suicide attempts. Reliability (internal consistency, test-retest), concurrent validity, construct (divergent, convergent) validity, factorial, incremental, and predictive validity were evaluated, along with calculation of predictive value of negative and positive tests, sensitivity, and specificity estimates. The B-SCS demonstrated good reliability and validity, a unidimensional factor structure across samples, along with good predictive validity and value in real-world clinical settings. The B-SCS is a brief, reliable and valid measure of suicide risk, with good ability to identify those with enduring risk for subsequent suicide attempts. The B-SCS offers a unique contribution to understanding and assessing the nature of suicide risk over time targeting the suicidal belief system, with easy application across inpatient and outpatient clinical settings, and good predictive value.

Background Identifying the interaction between dispositional and dynamic risk factors is necessary in understanding, predicting, and managing suicide risk. Interpersonal factors have consistently been linked to suicidal ideation over short-term periods. Additionally, distress tolerance may be a relevant dispositional protective factor against stressful events. Methods Seven hundred and seventeen psychiatric inpatients (Male = 30.31%, Average Age = 40.71 years, Min = 14, Max = 82) self-reported their distress tolerance at hospital admission, and interpersonal needs and suicidal ideation on a daily basis. Dynamic structural equation modelling was used to examine whether within-level dynamics were moderated by distress tolerance. Results Both perceived burdensomeness and thwarted belongingness were significantly associated with same-day suicidal ideation. Higher distress tolerance was associated with weaker daily associations between suicidal ideation and both perceived burdensomeness and thwarted belongingness. Distress tolerance was also associated with lower variability in suicidal ideation. Moderating effects were also evident when lifetime suicide attempts were added as a covariate, which was associated with stronger associations between interpersonal dysfunction and suicidal ideation, and higher variability in ideation. Conclusions Distress tolerance may be important to consider when examining the dynamic relationships between suicidal ideation and proximal factors. Psychotherapy that specifically targets distress tolerance may be effective in reducing reactivity to interpersonal stressors.

Objective Repeated exposure to traumatic events has consistently been shown to negatively impact mental health functioning; however, the role of timing of such events has received less attention. The present study evaluated the role of trauma that has occurred prior to military service, during service, and across both points in contributing to the most common and deleterious mental health concerns experienced by military personnel: posttraumatic stress, depression, suicide ideation, and suicide attempts. Method Utah and Idaho National Guard personnel (n = 997) completed online self-report questionnaires of their current posttraumatic stress and depression symptoms, as well as history of potentially traumatic experiences, suicidal thoughts, and actions. Results Results indicated that history of trauma across time points is associated with negative outcomes across each of these outcomes, with the exception of suicide attempts. Exploratory analyses further revealed that unwanted or uncomfortable sexual experiences (not sexual assault) is the most robust predictor of negative outcomes, with approximately 2 to 7.5 times increased risk for PTSD, depression, suicide ideation, and suicide attempts. Conclusions The present findings suggest that individuals with history of trauma prior to military service are at increased risk for developing clinically significant mental health problems if exposed to additional potentially traumatic experiences. Further, other unwanted sexual experiences appear to be particularly detrimental to mental health functioning. Potential implications for military recruitment and conceptualization of traumatic events are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Abstract. Background: Although financial strain is an identified risk factor for suicide among US military personnel, research is limited regarding the specific dimensions of financial strain that confer the greatest risk. Aims: The present study examined the associations among multiple indicators of financial strain, suicide ideation, and suicide attempts in a sample of US National Guard personnel, a high-risk subgroup of the US military. Method: National Guard personnel from Utah and Idaho ( n = 997) completed an anonymous online self-report survey. Weighted univariate and multivariate logistic regression was used to test hypothesized associations. Results: Lifetime history of suicide ideation was significantly more common among participants reporting recent income decrease, credit problems, and difficulty making ends meet, even when adjusting for other covariates. Lifetime history of suicide attempt was significantly associated with recent foreclosure or loan default, credit problems, and difficulty making ends meet, but only in univariate analyses. Recent credit problems were the only financial strain indicator that significantly predicted a history of suicide attempt among participants with a history of suicide ideation. Limitations: The present study includes self-report methodology and cross-sectional design. Conclusion: Although multiple indicators of financial strain are associated with increased risk for suicidal thinking among National Guard military personnel, credit problems had the strongest association with suicide attempts.

Although most individuals who experience suicidal thoughts will never attempt suicide and the majority of those who survive a suicide attempt will neither re-attempt nor die by suicide, lit...

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.

Protective factors associated with reductions in posttraumatic stress disorder (PTSD) have received much less empirical attention than risk factors for PTSD. Happiness and meaning in life are two protective factors that are inversely correlated with PTSD symptom severity, but research to date has primarily considered associations at the participant level, ignoring group-level effects. As a result, little is known about how various characteristics of military units may impact military personnel exposed to traumatic and/or stressful life experiences. In a sample of 997 National Guard personnel assigned to 40 units, we examined associations among happiness, meaning in life, and PTSD symptoms at both the participant and unit level using multilevel modeling. Higher levels of happiness at both the participant and unit level significantly moderated the effect of lifetime trauma exposure with PTSD symptom severity. Meaning in life at both the participant and the unit levels were inversely correlated with PTSD symptom severity. Results suggest that service members tend to report less severe PTSD symptoms if they experience positive emotions more frequently, have a stronger sense of purpose, and are assigned to units with higher levels of happiness and meaning in life. This protective effect may be due to the “transfer” of positive cognitive–affective states from one unit member to another.

U.S. National Guard (NG) military personnel experience many barriers to care such as limited access to health-care services and geographic separation from service providers. Although stigma and barriers to mental health care have been examined in the military, little is known about how different facets of stigma and barriers to care might impact different military subgroups. In a sample of 965 NG personnel, latent class analysis was used to identify distinct subgroups of stigma and barriers to care. Four groups were identified: no stigma or barriers (31%), mild stigma and barriers (30%), high stigma and career concerns (20%), and moderate stigma and barriers (20%). Classes significantly differed with respect to several demographic characteristics, rates of mental health conditions, and rates of previous suicidal thoughts and behaviors. Results suggest that different subgroups of NG personnel vary with respect to levels of perceived stigma, barriers to care, and mental health needs.

We conducted several analyses with data from undergraduate students (N = 309) and active duty US Air Force Security Forces personnel (N = 273) to examine the utility of scores on the Anxiety Depres...

Individuals who are exposed to traumatic events that violate their moral values may experience severe distress and functional impairments known as "moral injuries." Over the last decade, moral injury has captured the attention of mental health care providers, spiritual and faith communities, media outlets, and the general public. Research about moral injury, especially among military personnel and veterans, has also proliferated. For this article, we reviewed scientific research about moral injury. We identified 116 relevant epidemiological and clinical studies. Epidemiological studies described a wide range of biological, psychological/behavioral, social, and religious/spiritual sequelae associated with exposure to potentially morally injurious events. Although a dearth of empirical clinical literature exists, some authors debated how moral injury might and might not respond to evidence-based treatments for posttraumatic stress disorder (PTSD) whereas others identified new treatment models to directly address moral repair. Limitations of the literature included variable definitions of potentially morally injurious events, the absence of a consensus definition and gold-standard measure of moral injury as an outcome, scant study of moral injury outside of military-related contexts, and clinical investigations limited by small sample sizes and unclear mechanisms of therapeutic effect. We conclude our review by summarizing lessons from the literature and offering recommendations for future research.Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Daño Moral: Una revisión integrativa REVISION INTEGRATIVA DE LA INVESTIGACION EN DAÑO MORAL Las personas que están expuestas a eventos traumáticos que violan sus valores morales pueden experimentar una angustia grave y discapacidades funcionales conocidas como “daño moral”. En la última década, el daño moral ha captado la atención de proveedores de servicios de salud mental, comunidades espirituales y religiosas, medios de comunicación y el público en general. La investigación sobre daño moral, especialmente entre el personal militar y los veteranos, también ha proliferado. Para este artículo, revisamos la investigación científica sobre el daño moral. Se identificaron 116 estudios epidemiológicos y clínicos relevantes. Los estudios epidemiológicos describieron una amplia gama de secuelas biológicas, psicológicas / conductuales, sociales y religiosas / espirituales asociadas con la exposición a eventos potencialmente dañinos moralmente. Aunque existe una escasez de literatura clínica empírica, algunos autores debatieron cómo el daño moral podría y no podría responder a los tratamientos basados ​​en la evidencia para el trastorno de estrés postraumático (TEPT), mientras que otros identificaron nuevos modelos de tratamiento para abordar directamente la reparación moral. Las limitaciones de la literatura incluyeron definiciones de variables de eventos potencialmente perjudiciales desde el punto de vista moral, la ausencia de una definición consensuada y una medida de gold-estándar de daño moral y sus consecuencias, escaso estudio de daño moral fuera de contextos relacionados con el ejército e investigaciones clínicas limitadas por muestra de tamaño pequeños y mecanismos poco claros del efecto terapéutico. Concluimos nuestra revisión resumiendo las lecciones de la literatura y ofreciendo recomendaciones para futuras investigaciones.Traditional and Simplified Chinese Abstracts by the Asian Society for Traumatic Stress Studies (AsianSTSS) 簡體及繁體中文撮要由亞洲創傷心理研究學會翻譯 Moral Injury: An Integrative Review Traditional Chinese 標題: 道德創傷:一項綜合評估 撮要: 經歷與自己的道德價值相違的創傷事件, 可導致嚴重悲痛和功能損傷, 此為「道德創傷」。過去十年來, 心理治療人士、信仰團體、媒體和普羅大眾開始關注道德創傷, 而針對道德創傷的研究, 特別是專門檢視現役和退役軍人的研究, 亦大大提升。本文將審視有關道德創傷的科學研究, 找出116份相關的流行病學及臨床研究。流行病學研究描述跟經歷潛在會導致道德創傷的事件相關的生物學、心理/行為、社會、信仰/精神層面廣泛的後遺症。雖然目前只有少量具臨床實證的文獻, 但當中有些探討針對創傷後壓力症(PTSD)的實證為本治療是否能治理道德創傷, 有些則找出新的治療模型以直接治理道德創傷。這些文獻的限制, 包括對潛在會導致道德創傷的事件有不同定義、缺乏對定義的共識、未能得出測量道德創傷的黃金標準、缺乏軍事相關環境以外的道德創傷研究, 而臨床研究的樣本數量小而且療效的機制模糊。最後, 我們總結文獻帶來的貢獻, 並為未來研究提供建議。 Simplified Chinese 标题: 道德创伤:一项综合评估 撮要: 经历与自己的道德价值相违的创伤事件, 可导致严重悲痛和功能损伤, 此为「道德创伤」。过去十年来, 心理治疗人士、信仰团体、媒体和普罗大众开始关注道德创伤, 而针对道德创伤的研究, 特别是专门检视现役和退役军人的研究, 亦大大提升。本文将审视有关道德创伤的科学研究, 找出116份相关的流行病学及临床研究。流行病学研究描述跟经历潜在会导致道德创伤的事件相关的生物学、心理/行为、社会、信仰/精神层面广泛的后遗症。虽然目前只有少量具临床实证的文献, 但当中有些探讨针对创伤后压力症(PTSD)的实证为本治疗是否能治理道德创伤, 有些则找出新的治疗模型以直接治理道德创伤。这些文献的限制, 包括对潜在会导致道德创伤的事件有不同定义、缺乏对定义的共识、未能得出测量道德创伤的黄金标准、缺乏军事相关环境以外的道德创伤研究, 而临床研究的样本数量小而且疗效的机制模糊。最后, 我们总结文献带来的贡献, 并为未来研究提供建议。.

Low rates of help-seeking among military service members (SMs) remains a persistent problem. Data from 997 National Guard (NG) SMs were examined to assess predictors of help-seeking behavio...

This introductory chapter provides an overview of suicide in the military, detailing the author’s experience in Iraq. The prevailing method for suicide prevention was limited by survival bias, a logical error wherein we focus on the people or things that survive some selection process while overlooking those who did not. This book challenges some of the core assumptions about suicide and typical practices that may not be so helpful or useful after all. It also presents alternative perspectives that implicate different approaches that may work better than prevailing methods. These alternative perspectives have been heavily influenced by the many suicidal individuals who have shared their experiences, trials, and triumphs.

This chapter examines how the mental illness model of suicide has led us to place more faith than may be warranted in concepts such as suicide “warning signs” and suicide-risk screening tools. These concepts are notoriously unreliable indicators of emerging suicidal behaviors because they do not sufficiently reflect the inherently dynamic and ever-changing nature of suicide risk. Any given warning sign for suicide will be wrong much, much more often than it will be right. Even when multiple warning signs are experienced or expressed by an individual, this problem persists. One factor limiting the accuracy of suicide-risk screening is that thoughts about death and suicide fluctuate over time. Thus, we should move away from assuming that we must know who will and who will not attempt suicide to prevent these behaviors from occurring.

This chapter argues for a potentially high-impact but underutilized strategy: restricting or limiting access to highly lethal methods for suicide, especially firearms. It begins by describing the role of seatbelts in traffic fatality prevention. Prevention through design assumes that injuries, illnesses, and fatalities can be most effectively reduced or controlled by designing and building systems that eliminate or remove potential hazards from the very beginning, before they can cause any harm. If we shifted our mindset surrounding suicide prevention in a way that better aligned with the prevention through design approach underlying traffic fatality prevention, we might reconsider the considerable time, effort, and resources being devoted to the development and implementation of suicide risk identification and detection methods, and consider instead the potential impact of redirecting these efforts toward environmentally focused strategies that are more likely to reduce suicide rates. The chapter then considers the life-saving effects of laws and policies designed to reduce access to firearms, discussing firearm suicide in the United States.

This chapter presents an overview of newer thinking about how suicide risk fluctuates over time using concepts informed by mathematics, which provides a useful model for understanding why and how suicide emerges in different ways for different people at different times. It focuses in particular on the implications of this perspective for understanding suicides that emerge suddenly or “out of the blue” without much advance notice or warning signs. In the world of dynamical systems, sudden and discontinuous change processes are often referred to as “catastrophic” change because they represent a fundamental shift in how a system operates. Catastrophic change can be so dramatic that it defies reason and cannot be easily anticipated. The chapter then considers the cusp catastrophe model, which stands in contrast to the unidimensional suicide-risk continuum model that has dominated thinking about suicide risk for decades.

This chapter evaluates the centrality of mental illness in discussions of suicide and argues that the predominance of this perspective reflects confirmation bias, which is the tendency to search for and interpret information in a way that supports our beliefs and assumptions. Most people who are actively involved in suicide prevention learned that 90% of those who die by suicide were struggling with a mental illness at the time of their death. As a tool for diagnosing mental illness among individuals who cannot speak for themselves, however, the psychological autopsy method is vulnerable to confirmation bias. Instead of assuming that most or all individuals who die by suicide have a mental illness, a more balanced and accurate perspective would be that some individuals who die by suicide have a mental illness and some individuals who die by suicide do not. The chapter concludes that mental illness is only weakly correlated with suicidal behaviors and a much larger percentage of suicides than we may have traditionally recognized occur in the absence of mental illness.