In military veterans, depression, posttraumatic stress disorder (PTSD), and suicidal thoughts are common and closely linked. Veterans are less likely to seek care and more likely to act successfully on suicidal thoughts. Therefore, screening, timely diagnosis, and effective intervention are critical.1
In this article, we review the signs and symptoms of depression and PTSD, the relationship of these conditions to suicidality in veterans, and the role of the non-mental-health clinician in detecting suicidal ideation early and then taking appropriate action. Early identification of suicidality may help save lives of those who otherwise may not seek care.
FROM IDEA TO PLAN TO ACTION
Suicide can be viewed as a process that begins with suicidal ideation, followed by planning and then by a suicidal act,2–9 and suicidal ideation can be prompted by depression or PTSD.
Suicidal ideation, defined as any thought of being the agent of one’s own death,2 is relatively common. Most people who attempt suicide report a history of suicidal ideation.10 In fact, current suicidal ideation increases suicide risk,11,12 and death from suicide is especially correlated with the worst previous suicidal ideation.3
Suicidal ideation is an important predictor of suicidal acts in all major psychiatric conditions.3,13–17 In a longitudinal study in a community sample, adolescents who had suicidal ideation at age 15 were more likely to have attempted suicide by age 30.5
The annual incidence of suicidal ideation in the United States is estimated to be 5.6%,18 while its estimated lifetime prevalence in Western countries ranges from 2.09% to 18.51%.19 A national survey found that 13.5% of Americans had suicidal ideation at some point during their lifetime.20 About 34% of people who think about suicide report going from seriously thinking about it to making a plan, and 72% of planners move from a plan to an attempt.20 In the European Study of the Epidemiology of Mental Disorders,21 the lifetime prevalence of suicidal ideation was 7.8%, and of suicide attempts 1.3%. Being female, younger, divorced, or widowed was associated with a higher prevalence of suicide ideation and attempts.
Although terms such as “acute suicidal ideation,” “chronic suicidal ideation,” “active suicidal ideation,” and “passive suicidal ideation” are used in the clinical and research literature, the difference between them is not clear. Regardless of the term one uses, any suicidal ideation should be taken very seriously.
HABITUATION IN VETERANS
Interestingly, according to the Interpersonal-Psychological Theory of Suicide,22 the suicidal process is related to 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 of pain associated with suicide.22 Veterans are likely to have acquired this capability as the result of military training and combat exposure, which may cause habituation to fear of painful experiences, including suicide.
FEATURES AND CAUSES OF PTSD
PTSD—a severe, multifaceted disorder precipitated by exposure to a psychologically distressing experience—first appeared in the Diagnostic and Statistical Manual of Psychiatric Disorders (DSM-III) in 1980,23,24 arising from studies of veterans of the Vietnam war and of civilian victims of natural and man-made disasters.44,45 However, the study of PTSD dates back more than 100 years. Before 1980, posttraumatic syndromes were recognized by various names, including railway spine, shell shock, traumatic (war) neurosis, concentration-camp syndrome, and rape-trauma syndrome.24,25 The symptoms described in these syndromes overlap considerably with what we now recognize as PTSD.
According to the most recent edition of the Diagnostic and Statistical Manual, DSM-IV-TR,27 the basic feature of PTSD is the development of characteristic symptoms following exposure to a stressor event. Examples include:
- Direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical integrity
- Witnessing an event that involves death, injury, or a threat to the physical integrity of another person
- Learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate.
People react to the event with fear and helplessness and try to avoid being reminded of it.
Traumatic events leading to PTSD include military combat, violent personal assault, being kidnapped or taken hostage, experiencing a terrorist attack, torture, incarceration, a natural or man-made disaster, or an automobile accident, or being diagnosed with a life-threatening illness.
PTSD is a potentially fatal disorder through suicide. There may be differences in the psychobiology of PTSD and suicidal behavior between war veterans and civilians.28
PTSD often coexists with other psychiatric illnesses29,30: the National Comorbidity Survey found that about 80% of patients with PTSD meet the criteria for at least one other psychiatric disorder.30 Symptoms of PTSD and depression overlap significantly. Common features include diminished interest or participation in significant activities; irritability; sleep disturbance; difficulty concentrating; restricted range of affect; and social detachment.
PTSD also often coexists with traumatic brain injury and other neurologic and medical conditions.31,32 The clinician is more often than not faced with a PTSD patient with multiple diagnoses—psychiatric and medical.
Unfortunately, studies show that PTSD often goes unrecognized by non-mental-health practitioners.31,33 In a national cohort of primary care patients in Israel, 9% met criteria for current PTSD, but only 2% of actual cases were recognized by their treating physician.33