Posttraumatic stress disorder, depression, and suicide in veterans

SUICIDE RISK IN VETERANS

Suicidal behavior is a critical problem in war veterans. During the wars in Iraq and Afghanistan, the US Army’s suicide rate has increased from 12.4 per 100,000 in 2003 to 18.1 per 100,000 in 2008.³⁴ In the United Kingdom, more veterans have committed suicide since the end of the 1982 Falklands War than the number of servicemen killed in action during the Falklands War.³⁵ The South Atlantic Medal Association, which represents and helps Falklands veterans, believes that 264 veterans had taken their own lives by 2002, a number exceeding the 255 who died in active service. The suicide rate in Falklands War veterans is about three times higher than the rate in those who left the UK armed forces from 1996 to 2005.^36,37

Observations have suggested a relatively high prevalence of suicide ideation and attempts in different generations of war veterans and in different countries.³⁸

Suicidal ideation is more dangerous in war veterans than in the general population because they know how to use firearms and they often own them. In other words, they often possess the lethal means to act on their suicidal thoughts.

And female veterans may be more likely to commit suicide with a firearm. A US study³⁹ observed that female veterans who committed suicide were 1.6 times more likely to have used a firearm and male veterans were 1.3 more likely, compared with nonveterans and adjusting for age, marital status, race, and region of residence.

DEPRESSION, PTSD, AND SUICIDE RISK

Suicidal ideation in war veterans is often associated with PTSD and depression, conditions that often coexist. And PTSD has been shown to be a risk factor for suicidal ideation in American veterans of the wars in Iraq and Afghanistan.⁴⁰ In a survey of 407 veterans, those who screened positive for PTSD (n = 202) were more than four times as likely to endorse having suicidal ideation compared with veterans who screened negative for PTSD. In veterans who screened positive for PTSD, the risk of suicidal ideation was 5.7 times higher in those with two or more coexisting psychiatric disorders compared with veterans with PTSD alone.⁴⁰

Additional risk factors

Factors contributing to the risk of suicidal ideation and behavior in patients with PTSD include comorbid disorders (especially depression and substance abuse), impulsive behavior, feelings of guilt or shame, re-experiencing symptoms, and prewar traumatic experiences.^41–45

Recent studies have analyzed factors associated with suicidal ideation in US veterans of the wars in Iraq and Afghanistan. Pietrzak et al⁴⁶ surveyed 272 veterans, of whom 34 (12.5%) reported contemplating suicide in the 2 weeks prior to completing the survey. Screening positive for PTSD and depression and having psychosocial difficulties were associated with suicidal ideation, while postdeployment social support and a sense of purpose and control were negatively associated with it.

Other authors⁴⁷ found that only the “emotional numbing” cluster of PTSD symptoms and the “cognitive-affective” cluster of depression symptoms were distinctively associated with suicidal ideation. Maguen et al⁴⁸ recently reported that 2.8% of newly discharged US soldiers endorsed suicidal ideation. Prior suicide attempts, prior psychiatric medication, and killing in combat were each significantly associated with suicidal ideation, with killing exerting a mediated effect through depression and PTSD symptoms.

Another recent study⁴⁹ suggests that veterans reporting subthreshold PTSD (ie, having symptoms of PTSD but not meeting all the criteria for the diagnosis) were three times more likely to admit to having suicidal ideation compared with veterans without PTSD,⁴⁹ which indicates that subthreshold PTSD may increase suicide risk.

Lemaire and Graham⁵⁰ reported that prior exposure to physical or sexual abuse and having a history of a prior suicide attempt, a current diagnosis of a psychotic disorder, a depressive disorder, and PTSD were associated with current suicidal ideation. Other factors related to suicidal ideation were female sex, deployment concerns related to training (a protective factor—ie, it reduces suicide risk by enhancing resilience and by counterbalancing risk factors), the deployment environment, family concerns, postdeployment support (a protective factor), and postdeployment stressors.

PTSD and depression: An additive effect

These findings also suggest that the coexistence of PTSD and depression increases the risk of suicidal ideation more than PTSD or depression alone. This is consistent with the concept of posttraumatic mood disorder, ie, that when these diagnoses coexist, they are different than when they occur alone, and that the coexistence increases the risk of suicidal ideation and behavior.^51,52

HOW TO ASSESS SUICIDE RISK

Physicians are in a key position to screen for depression and PTSD in all their patients, including those who are veterans.^31,53

Traumatic events of adulthood can be asked about directly. For example, “Have you ever been physically attacked or assaulted? Have you ever been in an automobile accident? Have you ever been in a war or a disaster?” A positive response should alert the physician to inquire further about the relationship between the event and any current symptoms.

Traumatic childhood experiences require reassuring statements of normality to put the patient at ease. For example, “Many people continue to think about frightening aspects of their childhood. Do you?”

Physicians working with war veterans suffering from PTSD or depression should regularly inquire about suicidal ideation, and if the patient admits to having suicidal ideation, the physician should ask about the possession of firearms or other lethal means.

This type of screening has limitations. Fear of being socially stigmatized or of appearing weak may prevent veterans from disclosing thoughts of suicide. And one study⁵⁴ found little evidence to suggest that inquiring about suicide successfully identifies veterans most at risk of suicide.

Indirect indicators of suicidality

Identifying indirect indicators of suicidal thoughts is also important: these can include pill-seeking behavior; talking or writing about death, dying, or suicide; hopelessness; rage or uncontrolled anger; seeking revenge; reckless or risky behaviors or activities; feeling trapped; and saying or feeling there is no reason for living.⁵⁵

Other warning signs include depressed mood, anhedonia, insomnia, severe anxiety, and panic attacks.⁵⁶ A prior suicide attempt, a family history of suicidal behavior, and comorbidity of depression and alcoholism are associated with a high suicide risk.^56–59

Suicidal behavior is more common after recent, severe, stressful life events and in physical illnesses such as HIV/AIDS, Huntington disease, malignant neoplasm, multiple sclerosis, peptic ulcer, renal disease, spinal cord injury, and systemic lupus erythematosus. This is true in both veterans and nonveterans.⁶⁰

Useful questions

Useful questions in the assessment of suicidal risk can be formulated as follows⁶¹:

• How have you reacted to stress in the past, and how effective are your usual coping strategies?
• Have you contemplated or attempted suicide in the past? If so, how many times and under what circumstances? And how is your current situation compared with past situations when you considered or attempted suicide?
• Do you ever feel hopeless, helpless, powerless, or extremely angry?
• Do you ever have hallucinations or delusions?

The role of guilt

It is important to ask about guilt feelings. Hendin and Haas⁶² observed that in veterans with PTSD related to combat experience, combat-related guilt was the most significant predictor of suicide attempts and of preoccupation with suicide after discharge. Combat veterans may feel guilt about surviving when others have died, acts of omission and commission, and thoughts or feelings.⁶³ Some have suggested that guilt may be a mechanism through which violence is related to PTSD and major depressive disorder in combat veterans.⁶⁴