Clinical Review

Depression and Substance Abuse Intensify Suicide Risk

Researchers examined the unique and combined contributions of the polytrauma clinical triad in certain combinations among Operation Iraqi Freedom/Operation Enduring Freedom veterans.


Posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), and chronic pain have affected so many veterans that this combination has become known as the polytrauma clinical triad (PCT). Individually and together, they have also been linked to an increased risk of suicide-related behavior (SRB), but no studies have examined the “unique or combined contributions” of the PCT among Operation Iraqi Freedom/Operation Enduring Freedom veterans, say researchers from South Texas Veterans Health Care System and the University of Texas, both in San Antonio; Edith Nourse Rogers Memorial VA Hospital in Bedford, Massachusetts; the Center for Applied Health Research in Temple, Texas; and the University of Utah in Salt Lake City.

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Thus, the researchers designed a study to help determine whether PTSD, TBI, and pain are more strongly associated with suicide in certain combinations as well as how they compare as risk indicators with other disorders, such as depression and substance abuse.

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In this retrospective study of 211,652 veterans, 5,653 (2.6%) had demonstrated SRB—either ideation, attempt (suicide and self-inflicted injury), or both. But although veterans in the PCT had a greater risk of SRB, the co-occurrence of all 3 conditions did not increase risk above that associated with PTSD, depression, or substance abuse alone. Instead, adding depression or substance abuse to PTSD increased the risk of suicidal ideation by more than 4-fold.

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Their findings reassert the importance of depression and substance abuse as additional risk factors for suicide among veterans, particularly those with comorbid PTSD, the researchers say. It is more essential than ever, they urge, to ensure that all veterans receive appropriate screening and treatment for symptoms of depression and substance abuse. They suggest an assessment template that targets subgroups at highest risk for depression and substance abuse, especially in conjunction with PTSD, as red flags warranting additional screening, care integration, and follow-up.

Finley EP, Bollinger M, Noël PH, et al. Am J Public Health. 2015;105(2):380-387.
doi: 10.2105/AJPH.2014.301957.

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