Elsevier

Comprehensive Psychiatry

Volume 77, August 2017, Pages 12-19
Comprehensive Psychiatry

Exposure to suicide is associated with increased risk for suicidal thoughts and behaviors among National Guard military personnel

https://doi.org/10.1016/j.comppsych.2017.05.006Get rights and content

Abstract

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 < .001), but not suicide attempt (OR = 1.34, p = .472). Perceived closeness to the suicide decedent was associated with significantly increased risk for PTSD (OR = 1.54, p < .001), depression (OR = 1.36, p = .031), suicide ideation (OR = 1.24, p = .039), and suicide attempt (OR = 1.69, p = .026). The majority of participants who experienced suicidal thoughts and attempts after the suicide exposure had a previous history of suicide ideation.

Conclusions

Suicide exposure is common among National Guard personnel, and is associated with increased risk for PTSD, depression, and suicidal thoughts and behaviors. Risk is highest for those personnel who know multiple suicide decedents and were closer to the suicide decedent.

Introduction

Suicide rates continue to rise in the US and in military populations. In 2014, there were 41,425 suicides among U.S. adults. Of these, 18% were identified as veterans of U.S. military service [1]. Since 2001, the age-adjusted rate of suicide among U.S. veterans has increased by 32.2% [1]. In addition to veterans, military service members have been shown to be at especially high risk for suicide [2], [3]. Though suicides have been increasing across all branches of service, the rise has been particularly pronounced among National Guard personnel [4]. From 2012 to 2013, for instance, suicides among active duty soldiers decreased by 15% but among Army National Guard personnel, the number of suicides actually increased [4]. Furthermore, National Guard personnel are now almost twice as likely to die by suicide as their active duty peers [4], suggesting that National Guard personnel may have higher rates of exposure to suicidal behavior and suicide loss.

A wide range of people are exposed to and affected by suicide. The impact of suicide exposure is thought to lie on a continuum, with effects extending well beyond the decedent's closest family members [5]. Recent studies examining exposure to the suicide of family members [6] and non-family members [7] show that suicide exposure is associated with depression, anxiety, and suicidal behavior in people who are close to the decedent. Several studies in one U.S. state have shown that almost half the adult population has lifetime exposure (i.e., personally knows) someone who has died by suicide [8], [9]. Research further suggests that approximately 135 people are affected by each suicide death (Cerel, under review), suggesting that suicide can have far-reaching effects.

Only two studies to date have examined the prevalence and correlates of suicide exposure among military and veteran populations. Cerel et al. [10] utilized a random digit dial methodology and queried veterans about their suicide exposure. Of the 931 veteran participants, nearly half (47.1%) reported exposure to suicide at some point during their lives [10]. Those with suicide exposure were more likely than those without to report clinically significant depression, anxiety, and suicidal ideation. Among those exposed to suicide, perceived closeness to the decedent was the variable that was most strongly associated with increased symptoms. Because the sample utilized in this study was older in age (M = 61.6 years, SD = 15.4), results may not reflect the larger community of veterans or current military members, however. In a more recent study of 1753 United States military service members and veterans, more than half (57.3%) reported lifetime exposure to suicide [11]. In this study, service members and veterans exposed to suicide were more likely to report that they anticipated making a suicide attempt in the future, and were more likely to endorse a history of suicidal thoughts and behaviors. Similar to the findings of Cerel et al., perceived closeness to a suicide decedent was significantly associated with symptom severity. Specifically, those who reported greater closeness to a suicide decedent reported a higher likelihood of a future suicide attempt even after controlling for current suicidal symptoms and prior suicidal thoughts and behaviors.

These results suggest the possibility that knowing someone who has died by suicide increases service members' risk of experiencing suicidal thoughts and making a suicide attempt, such that a suicide loss potentially “triggers” a suicidal episode or suicide attempt among vulnerable service members. An alternative possibility is that service members who experience suicidal thoughts and behaviors are more likely to know service members who die by suicide, such that suicide deaths occur among high-risk subgroups or pockets of the population. Often referred to as suicide “contagion” or “clustering,” both of these possibilities align with social learning theory, which posits that the likelihood of suicidal behavior increase when individuals observe (or learn about) such behaviors in others, especially if the suicide decedent is well-respected or carries high social status [12]. The social learning perspective is also consistent with contemporary models of suicide such as the interpersonal–psychological theory, which posits that individuals acquire the capacity to engage in suicidal behavior as a result of exposure to provocative experiences such as others' suicidal behavior [13]. Unfortunately, studies to date have not taken into account the timing of initial onset of suicidal thoughts and behaviors relative to the occurrence of the suicide loss. Studies that disentangle the temporal sequencing of suicidal thoughts and behaviors relative to suicide exposure are therefore needed to understand the potential social dynamics of suicide exposure.

To this end, the present study had several aims. First, we aimed to describe rates of suicide exposure among National Guard personnel, an especially high-risk subgroup of the U.S. military. Second, we aimed to examine the correlations among suicide exposure, mental health conditions including depression, PTSD and problematic drinking, and suicidal thoughts and behaviors. For this aim, we specifically hypothesized that rates of mental health conditions and suicidal thoughts and behaviors would be significantly higher among participants who reported suicide exposure, a greater number of suicide losses, and greater closeness to a suicide decedent. Third, we aimed to determine what proportion of National Guard personnel who were exposed to suicide first experienced the emergence of suicidal thoughts and behaviors prior to and after the suicide loss.

Section snippets

Participants

Participants included 971 military personnel assigned to the Utah Army National Guard (n = 313, 32.2%), Utah Air National Guard (n = 216, 22.2%), and the Idaho Army National Guard (n = 442, 45.5%). The sample was predominantly (84.3%) male and had the following age distribution: 15.3% 17–24 years, 31.5% 25–34 years, 32.0% 35–44 years, 17.1% 45–54 years, and 4.0% 55–64 years. Self-reported racial identification (participants were allowed to endorse more than one) was 2.1% African American, 3.3% Asian,

Results

Almost two-thirds (65.4%, n = 605) of participants reported lifetime suicide exposure. Suicide exposed respondents were significantly less likely to identify as African American, but were significantly more likely to be married, previously deployed, older in age, and higher ranking (see Table 1). Participants endorsing suicide exposure reported knowing a mean of 3.0 (SD = 2.0, range: 1 to 11 or more) individuals who died by suicide; 71.3% (n = 473) reported they know at least two individuals who died

Discussion

Results of the present study suggest that approximately two-thirds (65.4%) of National Guard personnel know someone who has died by suicide, a rate that is higher than the 47% rate previously reported in a sample of community veterans [10] and the 57% rate reported in a mixed sample of military personnel and veterans [11]. Given that the National Guard has an especially high rate of suicide, the high rate of suicide exposure observed in the present study is not surprising. Overall,

References (25)

  • A. Pitman et al.

    Effects of suicide bereavement on mental health and suicide risk

    Lancet Psychiatry

    (2014)
  • J. Cerel et al.

    Veteran exposure to suicide: prevalence and correlates

    J Affect Disord

    (2015)
  • M.A. Hom et al.

    Exploring the association between exposure to suicide and suicide risk among military service members and veterans

    J Affect Disord

    (2017)
  • Department of Veterans Affairs

    VA suicide prevention program, facts about veteran suicide, July 2016

    (2016)
  • M. Schoenbaum et al.

    Predictors of suicide and accident death in the Army study to Assess risk and Resilience in Servicemembers (Army STARRS): results from the Army study to Assess risk and Resilience in Servicemembers (Army STARRS)

    JAMA Psychiat

    (2014)
  • D. Smolenski et al.

    Department of Defense Suicide Event Report (DoDSER): calendar year 2014 annual report

    (2014)
  • K. Franklin

    Department of Defense Quarterly Suicide Report, calendar year 2015 4th quarter, Defense suicide prevention office (DSPO)

    (2016)
  • J. Cerel et al.

    The continuum of "survivorship": definitional issues in the aftermath of suicide

    Suicide Life Threat Behav

    (2014)
  • M. Maple et al.

    Is exposure to suicide beyond kin associated with risk for suicidal behavior? A systematic review of the evidence

    Suicide Life Threat Behav

    (2016)
  • J. Cerel et al.

    Exposure to suicide and identification as survivor. Results from a random-digit dial survey

    Crisis

    (2013)
  • J. Cerel et al.

    Exposure to suicide in the community: prevalence and correlates in one U.S. state

    Public Health Rep

    (2016)
  • S. Stack

    Media coverage as a risk factor in suicide

    J Epidemiol Community Health

    (2003)
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      Individuals exposed to suicide are at an increased risk for developing suicidal ideation and engaging in suicidal behaviors (Cerel et al., 2016; Maple et al., 2017; Pitman et al., 2014). This risk has been evidenced in a variety of populations, including family members of decedents, adolescents and adults exposed to non-kin suicides, and military service members and veterans (Andriessen et al., 2016; Bryan et al., 2017; Cerel et al., 2015; Hedstrom et al., 2008; Hom et al., 2017; Maple et al., 2017; Qin et al., 2002; Tidemalm et al., 2011). The impact a suicide death has on an individual is influenced not just by the relationship to the decedent (i.e., kin vs. non-kin) but also by perceived closeness to the decedent (Andriessen et al., 2016; Cerel et al., 2013; Cerel et al., 2016; Maple et al., 2017).

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