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VA research on

Suicide Prevention


Introduction

According to the Centers for Disease Control and Prevention, there were 42,773 suicides in 2014 in the United States, or 117 suicides each day. About 18 percent of those who die by suicide are Veterans.

Veterans can be at risk for suicide for a variety of reasons. Some are coping with aging, stress, or lingering effects stemming from their military service that have never been addressed. Many have underlying mental health conditions or substance use disorders, in some cases aggravated by their military service, which increases their risk. Many recently discharged Veterans have difficulty with personal relationships or their transition back to civilian life.

As part of its efforts to address this problem, VA has established a toll-free, confidential Veterans Crisis Line at 1-800-273-8255 (1-800-273-TALK). The hotline was established in 2007 and is staffed by mental health professionals 24 hours a day, seven days a week. It has received more than 3 million calls as of September 2017, and has initiated the dispatch of emergency services to callers in imminent crisis more than 84,000 times. VA also offers a texting service at #838255.

Veterans and their families can also chat online with trained counselors at www.VeteransCrisisLine.net. Since November 2011, the Veterans Crisis line has answered nearly 359,000 chat requests and nearly 78,000 texts. Registration with VA or enrollment in VA health care is not necessary. VA also has full-time suicide prevention coordinators at each of its 145 hospitals.

VA's Center of Excellence for Suicide Prevention, located at the Canandaigua, New York, VA Medical Center, has a mission to reduce occurrences of suicide, primarily by studying and applying public health approaches to suicide prevention.

VA's Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) studies suicide with the goal of reducing suicide in the Veteran population.

Researchers at the VISN 19 MIRECC in Denver work to provide useful information about suicide prevention in ways that are accessible to Veterans and the community at large. They also look at strategies to translate research-informed practices into everyday care.

The VISN 19 MIRECC has developed an ACE (Ask, Care, Escort) card to help Veterans, their family members, and friends learn the steps they can take to get help in order to prevent a suicide. The acronym ACE summarizes those steps.  They also provide a consulting service for those in clinical positions who are serving Veterans at risk for suicide.

The MIRECC's website also offers a suicide attempt survivor family resource guide, and guides to talking to children about suicide attempts in their family. Both products are available in English and Spanish.

VA is also part of the Military Suicide Research Consortium, a partnership with DoD that manages studies to increase knowledge on topics such as risk assessment, treatment, and prevention as they pertain to suicidal behavior in the military and among Veterans.

In 2016, Dr. David Shulkin, then VA's Under Secretary for Health and today the agency's Secretary, announced several additional steps the department is taking to reduce Veteran suicide. These include:

  • Elevating VA's Suicide Prevention Program with additional resources to manage and strengthen current programs and initiatives.
  • Meeting urgent mental health needs by providing Veterans with same-day evaluations and access to care by the end of calendar year 2016.
  • Establishing a new standard of care by using measures of Veteran-reported symptoms to tailor mental health treatments to individual needs.
  • Launching a new study, "Coming Home from Afghanistan and Iraq," to look at the impact of deployment and combat as it relates to suicide, mental health, and well-being.
  • Using predictive modeling to guide early interventions for suicide prevention.
  • Using data on suicide attempts and overdoses for surveillance to guide strategies to prevent suicide.
  • Increasing the availability of naloxone rescue kits throughout VA to prevent deaths from opioid overdoses.
  • Enhancing Veteran mental health access by establishing three regional tele-mental health hubs.
  • Partnering with the Department of Defense on suicide prevention and other efforts for a seamless transition from military service to civilian life.

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Selected Major Accomplishments

  • 2007: Established a Center of Excellence for Suicide Prevention in Canandaigua, New York
  • 2012:
    • Completed a report providing data on suicides and attempted suicides among Veterans
    • Found that the experience of killing in war was strongly associated with thoughts of suicide
  • 2016:
    • Determined that Veterans receiving high doses of opioid painkillers were more than twice as likely to die by suicide than those receiving low doses
    • Announced a series of actions to reduce Veteran suicide, including using data on suicide attempts and overdoses to guide prevention strategies
    • Launched the REACH VET program, which analyzes existing data to identify Veterans at a statistically elevated risk for suicide and allows VA to provide them with pre-emptive care and support
  • 2017: Found that, after adjusting for differences in age and sex, risk for suicide was 22 percent higher among Veterans when compared to U.S. non-Veteran adults

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New, Ongoing, and Published Research

Times of crisis can be related to chronic pain, anxiety, depression, sleeplessness, anger, or disturbing memories of combat service. VA researchers are taking steps to prevent at-risk Veterans from contemplating, attempting, and completing the act of suicide.

Investigators are exploring risk factors for suicide in individual Veterans and helping to improve risk assessments. Risk factors include behavioral health conditions such as depression; major stressful events, such as the loss of a loved one; and physical health problems, such as chronic pain. They are also working to develop effective interventions that could address multiple conditions at the same time and to identify crucial time periods at which to intervene.

Other researchers are developing national systems to capture and manage data on the overall population of Veterans relating to suicide, attempted suicide, and suicide reattempts among Veterans. These systems will help investigators determine risk and protective factors for suicidal behavior.

For more information on Suicide Prevention, visit our Depression, Mental Health, PTSD, Substance Use Disorders, Traumatic Brain Injury, and Women Health topic pages.

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➤ Reporting on Veteran suicide

First comprehensive data on Veteran suicideIn 2013, VA released its first comprehensive report on Veterans who die by suicide. Before this report was issued, data on Veterans who died by suicide was only available for those who had sought VA health care services.

The report indicated that the percentage of Veterans who die by suicide decreased slightly from 1999 through 2009, while the estimated total number of Veterans who died by suicide increased. Investigators learned that a majority of Veteran suicides are among those aged 50 years and older, and that male Veterans who die by suicide are older than non-Veteran males who die in that way. This was not true of women, however. For women, the age distribution was similar between Veterans and non-Veterans.

Researchers found that the first four weeks after discharge from military service is a crucial time for new Veterans at risk of suicide, and that these Veterans should be intensively monitored. They also learned that the majority of Veterans who die by suicide were last seen by clinicians in an outpatient setting.

The report also profiled those who use the Veterans Crisis Line for help (mostly men between the ages of 50–59) and noted that "a high prevalence" of non-fatal suicide events result from overdoses or other intentional poisonings.

Updated analysis of Veteran suicide—An updated report issued in 2016 represented the most comprehensive analysis to date of Veteran suicide rates. It included data from 1979 to 2014, from every state in the U.S. Data from that report include:

  • Sixty-five percent of Veterans who died from suicide in 2014 were 50 years of age or older.
  • Veterans accounted for 18 percent of all deaths from suicide among U.S. adults. This is a decrease from 22 percent in 2010.
  • Since 2001, U.S. adult civilian suicides increased 23 percent, while Veteran suicides increased 32 percent in the same period. After statistical adjustments for age and gender, this makes the risk of suicide 21 percent greater for Veterans.
  • Since 2001, the rate of suicide among U.S. Veterans who use VA services increased by 8.8 percent, while the rate of suicide among Veterans who do not use VA services increased by 38.6 percent.

In September 2017, VA issued additional data from that report. The new data include overall Veteran suicide rates as well as suicide rates by state, age group, and gender, and lists the most common suicide methods. Analysis of this information will help VA researchers to gain greater insight into high risk populations. Findings from that report include:

  • There is variability across the nation in the rates and numbers of deaths by suicide among Veterans. Overall, the Veteran rates mirror those of the general population in the geographic region, with the highest rates in Western states.
  • After adjusting for differences in age and sex, risk for suicide was 22 percent higher among Veterans when compared to U.S. non-Veteran adults. After adjusting for differences in age, risk for suicide was 19 percent higher among male Veterans when compared to U.S. non-Veteran adult men. After adjusting for differences in age, risk for suicide was 2.5 times higher among female Veterans when compared to U.S. non-Veteran adult women.

Evidence-based Synthesis Program (ESP) reports on suicide prevention in Veterans—The accuracy of methods to identify those at increased risk for suicide, and the effectiveness of interventions to reduce suicide and self-directed violence, were addressed in a 2015 report by the ESP team at the VA Portland Health Care System.

The investigators looked at the effectiveness and efficacy of suicide prevention interventions in reducing suicide rates and self-directed violence. They found that in six of the eight studies they reviewed, suicide rates were lower after interventions, including studies of the Air Force Suicide Prevention Program, a program for an Army infantry division deployed to Iraq, and studies of police, college students, and health systems. Suicide rates were not lower in two studies of community programs.

They also looked at ongoing research and remaining evidence gaps in research on suicide prevention in Veterans and service members, and ways these gaps could be addressed by future research. They found there are many single, inconclusive studies of various risk assessment instruments and prevention interventions; that many studies had methodological deficiencies; and that there was a lack of studies addressing possible adverse effects of suicide prevention programs.

The authors suggest future research be directed toward more in-depth examination of promising survey questionnaires that assess suicide risk, and that additional research be done on other methods of determining who is at risk for possible suicide, including neuroimaging and biomarkers.

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➤ Risk factors for suicide among Veterans

Link between mental health conditions and suicideIn 2015, a team of researchers from the VA Portland Health Care System published the results of a study in which they analyzed the health records of Veterans who died by suicide in 2009 and had received VA health care in the 12 months before their deaths. They found that mental health conditions and psychosocial stressors were very common in those Veterans, and that a majority of Veterans who were asked about whether they were having thoughts of suicide in their last interactions with VA clinicians denied they were having such thoughts.

The team concluded that it was particularly important for patients with mental health conditions to be assessed for anxiety disorders, functional decline, and acute psychological stressors, in order to determine their risk for suicide, and that new identification strategies and specific treatment approaches should continue to be developed.

Additional risk factors associated with suicideIn 2013, a team of Department of Defense researchers, including one VA investigator, published a study that looked at risk factors associated with suicide in current and former military personnel from 2001 through 2008. Of the more than 151,000 service members and Veterans whose records were reviewed, 83 had died by suicide.

The team found that factors significantly associated with an increased risk of suicide included male gender, depression, manic-depressive disorder, heavy or binge drinking, and alcohol-related problems. They found that no deployment-related factors—such as combat experience, the cumulative number of days deployed, or the number of deployments—were associated with an increased risk of suicide.

The research team concluded that suicide risk in the population they studied was independently associated with male gender and mental disorders but not with military-specific variables.

Possible link between low cholesterol and suicide—Researchers at the Coatesville VA Medical Center in Pennsylvania found in 2017 that Veterans with total cholesterol levels below 168 mg/dL (milligrams per deciliter) appeared to be at higher suicide risk than those with higher cholesterol levels. The researchers looked at 128 Veterans who received care at Coatesville.

In addition, cholesterol levels in Veterans with thoughts of dying by suicide, and those who had attempted suicide, were much lower than those who did not report having done or thought either. The researcher urged caution, however, before anyone determines there is a definitive link between low cholesterol and suicide risk, because there are many variables that determine an individual’s capacity for suicide, and it is not clear from the research whether changes in cholesterol levels is sufficient in itself to alter an individual’s capacity for suicide.

TBI and psychiatric conditions may lead to greater suicide risk—In 2017, researchers with the VA Boston Healthcare System looked at data for more than 270,000 Veterans deployed to Iraq and Afghanistan, and found Veterans with a traumatic brain injury (TBI) had an increased risk of a suicide attempt, and that 83 percent of those with TBI who attempted suicide also had either posttraumatic stress disorder (PTSD), depression, anxiety, or a substance use disorder.

The team therefore concluded that psychiatric conditions may add to the relationship between TBI and suicide, and that Veterans with these conditions should be closely monitored for suicidal behavior.

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➤ Predictors of suicidal behavior

Suicidal thoughts and behaviors, including suicide attempts and death by suicide, are commonly found at higher rates among people with psychiatric disorders. VA researchers have studied warning signs, in hopes of being able to prevent suicide in Veterans and others.

Suicidal thinking among Veterans—As part of the National Health and Resilience in Veterans study, led by VA's National Center for PTSD, more than 2,000 Veterans were asked twice, in 2011 and 2013, whether they had experienced suicidal thoughts in the two weeks before the question was asked. Nearly 14 percent reported they had.

The results of the study, published in 2016, also determined that higher levels of psychiatric distress, physical health problems, and a history of substance abuse predicted chronic suicidal thinking. In addition, because many Veterans reported having had suicidal thoughts in one survey but not the other, the researchers determined thoughts of suicide can come and go over time.

This determination underscored the need for ongoing periodic monitoring of Veterans for suicidal thoughts, not just one-time screenings. Study researchers also found that being connected to others socially could keep some Veterans from thinking about suicide.

Substance use disorders and suicide risk—By looking at data on more than 4.8 million Veterans, a team of researchers led by the VA Center for Clinical Management Research in Ann Arbor found in 2017 that Veterans with substance use problems have a higher risk of suicide than those who do not. They found that drug and alcohol problems affected 8 percent of males and 3 percent of females in the database, and that those Veterans had more than twice the risk of suicide compared to those without a substance use disorder.

The suicide rate was especially high among women Veterans with drug or alcohol problems. These women had a more than five times greater rate of suicide than women Veterans who did not have substance abuse problems.

Exposure to suicide increases risk—Veterans and active-duty service members who have been bereaved by suicide may themselves be at elevated risk of suicide, according to a 2017 study by researchers at the VA Eastern Colorado Health Care System and the University of Florida. The study's authors believe that this is especially true for those who were particularly close to the person who died by suicide.

The authors did not look at how service members and Veterans compared to the civilian population, nor did they study the degree to which the service member or Veteran was exposed to the suicide.

Anxiety sensitivity may be a link between PTSD and suicide—Anxiety sensitivity is an exaggerated fear of experiencing symptoms related to anxiety, separate from the actual symptoms. In a 2017 study of 60 male Veterans, researchers at the Southeast Louisiana VA Health Care System found that when people with PTSD worry that their personalities have changed or that they are not thinking normally, they may have an increased risk of suicidal behavior, helping to explain the connection between PTSD and suicide.

Non-suicidal self-injury and Veterans—A 2015 study led by researchers at the Durham VA Medical Center found that non-suicidal self-injury (purposely hurting oneself without conscious suicidal intent) is relatively common among Iraq and Afghanistan Veterans. Of the 151 Veterans of the two wars studied by the research team, 14 percent reported a history of such injuries.

Veterans with schizophrenia or bipolar disorder were excluded from the group, but there was a higher than average proportion of Veterans with PTSD. In the study group, 35 percent had PTSD, 21 percent had depression, and 8 percent had alcohol use disorder. More than 90 percent of the group was male and 67 percent was white.

The study found those who deliberately hurt themselves were more likely to engage in suicidal behavior. The researchers believe that these injuries could serve as a marker for identifying which Veterans are more likely to attempt suicide in the future.

Opioid doses and risk of suicide—Researchers with the University of Michigan and with the Serious Mental Illness Treatment, Resource and Evaluation Center and the Center for Clinical Management Research at the VA Ann Arbor Healthcare System found in 2016 that Veterans receiving the highest doses of opioid painkillers were more than twice as likely to die by suicide, compared with those receiving the lowest doses.

The research team looked at nearly 124,000 Veterans who received VA care in 2004 and 2005. All had non-cancer chronic pain and received prescriptions for opioids. Using the National Death Index, the researchers identified 2,601 patients who died by suicide before the end of 2009.

They found that the suicide risk rose as dose increased. The researchers could not tell, however, whether there was a direct causal link between the pain medications and suicide risk. Instead, the high doses may be a marker for other factors that drive suicide, including unresolved severe chronic pain.

Algorithm identifies suicide risk—Clinicians are challenged every day to make difficult decisions regarding patients' suicide risk. In a study published in 2015, VA and National Institute of Mental Health (NIMH) researchers demonstrated that they had developed a formula that can identify very small groups of Veterans at a high risk of attempting suicide, most of whom had not been identified as a suicide risk by clinicians.

The algorithm, developed by the investigators in collaboration with STARRS investigators, was derived by studying VA's patient population from 2001–2009. The team identified a range of factors, from age, gender, and race to service-connected disabilities, homelessness, and hospitalizations, that could be part of a formula for finding Veterans at high risk of suicide.

The team used the formula to identify about 600 Veterans whose suicide risk was 60 to 80 percent higher than that of other VA patients. The researchers envision the approach being used along with information obtained during clinical encounters to provide at-risk Veterans with enhanced prevention and treatment services.

In 2016, VA began using a predictive model to analyze current data from Veterans' health records to identify those at a statistically elevated risk for suicide, hospitalization, illness, or other adverse outcomes. The program, called Recovery Engagement and Coordination for Health—Veterans Enhanced Treatment (REACH VET) allows VA to provide pre-emptive care and support for Veterans, in some cases before a Veteran even has suicidal thoughts.

Early intervention can lead to better recovery outcomes, lessen the likelihood of challenges becoming crises, and reduce the stress Veterans and their loved ones face. VA is funding a randomized program evaluation on treatment facilitation for facilities having difficulties implementing the REACH VET program.

In 2017, VA and the U.S. Department of Energy (DoE) announced a new partnership focused on the secure analysis of large amounts of digital health and genomic data to help advance heath care for Veterans and others in areas including suicide prevention. The partnership is based within DoE's National Laboratory System, one of the world's top supercomputing resources.

Insomnia and suicideA 2012 study of 423 Veterans who died by suicide by researchers with VA’s VISN 2 Center of Excellence for suicide prevention found that nearly half (173) of those Veterans had had a sleep disturbance such as insomnia documented by a clinician, and that those with a sleep disturbance died sooner after their final visit to a VA facility than those who did not. They therefore concluded there the presence of a sleep disturbance might pose a near-term risk of suicide, and that intervening to reduce sleep disturbances might be an important way to reduce that risk.

In 2016, researchers with the Center published a study that found that two therapies used to treat disrupted sleep were successful in reducing insomnia, nightmare, depression and posttraumatic stress severity. The treatments were cognitive behavioral therapy for insomnia (CBT-I) and imagery rehearsal therapy (IRT) for nightmares. The researchers described a combination of CBI and IRT as a promising treatment for Veterans with combat-related trauma and psychiatric morbidity.

  

Biomarkers of suicide—VA researchers at the Durham VA Medical Center and the Mid-Atlantic MIRECC found, in a study published in 2014 that changes in the levels of certain amino acids in the body may contribute to suicide risk. The amino acids in question are important in regulating people's mood and behavior, although understanding their exact relationships to suicide will require further study.

In 2016, VA researchers at the Rocky Mountain MIRECC for Suicide Prevention in Denver, along with researchers in three other countries, found reduced activity in the enzyme ACMSD in people who have tried to kill themselves.

The enzyme is part of a chain of biochemical reactions called the kynurenine pathway, which is activated by inflammation. When it behaves sluggishly, it causes abnormal levels of two acids in the body, which could be measured in blood tests to help identify patients of high risk of suicide.

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➤ Responding to suicide risk

While the studies described above and others help clinicians identify patients who are at risk of harming themselves, VA researchers are also considering ways to decrease that risk.

WHO develops promising strategy—The World Health Organization (WHO), a United Nations Body, has made suicide prevention a top priority on the global public health agenda. WHO has developed a program called "brief intervention and contact," providing people who go to an emergency room following a suicide attempt with a one-hour educational session and regular contact with a health care professional after they are discharged.

A team of researchers with the White River Junction VA Medical Center in Vermont and Dartmouth College found that this program was linked to significantly lower odds of suicide, based on a literature search. No other suicide prevention technique produced significant effects in reducing suicide, according to the research team. The team recommended additional research into this strategy.

Health-promoting behaviors may reduce suicidal thoughts in Veterans with PTSD—Research has shown that Veterans with PTSD are more likely to have suicidal thoughts. However, a survey of more than 100 Iraq and Afghanistan Veterans with PTSD led by researchers with VA's VISN 17 Center of Excellence for Research on Returning War Veterans in Waco, Texas, found that those who routinely engaged in activities to foster good nutrition, physical activity, stress management, spiritual growth, health responsibility, and interpersonal relationship have a less pronounced link to such thoughts.

The researchers believe that promoting these activities in Veterans with PTSD could help lower suicide risk among that group of Veterans.

RTMS and suicidal thoughts—A team of VA and Department of Defense (DoD) researchers found in 2014 that high doses of magnetic stimulation to the part of the brain that controls emotion could effectively cut suicidal thoughts in half after only one day.

Repetitive transcranial magnetic stimulation (rTMS) involves taking an electromagnet (a wire wrapped around a solid coil), charging it with electricity, and applying it to specific points on the skull to target the underlying brain area. The result is a powerful magnetic field that can affect brain cells.

The Food and Drug Administration approved this kind of treatment for acute depression in 2008, but at lower doses than were used for this study.

The investigators looked at 41 Veterans who had been admitted to VA hospitals in a suicidal crisis—half of whom received rTMS, and the other half of whom did not. Treatment lasted for three days, and for the six-month period afterward no one died by suicide.

While suicidal thoughts were significantly less in the group receiving the treatment after the first day, the counseling and medication the other group received had enabled them to catch up by the third day, and nine months after the beginning of treatment the two groups' levels of suicidal thoughts were identical.

Firearms and suicide attemptsAccording to a 2015 VA study by researchers from the Central Arkansas Veteran Healthcare System, about 67 percent of Veterans who completed suicides died by firearm, compared to about 50 percent of deaths in the general public. The study looked at fifteen Veterans who were admitted to a VA hospital within 72 hours of a serious suicidal ideation or attempt involving firearms to try to understand what was involved in the attempt and the context in which the event occurred.

The researchers found that two-thirds of the Veterans in the study had actually attempted suicide and really hoped to die. The Veterans chose firearms as their means of attempting suicide because they were familiar with them and because of their high lethality rate. If firearms were not available, however, they said that they either had already tried another method, or would consider one if firearms were not available.

Can lithium reduce suicide attempts?—VA's Cooperative Study Program has begun a trial (CSP #590) to determine whether lithium, a mood stabilizing drug used since the 19th century, can be used to prevent suicide. The study is enrolling more than 1,800 Veterans from 28 VA medical centers who have either bipolar disorder or depression and who either recently survived a suicide attempt or were hospitalized to prevent one.

Each participant will be followed for a year, and the team will look at outcomes such as repeat suicide attempts and hospitalizations to prevent suicide, as well as deaths from suicide.

Half the volunteers in the study will get a form of the drug known as lithium carbonate in an extended-release tablet to minimize side effects. The other half will get a placebo. All will get VA's standard mental health care plus extra care coordination. The study is scheduled to be completed in 2019.

VA researchers are also looking at the effects of sleep, behavioral activation therapy (a method of treating depression and other disorders) and mindfulness (a way of paying attention to present experiences that originated in Eastern meditation practices), as well as beginning a study on how clergy members can support those at risk.

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Selected Scientific Articles by Our Researchers

Posttraumatic stress disorder and suicidal ideation, plans, and impulses: the mediating role of anxiety sensitivity cognitive concerns among Veterans. Raines AM, Capron DW, Stentz LA, Walton JL, Allan NP, McManus ES, Uddo M, True G, Franklin CA. There is a significant association between PTSD symptom severity and higher suicidality, even after accounting for relevant demographic and psychological constructs. J Affect Disord. 2017 Nov;222:57-62.

Risk of suicide attempt among soldiers in Army units with a history of suicide attempts. Ursano RJ, Kessler RC, Naifeh JA, Herberman Mash H, Fullerton CS, Bliese PD, Zaslavsky AM, Ng THH, Aliaga PA, Wynn GH, Dinh HM, McCarroll JE, Sampson NA, Kao TC, Schoenbaum M, Heeeringa SG, Stein MB, Army Study to Assess Risk and Resilience in Servicemembers (STARRS) Collaborators. Risk of suicide attempt among soldiers increased as the number of past-year suicide attempts within their unit increased—particularly for smaller units. Units with a history of suicide attempts may be important targets for preventive interventions. JAMA Psychiatry. 2017 Sep 1;74(9):924-931.

Reducing suicidal ideation through evidence-based treatment for posttraumatic stress disorder. Cox KS, Mouilso ER, Venners MR, Defever ME, Duvivier L, Rauch SAM, Strom TQ, Joiner TE, Tuerk PW. Treating PTSD symptoms with an evidence based therapy for PTSD can be an effective way to reduce suicidal ideation, at least partially, for some patients. J Psychatr Res. 2016 Sep:80:59-63.

Evaluation of cholesterol as a biomarker for suicidality in a Veteran sample. Reuter C, Caldwell B, Basehore H. Veterans with total cholesterol levels below 168 mg/dL appeared to have a higher suicide risk than those with higher levels. Res Nurs Health. 2017 Aug;40(4):341-349.

Traumatic brain injury and attempted suicide among Veterans of the wars in Iraq and Afghanistan. Fonda JR, Fredman L, Brogly SB, McGlinchey RE, Milberg WP, Gradus JL. Veterans with traumatic brain injury and psychiatric diagnoses should be closely monitored for suicidal behavior. Am J Epidemiol. 2017 Jul 15;186(2):220-226.

Substance use disorders and the risk of suicide mortality among men and women in the U.S. Veterans Health Administration. Bohnert KM, Ilgen MA, Louzon S, McCarthy JF, Katz IR. Current substance use disorders signal increased suicide risk, especially among women, and may be important markers to consider including in suicide risk assessment strategies. Addiction. 2017 Jul;112(7):1193-1201.

Strategies to prevent death by suicide: meta-analysis of randomized controlled trials. Riblet NBV, Shiner B, Young-Xu Y, Watts BV. The World Health Organization brief intervention and contact program of preventing death by suicide was associated with significantly lower odds of suicide, and is a promising suicide prevention strategy. Br J Psychiatry. 2017 Jun;210(6):396-402.

Assessment of psychological pain in suicidal Veterans. Reist C, Mee S, Fujimoto K, Rajani V, Bunney WE, Bunney BG. Psychological pain can be defined as an adverse emotional reaction to a severe trauma, and is a relatively understudied and potentially important construct in the evaluation of suicidal risk. PLoS One. 2017 May 30: 12(5):e0177974.

Childhood maltreatment and lifetime suicidal behaviors among new soldiers in the US Army: results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Stein MB, Campbell-Sills L, Ursano RJ, Rossellini AJ, Colpe LJ, He F, Heeringa SG, Nock MK, Sampson NA, Shoenbaum M, Sun X, Jain S, Kessler RC, Army Starrs Collaborators. Childhood maltreatment is strongly associated with suicidal behavior among new soldiers, even after adjusting for intervening mental disorders. J Clin Psychiatry. 2017 May 23. Pii:16m10900.

Health care contact and suicide risk documentation prior to suicide death: results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Ribeiro JD, Gutierrez PM, Joiner TE, Kessler RC, Petukhova MV, Sampson NA, Stein MB, Ursano RJ, Nock MK. Many soldiers who die by suicide access health care shortly before death, presenting an opportunity for suicide prevention. However, in most cases, there was no documentation of prior suicidal thoughts or behaviors. J Consult Clin Psychol. 2017 Apr;85(4):403-408.

Suicide and suicide attempts on hospital grounds and clinic areas. Mills PD, Watts BV, Hemphill RR. The most common methods of suicide and suicide attempts occurring on VA hospital grounds were gunshot, overdose, cutting, and jumping, and those events have increased since 2011. J Patient Saf. 2017 Feb 22 (epub ahead of print).

Exploring the association between exposure to suicide and suicide risk among military service members and veterans. Horn MA, Stanley IH, Gutierrez PM, Joiner TE Jr. Military personnel and veterans who have been bereaved by suicide may themselves be at elevated risk for suicidal thoughts and behaviors. J Affect Disord. 2017 Jan 1;207:327-335

Predicting suicide risk in trauma exposed Veterans: the role of health promoting behaviors. DeBeer BB, Kittel JA, Cook A, Davidson D, Kimbrel NA, Meyer EC, Gulliver SB, Morrissette SB. Health promoting behaviors could be important for reducing suicidal ideation among Veterans with high levels of PTSD symptoms. PloS One. 2016 Dec 21;11(12):e0167464.

An enzyme in the kynurenine pathway that governs vulnerability to suicidal behavior by regulating excitotoxicity and neuroinflammation. Brundin L, Seligren CM, Lim CK, Grit J, Palsson E, Landen M, Samuelsson M, Lundgren K, Brundin P, Fuchs D, Postolache TT, Traskman-Bendz L, Guellemin GJ, Erhardt S. Measures of kynurenine metabolites can be explored as biomarkers of suicide risk, and the enzyme ACMSD is a potential therapeutic target in suicidal behavior. Transi Psychiatry. 2016 Aug 2;6(8):e865.

Nature and determinants of suicidal ideation among U.S. Veterans: results from the national health and resilience in Veterans study. Smith NB, Mota N, Tsai J, Monteith L, Harpaz-Rotem I, Southwick SM, Pietrzak RH. A significant number (13.7 percent) of Veterans have chronic, onset, or remitted suicidal ideation. J Affect Disord. 2016 Jun;197:66-73.

Cognitive behavioral therapy for insomnia and imagery rehearsal in combat Veterans with comorbid posttraumatic stress: a case series. Bishop TM, Britton PC, Knox KL, Pigeon WR. A combination of cognitive behavioral therapy for insomnia and imagery rehearsal therapy for nightmares is a promising treatment for patients with combat-related trauma and psychiatric morbidity. Mil Behav Health. 2016;4(1):58-64.

Predictive modeling and concentration of the risk of suicide: implications for preventive interventions in the U.S. Department of Veterans Affairs. McCarthy JF, Bossarte RM, Katz IR, Thompson C, Kemp J, Hannemann CM, Nielson C, Schoenbaum M. Predictive modeling can identify patients at high-risk of suicide who were not identified on clinical grounds. Am J Public Health. 2015 Sep;105(9):1935-42.

Non-suicidal self-injury as a predictor of active and passive suicidal ideation among Iraq/Afghanistan war Veterans. Kimbrel NA, Gratz KL, Tull MT, Morrisette SB, Meyer EC, DeBeer BB, Silvia PJ, Calhoun PC, Beckham JC. Non-suicidal self-injury may be a particularly useful marker of active suicidal ideation among Veterans. Psychiatry Res. 2015 Jun 30:227(2-3):360-2.

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. Schoenbaum M, Kessler RC, Gilman SC, Colpe LJ, Heeringa SG, Stein MB, Ursano RJ, Cox KL: Army STARRS Collaborators. Predictors of Army suicides were largely like those reported elsewhere for civilians, although some predictors distinct to Army service emerged that deserve more in-depth analysis. JAMA Psychiatry. 2014 May;61(5):493-503.

A two-site pilot randomized 3-day trial of high dose left prefrontal repetitive transcranial magnetic stimulation (rTMS) for suicidal inpatients. George MS, Raman R, Benedek DM, Pelic CG, Grammer GG, Stokes KT, Schmidt M, Spiegel C, Dealmelda N, Beaver KL, Borckart JJ, Sun X, Jain S, Stein MB. Delivering high doses of left prefrontal repetitive transcranial magnetic stimulation over three days to suicidal inpatients is possible and safe, with few side effects and no worsening of suicidal thinking. Suggestions of a rapid anti-suicide effect need to be tested for replication in a larger sample. Brain Stimul. 2014 May-Jun;7(3):421-31.

Risk factors associated with suicide in current and former U.S. military personnel.

LeardMann CA, Powell TM, Smith TC, Bell MR, Smith B, Boyko EJ, Hooper TI, Gackstetter GD, Ghamsary M, Hoge CW. In a sample of current and former military personnel observed between 2001 and 2008, suicide risk was independently associated with male sex and mental disorders but not with military-specific variables. JAMA. 2013 Aug 7:310(5):496-506.

Sleep disturbance preceding suicide among Veterans. Pigeon WR, Britton PC, Ilgen MA, Chapman B, Conner KR. Sleep disturbances are associated with time to suicide in a sample of Veterans who died by suicide. Am J Public Health. 2012 Mar;102 Suppl 1:S93-7.

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Suicide Prevention Fact Sheet

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