Universitatea “Lucian Blaga”

Facultatea de Ştiinţe Socio-Umane

Departamentul de Psihologie

Riscul comportamentului suicidar

în mediul militar. Factori predictori
în cazul militarilor.

Coordonator: Crînguş Costin Marian Student: Cristea Ana-Maria

An: II
Grupa: III
CUPRINS

INTRODUCERE 3

Delimitări conceptuale 3

MOTIVAREA ALEGERII TEMEI 3

PREDICTORI AI IDEAŢIEI SUICIDARE LA PERSONALUL MILITAR ACTIV CU STRES POSTTRAUMATIC 4

Introducere 4

Metode 5

Procedura 5

Participanţi 5

Instrumente 5

REZULTATE 5

DISCUŢII 6

LIMITE 6

BIBLIOGRAFIE 7

ANEXE 7
 “Do you remember the last thing you said to me?
The last thing you did to me?
And what was the last thing I said to you?
Because, trust me, when I said it I knew it was the last thing I’d ever say.”
― Jay Asher, Thirteen Reasons Why
INTRODUCERE

Delimitări conceptuale

Comportamentul suicidar reprezintă un fenomen ale cărui începuturi se confundă cu începuturile

umanităţii. Actul sinuciderii deliberate, cu sau fără urmări fatale, a invocat divergenţe de opinii de-a
lungul istoriei până în zilele noastre, în diferite societăţi şi culturi. Totuşi, recent căutarea explicaţiilor
universale ale actului suicidar a fost înlocuită cu acceptarea faptului că motivele actului suicidar prezintă
variaţii între culturi şi subculturi, între bărbaţi şi femei, între tineri şi vârstnici.1
Conceptual, sinuciderea se defineşte ca fiind o formă specifică de conduită deviantă autodistructivă, de
suprimare a propriei vieţi în mod voit şi conştient. Reprezintă un răspuns extrem la o situaţie de criză a
individului. El apare ca reacţie la lipsa perspectivei unei schimbări, la încercările eşuate de a rezolva
problemele (sau care sunt percepute ca eşecuri) sau la dificultăţi de adaptare.2
Un veteran (din „vetus” latin, adică „vechi”) este o persoană care a avut mult timp experiență într-o
anumită ocupație sau domeniu. Un veteran militar este o persoană care a servit în forțele armate. Acești
veterani au fost, de asemenea, menționați ca veterani de război (deși nu toate conflictele militare sau zonele
în care au loc lupte armate sunt legate de războaie).3
Motivarea alegerii temei

Am ales această temă din cauza faptului că impactul negativ al suicidului se resimte atât asupra famililor
care îşi pierd o persoană dragă în aceste circumstanţe, cât şi asupra societăţii. Scopul acestei lucrări este de a
analiza trei studii de specialitate care tratează tema privind riscul comportamentului suicidar în rândul
veteranilor de război, posibile explicaţii ale fenomenlui şi factori care ar putea preveni acest tip de
comportament.

1
https://onlinepsihologie.wordpress.com/2011/01/31/comportamentul-suicidar/
2
http://www.stiucum.com/management/managementul-carierei/423/Comportamentul-suicidar53843.php
3
https://en.wikipedia.org/wiki/Veteran
 Un articol4 publicat în anul 2014 avea ca scop găsirea unor diferenţe între bărbaţii şi femeile care
erau înrolaţi în armata Statelor Unite ale Americii, cu privire la suicid şi tentativele de suicid.
Conform acestui articol ratele de suicid sunt de două ori mai mari în rândul bărbaţilor şi veteranilor decât a
celor care nu sunt în mediul militar, pe când în cazul femeilor înrolate în armată există un risc de trei ori mai
mare faţă de femeile din afara mediului militar.
Acest studiu este primul care subliniază diferențele de gen în sinucidere într-o echipă mai tanară, din mediul
militar, care include ţi tentativele de suicid. S-a constatat că soldații, atât femeile, cât şi bărbaţii, aveau mult
mai multe asemănări decât diferențe atunci când era vorba de factorii de risc pentru sinucidere. Dificultățile
locului de muncă au apărut ca o posibilă diferență între bărbați și femei, femeile dovedind o asociere mai
ușoară între dificultățile locului de muncă și sinucidere, deși această relație nu a atins semnificația statistică.
Cercetări suplimentare sunt necesare pentru a înțelege mai bine dacă această constatare poate fi reprodusă.
De asemenea, s-a constatat că, deși relațiile recente au eșuate au fost asociate cu sinucideri, diagnosticul în
legătură cu sănătatea mintală a fost mai puternic asociat cu tentativele de suicid. Aceştia sunt factori de risc
importanți pentru monitorizare, având în vedere rolul important al prevenirii sinuciderilor în rândul
populațiilor militare. Acest lucru evidențiază în mod deosebit importanța întrebării despre conflictele de
relații, care nu sunt monitorizate în sistemele de asistență medicală pe care îl folosesc personalul militar și
veteranii. O mai bună înțelegere a diferențelor dintre sexe și a factorilor de risc uniți în mod unic cu
sinuciderea are implicații critice în activitatea de prevenire și pentru o mai bună înțelege a mortalităţii în
cea mai tânără generație de membri ai serviciului nostru.
Pornind de la acest studiu am decis să aflu mai multe despre acest fenomen deoarece consider că
există anumite cazuri în care suicidul poate fi prevenit şi cred că trebuie să se intervină cu programe de
prevenţie în special în mediul militar, mediu care este destul de stresant.

Predictori ai ideaţiei suicidare la personalul militar activ cu stres posttraumatic

Introducere
Rata suicidului în armata Statelor Unite ale Americii aproape s-a dublat de la iniţierea Operation
Enduring Freedom (OEF), Iraqi Freedom (OIF) şi New Dawn, depăşind rata suicidului din rândul civililor
pentru prima dată în anul 2008. Se estimează că un militar activ moare din cauza suicidului o dată la
aproximativ 36 de ore. Această rată de suicid în rândul personalului militar a ridicat atât îngrijorarea
publică, cât şi pe cea a specialiştilor care au căutat să identifice factorii de risc pentru suicid în cazul acestei
populaţii.
În prezent cercetarea este necesar să treacă peste faptul că PTSD este asociat cu ideaţia suicidară şi cu
comportamentul suicidar şi să se îndrepte spre cum influenţează acesta ideaţia suicidară.

4
https://www.sciencedirect.com/science/article/pii/S0165178114009421
 Scopul acestui studiu este de a examina contribuţia expunerii la luptă, a suportului social, al PTSD-ului,
a depresiei, a cogniţiilor legate de traume şi vinovăţiei asupra ideaţiei suicidare în rândul personalului
militar căutând un tratament pentru PTSD.
Metode
Procedura
Acest studiu a utilizat date de referinţă colectate ca parte a unui număr mai mare dintr-un studiu clinic
randomizat, controlat care evalua eficacitatea expunerii prelungite la terapie pentru tratarea PTSD-ului
în cazul personalului militar activ. A urmat consimţământul informat al participanţilor, eligibilitatea
acestora a fost stabilită printr-un interviu clinic şi prin măsuri de auto-raport.
Participanţi
Participanții au fost 366 de militari activi care erau în căutare de tratament fiind diagnosticați cu PTSD
după evenimentul din septembrie 2001, aceștia întorcându-se din Afghanistan, Irak sau alte locații
apropiate. Pentru a putea fi incluși în acest studiu aceștia trebuiau să îndeplinească următoarele condiții:
(1) să fie adulți (18-65 ani), femei și bărbați personal activ militar sau în rezervă; sau care au activat în
Garda Naţională necesitând tratament ambulatoriu pentru PTSD; (2)diagosticul de PTSD fiind
determinat de PSS-I (Posttraumatic Stress Scale-Interview); (3) expunerea la un eveniment traumatic,
care conform DSM-IV-TR a fost un eveniment legat de luptă sau de mare magnitudine operațională care
a avut loc în timpul unei desfășurări militare. Criteriile de excludere au fost: (1) tulburearea bipolară sau
psihotică; (2) dependenţa de alcool; (3) leziuni uşoare sau grave ale creierului; (4) ideaţia uicidară
puternică; (5) alte tulburări de natură psihică.
Instrumente
PSS-I (PTSD Symptom Scale – Interview Version)
BDI-II(The Beck Depression Inventory)
BSS(The Beck Scale for Suicide Ideation)
ISEL-12(Interpersonal Support Evaluation List)
WRAIR(The Walter Reed Army Institute of Research)
PTCI(The Posttraumatic Cognitios Inventory)
TRGI(The Trauma Related Guilt Inventory)
DRRI(The Deployment Risk and Resiliance Inventory)
CES(Combat Experiences Subscale)
ABS(Aftermath of Battle Subscale)
Rezultate

Sevrittea PTSD-ului au covariat cu severitatea depresiei. Simptomele PTSD-ului au fost asociate cu cogniţii
negative despre sine. Depresia a fost asociată cu sprijin interpersonal scăzut şi cu un grad mai mare de
cogniţii negative despre sine. Cogniţiile negative despre sine au fost asociate cu sprijin interpersonal scăzut
şi cu un grad mai mare al ideaţiei suicidare. Sprijinul interpersonal a fost asociat cu un grad scăzut al
ideaţiei suicidare.
Discuţii

Acest studiu şi-a propus să găsească factorii asociaţi cu severitatea ideaţiei suicidare în rândul personalului
militar activ care caută un tratament pentru PTSD. Contrar ipotezelor, severitatea PTSD-ului nu a fost
direct asociată cu ideaţia suicidară. Totuşi, PTSD-ul a fost indirect asociat cu ideaţie suicidară crescută prin
cogniţii negative legate de traume, gânduri negative despre sine.
Printre participanţii cu cel puţin o tentativă anterioară de suicid, depresia a fost factorul principal asociat cu
ideaţia suicidară.
Contrar ipotezelor, expunerea la ucidere şi experienţele de după bătălie nu au fost legate de ideaţia
suicidară.

Limite

Eșantionul era format din personal militar care căuta tratament pentru PTSD, prin urmare, constatările pot fi
generalizate doar la eșantioane similare (de exemplu, pacienți militari care prezintă PTSD) și nu pot
generalizate personalului militar care se întoarce din misiune fără
PTSD. De asemenea, trebuie menționat faptul că numai pacienții cu un ușor până la un moderat
nivel de ideație suicidară au fost incluşi în studiu și, prin urmare, rezultatele nu se pot generaliza la cei cu
ideație suicidală severă sau la pacienți cu tulburare bipolară, psihoze sau tulburări de consum de alcool, care
au fost, de asemenea, excluşi din acest studiu.
Bibliografie

1. ShiraMaguena, Nancy A.Skoppc, YingZhang, Derek J.Smolenski, Gender differences in suicide and
suicide attempts among US Army soldiers în Psychiatry Research, 5 decembrie 2014
2. Carmen P. McLean, Yinyin Zang, Laurie Zandberg, Craig J. Bryan, Natalie Gay, Jeffrey S. Yarvis, Edna B. Foa,
the STRONG STAR Consortium, Predictors of suicidal ideation among active duty military personnel
with posttraumatic stress disorder în Journal of Affective Dissorters,23 noiembrie 2016

Anexe

Psychiatry Research 225 (2015) 545–549

Contents lists available at ScienceDirect

Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Gender differences in suicide and suicide attempts among US Army

soldiers$
Shira Maguen a,b,n, Nancy A. Skopp c,d, Ying Zhang c, Derek J. Smolenski c
a
San Francisco VA Medical Center, San Francisco, CA, USA
b Department of Psychiatry, University of California, San Francisco, San Francisco, CA, USA
c
National Center for Telehealth & Technology, Defense Centers of Excellence for Psychological Health & Traumatic Brain Injury, Joint
Base Lewis-McChord, Tacoma, WA, USA
d
Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
Article history:
Received 25 September 2014 Received in revised form 19 November 2014 Accepted 25 November 2014 Available online 5
December 2014
article info
Keywords:
Suicide
Military personnel
Female
Mental Health abstract
Risk
In order to best tailor suicide prevention initiatives and programs, it is critical to gain an understanding of how service
members' suicide risk factors may differ by gender. We aimed to better understand gender differences in suicide and suicide
attempts among soldiers, including demographic, military, mental health, and other risk factors. We also examined risk
factors uniquely associated with suicide and suicide attempts. We conducted a retrospective study of 1857 US Army soldiers
who died by suicide or attempted suicide between 2008 and 2010 and had a Department of Defense Suicide Event Report.
Female and male soldiers had more similarities than differences when examining risk factors associated with suicide. The
only gender difference approaching significance was workplace difficulties, which was more strongly associated with suicide
for female soldiers, compared to their male counterparts. Among suicide decedents, the most common risk factor was having
a failed intimate relationship in the 90 days prior to suicide. Among those who attempted suicide, the most common risk
factor was a major psychiatric diagnosis. Better understanding both gender differences and risk factors uniquely associated
with suicide has critical prevention and public health implications as we work to better understand preventable mortality in
our youngest generation of service members.

Published by Elsevier Ireland Ltd.

1. Introduction
Rates of suicide among US military service members and veterans have
recently reached unprecedented levels (Kuehn, 2009; Nock et al., 2013).
Suicide rates are higher for both male and female veterans, compared to non-
veterans; male veterans have double the risk of suicide, compared to male
non-veterans; female veterans have over triple the risk of suicide, compared
to their non-veteran counterparts (Kaplan et al., 2007). A recent study
examined female veterans of varying ages and found that for all age groups,
veterans had higher rates of suicide than non-veterans, with females who were
18–34 years having the highest suicide rates (McFarland et al., 2010), which
is a particular concern
☆
The opinions or assertions contained herein are the private views of the authors and are not
to be construed as official or representing the views of the Department of the Army, the
Department of Defense, or the Department of Veterans Affairs. None of the authors have any
conflicts of interest to report.
n
Corresponding author at: San Francisco VA Medical Center, PTSD Program
(116-P), 4150 Clement Street, San Francisco, CA 94121, USA. Tel.: þ1 415 221 4810
x2511, fax: þ1 415 379 5562.
E-mail address: Shira.Maguen@va.gov (S. Maguen).
for the newest generation of veterans. Furthermore, although male service
members and veterans have higher suicide rates than their female counterparts
(LeardMann et al., 2013), little is known about demographic, military and
other risk factors that may differ among male and female service members
who have attempted or com-pleted suicide.
A gap in research on suicidal behaviors in female service mem-bers is of
particular importance given that suicide rates among Operation Enduring
Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn
(OND) service members and veterans are a growing public health concern,
with the Department of Defense (DoD) and the Veterans Administration (VA)
conducting several initiatives to help decrease rising suicide rates
(Weiderhold, 2008). In order to best tailor suicide prevention initiatives and
programs, it is critical to gain an understanding of how service members'
suicide risk factors may differ by gender. The current research was designed
to shed light on gender differences in suicide and suicide attempts, including
demographic, military, mental health, and other risk factors that have been
found to be associated with suicidal behaviors in service members and
veterans. Other risk factors include both distal antecedents—history of abuse
(Bryan et al., 2013; Tiet et al., 2006) and self-injurious behavior (Bryan et al.,
2014; Nock et al., 2013) and

http://dx.doi.org/10.1016/j.psychres.2014.11.050
0165-1781/Published by Elsevier Ireland Ltd.
546 S. Maguen et al. / Psychiatry Research 225 (2015) 545–549

proximal antecedents—relationship problems, work problems, and legal
issues (Bush et al., 2013; Crawford et al., 2009; Holmes et al., 1998; Kaplan
et al., 2007, 2012; Logan et al., 2012; Nock et al., 2013; Skopp et al., 2012).
We predicted that there would be more similarities than differences across
risk factors, particularly for mental health diagnoses, which are stable
predictor of suicide across studies (Bossarte et al., 2012; Bush et al., 2013;
Ilgen et al., 2012; LeardMann et al., 2013; Luxton et al., 2013; Nock et al.,
2013; Skopp et al., 2012). However, gender differences in suicide risk factors
are not well understood. This is the first known study to examine gender
differences in suicides and suicide attempts in a national military sample. We
also examined risk factors uniquely associated with suicide and suicide
attempts.
2. Methods
2.3. Statistical methods
We used a series of logistic regression models to test the null hypothesis of no difference in
the association between suicide and the included risk factors by gender. For the purposes of
these analyses, our comparison group was individuals who attempted suicide, given that those
without a suicide or suicide attempt were not included in the DoDSER dataset. Initial models
included all demographic/ military variables and risk factors as well as a single multiplicative
interaction term between gender and one of the risk factors. We chose this approach given the
small sample size of female suicides and convergence problems with multiple two-way
interaction terms entered into a single model. From these models, any interaction terms that
achieved a statistical significance of po0.10 were selected to be included in the final model.
After identifying any possible effect measure modifica-tion, we estimated two final models
stratified by gender to elucidate the differences in the associations suggested by the identified
interaction terms. Prior to estimating the logistic regression models, we used proc mi in SAS
9.2s to generate 50 multiply imputed datasets to account for the large amount of data
unavailable on risk factors (see Table 2). We chose 50 datasets to allow for sufficient variability
in the imputed variables (Enders, 2010). Results from the multiple imputation analysis were
compared to a complete cases analysis to identify any large departures in the overall
conclusions of the analysis. We also examined relationships between suicide method (guns vs.
other) and suicide type (suicide vs. attempt) as well as suicide method and gender.

2.1. Participants

Participants in this study included US Army soldiers who died by suicide or attempted
suicide between 2008 and 2010 and had a Department of Defense Suicide Event Report
(DoDSER; Gahm et al., 2012) submitted (N¼1857). The DoDSER system is the surveillance
tool used by all services in the Department of Defense (DoD) to collect data on demographics, 3. Results
service characteristics, and psychosocial factors associated with a suicide event. When an event
occurs, a designated service member is tasked with compiling information from personnel and We display the demographic characteristics of suicide dece-dents and
medical records and interviews. The findings from the data review are uploaded into the
DoDSER system by answering a series of questions about known or suspected risk and
soldiers who attempted suicide between 2008 and 2010 (Table 1). The
protective factors. All suicide events (suicide or attempt) are required to be reported for active- distribution of gender differed substantially between the two outcome groups
duty service members and activated Guard and Reserve. The DoD began collecting with women comprising a
standardized data on suicide decedents through the DoDSER system for all services in 2008.
Prior to 2008, each service had separate systems for suicide surveillance. The DoDSER contains
Army suicide attempts from 2008 forward; data collection for suicide attempts expanded to all
services in 2010. To have comparable data over the 2008–2010 period, we restricted the
Table 1
analysis to US Army soldiers. This study was conducted under a protocol approved by the
Characteristics of suicide decedents and individuals with suicide attempts, US Army, 2008–
Institutional Review Board at Madigan Army Medical Center.
2010.

Suicide Suicide attempt

Variable n % n %
Gender
2.2. Measures
Female 20 4.72 341 23.80
Male 404 95.28 1092 76.20
The measures used in this study included demographic/military service (gender, age, Age
race/ethnicity, education, marital status, rank and grade) and psychosocial risk factors. For 17–20 97 22.88 506 35.31
many of the items about specific risk factors, follow-up questions probed the time prior to the 21–24 114 26.89 414 28.89
event in which the factor occurred. We used the information on the time prior to the event for 25–29 102 24.06 276 19.26
several of the risk factors to limit the presence of a risk factor to the 90 days prior to the event. 30–39 76 17.92 182 12.70
For risk factors with the potential for long-term influence on suicidal behavior (e.g., a major Z40 30 7.08 46 3.21
psychiatric diagnosis) we did not limit the time of exposure to just the 90 days prior to the Missing 5 1.18 9 0.63
event. Race/ethnicity
Non-Hispanic White 265 62.50 960 66.99
The risk factors included in this study were history of deployment (at any time), known or Non-Hispanic African American 50 11.79 213 14.86
alleged abuse victimization (at any time), failed intimate relationship (within 90 days of the Hispanic 6 1.42 29 2.02
event), military or civil legal problems (within 90 days of the event), prior history of self-harm Non-Hispanic Asian American/Pacific Islander 8 1.89 16 1.12
(at any time), major psychiatric diagnosis (at any time), separation proceedings (within 90 days Other 24 5.66 108 7.54
of the event), history of substance abuse (at any time), and workplace difficulties (within 90 Missing 71 16.75 107 7.47
days of the event). We used a series of binary indicators to indicate the presence or absence of Education
the specific risk factors. Known or alleged abuse victimization was asked as three separate Up to high school 194 45.75 798 55.69
items: physical, emotional, and sexual; given the low prevalence for these items, they were Some college 55 12.97 398 27.77
pooled so that a positive response to any was equated to presence of any abuse victimization. 4-year college degree or more 32 7.55 75 5.23
The presence of military or civil legal problems was defined as evidence of Courts Martial, civil Missing 143 33.73 162 11.30
legal proceedings, Article 15 (non-judicial punishment), or being in an absence without leave Marital status
status (AWOL) in the 90 days prior to the event. A major psychiatric diagnosis was indicated by Never married 151 35.61 595 41.52
a recorded diagnosis of any mood, anxiety, personality, or psychotic disorder. Separation Married 200 47.17 629 43.89
proceedings included records of undergoing administrative separation proceedings or a medical Separated/divorced/widowed 49 11.56 177 12.35
evaluation board during the 90 days prior to the event. The presence of workplace difficulties Missing 24 5.66 32 2.23
was defined as a positive response to any of the follo-wing items: nonselection for promotion, Rank and grade
job problems, coworker issues, poor performance evaluation, or workplace hazing, all within E1–E4 249 58.73 1077 75.16
the 90 days prior to the event. The remaining risk factors—failed intimate relationship, prior E5–E9 139 32.78 297 20.73
history of self-harm, and history of substance abuse—were all single items asked in the Officer 36 8.49 59 4.12
DoDSER. Data on suicide methods were also collected and are examined in this study (i.e., Year of event
guns vs. other). 2008 126 29.72 564 39.36
2009 151 35.61 476 33.22
2010 147 34.67 393 27.42
 S. Maguen et al. / Psychiatry Research 225 (2015) 545–549 547

larger proportion of the suicide attempt outcome group. Partici- In Table 4 we present the prevalence odds ratios from the
pants were predominantly under 30 years of age, identified as logistic regression model after stratifying by gender. The pattern of
non-Hispanic white, had completed a high school education, and association between the risk factors and suicide was largely
were enlisted soldiers (vs. officers). The distribution of DoDSERs
Table 3
was approximately equivalent over time among suicide decedents.
Prevalence odds ratios (POR) and 95% confidence intervals (CIs) for the associations
In contrast, there was a decrease in the number of suicide attempt
between demographic and risk factors and suicide in the 2008–2010 DoDSER data,
reports over time. US Army.
Table 2 provides the distributions of the included risk factors
for both the suicide and suicide attempt outcome groups. Among Variable POR 95% CI
suicide decedents, the most common risk factor was having a
Age 1.03 1.00, 1.05
failed intimate relationship in the 90 days prior to suicide. Among Female 0.13 0.06, 0.28
soldiers who attempted suicide, the most common risk factor was Race/ethnicity other than non-Hispanic, white 1.19 0.90, 1.56
a major psychiatric diagnosis. The proportions of participants with No education beyond high school 1.52 1.09, 2.12
Not married 1.18 0.91, 1.53
evidence of abuse victimization, major psychiatric diagnosis, and a
Rank and grade
prior history of self-harm were higher for those with a suicide
E1–E4 0.31 0.18, 0.53
attempt. E5–E9 0.52 0.31, 0.89
In Table 3 we present the results of a logistic regression model Officer Ref.
that includes a term for a two-way interaction between gender Year of event
2008 0.66 0.49, 0.88
and a history of workplace difficulties. Compared to those with a
2009 0.91 0.69, 1.21
suicide attempt, suicide decedents were older, had less formal 2010 Ref.
education, and were less likely to be enlisted soldiers. Three risk History of deployment 1.13 0.87, 1.47
factors were associated with suicide in these data: suicide dece- Victim of abuse (physical, emotion, or sexual) 0.49 0.34, 0.69
Failed intimate relationship, last 90 days 1.37 1.04, 1.80
dents were less likely to have reports of abuse victimization or a
Military or civilian legal problems, last 90 days 1.14 0.85, 1.54
major psychiatric diagnosis and were more likely to have reports
Prior history of self-harm 0.80 0.59, 1.09
of a failed intimate relationship during the 90 days prior to suicide, Major psychiatric diagnosis 0.54 0.41, 0.72
compared to those with suicide attempts. The interaction term Separation proceedings 1.14 0.78, 1.66
between gender and workplace difficulties suggested a stronger History of substance abuse 1.18 0.88, 1.59
Workplace difficulties 0.80 0.60, 1.06
risk association between workplace difficulties and suicide for Gender by workplace difficulties 2.62 0.94, 7.31
female soldiers (p¼0.067).

Table 2
Distribution of risk factors between suicide decedents and individuals who attempted suicide, US Army, 2008–2010.

Variable Female Male

Suicide Suicide attempt Suicide Suicide attempt

History of deployment
Yes 10 134 256 617
No 10 207 148 473
Missing 0 0 0 2
Victim of abuse (physical, emotion, or sexual)
Yes 6 169 35 284
No 7 137 207 658
Missing 7 35 162 150
Failed intimate relationship, last 90 days
Yes 5 120 155 429
No 8 193 149 564
Missing 7 28 100 99
Military or civilian legal problems, last 90 days
Yes 5 52 90 259
No 14 271 254 738
Missing 1 18 60 95
Prior history of self-harm
Yes 5 149 67 346
No 9 162 222 616
Missing 6 30 115 130
Major psychiatric diagnosis
Yes 6 182 128 515
No 11 138 223 487
Missing 3 21 53 90
Separation proceedings
Yes 4 49 46 153
No 15 271 303 828
Missing 1 21 55 111
History of substance abuse
Yes 3 66 102 313
No 12 245 219 640
Missing 5 30 83 139
Workplace difficulties
Yes 11 124 106 394
No 7 198 229 605
Missing 2 19 69 93
548 S. Maguen et al. / Psychiatry Research 225 (2015) 545–549

Table 4
Prevalence odds ratios (POR) and 95% confidence intervals (CIs) for the associations between demographic and risk factors and suicide in the 2008–2010 DoDSER data, by gender, US Army.

Variable Female Male

Total n ¼361 # of suicides¼20 Total n¼1496 # of suicides¼404

POR 95% CI POR 95% CI

Age 1.00 0.92, 1.09 1.03 1.01, 1.06

Race/ethnicity other than non-Hispanic, white 1.52 0.50, 4.66 1.17 0.88, 1.56
No education beyond high school 1.71 0.46, 6.35 1.52 1.08, 2.14
Not married 0.71 0.23, 2.24 1.23 0.94, 1.60
Rank and grade
E1–E4 0.34 0.04, 2.84 0.30 0.17, 0.54
E5–E9 0.73 0.09, 5.69 0.49 0.28, 0.87
Officer Ref. Ref.
Year of event
2008 0.71 0.23, 2.22 0.65 0.48, 0.89
2009 0.39 0.11, 1.43 0.96 0.71, 1.29
2010 Ref. Ref.
History of deployment 1.13 0.38, 3.40 1.12 0.86, 1.48
Victim of abuse (physical, emotion, or sexual) 0.60 0.18, 1.99 0.47 0.32, 0.69
Failed intimate relationship, last 90 days 0.86 0.26, 2.87 1.42 1.07, 1.88
Military or civilian legal problems, last 90 days 1.61 0.46, 5.61 1.11 0.82, 1.51
Prior history of self-harm 0.73 0.22, 2.42 0.81 0.58, 1.11
Major psychiatric diagnosis 0.46 0.15, 1.48 0.55 0.41, 0.73
Separation proceedings 1.51 0.41, 5.60 1.11 0.75, 1.64
History of substance abuse 1.22 0.29, 5.15 1.18 0.87, 1.60
Workplace difficulties 2.26 0.77, 6.60 0.80 0.60, 1.07

consistent between male and female soldiers with the exception of workplace
difficulties. While the 95% confidence intervals have substantial overlap and
intervals include unity, the pattern of the stratified prevalence odds ratios
suggests that workplace difficulties have a risk association with suicide
among female soldiers.
Finally, we examined suicide method (guns vs. other) for the 1857
individuals included in the study, which we expected to be associated with
both suicide type (suicide vs. attempt) and gender (male vs. female), and
found significant relationships with both. Those with suicides were more
likely to use a gun (65%), as compared to those with an attempt (8%), χ2 test
po0.0001. Men were more likely to use a gun (25%) than women (5%), χ2
test po0.0001.
4. Discussion
We found that female and male soldiers had more similarities than
differences when examining risk factors associated with suicide. This is a
particularly important finding because as women take on more combat-
specific roles, it is critical that we better understand potential gender
differences in mental health related outcomes and mortality. In this
investigation we found that risk factors were similar for both groups. The only
gender difference was workplace difficulties, which was more strongly
associated with suicide for female soldiers, compared to their male
counterparts, although this association did not reach statistical significance. A
recent study found that women deployed to combat zones reported a general
environment of stress, heterogeneous job responsibilities, home issues
impinging on duties, and gender-related stress (Kelly et al., 2014). These are
all factors that can impact the work environment in an adverse fashion.
Furthermore, for female active-duty U.S. Air Force members, poorer
workplace relationship satisfaction was associated with suicidal ideation,
whereas this was not the case for their male counterparts (Langhinrichsen-
Rohling et al., 2011). Consequently, workplace difficulties may place female
service members at greater risk for suicide. Given that workplace difficulties
are a modifiable risk
factor, better understanding the particular work-related circum-stances that
are associated with increased suicide for female soldiers is critical. From a
public health perspective, factors poten-tially contributing to a reduction of
suicide associated with work-place difficulties include, “increased awareness,
education, early detection and referral, help hotlines, availability of
counseling, as well as asking about suicide ideation/intent/attempts during
rou-tine medical checkups” (Woo and Postolache, 2008).
We also found that while recent failed relationships were most strongly
associated with suicide, psychiatric diagnoses were most strongly associated
with suicide attempts. Similarly, another study found that separation and
divorce were both associated with suicide among service members (Hyman et
al., 2012). In a retrospective case-control study where military personnel were
matched on a number of demographic and military variables, several
differences emerged between those who died by suicide and controls.
Increased odds of suicide were associated with mood disorders, partner
relationship problems, and family circumstance problems, but not with mild
TBI, alcohol dependence, or PTSD (Skopp et al., 2012). Similar to the current
study, relationship/family issues emerged as associated with suicide, and less
so with particular mental health diagnoses such as PTSD.
Certain demographic/military factors were also differentially associated
with suicide vs. attempt. For example, we found that officers were at greater
risk for suicide compared to non-officers. One possibility is that officers have
been in the military longer (i.e., exposed to more trauma). Because of the
level of responsi-bility that officers have, challenging traumas (e.g., losses of
sold-iers, feeling like they made the wrong decisions) may carry a heavy
burden due to the level of leadership and responsibility. It is possible that if a
decision is made to complete a suicide, these factors are potent and result in
use of lethal means. Officers may be more resolute in their suicide decision,
rather than making an attempt that may not result in completed suicide.
A number of limitations should be considered when interpret-ing these
data. First, although this is the first study to examine gender differences in
suicide, our analyses were limited due to the low numbers of suicide in
female soldiers (n¼20); consequently,
S. Maguen et al. / Psychiatry Research 225 (2015) 545–549 549
even though some of our findings did not reach statistical significance in female soldiers, many of the estimates were in the same direction as their male
counterparts. Second, we exam-ined suicides compared to suicide attempts due to the nature of our data, which should be kept in mind when interpreting all of
these data and implications. Although we were not able to compare each group to those without either attempts or suicide, this is an important area for future
investigation. In addition, these analyses were conducted for those in the Army and should not be generalized to other branches. However, the Army is the branch
with the highest number of suicides reported for the years under investigation. In subsequent years we will be able to examine suicides and suicide attempts in all
branches, which will help with generalizibility. Finally, we were not able to link these data with other DoD datasets and consequently we could neither ascertain
the location or length of deployment for each soldier, nor their specific level of combat exposure. We also did not have access to other variables that may impact
the outcomes, such as level of social support.

This study is the first to highlight gender differences in suicide in a younger, Army cohort which includes suicide attempters as controls. We found that female
and male soldiers had far more similarities than differences when examining risk factors for suicide. Workplace difficulties emerged as one possible difference
among men and women, with women evidencing a slightly stronger asso-ciation between workplace difficulties and suicide, although this relationship did not
reach statistical significance. Further research is needed to better understand if this finding can be replicated with larger samples. We also found that while recent
failed relationships were more strongly associated with suicides, mental health diag-noses were more strongly associated with suicide attempts. Both are
important risk factors to monitor, given the important role of suicide prevention in military populations. This particularly highlights the importance of asking
about relationship strife and dissolution, which are not consistently monitored across healthcare systems in which military personnel and veterans use. Better
understanding both gender differences and risk factors uniquely associated with suicide has critical prevention and public health implications as we work to better
understand preventable mortality in our youngest generation of service members.

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Journal of Affective Disorders 208 (2017) 392–398

Contents lists available at ScienceDirect

Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad
Predictors of suicidal ideation among active duty military personnel with MARK
posttraumatic stress disorder
Carmen P. McLeana, Yinyin Zanga, , Laurie Zandberga, Craig J. Bryanb,c, Natalie Gaya, Jeffrey
S. Yarvisd, Edna B. Foaa, the STRONG STAR Consortium1
e
Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, United States
f
National Center for Veterans Studies, Salt Lake City, UT, United States
g
Department of Psychology, University of Utah, Salt Lake City, UT, United States
h
Headquarters, Carl R. Darnall Army Medical Center, Fort Hood, TX, United States

ARTICLE INFO ABSTRACT

Keywords: Background: Given the alarming rate of military suicides, it is critical to identify the factors that increase risk of suicidal
Posttraumatic stress disorder thoughts and behaviors among active duty military personnel.
Suicide Methods: This study examined a predictive model of suicidal ideation among 366 treatment-seeking active duty military
Depression personnel with posttraumatic stress disorder (PTSD) following deployments to or near Iraq or Afghanistan. Structural
Trauma
equation modeling was employed to examine the relative contribution of combat exposure, social support, PTSD severity,
Cognitions
depressive symptoms, guilt, and trauma-related cognitions on suicidal ideation.

Results: The final structural equation model had a highly satisfactory fit [χ2 (2) =2.023, p=.364; RMSEA =.006; CFI =1; GFI
=.998]. PTSD severity had an indirect effect on suicidal ideation via trauma-related cognitions. Depression had a direct
positive effect on suicidal ideation; it also had an indirect effect via trauma-related cognitions and interpersonal support.
Among participants who had made a previous suicide attempt, only depression symptom severity was significantly linked to
suicidal ideation.
Limitations: Data are cross-sectional, precluding causal interpretations. Findings may only generalize to treatment seeking
active duty military personnel with PTSD reporting no more than moderate suicidal ideation. Conclusions: These findings
suggest that depression and trauma-related cognitions, particularly negative thoughts about the self, play an important role in
suicidal ideation among active duty military personnel with PTSD. Negative cognitions about the self and interpersonal
support may be important targets for intervention to decrease suicidal ideation.

1. Introduction Freedom (OIF), and New Dawn (OND; Luxton et al., 2012), surpassing the
civilian suicide rate for the first time in 2008 (Kuehn, 2010). It is estimated
The rate of suicide in the United States Army has nearly doubled since the that one active duty US military service member dies by suicide
initiation of Operations Enduring Freedom (OEF), Iraqi approximately every 36 h (Kinn et al., 2011). Some evidence

Abbreviations: ABS, Aftermath of Battle Subscale; ADF, asymptotically distribution free; BDI-II, Beck Depression Inventory-II; BSS, Beck Scale for Suicide Ideation; CES, Combat Experiences
Subscale; DRRI, Deployment Risk and Resilience Inventory; DSM-IV-TR, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision; ISEL-12, Interpersonal Support
Evaluation List – 12; OEF, Operation Enduring Freedom; OIF, Operation Iraqi Freedom; OND, Operation New Dawn; PSS-I, Posttraumatic Stress Scale – Interview; PTCI, Posttraumatic Cognitions
Inventory; PTSD, posttraumatic stress disorder; SEM, structural equation modeling; SI, suicidal ideation; TRGI, Trauma Related Guilt Inventory; WRAIR, Walter Reed Army Institute of Research
(WRAIR) Military Vertical & Horizontal Cohesion Scales
Corresponding author.
E-mail address: yinyinz@mail.med.upenn.edu (Y. Zang).
1
The STRONG STAR Consortium group authors include (listed alphabetically): Brett T. Litz, Ph.D., Massachusetts Veterans Epidemiological Research Center, VA Boston Healthcare System,
Department of Psychiatry, Boston University School of Medicine, and Department of Psychology, Boston University, Boston, Massachusetts; Jim Mintz, Ph.D., Department of Psychiatry and
Department of Epidemiology and Biostatistics, University of Texas Health Science Center at San Antonio, San Antonio, Texas; Alan L. Peterson, Ph.D., A.B.P.P., Department of Psychiatry,
University of Texas Health Science Center at San Antonio, Office of Research and Development, South Texas Veterans Health Care System, and Department of Psychology, University of Texas at
San Antonio, San Antonio, Texas; John D. Roache, Ph.D. , Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas; Elna Yadin, Ph.D., Department
of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania; and Stacey Young-McCaughan, R.N., Ph.D., Department of Psychiatry, University of Texas Health Science Center at San
Antonio, San Antonio, Texas.

http://dx.doi.org/10.1016/j.jad.2016.08.061
Received 16 June 2016; Accepted 24 August 2016
Available online 23 November 2016
0165-0327/ © 2016 Elsevier B.V. All rights reserved.
C.P. McLean et al.
Fig. 1. Hypothesized SEM model. SEM, structural equation modeling; PTSD, posttraumatic stress disorder.
suggests that military suicide rates have stabilized or decreased in the last few
years, but there is considerable variation from year to year and across military
branches (Franklin, 2015). This suicide rate among military personnel has
raised great public and professional concern and has prompted a call for
research to identify risk factors for suicide in this population.
Posttraumatic stress disorder (PTSD) is associated with increased risk for
suicidal thoughts and behaviors in the general population (Tarrier and Gregg,
2004) and in active duty military samples (Bryan and Corso, 2011; Nock et
al., 2014) and Iraq and Afghanistan veterans (Guerra and Calhoun, 2011;
Jakupcak et al., 2011). PTSD is also associated with more severe suicidal
ideation (SI) in deployed military personnel (Bryan et al., 2013a, 2013b) and
combat veterans (Butterfield et al., 2005; Rudd et al., 2011) and with
attempted suicide (Nad et al., 2008) and death by suicide (Boscarino, 2006;
Drescher et al., 2003) in combat veterans. Moreover, PTSD is highly
prevalent among military personnel: studies show that 5–20% of US military
personnel returning from deployments in support of OIF/OEF have symptoms
of PTSD (Institute of Medicine, 2014). Depression, which is frequently
comorbid with PTSD (Galatzer-Levy et al., 2013), is also associated with
suicide risk in active duty military samples (Bryan et al., 2013c; Bush et al.,
2011). Some studies (e.g., Lemaire and Graham, 2011) but not all (e.g.,
Guerra and Calhoun, 2011) indicate that suicide risk is higher among
OEF/OIF veterans with both depression and PTSD than those with either
disorder alone.
At present, research is needed that moves beyond whether PTSD is associated
with suicidal thoughts and behaviors to examine how PTSD is associated with
SI. One possibility is that PTSD increases SI through associated negative
perceptions about the meaning of the trauma. This notion is consistent with
evidence that even when controlling for severity of combat exposure, guilt is
significantly associated with PTSD severity in veterans (Henning and Frueh,
1997). In active duty military personnel, guilt predicted greater SI above and
beyond the effects of PTSD, depression, and their interaction (Bryan et al.,
2013a, 2013b). Moreover, guilt has been found to fully mediate the
relationships of PTSD and depression with SI in active duty and veteran
samples (Bryan et al., 2015b, 2013a, 2013b). These studies suggest that PTSD
and depression increase the severity of SI via cognitive-affective processes
that are more proximally related to SI than PTSD or depression. Related to the
construct of guilt are negative trauma-related cognitions, which include
negative cognitions about the self (e.g., “I’m incompetent”), negative
cognitions about the world (e.g., “the world is a dangerous place”; “no one can
be trusted”), and self-blame (e.g., “the event [trauma] happened because of the
sort of person
I am”; Foa et al., 1999). Although research has consistently shown strong
associations between negative trauma-related cognitions and PTSD severity,
no published study has examined the relationship between PTSD, negative
trauma-related cognitions, and SI (Mueser
393
Journal of Affective Disorders 208 (2017) 392–398
et al., 2008; Zalta et al., 2014; Zoellner et al., 2011).
The stress of combat exposure has been hypothesized to increase suicide risk
(e.g., Selby et al., 2010). While combat exposure has not been found to
predict death by suicide in current and former military personnel (LeardMann
et al., 2013) and OEF/OIF veterans (e.g., Reger et al., 2015), a recent meta-
analysis found that certain types of combat exposure are associated with
suicidal thoughts and behaviors in active duty military personnel and veterans
(Bryan et al., 2015b). In particular, exposure to the grotesque aftermath of
battle and death (e.g., seeing dead bodies or body parts, exposure to
devastated communities and prisoners of war) and acts of killing were
associated with suicidal thoughts and behaviors among military personnel,
while other forms of combat exposure (e.g., firing a weapon at enemy
combatants, disarming explosive devices) were not (Bryan et al., 2015b).
Much less is known, however, about how these specific types of combat
experiences relate to SI among military personnel with PTSD.
In contrast to risk factors such as guilt and exposure to killing and death,
perceived social support has been associated with decreased suicidal ideation,
suggesting it functions as a protective factor in OEF/ OIF veterans (Jakupcak
et al., 2010; Lemaire and Graham, 2011; Pietrzak et al., 2011). However, the
protective effect of social support was found to be lower in those with PTSD
than those without PTSD, highlighting the need to examine the relationship
between social support and SI in treatment-seeking soldiers (Jakupcak et al.,
2010). Because military personnel may derive social support from civilian
family and friends as well as members of their unit, an examination of social
support resources should include both military unit cohesion and general
interpersonal social support.
The purpose of the current study was to examine the relative contribution of
combat exposure, social support, PTSD, depression, trauma-related
cognitions, and guilt on SI among active duty military personnel seeking
treatment for PTSD. As depicted in Fig. 1, based on previous research, we
hypothesized that: (1) combat exposure (speci-fically, exposure to the
aftermath of battle and killing) would show both a direct relationship with SI
and an indirect relationship with SI through PTSD and depressive symptoms;
(2) PTSD and depressive symptoms would each show both a direct
relationship with SI and an indirect effect on SI through guilt; and (3) the
effect of PTSD and depressive symptoms on SI would be moderated by social
support. In addition, we hypothesized that the effects of PTSD and depression
on SI would be accounted for by negative trauma-related cognitions.
Finally, we sought to test this model among those with and without a history
of suicide attempts. Several studies show that factors similar to guilt and
negative trauma-related cognitions, such as self-blame and self-criticism,
differentiate those with SI-only from those who have acted upon suicidal
thoughts (Bryan et al., 2014). In fact, it has been proposed that these types of
negative self-perceptions account for the
C.P. McLean et al.
relationships between PTSD, depression, and increased risk for suicide
attempts (Bryan et al., 2015a). If the hypothesized relationships differ across
groups, this may help identify factors related to the progression from SI to
suicide attempts.
2. Methods
2.1. Procedure
This study utilized baseline data collected as part of a larger randomized
controlled trial evaluating the efficacy of Prolonged Exposure (PE) therapy
for the treatment of PTSD in active duty military personnel (Principal
Investigator: Edna B. Foa). Following informed consent, eligibility was
determined during a baseline evalua-tion consisting of a clinical interview and
self-report measures. The institutional review boards of Brooke Army
Medical Center, the University of Texas Health Science Center at San
Antonio, and the University of Pennsylvania approved the protocol.
2.2. Participants
Participants included 366 treatment-seeking post-9/11 active duty military
personnel who had returned from deployments to Afghanistan, Iraq, or nearby
locations and were diagnosed with PTSD according to the fourth edition, text
revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-
IV-TR; American Psychiatric Association, 2000). Inclusion criteria were: (1)
adult (ages 18–65) men and women active duty military personnel, activated
Reservist, or activated National Guard seeking outpatient treatment for PTSD;
(2) diagnosis of PTSD as determined by the Posttraumatic Stress Scale-
Interview (PSS-I); (3) exposure to a DSM-IV-TR Criterion A traumatic event
that was a combat-related event or high magnitude operational experience that
occurred during a military deployment. Exclusion criteria were: (1) current
bipolar disorder or psychotic disorder; (2) current alcohol dependence; (3)
moderate or severe traumatic brain injury; (4) current suicidal ideation severe
enough to warrant immedi-ate attention; and (5) other disorders severe
enough to warrant immediate treatment.
2.3. Measures
2.3.1. PTSD Symptom Scale – Interview Version (PSS-I; Foa et al.,
1993)
The PSS-I is a 20-min, 17-item clinician-administered interview that
evaluates DSM-IV PTSD symptoms in the past 2 weeks on frequency and
severity. Items are rated on a 4-point scale (0=not at all to 3=very much. The
PSS-I has excellent test-retest reliability (.80) and inter-rater reliability (kappa
=.91; Foa and Tolin, 2000). The PSS-I is comparable to the gold standard
employed in studies of veterans (the Clinician Administered PTSD Scale) and
is considered a common data element for PTSD research (Foa and Tolin,
2000; Kaloupek et al., 2010). The Cronbach's alpha for the PSS-I in the
current sample was .67.
2.3.2. The Beck Depression Inventory (BDI-II; Beck et al., 1996a,
1996b)
The BDI-II is a 21-item self-report measure of depressive symp-toms during
the past 2 weeks. Items are rated on a 4-point scale (0= no disturbance to 3=
maximal disturbance). The BDI-II has demon-strated 1-week test-retest
reliability and concurrent validity (Beck et al., 1996a, 1996b). The Cronbach's
alpha for the BDI-II in the current sample was .89.
2.3.3. The Beck Scale for Suicide Ideation (BSS; Beck and Steer, 1991) The
BSS is a 19-item self-report measure of the severity of SI during the past
week, including the frequency and duration of ideation,
394
Journal of Affective Disorders 208 (2017) 392–398
specificity of planning, and preparations for death. The BSS has demonstrated
good concurrent validity (Beck et al., 1997). The Cronbach's alpha for the
BSS in the current sample was .83. Item #20, which is rated on a 3-point scale
(0= I have never attempted suicide, 1= I have attempted suicide once, 2= I
have attempted suicide two or more times), was used to identify participants
who had attempted suicide one or more times.
2.3.4. Interpersonal Support Evaluation List – 12 (ISEL-12; Cohen and
Hoberman, 1983)
The ISEL-12 is a 12-item self-report measure of perceived current social
support that consists of three subscales: appraisal support (perceived
availability to speak with someone about personal pro-blems), belonging
support (perception that one can identify and socialize with a group), and
tangible support (perceived availability of material aids; Brookings and
Bolton, 1988). Items are rated on a 4-point scale (1= definitely false to 4=
definitely true). The measure has demonstrated strong psychometric properties
(Cohen et al., 1985). The Cronbach's alpha for the ISEL in the current sample
was.87.
2.3.5. The Walter Reed Army Institute of Research (WRAIR) Military
Vertical & Horizontal Cohesion Scales; Podsakoff and MacKenzie, 1994)
The WRAIR is the gold standard method of evaluating perceived current
support from peers (horizontal) and leaders (vertical) in the military.
Horizontal cohesion was measured using a revised three-item cohesion scale
assessing the degree to which unit members are cooperative, can depend on
one another, and stand up for one another (Podsakoff and MacKenzie, 1994).
The Cronbach's alpha for the WRAIR in the current sample was.94.
2.3.6. The Posttraumatic Cognitions Inventory (PTCI; Foa et al.,
1999)
The PTCI is a 36-item self-report questionnaire of negative trauma-related
thoughts and beliefs during the past 2 weeks. The measure consists of three
subscales: negative cognitions about the self, negative cognitions about the
world, and self-blame. The PTCI has demon-strated good test-retest
reliability, discriminant validity, and conver-gent validity (Beck et al., 2004;
Foa et al., 1999). The Cronbach's alpha for the PTCI in the current sample
was .95.
2.3.7. The Trauma Related Guilt Inventory (TRGI) – Brief; Kubany et al.,
1996)
The TRGI-Brief is a 16-item version of the TRGI, a self-report measure of
current feelings of guilt related to a specific traumatic event. The TRGI-Brief
is comprised of three subscales: Hindsight-Bias/ Responsibility, Wrongdoing,
and Lack of Justification. The TRGI has demonstrated good temporal stability
and convergent validity (Kubany et al., 1996). The Cronbach's alphas for the
three subscales of the TRGI-Brief in the current sample were .89, .71, and .84,
respectively.
2.3.8. The Deployment Risk and Resilience Inventory (DRRI) Combat
Experiences Subscale (CES) and Aftermath of Battle Subscale (ABS; King et
al., 2006)
The CES and ABS are two of 14 sub-measures comprising the DRRI. The
CES measures exposure to common warfare experiences during deployment.
Two of the 15 items comprising the CES were used in the current study: “I
killed or think I killed the enemy in combat” and “I wounded or think I
wounded someone during combat opera-tions.” The Cronbach's alpha of these
two items in the current sample was .95. The ABS is a 15-item self-report
measure of exposure to the consequences of combat, including observing or
handling human remains and observing devastated communities and homeless
refugees. The ABS has demonstrated convergent and discriminant validity
(Vogt et al., 2008). The Cronbach's alpha for the DRRI ABS in the current
sample was .91.
C.P. McLean et al. Journal of Affective Disorders 208 (2017) 392–398

2.4. Data analyses Table 1

Participant characteristics (N=366).
The hypothesized model (see Fig. 1) was tested via structural equation
Characteristic #/Mean %/(SD)
modeling (SEM). SEM allows for the simultaneous calculation of regression
equations and generates fit statistics to determine the adequacy of the model Gender
(Ullman and Bentler, 2003). Because most participants had a score of 0 on the Men 322 88.0
BSS, the SEM with asymptotically distribution-free (ADF) estimation, which Women 44 12.0
Age M = 32.73 (7.34)
does not require multivariate normality, was selected as most appropriate
(Browne, 1984). Indirect and direct effects of the variables on SI were Marital status
calculated to understand relationships among variables. Bootstrapping was Not married 104 28.4
employed to esti-mate bias-corrected standard errors and confirm indirect Married or cohabiting 262 71.6
effects. Using AMOS 23 software, models were constructed and compared
Education
using the following indices of fit: nonsignificant χ2 value, root mean square High school 117 32.0
error of approximation (RMSEA) < .08, comparative fit index (CFI) > .90, College 241 65.8
and goodness-of-fit index (GFI) > .90 (Hair et al., 2006; Hu and Bentler, Postgraduate 8 2.2
1999). Standardized regression coefficients are reported.
Ethnicity
Hispanic 71 19.4
As an exploratory aim, the final SEM model was evaluated among Non-Hispanic 295 80.6
participants who did (n =40) and did not (n =326) report at least one past
suicide attempt. Given the small number of participants reporting a past Race
Black 86 23.5
attempt, the results of this exploratory analysis should be interpreted with White 224 61.2
caution because small sample sizes may increase the risk of type II error, Asian 3 .8
nonconvergence, and improper solutions. Other 53 14.5
Military service Army 363 99.2
Air Force 3 .8

3. Results Military grade

3.1. Structural Equation Modeling Enlisted

E−1 to E−3 2 .5
E−4 to E−6 285 77.9
Participant characteristics are reported in Table 1. The means and standard E−7 to E−9 62 16.9
deviations of all study variables and the Pearson's correlations among all Officer 9 2.5
variables included in the hypothesized model are reported in Table 2. Warrant officer 5 1.4
SEM failed to identify the full, initial model because there were several Time in military, years M = 11.12 (6.35)
Number of deployments M = 2.26 (1.04)
hypothesized paths among uncorrelated variables. Combat experiences were
not significantly associated with either PTSD or depression and were E−1 to E−3, junior enlisted; E−4 to E−6, junior noncommissioned officers; E−7 to E−9, senior
excluded from the model. Subsequent models were constructed and trimmed noncommissioned officers.
by comparing standardized beta coefficients and fit indices. Contrary to
hypothesis, interpersonal support did not moderate the relationship between 3.2. Exploratory analyses
either PTSD and SI or depression and SI. Guilt was tested and excluded from
the model because no path through it resulted in a significant effect. The final, Neither convergence problems nor improper solutions were found in the
simplified model (see Fig. 2) demonstrated very good fit: χ2 (2) =2.023, exploratory model. Among participants with a past attempt (n =40), the paths
p=.364; RMSEA =.006; CFI =1; GFI =.998. All paths and covariates in the from depression to interpersonal support, from interpersonal support to SI,
final model were significant. PTSD severity covaried with depres-sion and from negative cognitions about the self to SI were nonsignificant. After
severity (β=.436, SE =.043). PTSD symptoms were associated with greater eliminating these paths, the model demonstrated good fit: χ2 (5) =4.411,
negative cognitions about the self (β=.229, SE =.045). Depression was p=.492; RMSEA < .001; CFI =1; GFI =.956. Only depression demonstrated a
associated with lower interpersonal support (β=−.147, SE=.061), greater direct effect on SI (β=.390, SE =.134). Independent t-tests showed that
negative cognitions about the self (β=.512, SE =.041), and greater SI (β=.212, depression severity was higher among those with a past attempt (M =31.40,
SE=.063). Negative cognitions about the self were associated with lower SD =9.64) than those with no past attempt [M =28.04, SD =9.91, t (364)
interpersonal support (β=−.361, SE =.054) and greater SI (β=.142, SE =.065). =−2.03, p=.04]. Among those without a past attempt (n =326), the model was
Interpersonal support was associated with lower SI (β=−.107, SE =.057). the same as the final model and demonstrated good fit: χ2 (2) =4.337, p=.114;
RMSEA =.06; CFI =.983; GFI =.994.

Standardized regression coefficients for the final model are sum-marized in

Table 3, and standardized direct and indirect effects are reported in Table 4.
There were no significant pathways from PTSD to SI or from PTSD to
interpersonal support. PTSD demonstrated an indirect effect on SI through
negative cognitions about the self (β=.041, SE =.015). Depression
demonstrated both a direct (β=.212, SE =.063) and indirect effect (β=.108, SE
=.034) on SI through negative cogni-tions about the self and interpersonal
support, and it had the greatest accumulated total effect on SI (β=.320, SE
=.048). Negative cognitions about the self had the second greatest total effect
on SI (β=.181, SE =.060). Interpersonal support had only a direct effect on SI
(β=−.107, SE=.057).
4. Discussion
This study aimed to elucidate factors associated with SI severity among
treatment-seeking active duty military personnel with PTSD. Contrary to
hypothesis, PTSD severity was not directly associated with SI. Direct
associations between PTSD and SI have been found in some prior studies
(e.g., Bush et al., 2011; Maguen et al., 2012; Ramsawh et al., 2014) but not in
those that included cognitive and affective variables as potential mediators of
the PTSD-SI relationship (e.g., Bryan and Corso, 2011; Bryan et al., 2013a,
2013b). PTSD was, however, indirectly associated with increased SI via
trauma-related negative cognitions. In particular, negative thoughts about the
self fully

395
C.P. McLean et al. Journal of Affective Disorders 208 (2017) 392–398

Table 2
Correlations between all study variables (N=366).

Measures 1 2 3 4 5 6 7 8 9 10 11 12 13 14

1. BSS –
2. PSS-I .147** –
3. BDI-II .337** .436** –
4. PTCI_NS .320** .453** .616** –
5. PTCI_NW .143** .274** .365** .584** –
6. PTCI_SB .185** .236** .294** .513** .294** –
7. ISEL −.228** −.273** −.360** −.448** −.282** −.215** –
8. WRAIR −.135** −.170** −.211** −.263** −.221** −.161** .207** –
9. TRGI_R .118* .189** .226** .329** .235** .626** −.143** −.075 –
10. TRGI_W .164** .220** .235** .412** .289** .386** −.170** −.152** .440** –
11. TRGI_J .061 .052 .103* .134* −.031 .285** −.213** −.061 .222** .131* –
12. DRRI_C .084 .036 −.067 −.064 .047 .009 .123* −.072 .109* .023 −.114* –
13. DRRI_A .103* .081 .105* .039 .149** −.047 .019 −.044 .088 .066 −.099 .540** –
14. BSS-Attempt .119* .046 .081 .094 .049 .059 −.098 −.011 .066 .100 .019 −.010 −.020 –
M .99 25.47 28.40 3.26 4.98 2.37 34.22 44.19 1.13 1.09 1.90 3.83 34.45 .14
SD 2.72 6.39 9.92 1.19 1.23 1.27 7.80 13.20 1.12 .92 1.28 2.04 11.40 .44

BSS, Beck Scale for Suicide Ideation; PSS-I, PTSD Symptom Scale – Interview Version; BDI, Beck Depression Inventory; PTCI_NS, Posttraumatic Cognitions Inventory-negative cognitions about
the self; PTCI_NW, Posttraumatic Cognitions Inventory-negative cognitions about the world; PTCI_SB, Posttraumatic Cognitions Inventory-self -blame; ISEL, Interpersonal Support Evaluation List;
WRAIR, Walter Reed Army Institute of Research (WRAIR) Military Vertical & Horizontal Cohesion Scales; TRGI_R, Trauma Related Guilt Inventory-Hindsight-Bias/Responsibility; TRGI_W,
Trauma Related Guilt Inventory-wrongdoing; TRGI_J, Trauma Related Guilt Inventory-Lack of Justification; DRRI_C, Deployment Risk and Resilience Inventory - killing or wounding combat
experiences; DRRI_A, Deployment Risk and Resilience Inventory-Aftermath of Battle; BSS-Attempt, Beck Scale for Suicide Ideation-item 20 previous suicidal attempt.

*
P < .05
**
P < .01;

accounted for the association between PTSD and SI. This suggests that the Table 3
link between PTSD and SI among military personnel with PTSD is mediated Standardized regression coefficients and standard errors for all pathways of the final SEM
model (N =366).
by negative self-perceptions related to the trauma.
Consistent with Bryan et al. (2013a, 2013b), we found that negative trauma- Path Final model
related cognitions about oneself were associated with SI. In contrast, trauma-
related guilt was not associated with SI in the current sample. Although these Variable 1 Variable 2 B SEa β SEb P
variables are conceptually similar, negative trauma-related cognitions about ***
PTSD Negative .043 .008 .229 .045
the self reflect more global self-perceptions (e.g., “I’m incompetent”; “I have cognitions about
permanently changed for the worse”) than trauma-related guilt, which is more the self
specific and similar to self-blame (e.g., “I should have known better”; “I did Depression Negative .061 .005 .512 .041 ***

something that went against my values”). Thus, our finding suggests that cognitions about
the self
global negative trauma-related self-perceptions are more closely associated ***
Negative cognitions Interpersonal −2.375 .372 −.361 .054
with SI than trauma-related guilt. Future research on SI in military personnel about the self support
should consider guilt stemming from sources other than trauma (see Kopacz Depression Interpersonal .116 .049 −.147 .061 .030
et al., 2015). support
Negative cognitions Suicidal ideation .323 .149 .142 .065 .016
about the self
This is the first study of PTSD and SI to examine negative trauma-related Depression Suicidal ideation .057 .018 .212 .063 ***

cognitions. Prior studies document that negative trauma-related cognitions are Interpersonal Suicidal ideation −.037 .020 −.107 .057 .026
closely associated with PTSD severity (Zoellner et al., 2011) and mediate support
PTSD reduction during treatment (McLean et al., 2015; Zalta et al., 2014),
Covariate
suggesting that they are an important mechanism of therapeutic recovery. The ***
PTSD Depression 27.356 3.520 .436 .043
current findings expand our understanding of negative trauma-related
cognitions by identifying their importance in understanding SI among military SEM, structural equation modeling; PTSD, posttraumatic stress disorder.
a
personnel with PTSD. Additional research to determine the directionality of Standard error of unstandardized coefficient (B).
b
the relationship between negative trauma-related cognitions and SI is clearly Standard error of standardized coefficient (β).
***
warranted. If negative cognitions are found to predict SI, monitoring and P < .001.

targeting these cognitions during treatment may help alert providers to suicide
risk in military personnel with PTSD. depression demonstrated a direct positive effect on SI. It also demon-strated
an indirect effect via trauma-related cognitions and interperso-nal support.
Consistent with our hypothesis and replicating previous research, Interpersonal support is frequently conceptualized as a

Fig. 2. Final model for the whole sample (N =366), with standardized beta weights and significant level. Fit statistics: χ2 (2) =2.023, P=.364; RMSEA =.006; CFI =1; GFI =.998. PTSD, posttraumatic
stress disorder. ***P < .001; *P < .05.

396
C.P. McLean et al.
Table 4
Standardized direct, indirect, and total effects of all study variables on suicidal ideation.
Variable Direct effect Indirect effect Total effect
β SE P β SE P β
PTSD .000 0 / .041 .015 .004 .041
Depression .212 .063 .005 .108 .034 .002 .320
Negative .142 .065 .046 .039 .021 .018 .181
cognitions
about the self
Interpersonal −.107 .057 .016 .000 0 / −.107
support
PTSD, posttraumatic stress disorder.
protective buffer against SI, and it has been found to moderate the relationship
between PTSD and SI. For example, one study of military personnel found
that PTSD and depression had almost no relationship to SI when
postdeployment social support was high (DeBeer et al., 2014). The present
study did not find that social support moderated the effects of PTSD or
depression on SI, but it did find that low social support significantly
contributed to the association between depression and SI.
Interestingly, we found that interpersonal social support, but not unit
cohesion, was associated with SI. A sense of belonging and perceived support
engendered through connections with others gen-erally, rather than military
peers and leaders specifically, may serve a protective function thwarting
negative thought processes that engender SI among service members. This
suggests that enhancing social support in general among service members
seeking treatment for PTSD, focusing on connections with friends and family
outside of the military unit, may be especially critical to mitigating SI among
PTSD patients with higher levels of depression.
Among participants with at least one previous suicide attempt, depression
emerged as the sole factor associated with SI. This finding, which should be
considered preliminary due to the restricted sample size, suggests that
depression and SI are more closely linked among those with a past attempt
than those who have never attempted, and it shows that depression may
represent a critical variable in under-standing the progression from SI to
suicide attempt. This finding aligns with results from a recent clinical trial
showing that depression, but not PTSD, drove reductions in SI during
treatment for PTSD among active duty military personnel (Bryan et al.,
2015c).
Contrary to hypothesis, exposure to killing and aftermath of battle
experiences were not related to SI, either directly or indirectly. This is
inconsistent with results of a meta-analysis showing that these types of
combat experiences had a small but significant effect on suicide-related
outcomes (Bryan et al., 2015b); however, the meta-analysis included military
personnel with and without PTSD. Thus, it may be that these types of
experiences relate to SI in general military samples, but not among
individuals with PTSD specifically, for whom overall levels of both combat
exposure and PTSD are more consistently elevated, resulting in a restricted
range within which correlations may not occur.
4.1. Limitations
The sample was comprised of treatment-seeking military personnel with
PTSD, therefore findings may only be generalized to similar samples (e.g.,
military PTSD patients presenting for care) and may not generalize to military
personnel returning from deployment without PTSD. It should also be noted
that only patients with mild to moderate levels of suicidal ideation were
included in the study and therefore the results may not generalize to those
with severe suicidal ideation, or to patients with bipolar disorder, psychosis or
alcohol use disorders, who were also excluded from this study. Other
limitations of the study include the reliance on self-report data to assess
suicidal ideation,
Journal of Affective Disorders 208 (2017) 392–398
which can be influenced by demand characteristics and thus be susceptible to
bias. In addition, the cross-sectional design precludes causal interpretations
regarding mediation and the factors that lead to the development or increase
of SI over time. Longitudinal studies with repeated assessments of military
SE P personnel are needed to elucidate how and for whom PTSD predicts SI.
.015 .004
.048 .005
.060 .005 Funding
Funding for this work was made possible by the US Department of Defense
.057 .016 through the US Army Medical Research and Materiel Command,
Congressionally Directed Medical Research Programs, Psychological Health
and Traumatic Brain Injury Research Program awards W81XWH-08-02-109
(Alan Peterson), W81XWH-08-02-0111 (Edna B. Foa), and W81XWH-08-
02-0114 (Brett T. Litz).
Disclaimer
The views expressed in this article are solely those of the authors and do not
reflect an endorsement by or the official policy of the US Army, the
Department of Defense, the Department of Veterans Affairs, or the US
Government.
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