Posttraumatic stress disorder symptoms and suicide ideation, attempt, and risk among active-duty service members and veterans: A systematic review with three meta-analyses of associations and moderators.

Posttraumatic stress disorder (PTSD) is associated with suicidal ideation and suicide attempts. Distress tolerance, or the perceived capacity to tolerate negative emotional states, is a cognitive-affective factor with clinical relevance to PTSD-suicide relations. No studies to date have examined the associations of PTSD symptoms, distress tolerance, and suicidal ideation or suicide risk among university students, a population at risk for suicidal ideation and behavior. It was hypothesized that greater PTSD symptom severity and lower perceived distress tolerance, respectively, would be associated with greater suicidal ideation and suicide risk; and that PTSD symptom severity would exert an indirect effect on suicidal ideation and risk through perceived distress tolerance. Covariates included trauma load, negative affectivity, and gender. Participants were comprised of 819 trauma-exposed university students (78.0% female; Mage = 22.0), who completed a battery of questionnaires. Mediation analyses were conducted, and results indicated that greater PTSD symptom severity and lower distress tolerance, respectively, were significantly associated with greater suicidal ideation and suicide risk. PTSD symptom severity exerted an indirect effect on suicidal ideation and suicide risk through perceived distress tolerance. Effects were demonstrated after controlling for theoretically relevant covariates. Clinical and research implications are discussed.

Symptoms of post-traumatic stress disorder (PTSD) are common in military populations, and frequently associated with a history of combat-related mild traumatic brain injury (mTBI). In this study, we examined relationships between severity of PTSD symptoms and levels of extracellular vesicle (EV) proteins and miRNAs measured in the peripheral blood in a cohort of military service members and Veterans (SMs/Vs) with chronic mTBI(s). Participants (n = 144) were divided into groups according to mTBI history and severity of PTSD symptoms on the PTSD Checklist for DSM-5 (PCL-5). We analyzed EV levels of 798 miRNAs (miRNAs) as well as EV and plasma levels of neurofilament light chain (NfL), Tau, Amyloid beta (Aβ) 42, Aβ40, interleukin (IL)-10, IL-6, tumor necrosis factor-alpha (TNFα), and vascular endothelial growth factor (VEGF). We observed that EV levels of neurofilament light chain (NfL) were elevated in participants with more severe PTSD symptoms (PCL-5 ≥ 38) and positive mTBI history, when compared to TBI negative controls (p = 0.024) and mTBI participants with less severe PTSD symptoms (p = 0.006). Levels of EV NfL, plasma NfL, and hsa-miR-139–5p were linked to PCL-5 scores in regression models. Our results suggest that levels of NfL, a marker of axonal damage, are associated with PTSD symptom severity in participants with remote mTBI. Specific miRNAs previously linked to neurodegenerative and inflammatory processes, and glucocorticoid receptor signaling pathways, among others, were also associated with the severity of PTSD symptoms. Our findings provide insights into possible signaling pathways linked to the development of persistent PTSD symptoms after TBI and biological mechanisms underlying susceptibility to PTSD.

Service members and veterans (SM/Vs) with posttraumatic stress disorder (PTSD) can receive significant benefits from social support by a spouse or romantic partner. However, little is known about how providing support impacts partners. This study sought to identify (a) how provision of support is associated with partners' daily negative and positive affect and (b) how SM/Vs' PTSD symptom severity might moderate such associations. In a 14-day daily-diary study that assessed 64 couples in which one member was an SM/V with PTSD symptoms, partners reported nightly on whether or not they provided instrumental support and/or emotional support that day as well as their current negative and positive affect. Multilevel modeling showed that the provision of emotional and instrumental support were both significantly related to partners' lower levels of negative affect, f 2 = 0.09, and higher levels of positive affect, f 2 = 0.03, on that same day but not the next day. The positive same-day effects were seen if any support was given, with no additive effects when both types of support were provided. Severity of SM/V PTSD moderated the association between provision of emotional support and lower same-day negative affect such that the association was significant only when PTSD symptoms were more severe. Overall, these findings indicate that support provision to a partner with PTSD is associated with improved affect for the romantic partner providing support. However, given that only same-day affect was associated with support, the findings may also suggest that positive affect increases the provision of support.

Suicide is a major public health concern accounting for 800 000 deaths globally each year. Although there have been many advances in understanding suicide risk in recent decades, our ability to predict suicide is no better now than it was 50 years ago. There are many potential explanations for this lack of progress, but the absence, until recently, of comprehensive theoretical models that predict the emergence of suicidal ideation distinct from the transition between suicidal ideation and suicide attempts/suicide is key to this lack of progress. The current article presents the integrated motivational–volitional (IMV) model of suicidal behaviour, one such theoretical model. We propose that defeat and entrapment drive the emergence of suicidal ideation and that a group of factors, entitled volitional moderators (VMs), govern the transition from suicidal ideation to suicidal behaviour. According to the IMV model, VMs include access to the means of suicide, exposure to suicidal behaviour, capability for suicide (fearlessness about death and increased physical pain tolerance), planning, impulsivity, mental imagery and past suicidal behaviour. In this article, we describe the theoretical origins of the IMV model, the key premises underpinning the model, empirical tests of the model and future research directions.

Sleep disorder symptoms and suicidal urges among US Marines seeking suicide treatment: Findings from an intensive daily assessment study

Objective Chaplains are key care providers in a comprehensive approach to suicide prevention, which is a priority area for the U.S. Department of Veterans Affairs (VA) and the Department of Defense (DoD). In a cohort of 87 VA and military chaplains who completed the Mental Health Integration for Chaplain Services (MHICS) training–an intensive, specialty education in evidence-based psychosocial and collaborative approaches to mental health care–we assessed chaplains’ self-perceptions, intervention behaviors, and use of evidence-based practices, including Acceptance and Commitment Therapy (ACT), Problem-Solving Therapy (PST), and Motivational Interviewing (MI), in providing care for suicidality. Method Chaplains responded to a battery of items Pre- and Post-training and provided deidentified case examples describing their use of evidence-based practices in spiritual care for service members and veterans (SM/V) on various levels of a suicide prevention continuum. Results Post-training, chaplains reported increased abilities to provide care and mobilize collaborative resources. Over the course of MHICS, 87% of chaplains used one or more evidence-based practices with a SM/V at risk for suicide or acutely suicidal. Fifty-six percent of chaplains reported intervening with an acutely suicidal SM/V by using principles from ACT, 36% PST, and 48% MI. With persons at risk for suicide, 81% used principles from ACT, 66% PST, and 71% MI. Cases exemplified diverse evidence-based practice applications. Conclusions Findings indicate chaplains trained in evidence-based practices report effective application in caring for SM/V who are suicidal, thus offering a valuable resource to meet needs in a priority area for VA and DoD. HIGHLIGHTS Chaplains provide essential care for SM/V who are at risk for suicide or acutely suicidal Training helps chaplains mobilize interdisciplinary and community resources in suicide care Evidence-based practices can effectively integrate within the scope of chaplaincy practice for suicide care

Alcohol use disorder (AUD), posttraumatic stress disorder (PTSD), and suicide are substantial public health concerns among military service members, yet the nature of their relationships is not well understood. Here, we tested the hypothesis that AUD moderates the relationship between PTSD symptom severity and suicidal ideation. This secondary analysis uses data collected at baseline for a randomized clinical trial. The sample consists of 160 active-duty service members from three service branches (Army, Air Force, and Navy). All participants met diagnostic criteria for PTSD and were not engaged in evidence-based PTSD treatment at the time of enrollment. Zero-inflated Poisson generalized linear regression models were used to test the associations of PTSD and AUD symptom severity with the presence and severity of suicidal ideation. Findings suggest that AUD symptom severity moderates (i.e., amplifies) the relationship between PTSD symptoms and severity of suicidal ideation among military personnel with untreated PTSD. Among service members with mild or absent AUD, we found no significant association between PTSD symptoms and the severity of suicidal ideation. However, when AUD severity was average (i.e., sample mean) or high (mean + 1SD), PTSD symptoms were significantly positively associated with the severity of suicidal ideation. This study highlights the importance of assessing AUD and PTSD as a part of suicide risk evaluations of veterans. The results also provide strong support for the maintenance and further development in the military health system of treatment programs that simultaneously address AUD and PTSD comorbidity.

Traumatic brain injury (TBI) is a concern for US service members and veterans (SMV), leading to heterogeneous psychological and cognitive outcomes. We sought to identify neuropsychological profiles of mild TBI (mTBI) and posttraumatic stress disorder (PTSD) among the largest SMV sample to date. We analyzed cross-sectional baseline data from SMV with prior combat deployments enrolled in the ongoing Long-term Impact of Military-relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium prospective longitudinal study. Latent profile analysis identified symptom profiles using 35 indicators, including physical symptoms, depression, quality of life, sleep quality, postconcussive symptoms, and cognitive performance. It is important to note that the profiles were determined independently of mTBI and probable PTSD status. After profile identification, we examined associations between demographic variables, mTBI characteristics, and PTSD symptoms with symptom profile membership. The analytic sample included 1,659 SMV (mean age 41.1 ± 10.0 years; 87% male); among them 29% (n = 480) had a history of non-deployment-related mTBI only, 14% (n = 239) had deployment-related mTBI only, 36% (n = 602) had both non-deployment and deployment-related mTBI, and 30% (n = 497) met criteria for probable PTSD. A 6-profile model had the best fit, with separation on all indicators (p < 0.001). The model revealed distinct neuropsychological profiles, representing a combination of 3 self-reported functioning patterns: high (HS), moderate (MS), and low (LS), and 2 cognitive performance patterns: high (HC) and low (LC). The profiles were (1) HS/HC: n=301, 18.1%; (2) HS/LC: n=294, 17.7%; (3) MS/HC: n=359, 21.6%; (4) MS/LC: n=316, 19.0%; (5) LS/HC: n=228, 13.7%; and (6) LS/LC: n=161, 9.7%. SMV with deployment-related mTBI tended to be grouped into lower functioning profiles and were more likely to meet criteria for probable PTSD. Conversely, SMV with no mTBI exposure or non-deployment-related mTBI were clustered in higher functioning profiles and had a lower likelihood of meeting criteria for probable PTSD. Findings suggest varied symptom and functional profiles in SMV, influenced by injury context and probable PTSD comorbidity. Despite diagnostic challenges, comprehensive assessment of functioning and cognition can detect subtle differences related to mTBI and PTSD, revealing distinct neuropsychological profiles. Prioritizing early treatment based on these profiles may improve prognostication and support efficient recovery.

Research is limited regarding the role of high-risk behaviors, trauma, and posttraumatic stress disorder (PTSD) symptoms in people with severe mental illnesses (SMI).The current survey of 276 community mental health clients diagnosed with either a schizophrenia spectrum disorder or a major mood disorder examined the mediating role of lifetime high-risk behaviors with regard to lifetime traumatic events and PTSD symptom severity measured by the PTSD Symptom Scale-Interview version. Structural equation modeling revealed that lifetime high-risk behaviors had significant direct effects on PTSD symptom severity, and high-risk behaviors partially mediated the relationship between lifetime trauma and PTSD symptom severity. Lifetime trauma had the greatest total effect on PTSD symptoms, followed by primary Axis I diagnosis and lifetime high-risk behaviors. Implications for practice with people with SMI include more thorough assessments of trauma, PTSD, and high-risk behaviors and use of coping skills approaches to reduce high-risk behaviors. Limitations of the study include the cross-sectional nature of the data. KEY WORDS: high-risk behaviors; major mood disorders; posttraumatic stress disorder; schizophrenia; severe mental illness ********** People with severe mental illnesses (SMIs), including schizophrenia spectrum disorders (SSDs) and major mood disorders (MMDs), experience higher rates of trauma, such as physical and sexual abuse and exposure to violence, than do people in the general public (Mueser et al., 1998; Resnick, Bond, & Mueser, 2003), and they show rates of posttraumatic stress disorder (PTSD) four to five times greater (between 33% and 43%) than do people in the general population (about 8%) (Mueser et al., 1998; O'Hare, Sherrer, & Shen, 2006). People with SMI are also more likely to engage in high-risk behaviors--such as suicide attempts, substance abuse, drug overdoses, unprotected sex, and self-mutilation--and to demonstrate behaviors associated with more severe psychiatric symptoms, have more frequent hospitalizations, be at increased risk of trauma, and have poorer treatment outcomes (Gearon, Kaltman, Brown, & Bellack, 2003; Mueser et al., 1998; O'Hare et al., 2006). Few research investigations have focused on the relationship of high-risk behaviors to trauma and PTSD. Given that the consequences of high-risk behaviors can be retraumatizing, the current study tests whether high-risk behaviors mediate the relationship between lifetime trauma and PTSD symptom severity. AIMS OF THE CURRENT STUDY The relationships among traumatic events, high-risk behaviors, and PTSD remain poorly understood in the SMI population (Butler, Mueser, Sprock, & Braff, 1996; Mueser, Rosenberg, Goodman, & Trumbetta, 2002; O'Hare et al., 2006). Although PTSD symptoms in this population have been shown to be positively related to other measures of emotional distress (O'Hare et al. 2006; Resnick et al., 2003), there is only limited research on the linkages between the frequency of lifetime trauma and PTSD. In addition, the relationship between lifetime trauma and high-risk behaviors is even less understood. Although a recent study of clients, most of whom participated in the current investigation, showed that subjective distress from highrisk behaviors--that is, overdosing on medication, self-mutilation, and suicide attempts--mediated the connection between trauma-related subjective distress and PTSD symptoms (O'Hare et al., 2006), it is not known if high-risk events mediate the relationship between lifetime traumatic events and PTSD symptoms. Discovery of such a link could help improve our understanding of the mediating role of high-risk behaviors with regard to traumatic events and PTSD symptom severity. Gender is a key factor to consider when examining trauma, high-risk events, and PTSD. Women with serious psychiatric disorders appear to be at greater risk for certain stressors, including sexual abuse and interpersonal violence as adults, and men are more likely to witness serious acts of violence (Goodman et al. …

A-15 PTSD Symptoms Are Related to Cognition Following Complicated Mild and Moderate TBI, but Not Severe and Penetrating TBI

A dynamical systems analysis of change in PTSD symptoms, depression symptoms, and suicidal ideation among military personnel during treatment for PTSD

The current study examines the unique and interactive effects of posttraumatic stress disorder (PTSD) symptoms and days using alcohol, opioids, and marijuana on PTSD symptoms, suicidal ideation, and suicidal behavior up to 1 year, later in a high-risk sample of military personnel not active in mental health treatment. Current and former military personnel at risk for suicide (N = 545; M age = 31.91 years, standard deviation = 7.27; 88.2% male) completed self-report measures of PTSD symptoms, past 30 days heavy alcohol use, opioid use, marijuana use, and current suicidal ideation via telephone at baseline and 1, 3, 6, and 12 months later. PTSD symptoms and the substance use variables (and relevant covariates) were entered as predictors of changes in PTSD symptoms, the likelihood of suicidal ideation, suicidal ideation severity, and the likelihood of suicidal behavior during the 11-month follow-up period. PTSD symptoms predicted PTSD symptoms 1 month later. PTSD symptoms and marijuana use predicted the likelihood of suicidal ideation 1 month later and suicidal behavior during the 11-month follow-up period. The interaction between PTSD symptoms and marijuana use significantly predicted increased PTSD symptoms over time and suicidal behavior. At high, but not low levels of PTSD symptoms, more days using marijuana predicted increased PTSD symptoms over time and the likelihood of suicidal behavior. Results suggest marijuana, especially for military personnel experiencing elevated PTSD symptoms may negatively impact suicidal thoughts and behavior. These results are relevant to suggestions that medical marijuana could be used in treating or augmenting treatment for PTSD.

Active duty service members who are psychiatrically hospitalized for suicide are at the highest risk for suicide death following discharge. It is essential to test brief treatments that can be delivered during the short length of stay in inpatient psychiatry. Written Exposure Therapy, a brief treatment for posttraumatic stress disorder (PTSD), was augmented with Crisis Response Planning (WET + CRP) to address PTSD and suicidal ideation (SI). This randomized controlled trial evaluated the efficacy of the WET + CRP plus treatment as usual (n = 47; TAU) compared with TAU alone (n = 48) in reducing SI, PTSD symptoms, and rehospitalization among suicidal patients with at least moderate PTSD symptoms admitted to an inpatient psychiatric unit. PTSD symptoms and SI were assessed with clinician-administered interviews and self-report. Participants were primarily male (61.1%) and active duty/reserve (93.7%). There were no significant group differences in clinician-assessed SI presence and PTSD symptom severity (the primary outcomes) or self-reported SI severity. WET + CRP demonstrated significant reductions in self-reported PTSD symptom severity compared with TAU; these reductions were the strongest during the month following discharge. Although the findings were not fully consistent with hypotheses, WET + CRP is feasible to deliver to suicidal, psychiatrically hospitalized service members and warrants additional study. ClinicalTrials.gov Identifier: NCT04225130.

Treatment for posttraumatic stress disorder (PTSD) is a commonly sought mental health service among military service members and veterans (SM/Vs). Such treatment is typically individually-based, despite many SM/Vs reporting a desire for greater partner involvement in treatment. This review examined couple-based treatments for PTSD among SM/Vs and their romantic partners. A database search conducted in July, 2018 yielded 167 studies, of which 16 (10%) met inclusion criteria. Brief intervention summaries, effect sizes, and distress change scores (where applicable) are reported. The 16 studies tested 7 interventions, which showed a reduction in self-rated and clinician-rated PTSD symptoms with large effect sizes observed in most studies. Relationship outcomes also improved for SM/Vs and their partners, with effect sizes ranging from small-to-medium for SM/Vs and small-to-large for partners. Couple-based interventions show success in reducing PTSD symptoms and improving relationship outcomes, offering several alternatives to individual-based interventions among partnered SM/Vs.

The association between suicidality and treatment with Selective Serotonin Reuptake Inhibitors in older people with major depression: a systematic review