Suicidal Ideation In Veterans Research Articles

Association of interleukin-6 with suicidal ideation in veterans: a longitudinal perspective.

Studies showing associations between inflammation in suicide are typically cross-sectional. Present study investigated how cytokine levels track with suicidal ideation and severity longitudinally. Veterans with a diagnosis of major depressive disorder (MDD) with or without suicide attempt history (MDD/SA n = 38, MDD/NS n = 41) and non-psychiatric non-attempter controls (HC n = 33) were recruited, MDD/SA and HC groups were followed longitudinally at 3 months and 6 months. Blood plasma was collected and processed using Luminex Immunology Multiplex technology. Significant differences in depression severity (BDI) and suicidal ideation severity (SSI) were observed across all groups at study entry, wherein MDD/SA group had the highest scores followed by MDD/NS and HC, respectively. Cytokines IL-1β, IL-4, TNF-α, IFN-γ, and IL-6 were examined at study entry and longitudinally, with IL6 levels differing significantly across the groups (p = 0.0123) at study entry. Significant differences in changes in cytokine levels between depressed attempters and the control group were detected for IL-6 (interaction F1,91.77 = 5.58, p = 0.0203) and TNF-α (F1,101.73 = 4.69, p = 0.0327). However, only depressed attempters showed a significant change, in IL-6 and TNF-α levels, decreasing over time [IL-6: b = -0.04, 95% CI = (-0.08, -0.01), p = 0.0245 and TNF-α: b = -0.02, 95% CI = (-0.04, -0.01), p = 0.0196]. Although IL-6 levels were not predictive of suicidal ideation presence [OR = 1.34, 95% CI = (0.77, 2.33), p = 0.3067], IL-6 levels were significantly associated with suicidal ideation severity (b = 0.19, p = 0.0422). IL-6 was not associated with presence of suicidal ideation. IL-6 however, was associated with severity of ideation, suggesting that IL-6 may be useful in clinical practice, as an objective marker of heightened suicide risk.

Suicidal ideation in veterans enrolled in evidence-based psychotherapy for posttraumatic stress disorder.

Suicidal ideation (SI) is a highly prevalent public health issue in the veteran population and is increasingly common in veterans who are diagnosed with other mental health conditions, such as posttraumatic stress disorder (PTSD; U.S. Department of Veterans Affairs, 2020). The present study has an initial aim of examining changes in SI over treatment, and it is hypothesized that SI will decrease across PTSD treatments. A second aim is to examine the association of SI status with PTSD symptoms across treatment, and it is hypothesized that PTSD symptomatology will decrease at similar rates over the course of treatment for those who did and did not endorse SI at pretreatment. Participants included 717 (86.3% male) veterans who participated in outpatient treatment within a Veterans Affairs Post Traumatic Stress Disorder (VA PTSD) specialty clinic between July 2014 and December 2017. Descriptive analyses found that 37.2% of veterans endorsed SI at pretreatment, while 18.6% endorsed SI at posttreatment. The relationship between pre- and posttreatment SI was significant, χ²(1, N = 247) = 23.77, p < .001. A significant proportion of veterans who endorsed SI at pretreatment no longer endorsed SI at posttreatment (64.7%). There were no differences in changes in PTSD Checklist for DSM-5 (PCL-5) scores across treatment for those with and without SI at pretreatment. While those who endorsed SI at pretreatment had higher PCL-5 scores throughout treatment, they experienced a similar rate of improvement in symptoms as those without SI at pretreatment. This finding suggests that the presence of SI does not reduce the effectiveness of PTSD treatment. Limitations include the use of a single-item measure of SI, lack of adequate power to detect difference among treatments, and a cross-sectional design. Clinical and research implications are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Prevalence and risk factors of suicide and suicidal ideation in veterans who served in the British Armed Forces: a systematic review

IntroductionResearch into the factors resulting in suicide in the military veteran population has yet to reach a consensus. Available research is concentrated on a small number of countries, and there...

Spiritual struggles and suicidal ideation in veterans seeking outpatient treatment: The mediating role of perceived burdensomeness.

Spiritual struggles and suicidal ideation in veterans seeking outpatient treatment: The mediating role of perceived burdensomeness.

Impact of Lithium on Suicidality in the Veteran Population.

Lithium has known antisuicidal properties making it an important agent to study in veterans with psychiatric conditions, a population at high risk for suicide. A single-site, retrospective chart review was conducted at a US Department of Veterans Affairs (VA) teaching hospital. Patients taking lithium for at least 6 months were identified using the VA Lithium Lab Monitoring Dashboard. The primary and secondary objectives were to evaluate the change in number of suicide attempts and suicidal ideation from 3 months prior to lithium initiation to 3 months after a 6-month duration of lithium. The review included 98 patients; 47 (47.9%) received concomitant psychotherapy, 50 (51.0%) were taking an antipsychotic, and 29 (29.6%) an additional mood stabilizer. During the 6-month intervention period, 75 (76.5%) patients had a lithium level drawn and 28 were in the therapeutic range. Of the 98 patients, hospitalization for suicide attempt decreased from 4.1% before lithium use to 0% after lithium use for 6 months (P = .045). Hospitalization for suicidal ideation also decreased from 13.3% before lithium use to 1.0% after lithium use for 6 months (P = .0004). We observed a statistically significant reduction in hospitalization for suicide attempts and suicidal ideation in veterans prescribed lithium following nonfatal suicide behavior and suicidal ideation.

Psychosocial moderators of polygenic risk for suicidal ideation: Results from a 7-year population-based, prospective cohort study of U.S. veterans.

Polygenic risk scores (PRS) may help inform the etiology of suicidal thoughts and behaviors. In this study, we evaluated whether a suicidality PRS derived from a large genome-wide association study (GWAS) of suicidality from the UK Biobank (N = 122,935) predicted suicidal ideation (SI) in a 7-year population-based, prospective cohort of European-American US veterans (N = 1326). Results revealed that 8.8% (n = 115) of veterans developed new-onset SI, 4.0% (n = 52) had chronic SI, 3.4% (n = 31) had remitted SI, and 83.8% (n = 1128) denied SI over the study period. Suicidality PRSstandardized was positively associated with chronic SI (relative risk ratio [RRR] = 4.54, 95% confidence interval [CI] = 1.01-20.48) and new-onset SI (RRR = 2.97, 95%CI = 1.22-7.23), and negatively associated with remitted SI (RRR = 0.12, 95% CI = 0.02-0.60). Among veterans with higher suicidality PRS, those with higher baseline dispositional optimism had a lower likelihood of chronic SI (RRR = 0.67, 95% CI = 0.49-0.91) and higher likelihood of remitted SI (RRR = 1.98, 95% CI = 1.18-3.31). Among veterans with higher suicidality PRS, those with higher baseline levels of social support were less likely to develop new-onset SI (RRR = 0.95, 95% CI = 0.92-0.99). These interaction effects were enriched for genes implicated in neuron recognition and development, while the PRS main effect was enriched for genes involved in mannosylation. Collectively, results of this study suggest that suicidality PRS is linked prospectively to symptomatic courses of SI, and that dispositional optimism and social support moderate these associations. Interventions targeting these modifiable psychosocial factors may help mitigate risk of SI in veterans with high polygenic risk for suicidality.

Impact of intensive treatment programs for posttraumatic stress disorder on suicidal ideation in veterans and service members.

Intensive treatment programs (ITPs) are treating veterans with posttraumatic stress disorder (PTSD) and suicidal ideation (SI). The reduction of SI is a target to the abatement of suicide risk. This study examined whether ITPs utilizing PTSD treatments reduce SI and whether SI reduction is associated with PTSD symptom improvement. Veterans (N = 684) enrolled in a 2-week Prolonged Exposure (PE)-ITP or a 3-week Cognitive Processing Therapy (CPT)-ITP. Study data were drawn from self-report measures [PTSD Checklist for DSM-5 (PCL-5); item 9 of the Patient Health Questionnaire-9 (PHQ-9)] administered at intake and throughout treatment. The ITPs produced large treatment effects for PTSD. SI scores also decreased over time. Lower PTSD symptom severity was associated with less severe SI in both the PE-ITP and CPT-ITP. In conclusion, both PE- and CPT-ITPs effectively treat PTSD and reduce SI among veterans in as little as 2 weeks of intensive PTSD treatment. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Is Gratitude Associated With Suicidal Ideation in Veterans With Mental Illness and Student Veterans With PTSD Symptoms?

The present study is aimed to identify the effect of gratitude as an adaptive regulating mechanism from suicidal ideation (SI) for veterans with mental illness (study 1) and student veterans with posttraumatic stress disorder (PTSD) symptoms (study 2) in the United States. Descriptive statistics and regression analyses were used to examine sociodemographic characteristics and relationships between gratitude and SI. Our study 1 consisted of 156 veterans with mental illness. The mean age for study 1 was 37.85. Our study 2 consisted of 232 student veterans with PTSD symptoms. The mean age for study 2 was 28.43. Higher gratitude scores in study 1 and study 2 were significantly associated with lower SI scores after adjusting for demographics and depression. This study partially supports the association between gratitude and SI in veterans with mental illness. Based on the results from this study, gratitude interventions may be effective in reducing SI when working with veterans with mental illness.

Military sexual trauma and suicidal ideation in VHA-care-seeking OEF/OIF/OND veterans without mental health diagnosis or treatment

Sexual trauma is a suicide risk factor. While military sexual trauma (MST) is frequently associated with suicidal ideation (SI) in women and men veterans who served in recent conflicts, less is known about MST's relationship to SI in veterans who have no documented mental health concerns. Of the 1.1 million post-9/11 veterans enrolled in the Veterans Healthcare Administration (VHA) we examined 41,658 (12.3% women, 87.7% men) without evidence of mental health diagnosis or treatment and who were screened for MST and SI using the standard VHA clinical reminders between 2008 and 2013. Relative risk estimates were generated using separate models for women and men. MST was reported by 27.9% of women and 2.9% of men; SI by 14.7% and 16.5%, respectively. The adjusted relative risk of MST on SI was 1.65 (95% CI 1.35, 2.00) in women, and 1.49 (95% CI 1.26, 1.75) in men. In this sample of veterans without evidence of mental health diagnosis or treatment, MST was associated with a high risk of SI in both genders. Positive MST screening should prompt SI screening and risk management if indicated, and further study of barriers to mental healthcare among MST survivors at risk for suicide is warranted.

Acoustic and language analysis of speech for suicidal ideation among US veterans

BackgroundScreening for suicidal ideation in high-risk groups such as U.S. veterans is crucial for early detection and suicide prevention. Currently, screening is based on clinical interviews or self-report measures. Both approaches rely on subjects to disclose their suicidal thoughts. Innovative approaches are necessary to develop objective and clinically applicable assessments. Speech has been investigated as an objective marker to understand various mental states including suicidal ideation. In this work, we developed a machine learning and natural language processing classifier based on speech markers to screen for suicidal ideation in US veterans.MethodologyVeterans submitted 588 narrative audio recordings via a mobile app in a real-life setting. In addition, participants completed self-report psychiatric scales and questionnaires. Recordings were analyzed to extract voice characteristics including prosodic, phonation, and glottal. The audios were also transcribed to extract textual features for linguistic analysis. We evaluated the acoustic and linguistic features using both statistical significance and ensemble feature selection. We also examined the performance of different machine learning algorithms on multiple combinations of features to classify suicidal and non-suicidal audios.ResultsA combined set of 15 acoustic and linguistic features of speech were identified by the ensemble feature selection. Random Forest classifier, using the selected set of features, correctly identified suicidal ideation in veterans with 86% sensitivity, 70% specificity, and an area under the receiver operating characteristic curve (AUC) of 80%.ConclusionsSpeech analysis of audios collected from veterans in everyday life settings using smartphones offers a promising approach for suicidal ideation detection. A machine learning classifier may eventually help clinicians identify and monitor high-risk veterans.

Post-traumatic symptom severity mediates the association between combat exposure and suicidal ideation in veterans.

Previous studies of military veterans have produced mixed findings regarding whether combat exposure is directly related to suicidal ideation or is indirectly related to suicidal ideation via its influence on other factors. The present study used a longitudinal design to test the hypothesis that post-traumatic stress disorder (PTSD) symptom severity mediates the effect of combat exposure on suicidal ideation in veterans. Participants included 319 post-9/11 veterans (83.4% male; 42.1% White/52.1% Black; Mage =39.7) assessed at baseline, 6, and 12months. Structural equation modeling and bootstrapped confidence intervals were employed to examine the direct and indirect relationships between combat exposure, suicidal ideation, and PTSD symptom severity. Results from the mediation model, in which demographic variables and non-combat trauma were included as covariates, revealed that the indirect effect of combat exposure on suicidal ideation via PTSD symptom severity was statistically significant, accounting for 64.1% of the covariance between combat exposure and suicidal ideation. This study provides longitudinal evidence that the effects of combat exposure on suicidal ideation are mediated by PTSD symptom severity, suggesting the importance of targeting such symptoms in treatment to mitigate suicide risk among veterans with combat exposure.

Neuropeptide Y plasma levels and suicidal behavior in combat veterans

War veterans are at increased risk of suicide that may be related to deployment and/or post-deployment stressors and to adjustment-related factors. The aim of this study was to examine whether levels of plasma neuropeptide Y (NPY) might distinguish combat veterans who have made a post-deployment suicide attempt from those who have never made a suicide attempt. We focused on NPY because of prior findings linking NPY with the neurobiology of resilience, stress-related and other disorders, and suicidal behavior. Demographic and clinical parameters of suicide attempters and non-attempters were assessed and plasma NPY was determined by radioimmunoassay. NPY levels were higher among attempters in comparison to non-attempters, controlling for sex and body-mass index. Suicide attempters had higher Scale for Suicidal Ideation (SSI) scores than non-attempters. There was a positive correlation between NPY levels and SSI scores among non-attempters but not among attempters. Likewise, NPY levels positively correlated with Brown-Goodwin Aggression Scale scores among suicide attempters but not among non-attempters. This is the first demonstration of altered plasma NPY levels in association with suicide attempt history and suicidal ideation in veterans. Our findings suggest that clinical differences between combat veterans with or without a history of suicide attempt may have a neurobiological origin.

DSM-5 PTSD symptom clusters and suicidal ideation in veterans

Posttraumatic stress disorder (PTSD) is associated with significantly greater risk for suicidal ideation (SI). In civilians, the negative alterations in cognitions and mood (NACM) and alterations in arousal and reactivity (AAR) clusters are most strongly associated with SI. This study sought to examine the association between PTSD symptom clusters and SI in a large sample of veterans. Veterans (n = 1,789) completed the PTSD Checklist for DSM-5 and the Patient Health Questionnaire (PHQ) during primary care visits. Wald chi-square tests of parameter constraints were computed to test hypothesized relations between PTSD factors and the PHQ-9 suicidal ideation item. Each of the PTSD symptom clusters were significantly associated with SI. The NACM cluster was more strongly associated with SI than AAR and marginally more strongly associated with SI than the avoidance symptom clusters. In a restricted sample of only veterans with PTSD, NACM remained more strongly associated with SI than avoidance. Each of the NACM symptoms were significantly associated with SI. Changes in cognitions and mood were most strongly associated with SI in this large sample of veterans. These findings suggest that directly targeting the NACM symptom cluster may be an important goal for suicide prevention efforts among veterans with PTSD.

Anger mediates the relationship between posttraumatic stress disorder and suicidal ideation in veterans

BackgroundTheoretical models and cross-sectional empirical studies of suicide indicate that anger is a factor that may help explain the association between posttraumatic stress disorder (PTSD) and suicide, but to date no longitudinal studies have examined this relationship. The current study used longitudinal data to examine whether changes in anger mediated the association between changes in PTSD symptomatology and suicidal ideation (SI). MethodsPost 9/11-era veterans (N = 298) were assessed at baseline, 6-months, and 12-month time points on PTSD symptoms, anger, and SI. Analyses covaried for age, sex, and depressive symptoms. Multilevel structural equation modeling was used to examine the three waves of data. ResultsThe effect of change in PTSD symptoms on SI was reduced from B = 0.02 (p = .008) to B = −0.01 (p = .67) when change in anger was added to the model. Moreover, the indirect effect of changes in PTSD symptoms on suicidal ideation via changes in anger was significant, B = 0.02, p = .034. The model explained 31.1% of the within-person variance in SI. LimitationsFocus on predicting SI rather than suicidal behavior. Sample was primarily male. ConclusionsFindings suggest that the association between PTSD and SI is accounted for, in part, by anger. This study further highlights the importance of anger as a risk factor for veteran suicide. Additional research on clinical interventions to reduce anger among veterans with PTSD may be useful in reducing suicide risk.

Psychosocial protective factors and suicidal ideation: Results from a national longitudinal study of veterans

BackgroundThis study investigates the empirical association between psychosocial protective factors and subsequent suicidal ideation in veterans. MethodsWe conducted a national longitudinal survey in which participants were randomly drawn from over one million U.S. military service members who served after September 11, 2001. Data were provided by a total of 1090 veterans representative of all 50 states and all military branches in two waves of data collection one year apart (79% retention rate). ResultsIn chi-square analyses, psychosocial protective factors at wave 1 (employment, meeting basic needs, self-care, living stability, social support, spirituality, resilience, and self-determination) were significantly related to lower suicidal ideation at wave 2. In multivariable analyses controlling for covariates at wave 1 including suicidal ideation, the total number of protective factors endorsed at wave 1 significantly predicted reduced odds of suicidal ideation at wave 2. In multivariable analysis examining individual risk and protective factors, again controlling for covariates, results showed that money to cover basic needs and higher psychological resilience at wave 1 were associated with significantly lower odds of suicidal ideation at wave 2. LimitationsThe study measured the link between psychosocial protective factors and suicidal ideation but not suicide attempts, which would be an important next step for this research. ConclusionsThe results indicate that psychosocial rehabilitation and holistic approaches targeting financial well-being, homelessness, resilience, self-care, social support, spirituality, and work may offer a promising avenue in both veteran and non-veteran populations for treatment safety planning as well as suicide risk management and prevention.

Attenuated prefrontal and temporal neural activity during working memory as a potential biomarker of suicidal ideation in veterans with PTSD

BackgroundSuicide is a significant health concern among veterans, and suicidal ideation is a common and functionally debilitating condition that frequently precedes suicidal behavior. Characterizing neurobiological substrates associated with suicidal ideation in veterans may inform evaluation of risk for this population. Associations between suicidal ideation and functional abnormalities in prefrontal, temporal, and striatal regions supporting cognitive task performance have been documented in individuals with mood and psychotic disorders, suggesting a potential role for neurocognitive vulnerabilities in this condition. To date, however, relatively little research has explored neural correlates of suicidal ideation, particularly among individuals with posttraumatic stress disorder (PTSD). MethodsTwenty three combat veterans diagnosed with PTSD completed an adapted Reading Span (Rspan) working memory task during functional magnetic resonance imaging (fMRI). Participants were classified based on presence of current SI. We evaluated differences between these groups on neural activation in response to interference-based working memory demands within the task. Primary analyses were conducted using a voxel-wise between-group t-test. ResultsTask-based activations were observed in regions including the cingulate, middle frontal, parietal, and occipital cortex, striatum, and cerebellum. Relative to individuals without SI, individuals with SI demonstrated less activation in a large region spanning the lateral prefrontal cortex and cingulate cortex, as well as the inferior temporal cortex, in response to interference demands. ConclusionsResults are consistent with models proposing that prefrontal neural substrates involved in cognitive regulation are implicated in suicidal ideation. Involvement of temporal functioning may also exist based on current findings. Future research is needed to understand whether disturbances in prefrontal regulatory control reflect a specific profile subtype with distinct neural correlates, and how such neural patterns may be used to improve detection and treatment personalization.

Brief cognitive behavioral therapy reduces suicidal ideation in veterans with chronic illnesses

ObjectiveWe evaluated the effect of brief cognitive behavioral therapy (bCBT) on suicidal ideation among medically ill veterans receiving mental health treatment in primary care. MethodsSecondary analysis was conducted on data collected during a multisite, patient-randomized trial investigating the impact of bCBT (n = 180) on depression and anxiety symptoms, relative to enhanced usual care (EUC; n = 122), in patients with congestive heart failure and/or chronic obstructive pulmonary disease. BCBT was delivered by primary care mental health providers over 4 months, with follow-up posttreatment assessments of suicidal ideation, measured by the Patient Health Questionnaire-9 (item 9) at 4, 8, and 12 months. Suicidal ideation was the primary outcome examined in the current analysis. Generalized estimating equations modeling suicidal ideation were used to compare the study arms. ResultsParticipants receiving bCBT were less likely to have high suicidal ideation than participants receiving EUC posttreatment and at 8-month follow-up after accounting for baseline suicidal ideation. Within-group comparisons suggest participants receiving bCBT were less likely to have high suicidal ideation at 4, 8, and 12 months when compared with baseline. High suicidal ideation for EUC participants did not differ at 4, or 8 months, but they were less likely to have high suicidal ideation at 12 months. ConclusionbCBT in primary care reduces suicidal ideation and may help prevent future suicidal ideation.

Anger, social support, and suicide risk in U.S. military veterans

There have been considerable efforts to understand, predict, and reduce suicide among U.S. military veterans. Studies have shown that posttraumatic stress disorder (PTSD), major depression (MDD), and traumatic brain injury (TBI) increase risk of suicidal behavior in veterans. Limited research has examined anger and social support as factors linked to suicidal ideation, which if demonstrated could lead to new, effective strategies for suicide risk assessment and prevention. Iraq/Afghanistan era veterans (N = 2467) were evaluated in the ongoing Veterans Affairs Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC) multi-site Study of Post-Deployment Mental Health on demographic and psychological variables. Analyses revealed that suicidal ideation in veterans was positively associated with anger and negatively associated with social support. These results remained significant in multivariate logistic regression models controlling for relevant variables including PTSD, MDD, and TBI. Examining interrelationships among these variables, the analyses revealed that the association between PTSD and suicidal ideation was no longer statistically significant once anger was entered in the regression models. Further, it was found that TBI was associated with suicidal ideation in veterans with MDD but not in veterans without MDD. These findings provide preliminary evidence that suicide risk assessment in military veterans should include clinical consideration of the roles of anger and social support in addition to PTSD, MDD, and TBI. Further, the results suggest that suicide prevention may benefit from anger management interventions as well as interventions aimed at bolstering social and family support as treatment adjuncts to lower suicide risk in veterans.

Mild Traumatic Brain Injury Burden Moderates the Relationship Between Cognitive Functioning and Suicidality in Iraq/Afghanistan-Era Veterans.

Suicidal ideation (SI) is highly prevalent in Iraq/Afghanistan-era veterans with a history of mild traumatic brain injury (mTBI), and multiple mTBIs impart even greater risk for poorer neuropsychological functioning and suicidality. However, little is known about the cognitive mechanisms that may confer increased risk of suicidality in this population. Thus, we examined relationships between neuropsychological functioning and suicidality and specifically whether lifetime mTBI burden would moderate relationships between cognitive functioning and suicidal ideation. Iraq/Afghanistan-era Veterans with a history of mTBI seeking outpatient services (N = 282) completed a clinical neuropsychological assessment and psychiatric and postconcussive symptom questionnaires. Individuals who endorsed SI reported more severe post-traumatic stress disorder (PTSD), depression, and postconcussive symptoms and exhibited significantly worse memory performance compared to those who denied SI. Furthermore, mTBI burden interacted with both attention/processing speed and memory, such that poorer performance in these domains was associated with greater likelihood of SI in individuals with a history of three or more mTBIs. The pattern of results remained consistent when controlling for PTSD, depression, and postconcussive symptoms. Slowed processing speed and/or memory difficulties may make it challenging to access and use past experiences to solve current problems and imagine future outcomes, leading to increases in hopelessness and SI in veterans with three or more mTBIs. Results have the potential to better inform treatment decisions for veterans with history of multiple mTBIs. (JINS, 2019, 25, 79-89).

Posttraumatic stress disorder, depression, and suicidal ideation in veterans: Results from the mind your heart study

Veterans with PTSD or depression are at increased risk for suicidal ideation. However, few studies have examined that risk in those with comorbid PTSD and depression, instead focusing on these disorders individually. This study investigates the association of suicidal ideation with comorbid PTSD and depression and examines the role of military and psychosocial covariates. We evaluated 746 veterans using the CAPS to assess PTSD and the PHQ-9 to measure depression and suicidal ideation. Covariates were assessed via validated self-report measures. 49% of veterans with comorbid PTSD and depression endorsed suicidal ideation, making them more likely to do so than those with depression alone (34%), PTSD alone (11%), or neither (2%). In multivariate logistic regression models, this association remained significant after controlling for demographics and symptom severity. Anger, hostility, anxiety, alcohol use, optimism and social support did not explain the elevated risk of suicidal ideation in the comorbid group in fully adjusted models. As suicidal ideation is a known risk factor for suicide attempts and completions, veterans with comorbid PTSD and depression represent a vulnerable group who may need more intensive monitoring and treatment to reduce risk of suicide.