IPA: Suicide Exposure in Post 9/11 Veterans: Prevalence, Correlates and Treatment Needs

Suicide is a national public health problem that disproportionately affects Veterans. Until 2008, suicides in the general population exceeded US military rates. Presently, Veterans are 1.5 times more likely to die by suicide than members of the general population, after adjusting for age and sex.1 While suicide prevention is the highest priority for the Department of Veterans Affairs (VA),2 more work is needed to identify and address the issues that contribute to this public health crisis. This proposal focuses on a risk factor for Veteran suicide that has received little prior empirical attention – exposure to a suicide death. The toll associated with suicide goes well beyond the individual who died. It is estimated that for each person who dies by suicide, 135 others are exposed (defined as knowing the person)3 and that half of the US population knows someone who has died by suicide.4 Those exposed to a suicide death are at elevated risk for mental illness, physical disorders, impaired social functioning, and fatal and nonfatal suicide behavior.5 Because Veterans are at elevated risk for suicide, they may also be at elevated risk for suicide exposure. However, only a handful of studies have examined the effect of suicide exposure on Veterans.6 These few studies have been based on non-representative or geographically limited samples. There is also a dearth of evidence regarding modifiable factors that affect outcomes after exposure to suicide.6 The primary objective of this study is to describe the health and functional outcomes of suicide exposure among a cohort of Veterans at particularly high risk for suicide and of priority for VA suicide prevention strategies– post-9/11 Veterans transitioning to civilian life.1,7 Our second objective is to elucidate the reasons some Veterans develop persistent problems following suicide exposure while others do not. We propose an explanatory sequential mixed-methods study of a nationally representative sample of post-9/11 Veterans within 6 years of military separation. Our primary focus is on mental health problems associated with trauma and loss after Veterans have been exposed to suicide, including subsequent PTSD, Prolonged Grief Disorder, and suicide attempts and planning. Our sampling plan will ensure adequate representation of women and Native Americans, a group at high risk for suicide but understudied.8 We will supplement surveys with VA administrative data on diagnoses and treatments. Qualitative interviews in a diverse subsample of Veterans exposed to a suicide death who differ in outcomes will expand and illustrate quantitative findings. Aim 1 (Primary): Describe the prevalence of negative health outcomes following suicide exposure compared with other causes of sudden death. We will also identify subgroups of Veterans at particularly high risk for negative outcomes following suicide exposure. • Hypothesis 1: The prevalence of PTSD, Prolonged Grief Disorder, and suicide attempts and planning will be higher in Veterans exposed to suicide compared with Veterans exposed to other sudden deaths but not suicide after controlling for closeness with the decedent and other covariates. • Hypothesis 2. The prevalence of PTSD, Prolonged Grief Disorder, and suicide attempts and planning following suicide exposure will be higher among women compared with men after controlling for closeness of the relationship with the decedent and other covariates. Aim 2: Identify modifiable factors that explain the reasons some Veterans experience lasting and significant negative health outcomes after exposure to a suicide death while others do not. • Hypothesis 3: Social support will buffer, while stigma will worsen, the effect of suicide exposure on health outcomes after controlling for closeness with the decedent and other covariates. Aim 3 (Exploratory): Describe treatment experiences, interests, and patterns of VA service utilization among those affected by a suicide death and explore differences by gender, race, and time since military separation. Aim 4 (Exploratory): Elucidate quantitative findings through interviews with a purposive sample of Veterans exposed to suicide who vary in mental health outcomes. The interviews will focus on modifiable factors at each level of the socio- ecological model of suicide prevention to better understand targets for intervention. The numbers of Veterans needing intervention post-suicide exposure, the types of problems they are experiencing, and the interventions that might most benefit them are all unknown. This study will address these critical gaps in knowledge. This work advances the VA’s National Strategy for Veteran Suicide Prevention goal “to provide care and support to individuals affected by suicide deaths and attempts to promote healing, and implement community strategies to help prevent further suicides.”2 Findings will fill significant evidence gaps and prepare the VA to take the lead in post-vention research and interventions. Working with the VA team, Dr. Cerel from University of Kentucky will be involved in finalizing the study material, participating in study meetings, coding interview data, interpreting findings in light of other advances in the study of suicide loss, and contributing to dissemination activities.