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Background: The coronavirus disease-2019 (COVID-19) pandemic has caused myriad health, social, and economic stressors. To date, however, no known study has examined changes in mental health during the pandemic in the U.S. military veteran population. Methods: Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, a nationally representative, prospective cohort survey of 3,078 veterans. Pre-to-peri-pandemic changes in psychiatric symptoms were evaluated, as well as pre-pandemic risk and protective factors and pandemic-related correlates of increased psychiatric distress. Results: The prevalence of generalized anxiety disorder (GAD) positive screens increased from pre-to peri-pandemic (7.1% to 9.4%; p<0.001) and was driven by an increase among veterans aged 45-64 years (8.2% to 13.5%; p<0.001), but the prevalence of major depressive disorder and posttraumatic stress disorder positive screens remained stable. Using a continuous measure of psychiatric distress, an estimated 13.2% of veterans reported a clinically meaningful pre-to-peri-pandemic increase in distress (mean=1.1 standard deviation). Veterans with a larger pre-pandemic social network size and secure attachment style were less likely to experience increased distress, whereas veterans reporting more pre-pandemic loneliness were more likely to experience increased distress.Concerns about pandemic-related social losses, mental health COVID-19 effects, and housing stability during the pandemic were associated with increased distress, over-and-above prepandemic factors. Conclusions: Although most U.S. veterans showed resilience to mental health problems nearly one year into the pandemic, the prevalence of GAD positive screens increased, particularly among middle-aged veterans, and 1-of-7 veterans experienced increased distress.Clinical implications of these findings are discussed.

Objectives: Prevalence rates of death by euthanasia (EUT) and physician-assisted suicide (PAS) have considerably increased in older adults, and public debates on these practices are still taking place. In this context, it seemed important to conduct a systematic review of the predictors (demographic, physical, psychological, social, quality of life, religious or existential) associated with attitudes toward, wishes and requests for, as well as death by EUT/PAS among individuals aged 60 years and over. Method: The search for quantitative studies in PsycINFO and MEDLINE databases was conducted three times until April 2018. Articles of probable relevance (n = 327) were assessed for eligibility. Studies that only presented descriptive data (n = 306) were excluded. Results: The review identified 21 studies with predictive analyses, but in only 4 did older adults face actual end-of-life decision making. Most studies (17) investigated attitudes toward EUT/PAS (9 through various hypothetical scenarios). Younger age, lower religiosity, higher education and socioeconomic status, were the most consistent predictors of endorsement of EUT/PAS. Findings were heterogeneous with regard to physical, psychological and social factors. Findings were difficult to compare across studies because of the large variety of outcomes measures and sample characteristics. Conclusion: Future studies should adopt common and explicit definitions of these concepts, as well as mixed longitudinal research designs that would allow for better consideration of various personal and social factors, and their interplays, on the decisionmaking process with regard to EUT/PAS.

IMPORTANCEThe COVID-19 pandemic has raised considerable concerns about increased risk for suicidal behavior among US military veterans, who already had elevated rates of suicide before the pandemic.OBJECTIVE To examine longitudinal changes in suicidal behavior from before the COVID-19 pandemic to nearly 10 months into the pandemic and identify risk factors and COVID-related variables associated with new-onset suicide ideation (SI). DESIGN, SETTING, AND PARTICIPANTS This population-based prospective cohort study used data from the first and second wave of the National Health and Resilience in Veterans Study, conducted from November 18, 2019, to December 19, 2020. Median dates of data collection for the prepandemic and peripandemic assessments were November 21, 2019, and November 14, 2020, nearly 10 months after the start of the COVID-19 public health emergency in the US. A total of 3078 US military veterans aged 22 to 99 years were included in the study. MAIN OUTCOMES AND MEASURES Past-year SI and suicide attempts. RESULTS In this cohort study of 3078 US veterans (mean [SD] age, 63.2 [14.7] years; 91.6% men; 79.3% non-Hispanic White veterans, 10.3% non-Hispanic Black veterans, and 6.0% Hispanic veterans), 233 (7.8%) reported past-year SI, and 8 (0.3%) reported suicide attempts at the peripandemic assessment. Past-year SI decreased from 10.6% prepandemic (95% CI, 9.6%-11.8%) to 7.8% peripandemic (95% CI, 6.9%-8.8%). A total of 82 veterans (2.6%) developed new-onset SI over the follow-up period. After adjusting for sociodemographic and military characteristics, the strongest risk factors and COVID-19-related variables for new-onset SI were low social support (odds ratio [OR], 2.77; 95% CI, 1.46-5.28), suicide attempt history (OR, 6.31; 95% CI, 2.71-14.67), lifetime posttraumatic stress disorder and/or depression (OR, 2.25; 95% CI, 1.16-4.35), past-year alcohol use disorder severity (OR, 1.06; 95% CI, 1.01-1.12), COVID-19 infection (OR, 2.41; 95% CI, 1.41-5.01), and worsening of social relationships during the pandemic (OR, 1.47; 95% CI, 1.16-1.88). CONCLUSIONS AND RELEVANCEThe results of this cohort study suggest that despite grim forecasts that the COVID-19 pandemic would exacerbate suicidality among US military veterans, the rate of SI decreased at the population level nearly 10 months into the pandemic. Veterans who were infected with COVID-19 were more than twice as likely to report SI, which suggests the need for future research to examine the potential link between COVID-19 infection and suicidal behavior.

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