Combat Exposure and Risk for Suicidal Thoughts and Behaviors Among Military Personnel and Veterans: A Systematic Review and Meta‐Analysis

Abstract

Due to seemingly mixed empirical results, questions persist about the possible role of deployments and combat exposure. We conducted a narrative review and meta-analysis of 22 published studies to integrate findings regarding the relationship of deployment-related predictors (i.e., deployment, deployment to a combat zone, combat experience, and exposure to specific combat events) with suicide-related outcomes (i.e., suicide ideation, attempt, and death). Across all predictors and outcomes, the combined effect was small and positive, r = .08 [0.04, 0.13], and marked by significant heterogeneity, I = 99.9%, Q(21)=4880.16, p < .0001, corresponding to a 25% increased risk for suicide-related outcomes among those who have deployed. Studies examining the relationship between exposure to killing and atrocities (k = 5) showed the largest combined effect, r = .12 [0.08, 0.17], and less heterogeneity, I = 84.4%, Q(4)=34.96, p < .0001, corresponding to a 43% increased risk for suicide-related outcomes among those exposed to killing or atrocity. Implications for theory, research, and clinical practice are discussed.

Suicidal ideation among young Afghanistan/Iraq War Veterans and civilians: Individual, social, and environmental risk factors and perception of unmet mental healthcare needs, United States, 2013

“…Similar to other studies that explored combat exposure, in general, in relation to suicidal outcomes, this study did not find an association (Bryan et al, 2015a). In contrast, Bryan and colleagues conducted a meta-analysis of 22 published articles looking at the relationship between deployment, combat exposure, and suicidal outcomes and found that the strongest positive correlation between suicidal outcomes and combat exposure were among Veterans who were exposed to death or killing and/or killed others.…”

“…Suicidal ideation is also associated with lack of social support (Pietrzak et al, 2010; Monteith et al, 2013; Monteith et al, 2015), sexual trauma (Lemaire and Graham, 2011; Lutwak and Dill, 2013), and sleep deprivation (Luxton et al, 2011; Ribeiro et al, 2012). Some evidence has suggested that suicide-related outcomes are associated with deployment and combat exposure (Schoenbaum et al, 2014; Bryan et al, 2015a); however, study results have been mixed (Kang et al, 2015; Reger et al, 2015). Collectively, these risk factors have informed public health prevention efforts and clinical efforts including suicide screening, risk assessment, and mental health treatment (Logan et al, 2011b; Pringle et al, 2013; Castro, 2014; McCarthy et al, 2015).…”

Medically Documented Suicide Ideation Among U.S. Army Soldiers

“…Although the influence of deployment on adverse mental health outcomes is well supported,(Bray et al, 2010; Gadermann et al, 2012; Jacobson et al, 2008; Shen, Arkes, & Williams, 2012; Wells et al, 2010) the association of deployment with suicidal thoughts and behaviors has generated inconsistent results. (Bryan et al, 2015) Prior mental disorders are a robust predictor of both fatal(Black, Gallaway, Bell, & Ritchie, 2011) and nonfatal(Ursano, Kessler, Stein, et al, 2015) suicidal behaviors in service members, findings in line with a large body of civilian research. (Harris & Barraclough, 1997; Nock, Hwang, Sampson, & Kessler, 2010)…”

“…(Gilman et al, 2014) However, specific combat experiences while deployed may be more important than deployment, per se, in understanding suicide risk. (Bryan et al, 2015) Although reduced risk of SI during deployment could be influenced by a number of factors, including pre-deployment mental health screening (i.e. a healthy deployed soldier effect),(Warner, Appenzeller, Parker, Warner, & Hoge, 2011) it is also possible that medical documentation and coding procedures differ during deployment.…”

Sex Differences in Suicide-Related Symptoms in a Large Military Sample

“…For instance, current and former servicemembers may experience unique stressors that predispose them to suicide risk. A systematic review and meta-analysis by Bryan and colleagues (2015) found that exposure to specific combat experiences, particularly experiences of death or killing, were significantly associated with more severe suicidal ideation and suicide attempt histories. A positive association between post-deployment stressors and suicidal ideation has also been established (Griffith & West, 2010): National Guard servicemembers with three or more post-deployment readjustment stressors had higher levels of suicidal ideation than those with fewer stressors (Kline, Ciccone, Falca-Dodson, Black, & Losonczy, 2011).…”