Posttraumatic Stress Disorder, Suicidal Ideation, and Suicidal Self-Directed Violence Among U.S. Military Personnel and Veterans: A Systematic Review of the Literature From 2010 to 2018

Abstract

Rates of suicide and posttraumatic stress disorder remain high among United States military personnel and veterans. Building upon prior work, we conducted a systematic review of research published from 2010 to 2018 regarding: (1) the prevalence of suicidal ideation, suicide attempt, and suicide among United States military personnel and veterans diagnosed with posttraumatic stress disorder; (2) whether posttraumatic stress disorder was associated with suicidal ideation, suicide attempt, and suicide among United States military personnel and veterans. 2,106 titles and abstracts were screened, with 48 articles included. Overall risk of bias was generally high for studies on suicidal ideation or suicide attempt and low for studies on suicide. Across studies, rates of suicidal ideation, suicide attempt, and suicide widely varied based on study methodology and assessment approaches. Findings regarding the association between posttraumatic stress disorder diagnosis with suicidal ideation and suicide were generally mixed, and some studies reported that posttraumatic stress disorder was associated with lower risk for suicide. In contrast, most studies reported significant associations between posttraumatic stress disorder and suicide attempt. These findings suggest complex associations between posttraumatic stress disorder and suicidal ideation, suicide attempt, and suicide, which are likely influenced by other factors (e.g., psychiatric comorbidity). In addition, most samples were comprised of veterans, rather than military personnel. Further research is warranted to elucidate associations between posttraumatic stress disorder and suicidal ideation, suicide attempt, and suicide, including identification of moderators and mediators of this relationship. Addressing this among United States military personnel, by gender, and in relation to different trauma types is also necessary.

A Comparison of Dimensional and Categorical Approaches to Characterizing the Association Between Posttraumatic Stress Disorder and Future Suicide Attempts

“…Posttraumatic stress disorder (PTSD), one of the most prevalent and debilitating psychiatric disorders among veterans (Thomas et al., 2010), has been identified as a critical risk factor for suicide, particularly as successful treatment has been shown to reduce suicidal ideation (e.g., Gradus et al., 2013). Prior research has suggested that veterans with PTSD are at an increased risk for suicide relative to veterans without PTSD (see reviews by Holliday et al., 2020; Pompili et al., 2013). Of note, veterans with PTSD have a higher risk of experiencing the full spectrum of suicidal thoughts (e.g., suicidal ideation and suicide planning; Raines et al., 2017), suicide attempts (e.g., Legarreta et al., 2015), and suicide death (Conner et al., 2014).…”

“…First, most studies that have examined this association have focused on the link between PTSD diagnostic status and suicide risk. Of the 15 studies included in a review by Holliday and colleagues (2020) that aimed to examine the association between PTSD and suicide attempts, only three studies included measures that provided a continuous score. Although diagnostic status plays an important role in healthcare systems (e.g., treatment planning), the validity of the diagnostic threshold has been criticized as being relatively arbitrary.…”

“…The second major limitation of the literature is that most studies that have examined the association between PTSD and suicidal thoughts and behaviors have been cross‐sectional (see Holliday et al., 2020, for a review and discussion). Longitudinal designs are necessary to establish the temporal association between PTSD and the risk for future suicidal thoughts and behaviors (Kraemer et al., 1997).…”

“…Specifically, we compared these approaches to capturing overall symptom severity (i.e., diagnostic status vs. symptom severity) as well as symptom severity in specific symptom clusters, to determine the utility of each approach and establish the point along the symptom severity continuum at which PTSD symptoms most accurately predict future suicide attempts. We chose suicide attempts as the dependent variable because PTSD has been consistently associated with suicide attempts relative even to other self‐injurious thoughts and behaviors (Holliday et al., 2020; Law et al., 2019; Pompili et al., 2013) as well as because suicide attempts are the most robust predictor of suicide death currently identified (e.g., Ribeiro et al., 2016). We anticipated that both categorical and dimensional approaches would be predictive of future suicide attempts but that the diagnostic threshold may not represent the point along the symptom severity continuum at which PTSD symptoms most accurately predict future suicide attempts.…”

Effect of Cognitive-Behavioral Group Therapy on the Anxiety and Depression of War-Handicapped

“…While there is extensive research literature on the physical health of wartorn populations worldwide, the psychological effects of war on survivors are not yet well understood (4). Among the most important of these consequences are mood problems and anxiety that have a negative impact on the personal and social life of war survivors (5). Some studies show that the prevalence of depression in all Iranian veterans is 0.71%.…”