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Predictors of Suicide-Related Hospitalization among U.S. Veterans Receiving Treatment for Comorbid Depression and Substance Dependence Who is the Riskiest of the Risky?

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Abstract

This study examined whether widely accepted suicide risk factors are useful in predicting suicide-related hospitalization, beyond history of a suicide attempt, in high-risk treatment-seeking veterans with depression and substance dependence. Negative mood regulation expectancies were the only significant predictor of hospitalization during 6-months of outpatient treatment. History of a suicide attempt was the only significant predictor of hospitalization during the one-year follow-up period. Results suggest that within high-risk populations, standard suicide risk factors may not identify individuals who will engage in suicidal behaviors resulting in hospitalization. Assessing negative mood regulation expectations may assist in identifying those most at risk.

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... While strong emotion regulation expectancies lead to engagement in active and adaptive responses, such as problem-solving and seeking social support, weak expectancies result in avoidance of stressors (Catanzaro & Greenwood, 1994). Consistent with the theory, numerous studies showed that NMRE are associated with various psychological problems, such as depression (Catanzaro et al., 2014;Davis et al., 2005), anxiety (Catanzaro et al., 2000;Kassel et al., 2007) and suicide (Mrnak-Meyer et al., 2011). A recent meta-analysis also documented the relationship between NMRE and depression, anxiety, negative affect and positive affect (Mazur-Socha & Przepiorka, 2021b). ...
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Background This study aimed to investigate the relationship between interpersonal emotion regulation (IER) and social anxiety symptoms and the mediating role of negative mood regulation expectancies (NMRE). We hypothesised that IER is positively associated with social anxiety symptoms, controlling for depression and intrapersonal emotion regulation strategies of suppression and reappraisal, and NMRE mediate this relationship.Methods Study 1 was conducted with a student sample (N = 400) and Study 2 included a community sample with 271 participants.ResultsStudy 1 showed that, of four IER strategies, soothing and social modeling were positively, and perspective-taking was negatively related to social anxiety symptoms controlling for depression, suppression and reappraisal. Study 2 replicated these findings and extended them by showing the mediated relationship between the two IER strategies (i.e. enhancing positive affect and soothing) and social anxiety symptoms through NMRE.Conclusions The results contribute to the limited research on IER by portraying its relationship with social anxiety symptoms and revealing the mediating role of NMRE in this relationship.
... S uicidal behavior is a major cause of morbidity and mortality in the United States, 1 and active-duty and reserve military personnel and veterans account for nearly 18% of suicide deaths. 2 By one estimate, as many as 22 veterans die by suicide each day. 3 These rates are thought to be due to a higher incidence of mental illness in certain veteran populations relative to the general population. [4][5][6][7][8] Consequently, a number of mental health services are available to veterans in a variety of clinical and community settings. ...
... In recent years, considerable attention has been devoted to examining the increased risk of suicide observed in some Veteran populations (Bullman & Kang, 1996;Kang & Bullman, 2008, 2009Mrnak-Meyer et al., 2011;Pietrzak, Russo, Ling, & Southwick, 2011). The number of Veterans who die by suicide is estimated at 18-22 per day, with Veterans accounting for 22% of all suicide completions in the USA (Kemp & Bossarte, 2012;National Violent Death Reporting System, 2012). ...
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Introduction: In recent years, considerable empirical attention has been devoted to examining the increased risk of suicide observed in some Veteran populations. This has led to a renewed focus on developing novel support options which can be used to respond to Veterans in distress, reducing their risk of suicide. Spirituality and religion, however, have been largely absent from any public discourse related to suicide prevention, not least of all in Veteran populations. Aim: The aim of this cross-sectional study is to compare the self-rated spiritual health of Veterans with and without suicide ideation. Identifying differences which may exist between these two groups could highlight the relevance of spiritual well-being to Veteran suicide prevention efforts. Materials and Methods: Data were collected using pencil-and-paper surveys, called Spiritual Assessments, distributed within the general population of in- and outpatients at a U.S. Department of Veterans Affairs Medical Center. Using Likert-type scales, this study examines the self-rated spiritual health, spiritual devotion, and significance ascribed to spirituality in a sample of 5378 Veterans. Statistical analysis took place using chi-squared to examine differences in the distribution of responses between ideators and non-ideators. Results: Ideators significantly more often rated their spiritual health as worse than that of non-ideators. Even with similar levels of spiritual devotion or significance ascribed to spiritual life, ideators continued to significantly more often rate their spiritual health as worse than that of non-ideators. Conclusion: The results show that Veterans with suicide ideation more often rate their spiritual health as worse than that of Veterans without suicide ideation. This suggests that spiritual well-being may indeed be relevant to suicide prevention efforts in Veteran populations.
... Selective models of prevention are targeted to individuals "whose risk of becoming ill is above average" (Gordon, 1983). For example, some groups of service members and Veterans, such as those diagnosed with a mental health disorder, may have an increased risk of suicide relative to the general population (Pietrzak, Russo, Ling, & Southwick, 2011;Mrnak-Meyer et al., 2011;Kang & Bullman, 2008Bullman & Kang, 1996). Research further shows that service members and veterans are known to actively seek support from pastoral care providers (e.g., chaplains) (Besterman-Dahan, Gibbons, Barnett, & Hickling, 2012;Bonner et al., 2013;Greenawalt et al., 2011;Iversen et al., 2010;Kirchner, Farmer, Shue, Blevins, & Sullivan, 2011;Sullivan, 2007). ...
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Suicide is a major public health concern in the United States. Halting the rising trend of suicides requires that new options be identified and implemented so as to achieve the overarching goal of reducing the total number of suicide deaths and attempts in America. The aim of this article is to review constructs and outline a proposed operational framework for incorporating spiritual well-being into suicide prevention efforts. By presenting conceptual, preventive, and theoretical arguments, the hope is to elicit empirical interest in finding practical applications for the protective potential of spirituality.
... Negative moral assessment and suicide attempts are among the important predictive factors for hospitalization.8 Depression is also traced in addiction to other substances such as drugs.9 ...
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The SADPERSONS Scale is a simple, easily administered instrument developed to determine the likelihood for suicidal behavior in the community mental health setting. In order to determine if this instrument can be used within the Veterans Affairs (VA) system, it was completed on 271 veteran patients at a large Midwest Veterans Affairs Medical Center (VAMC). Results indicated that the veteran population is different enough from the general mental health population that the use of this instrument results in unacceptable false-positive and false-negative identification rates. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Suicide risk management in the Department of Veterans Affairs (VA) health care system is particularly challenging because of both patient characteristics and aspects of the delivery system. The prototypical suicide-prone person is an older white male with alcoholism, depression, physical problems, and poor psychosocial support. This describes a large portion of the veteran patient population. Suicide risk factors that are common in VA patients include male gender, older age, diminished social environment support (exemplified by homelessness and unmarried status), availability and knowledge of firearms, and the prevalence of medical and psychiatric conditions associated with suicide. A variety of characteristics of the VA system complicate suicide management. Efforts under way to emphasize ambulatory care and decrease the VA culture of reliance on inpatient treatment heighten the importance of accurate suicide assessment. The authors recommend several strategies that VA administrators can consider for improving the assessment and management of veterans with long-term suicide risk factors.
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Suicide rates have been increasing in military personnel since the start of Operation Enduring Freedom and Operation Iraqi Freedom, and it is vital that efforts be made to advance suicide risk assessment techniques and treatment for members of the military who may be experiencing suicidal symptoms. One potential way to advance the understanding of suicide in the military is through the use of the Interpersonal-Psychological Theory of Suicide. This theory proposes that three necessary factors are needed to complete suicide: feelings that one does not belong with other people, feelings that one is a burden on others or society, and an acquired capability to overcome the fear and pain associated with suicide. This review analyzes the various ways that military service may influence suicidal behavior and integrates these findings into an overall framework with relevant practical implications. Findings suggest that although there are many important factors in military suicide, the acquired capability may be the most impacted by military experience because combat exposure and training may cause habituation to fear of painful experiences, including suicide. Future research directions, ways to enhance risk assessment, and treatment implications are also discussed.
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Understanding how alcohol misuse interacts with beliefs that protect individuals against suicide can help to enhance suicide prevention strategies. One measure of suicide non-acceptability is the Moral Objections to Suicide (MOS) subscale of the Reasons for Living Inventory (RFLI). 521 mood disordered patients with and without alcohol use disorders (AUD) were administered a battery of clinical measures including the Scale for Suicidal Ideation and the Reasons for Living Inventory. A multivariate analysis of covariance (MANCOVA) was conducted, examining the effects of alcohol use history on the five RFLI subscales and suicidal ideation, while controlling for differences in age, education, marital status and sex. RFL scores were no different between groups, except in one respect: patients with AUD had fewer moral objections to suicide. Higher suicidal ideation was associated with lower MOS scores. Prior suicidal behavior was associated with lower MOS, and higher current suicidal ideation. However, AUD history was not associated with suicidal ideation. Patients with AUDs had fewer objections to suicide, even though their level of current suicidal ideation was similar to those without AUD, suggesting that attitudes about the acceptability of suicide may be conceptually distinguished from suicidal ideation, and may be differentially associated with risk for suicidal behavior. These findings suggest that alcohol use and suicidal behavior predict current attitudes toward suicide, however causal mechanisms are not clearly understood.
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The Addiction Severity Index (ASI) is 12 years old and has been revised to include a new section on family history of alcohol, drug, and psychiatric problems. New items were added in existing sections to assess route of drug administration; additional illegal activities; emotional, physical, and sexual abuse; quality of the recovery environment; and history of close personal relationships. No changes were made in the composite scoring to maintain comparability with previous editions. This article discusses the clinical and research uses of the ASI over the past 12 years, emphasizing some special circumstances that affect its administration. The article then describes the rationale for and description of the changes made in the ASI. The final section provides "normative data" on the composite scores and severity ratings for samples of opiate, alcohol, and cocaine abusers as well as drug abusing inmates, pregnant women, homeless men, and psychiatrically ill substance abusers.
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A scale measuring generalized expectancies for negative mood regulation (NMR) was developed. The construct was defined as the expectancy that some behavior or cognition will alleviate a negative mood state. Data from five samples of college undergraduates (N = 1,630) were reported. Internal consistency, discriminant validity from social desirability, and temporal stability were demonstrated for a 30-item scale derived from an initial pool of 50 items. Further analyses revealed (a) modest correlations of the 30-item scale with internal-external control, (b) that high scorers on the NMR scale reported few symptoms of depression, and (c) that the NMR scale predicted a different pattern of emotions than the Beck Depression Inventory did. Discussion focused on possible roles for expectancies for negative mood regulation in the coping process and directions for future research on the mood regulation process.
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Since the 1990-1991 Persian Gulf War, there has been persistent concern that U.S. war veterans may have had adverse health consequences, including higher-than-normal mortality. We conducted a retrospective cohort study of postwar mortality according to cause among 695,516 Gulf War veterans and 746,291 other veterans. The follow-up continued through September 1993. A stratified, multivariate analysis (with Cox proportional-hazards models) controlled for branch of service, type of unit, age, sex, and race in comparing the two groups. We used standardized mortality ratios to compare the groups of veterans with the general population of the United States. Among the Gulf War veterans, there was a small but significant excess of deaths as compared with the veterans who did not serve in the Persian Gulf (adjusted rate ratio, 1.09; 95 percent confidence interval, 1.01 to 1.16). The excess deaths were mainly caused by accidents (1.25; 1.13 to 1.39) rather than disease (0.88; 0.77 to 1.02). The corresponding rate ratios among 49,919 female veterans of the Gulf War were 1.32 (0.95 to 1.83) for death from all causes, 1.83 (1.02 to 3.28) for accidental death, and 0.89 (0.45 to 1.78) for death from disease. In both groups of veterans the mortality rates were significantly lower overall than those in the general population. The adjusted standardized mortality ratios were 0.44 (95 percent confidence interval, 0.42 to 0.47) for Gulf War veterans and 0.38 (0.36 to 0.40) for other veterans. Among veterans of the Persian Gulf War, there was a significantly higher mortality rate than among veterans deployed elsewhere, but most of the increase was due to accidents rather than disease, a finding consistent with patterns of postwar mortality among veterans of previous wars.
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Mental disorders have a strong association with suicide. This meta-analysis, or statistical overview, of the literature gives an estimate of the suicide risk of the common mental disorders. We searched the medical literature to find reports on the mortality of mental disorders. English language reports were located on MEDLINE (1966-1993) with the search terms mental disorders', 'brain injury', 'eating disorders', 'epilepsy', 'suicide attempt', 'psychosurgery', with 'mortality' and 'follow-up studies', and from the reference lists of these reports. We abstracted 249 reports with two years or more follow-up and less than 10% loss of subjects, and compared observed numbers of suicides with those expected. A standardised mortality ratio (SMR) was calculated for each disorder. Of 44 disorders considered, 36 have a significantly raised SMR for suicide, five have a raised SMR which fails to reach significance, one SMR is not raised and for two entries the SMR could not be calculated. If these results can be generalised then virtually all mental disorders have an increased risk of suicide excepting mental retardation and dementia. The suicide risk is highest for functional and lowest for organic disorders with substance misuse disorders lying between. However, within these broad groupings the suicide risk varies widely.
Article
Suicide risk management in the Department of Veterans Affairs (VA) health care system is particularly challenging because of both patient characteristics and aspects of the delivery system. The prototypical suicide-prone person is an older white male with alcoholism, depression, physical problems, and poor psychosocial support. This describes a large portion of the veteran patient population. Suicide risk factors that are common in VA patients include male gender, older age, diminished social environment support (exemplified by homelessness and unmarried status), availability and knowledge of firearms, and the prevalence of medical and psychiatric conditions associated with suicide. A variety of characteristics of the VA system complicate suicide management. Efforts under way to emphasize ambulatory care and decrease the VA culture of reliance on inpatient treatment heighten the importance of accurate suicide assessment. The authors recommend several strategies that VA administrators can consider for improving the assessment and management of veterans with long-term suicide risk factors.
Article
A group of 125 drug abusers admitted consecutively for detoxification and short-term rehabilitation were followed up 5 years after discharge. They were asked about possible suicide attempts in a semi-structured face-to-face interview. Nearly half of the group (45%) reported having attempted suicide at some point in their life. The most common reasons given were the loss of a person whom they loved, and feelings of loneliness. Only three respondents reported using their drug of choice in the attempt(s). The suicide attempters were more often found to have been in child psychiatric treatment earlier, and to have experienced loss of significant others in childhood, than those who did not report attempting suicide. At follow-up the suicide attempters indicated that they experienced more depressive moods and more severe psychological problems than those who had never made a suicide attempt. The importance of assessing the risk of suicide attempts among drug addicts in order to be able to take measures to prevent future suicidal behaviour is emphasized.
Article
To assess the long-term health consequences of the 1991 Persian Gulf War, the authors compared cause-specific mortality rates of 621,902 Gulf War veterans with those of 746,248 non-Gulf veterans, by gender, with adjustment for age, race, marital status, branch of service, and type of unit. Vital status follow-up began with the date of exit from the Persian Gulf theater (Gulf veterans) or May 1, 1991 (control veterans). Follow-up for both groups ended on the date of death or December 31, 1997, whichever came first. Cox proportional hazards models were used for the multivariate analysis. For Gulf veterans, mortality risk was also assessed relative to the likelihood of exposure to nerve gas at Khamisiyah, Iraq. Among Gulf veterans, the significant excess of deaths due to motor vehicle accidents that was observed during the earlier postwar years had decreased steadily to levels found in non-Gulf veterans. The risk of death from natural causes remained lower among Gulf veterans compared with non-Gulf veterans. This was mainly accounted for by the relatively higher number of deaths related to human immunodeficiency virus infection among non-Gulf veterans. There was no statistically significant difference in cause-specific mortality among Gulf veterans relative to potential nerve gas exposure. The risk of death for both Gulf veterans and non-Gulf veterans stayed less than half of that expected in their civilian counterparts. The authors conclude that the excess risk of mortality from motor vehicle accidents that was associated with Gulf War service has dissipated after 7 years of follow-up.
Article
Completed suicides over a one year period of time were reported from a nationwide survey of Department of Veteran Affairs medical centers. Of a total of 248 completed suicides, 11 occurred in outpatient substance abuse programs, and an additional 5 occurred among patients receiving combined outpatient substance abuse and psychiatric treatment. There were no inpatient suicides. During this time, there were 7 suicide attempts on inpatient units and 37 suicide attempts in outpatient chemical dependency treatment. The majority of suicides were committed by males who had a primary alcohol addiction (63%). Thirty-eight percent of the sample had a comorbid mood disorder and 38% had a comorbid personality disorder. Risk factors relating to the potential for suicide in chemical dependency programs are discussed.
Article
The purpose of this study is to evaluate the effectiveness of a shorter course of Dialectical Behavior Therapy (DBT) in enhancing treatment retention and reducing: urges to engage in non-suicidal self injury (NSSI), NSSI, suicide ideation, and subjective distress in borderline personality disorder (BPD). Twenty patients with BPD received a six-month course of Dialectical Behavior Therapy (DBT-B). DBT-B was delivered in the standard manner except for the shortened duration from one-year minimum to six months. All variables were measured at baseline, and at six months. Data were analyzed using paired t-tests. Treatment retention rate was 95%. Significant reductions were found in NSSI urges, NSSI, suicide ideation, subjective distress, depression, and hopelessness between baseline and six months. These results support the use of DBT-B in a six-month format when NSSI and suicidal behavior and ideation are the targeted behaviors. Target behaviors were reduced significantly and retention was extremely high in comparison to other interventions for this population. A large scale randomized controlled trial investigating its efficacy is warranted to determine if the results can be replicated and if improvement can be sustained.
Article
To compare psychiatric diagnoses and future suicide attempt outcomes of multiple attempters (MAs), single attempters (SAs), and ideators. Two hundred twenty-eight teens who reported recent ideation or a lifetime suicide attempt in a screening of 1,729 high school students completed the Adolescent Suicide Interview, which provided information on attempt number and characteristics and mood, anxiety, and substance use disorder modules of the Diagnostic Interview Schedule for Children; 191 were reinterviewed 4 to 6 years later to ascertain interval attempts and psychiatric disorder. Between screening and follow-up, 33 (17%) teens made an attempt, 12 of whom were previously classified as lifetime MAs (more than one attempt) and six as SAs. MAs more often met criteria for any one of the DSM diagnoses assessed at baseline (mood, anxiety, or substance use disorder; 71%), compared with SAs (39%) and ideators (41%), and at follow-up (mood, anxiety, substance use, or disruptive behavior disorder; 69%) compared with SAs (36%) (p <.05). As reported at baseline, MAs (versus SAs) more often wished to die during their attempt (53% versus 23%), less often planned their attempt for intervention (44% versus 76%), and more often regretted recovery (26% versus 7%; p <.05). Baseline MAs had significantly higher odds of making a later attempt compared to ideators (odds ratio 4.0, 95% confidence interval 1.5-10.2) and SAs (odds ratio 4.6, 95% confidence interval 1.0-20.2). No participants committed suicide during follow-up. SAs who made another attempt (versus those who did not) more often met criteria for a baseline anxiety disorder and more often wished to die during their baseline attempt. MAs more strongly predict later suicidality and diagnosis than SAs and ideation. Forms that assess past suicide attempts should routinely inquire about frequency of attempts. The similarity between the present findings and those of clinical samples suggests that screening may yield a representative sample of suicide attempters and ideators.
Article
Interventions for alcohol- and substance-dependent adults with comorbid depressive disorders are needed, but few have been empirically tested. In a randomized clinical trial of two psychotherapy interventions for these disorders, we examined whether initial focus of treatment was related to retention, substance use, and depression outcomes. Both interventions, integrated cognitive-behavioral therapy (ICBT; n = 105) and twelve-step facilitation (n = 92), were delivered in group formats with entry points every 4 weeks at the beginning of three content-distinct modules. Entry module (i.e., initial treatment focus) was not related to percentage days abstinent, proportion of the sample abstinent, or depression symptoms for either intervention. This was true at both 12 and 24 weeks postbaseline. Furthermore, attendance was similar for both treatments, regardless of initial treatment focus, with a single exception in the ICBT condition. Our findings support the use of modular formats with multiple or rotating entry points for psychotherapy group interventions.
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