Peter C. Britton

Sleep Disturbance Preceding Suicide Among Veterans

OBJECTIVES We examined the role of sleep disturbance in time to suicide since the last treatment visit among veterans receiving Veterans Health Administration (VHA) services. METHODS Among 423 veteran suicide decedents from 2 geographic areas, systematic chart reviews were conducted on the 381 (90.1%) who had a VHA visit in the last year of life. Veteran suicides with a documented sleep disturbance (45.4%) were compared with those without sleep disturbance (54.6%) on time to death since their last VHA visit using an accelerated failure time model. RESULTS Veterans with sleep disturbance died sooner after their last visit than did those without sleep disturbance, after we adjusted for the presence of mental health or substance use symptoms, age, and region. CONCLUSIONS Findings indicated that sleep disturbance was associated with time to suicide in this sample of veterans who died by suicide. The findings had implications for using the presence of sleep disturbance to detect near-term risk for suicide and suggested that sleep disturbance might provide an important intervention target for a subgroup of at-risk veterans.

Development and Psychometric Evaluation of the Reasons for Living—Older Adults Scale: A Suicide Risk Assessment Inventory

PURPOSE The purposes of these studies were to develop and initially evaluate the psychometric properties of the Reasons for Living Scale-Older Adult version (RFL-OA), an older adults version of a measure designed to assess reasons for living among individuals at risk for suicide. DESIGN AND METHODS Two studies are reported. Study 1 involved instrument development with 106 community-dwelling older adults, and initial psychometric evaluation with a second sample of 119 community-dwelling older adults. Study 2 evaluated the psychometric properties of the RFL-OA in a clinical sample. One hundred eighty-one mental health patients 50 years or older completed the RFL-OA and measures of depression, suicide ideation at the current time and at the worst point in ones life, and current mental status and physical functioning. RESULTS Strong psychometric properties were demonstrated for the RFL-OA, with high internal consistency (Cronbachs alpha coefficient). Convergent validity was evidenced by negative associations among RFL-OA scores and measures of depression and suicide ideation. RFL-OA scores predicted current and worst-episode suicide ideation above and beyond current depression. Discriminant validity was evidenced with measures of current mental status and physical functioning. Criterion-related validity was also demonstrated with respect to lifetime history of suicidal behavior. IMPLICATIONS These findings provide preliminary support for the validity and reliability of the RFL-OA. The findings also support the potential value of attending to reasons for living during clinical treatment with depressed older adults and others at risk for suicide.

The Relationship Between Negative Life Events and Suicidal Behavior

BACKGROUND Individuals who experience negative life events may be at increased risk for suicidal behavior. Intrapersonal characteristics, such as basic psychological needs, however, may buffer this association. AIMS To assess the potential moderating role of overall basic psychological needs, and the separate components of autonomy, competence, and relatedness, on the association between negative life events and suicidal behavior. METHOD Our sample of 439 college students (311 females, 71%) completed the following self-report surveys: Life Events Scale, Basic Psychological Needs Scale, Beck Depression Inventory - II, and the Suicide Behaviors Questionnaire-Revised. RESULTS In support of our hypotheses, negative life events were associated with greater levels of suicidal ideation and attempts, and satisfaction of basic psychological needs, including autonomy, relatedness, and competence, significantly moderated this relationship, over and above the effects of the covariates of age, sex, and depressive symptoms. CONCLUSIONS Suicidal behavior associated with the experience of negative life events is not inevitable. Therapeutically bolstering competence, autonomy, and relatedness may be an important suicide prevention strategy for individuals experiencing life stressors.

Suicide Attempts within 12 Months of Treatment for Substance Use Disorders

There are limited prospective data on suicide attempts (SA) during the months following treatment for substance use disorders (SUD), a period of high risk. In an analysis of the Drug Abuse Treatment Outcomes Study, a longitudinal naturalistic multisite study of treated SUDs, variables associated with SA in the 12 months following SUD treatment were examined. Participants included 2,966 patients with one or more SUDs. By 12 months, 77 (2.6%) subjects had attempted suicide. Multivariate logistic regression analyses were used to identify variables associated with SA. Variables collected at baseline that were associated with SA included lifetime histories of SA, suicidal ideation (SI), depression, cocaine as primary substance of use, outpatient methadone treatment, and short-term inpatient treatment. Male sex, older age, and minority race or ethnicity were associated with lower likelihood of SA. After controlling for baseline predictors, variables assessed at 12 months associated with SA included SI during follow-up and daily or more use of cocaine. The data contribute to a small but growing literature of prospective studies of SA among treated SUDs, and suggest that SUDs with cocaine use disorders in particular should be a focus of prevention efforts.

Psychometric Evaluation of the Life Orientation Test—Revised in Treated Opiate Dependent Individuals

We examined internal consistency and test-retest reliability of a measure of dispositional optimism, the Life Orientation Test — Revised, in 121 opiate-dependent patients seeking methadone treatment. Internal consistency was adequate at baseline (α = .69) and follow-up (α = .72). Low socioeconomic status and being on disability were significantly associated with reduced internal consistency; ethnic and educational differences approached significance. Test-retest reliability was good (ICC = .72), varying across gender, race, ethnicity, education, employment and income (ICC Range = .24 –.85). Criterion validity was strong; the LOT-R was significantly negatively correlated with hopelessness (r = -.65, p < .001) and depression (r = -.60, p < .001). Findings support the use of this measure of optimism and pessimism to assess positive cognitive and emotional attributes and improve treatment strategies for opiate-dependent individuals. Future research should address the measurement and significance of optimism in minority, low socioeconomic status and poorly-educated individuals.

Warning signs for suicide within a week of healthcare contact in Veteran decedents

OBJECTIVES This study examined warning signs for suicide observed in the final day(s) of life in Veteran decedents who received healthcare from Veterans Health Administration (VHA) (N=381), using data obtained from detailed chart reviews. METHODS Veterans who died within a week (7 days) of healthcare contact (18%) were compared to those who died later (82%). Multivariate logistic regression was used to examine differences in suicidal thoughts, psychiatric symptoms, and somatic symptoms as documented at the last visit, after controlling for demographic variables. A second multivariate regression examined whether the identified warning signs were also risk factors for suicide within a month (30 days) of contact. RESULTS Documented suicidal ideation, OR (95% CI)=3.46 (1.15-10.38), and psychotic symptoms, OR (95% CI)=2.67 (1.11-6.42), at the last visit increased the likelihood of suicide within a week of healthcare contact. Both variables also increased the odds of suicide within a month of contact. CONCLUSIONS The assessment of suicidal ideation is critical to identify Veterans at immediate risk. However, recognition of psychotic symptoms may also improve identification. In addition to indicating immediate risk, some warning signs may also suggest on-going risk.

Differences between veteran suicides with and without psychiatric symptoms.

OBJECTIVES Our objective was to examine all suicides (n = 423) in 2 geographic areas of the Veterans Health Administration (VHA) over a 7-year period and to perform detailed chart reviews on the subsample that had a VHA visit in the last year of life (n = 381). METHODS Within this sample, we compared a group with 1 or more documented psychiatric symptoms (68.5%) to a group with no such symptoms (31.5%). The groups were compared on suicidal thoughts and behaviors, somatic symptoms, and stressors using the χ(2) test and on time to death after the last visit using survival analyses. RESULTS Veterans with documented psychiatric symptoms were more likely to receive a suicide risk assessment, and have suicidal ideation and a suicide plan, sleep problems, pain, and several stressors. These veterans were also more likely to die in the 60 days after their last visit. CONCLUSIONS Findings indicated presence of 2 large and distinct groups of veterans at risk for suicide in the VHA, underscoring the value of tailored prevention strategies, including approaches suitable for those without identified psychiatric symptoms.

An open trial of motivational interviewing to address suicidal ideation with hospitalized veterans.

OBJECTIVE The purpose of this open trial was to test the acceptability of motivational interviewing to address suicidal ideation (MI-SI) for psychiatrically hospitalized veterans with suicidal ideation, estimate its pre-post effect size on the severity of suicidal ideation, and examine the rate of treatment engagement after discharge. METHODS Participants received a screening assessment, baseline assessment, one or two MI-SI sessions, posttreatment assessment, and 60-day follow-up assessment. Thirteen veterans were enrolled, 9 (70%) completed both MI-SI sessions and the posttreatment assessment, and 11 (85%) completed the follow-up assessment. RESULTS Participants found MI-SI to be acceptable. They experienced large reductions in the severity of suicidal ideation at posttreatment and follow-up. In the 2 months following discharge, 73% of participants completed two or more mental health or substance abuse treatment sessions each month. CONCLUSIONS These preliminary findings suggest that MI-SI has potential to reduce risk for suicide in psychiatrically hospitalized veterans and that a more rigorous trial is needed.

Veteran status and alcohol use in men in the United States

OBJECTIVE This study sought to compare patterns of alcohol use between male veterans and nonveterans. METHODS Data came from the 2004 Behavioral Risk Factor Surveillance System, a U.S. national telephone survey using stratified random sampling. Outcomes were 30-day alcohol use, binge drinking (5+ drinks on one occasion), and heavy drinking (2+ drinks per day). Age-stratified weighted regression analyses compared men who were veterans (n = 36,874) to those who were not (n = 77,056), and veterans who used Veterans Health Administration (VHA) services in the past year (n = 7,606) to veterans who did not, adjusting for potential confounders. RESULTS Veterans aged 41 to 60 were less likely to binge drink (adjusted odds ratio [AOR] = 0.8) and veterans aged 61 to 70 were more likely to drink heavily compared to same-age men without military experience (AOR = 1.7). There were no significant differences in binge or heavy drinking for other age groups. Among veterans aged 51 to 60, those who used VHA services were more likely to report binge drinking than those who did not (AOR = 1.4). CONCLUSIONS Male veterans generally have similar patterns of alcohol use as men without a history of military service, but the elevated alcohol use of specific groups of veterans merits concern.

PTSD symptoms and suicide risk in veterans: Serial indirect effects via depression and anger

BACKGROUND Suicide rates are higher in veterans compared to the general population, perhaps due to trauma exposure. Previous literature highlights depressive symptoms and anger as contributors to suicide risk. PTSD symptoms may indirectly affect suicide risk by increasing the severity of such cognitive-emotional factors. METHOD A sample of community dwelling veterans (N=545) completed online surveys, including the PTSD Checklist-Military Version, Suicidal Behaviors Questionnaire-Revised, Multidimensional Health Profile-Psychosocial Functioning, and Differential Emotions Scale -IV. Bivariate and serial mediation analyses were conducted to test for direct and indirect effects of PTSD symptoms on suicide risk. RESULTS In bivariate analyses, PTSD symptoms, depression, anger, and internal hostility were positively related to suicide risk. In serial mediation analyses, there was a significant total effect of PTSD symptoms on suicide risk in both models. PTSD symptoms were also indirectly related to suicidal behavior via depression and internal hostility, and via internal hostility alone. Anger was not a significant mediator. LIMITATION Our cross-sectional sample was predominantly White and male; prospective studies with diverse veterans are needed. DISCUSSION Our findings may have implications for veteran suicide prevention. The effects of PTSD and depression on anger, particularly internal hostility, are related to suicide risk, suggesting a potential mechanism of action for the PTSD-suicide linkage. A multi-faceted therapeutic approach, targeting depression and internal hostility, via cognitive-behavioral techniques such as behavioral activation and cognitive restructuring, may reduce suicide risk in veterans who have experienced trauma.