Tracy A. Clemans

Repetitive traumatic brain injury, psychological symptoms, and suicide risk in a clinical sample of deployed military personnel

IMPORTANCE Traumatic brain injury (TBI) is believed to be one factor contributing to rising suicide rates among military personnel and veterans. This study investigated the association of cumulative TBIs with suicide risk in a clinical sample of deployed military personnel referred for a TBI evaluation. OBJECTIVE To determine whether suicide risk is more frequent and heightened among military personnel with multiple lifetime TBIs than among those with no TBIs or a single TBI. DESIGN Patients completed standardized self-report measures of depression, posttraumatic stress disorder (PTSD), and suicidal thoughts and behaviors; clinical interview; and physical examination. Group comparisons of symptom scores according to number of lifetime TBIs were made, and generalized regression analyses were used to determine the association of cumulative TBIs with suicide risk. PARTICIPANTS Patients included 161 military personnel referred for evaluation and treatment of suspected head injury at a military hospitals TBI clinic in Iraq. MAIN OUTCOMES AND MEASURES Behavioral Health Measure depression subscale, PTSD Checklist-Military Version, concussion symptoms, and Suicide Behaviors Questionnaire-Revised. RESULTS Depression, PTSD, and TBI symptom severity significantly increased with the number of TBIs. An increased incidence of lifetime suicidal thoughts or behaviors was associated with the number of TBIs (no TBIs, 0%; single TBI, 6.9%; and multiple TBIs, 21.7%; P = .009), as was suicidal ideation within the past year (0%, 3.4%, and 12.0%, respectively; P = .04). The number of TBIs was associated with greater suicide risk (β [SE] = .214 [.098]; P = .03) when the effects of depression, PTSD, and TBI symptom severity were controlled for. A significant interaction between depression and cumulative TBIs was also found (β  = .580 [.283]; P = .04). CONCLUSIONS AND RELEVANCE Suicide risk is higher among military personnel with more lifetime TBIs, even after controlling for clinical symptom severity. Results suggest that multiple TBIs, which are common among military personnel, may contribute to increased risk for suicide.

Combat Exposure and Suicide Risk in Two Samples of Military Personnel

OBJECTIVE In light of increased suicidal behaviors among military personnel and veterans since the initiation of combat operations in Afghanistan and Iraq, questions have been raised about the potential causal role of combat. The objective of the current study was to identify any direct or indirect effects of combat exposure on suicide risk through depression symptom severity, posttraumatic stress disorder (PTSD) symptom severity, thwarted belongingness, perceived burdensomeness, and fearlessness about death, consistent with the interpersonal-psychological theory of suicide (Joiner, 2005). METHOD Structural equation modeling was utilized with two separate samples of deployed military personnel, 1 nonclinical (n = 348; 89.7% male, mean age = 24.50) and 1 clinical (n = 219; 91.8% male, mean age = 27.88), to test the effects of combat exposure on suicide risk. RESULTS Greater combat exposure was directly associated with fearlessness about death and PTSD symptom severity in both samples, but failed to show either a direct or indirect effect on suicide risk. PTSD symptom severity was strongly associated with depression symptom severity, which in turn was related to suicide risk directly (in the nonclinical sample) or indirectly through low belongingness and perceived burdensomeness (in the clinical sample). CONCLUSIONS In both samples of deployed active duty military personnel, combat exposure was either unrelated to suicide risk or was too distally related to have a measurable effect. Results do not support the interpersonal-psychological theorys hypothesis that combat exposure should be indirectly related to suicide risk through acquired fearlessness of death.

Loss of consciousness, depression, posttraumatic stress disorder, and suicide risk among deployed military personnel with mild traumatic brain injury

Objective:To identify clinical variables associated with suicidality in military personnel with mild traumatic brain injury (mTBI) while deployed to Iraq. Setting:Outpatient TBI clinic on a US military base in Iraq. Participants:Military personnel (N = 158) referred to an outpatient TBI clinic for a standardized intake evaluation, 135 (85.4%) who had a diagnosis of mTBI and 23 (14.6%) who did not meet criteria for TBI. Main Measures:Suicidal Behaviors Questionnaire–Revised, Depression subscale of the Behavioral Health Measure-20, Posttraumatic Stress Disorder Checklist-Military Version, Insomnia Severity Index, self-report questionnaire, and clinical interview addressing TBI-related symptoms. Results:Among patients with mTBI, increased suicidality was significantly associated with depression and the interaction of depression with posttraumatic stress disorder symptoms. Longer duration of loss of consciousness was associated with decreased likelihood for any suicidality. Conclusion:Assessment after TBI in a combat zone may assist providers in identifying those at risk for suicidality and making treatment recommendations for service members with mTBI.

Effect of crisis response planning vs. contracts for safety on suicide risk in U.S. Army Soldiers: A randomized clinical trial

OBJECTIVE To evaluate the effectiveness of crisis response planning for the prevention of suicide attempts. METHOD Randomized clinical trial of active duty Army Soldiers (N=97) at Fort Carson, Colorado, presenting for an emergency behavioral health appointment. Participants were randomly assigned to receive a contract for safety, a standard crisis response plan, or an enhanced crisis response plan. Incidence of suicide attempts during follow-up was assessed with the Suicide Attempt Self-Injury Interview. Inclusion criteria were the presence of suicidal ideation during the past week and/or a lifetime history of suicide attempt. Exclusion criteria were the presence of a medical condition that precluded informed consent (e.g., active psychosis, mania). Survival curve analyses were used to determine efficacy on time to first suicide attempt. Longitudinal mixed effects models were used to determine efficacy on severity of suicide ideation and follow-up mental health care utilization. RESULTS From baseline to the 6-month follow-up, 3 participants receiving a crisis response plan (estimated proportion: 5%) and 5 participants receiving a contract for safety (estimated proportion: 19%) attempted suicide (log-rank χ2(1)=4.85, p=0.028; hazard ratio=0.24, 95% CI=0.06-0.96), suggesting a 76% reduction in suicide attempts. Crisis response planning was associated with significantly faster decline in suicide ideation (F(3,195)=18.64, p<0.001) and fewer inpatient hospitalization days (F(1,82)=7.41, p<0.001). There were no differences between the enhanced and standard crisis response plan conditions. CONCLUSION Crisis response planning was more effective than a contract for safety in preventing suicide attempts, resolving suicide ideation, and reducing inpatient hospitalization among high-risk active duty Soldiers.

EVALUATING POTENTIAL IATROGENIC SUICIDE RISK IN TRAUMA-FOCUSED GROUP COGNITIVE BEHAVIORAL THERAPY FOR THE TREATMENT OF PTSD IN ACTIVE DUTY MILITARY PERSONNEL.

To determine whether group cognitive processing therapy‐cognitive only version (CPT‐C) is associated with iatrogenic suicide risk in a sample of active duty US Army personnel diagnosed with posttraumatic stress disorder (PTSD). Possible iatrogenic effects considered include the incidence and severity of suicide ideation, worsening of preexisting suicide ideation, incidence of new‐onset suicide ideation, and incidence of suicide attempts among soldiers receiving group CPT‐C. Comparison with group present‐centered therapy (PCT) was made to contextualize findings.

Acute vs. chronic stressors, multiple suicide attempts, and persistent suicide ideation in US soldiers

Abstract This study examined recent-onset (i.e., acute) and persistent (i.e., chronic) life stressors among 54 acutely suicidal US Army Soldiers and examined their relationship to persistence of suicidal crises over time. Soldiers with a history of multiple suicide attempts reported the most severe suicide ideation (F(2,51) = 4.18, p = 0.021) and the greatest number of chronic stressors (F(2,51) = 5.11, p = 0.009). Chronic but not acute stressors were correlated with severity of suicide ideation (r = 0.24, p = 0.026). Participants reporting low-to-average levels of chronic stress resolved suicide ideation during the 6-month follow-up, but participants reporting high levels of chronic stress did not (Wald &khgr;2(1) = 4.57, p = 0.032). Soldiers who are multiple attempters report a greater number of chronic stressors. Chronic, but not acute-onset, stressors are associated with more severe and longer-lasting suicidal crises.

DEPRESSION MEDIATES THE RELATION OF INSOMNIA SEVERITY WITH SUICIDE RISK IN THREE CLINICAL SAMPLES OF U.S. MILITARY PERSONNEL

A growing body of empirical research suggests insomnia severity is directly related to suicide ideation, attempts, and death in nonmilitary samples, even when controlling for depression and other suicide risk factors. Few studies have explored this relationship in U.S. military personnel.

Interactive Effects of Traumatic Brain Injury and Anxiety Sensitivity Cognitive Concerns on Post-traumatic Stress Among Active Duty Soldiers

Traumatic brain injury (TBI) history has been repeatedly linked with heightened risk for post-traumatic stress (PTS) among active duty soldiers. Yet, no research to date has examined the relationship between TBI and PTS in the context of anxiety sensitivity cognitive concerns (ASCC), a well-established cognitive-affective risk factor for PTS that may intensify the effects of TBI on PTS via the amplification of TBI-related symptoms of cognitive dyscontrol. The present study tested the moderating effects of ASCC on the relationship between the number of lifetime probable TBIs and PTS among a sample of 89 trauma-exposed active duty soldiers. Results demonstrated that high ASCC potentiated the relationship between number of probable TBIs and PTS while low ASCC muted this association. Interestingly, ASCC was more closely related to PTS among those with a greater number of probable TBIs compared to those with zero past TBIs. These results underscore the importance of ASCC in the association of TBI and PTS.

Associations of patient-rated emotional bond and vocally encoded emotional arousal among clinicians and acutely suicidal military personnel

Objective: To determine if synchrony in emotional arousal and affective regulation between patients and clinicians reflect emotional bonding during emergency behavioral health appointments. Method: Audio recordings of suicide risk assessment interviews and crisis intervention planning with 54 suicidal active duty soldiers presenting to an emergency department or behavioral health clinic were analyzed. Emotional arousal was assessed using mean fundamental frequency. Patient-rated emotional bond was assessed with the Working Alliance Inventory, Short Form (Hatcher & Gillaspy, 2014). Actor-partner interdependence modeling was used to identify moment-to-moment patterns of covariance among clinician and patient emotional arousal. Results: Greater synchrony in clinician and patient emotional arousal was positively associated with higher emotional bond ratings during the crisis intervention but not the risk assessment interview. During the risk assessment interview, higher emotional bond was associated with a dysregulating effect of the clinician on the patient’s emotional arousal (i.e., larger fluctuations in the patient’s emotional arousal). The reverse pattern was seen during the intervention: Higher emotional bond was associated with a regulating effect of the clinician on the patient’s emotional arousal (i.e., smaller fluctuations in the patient’s emotional arousal). Emotional bond during the intervention was also positively associated with a regulating effect of the patient on the clinician’s emotional arousal. Conclusion: Emotional bonding during emergency clinical encounters is associated with patient–clinician synchrony in emotional states. During crisis interventions, emotional bonding is also associated with mutual down-regulation of emotional arousal among patients and clinicians.

Suicides among military personnel.

time spent in sedentary behavior was 65.5% (9.0%), equivalent to a mean (SD) of 9.7 (1.5) hours per day (Table 1). The mean (SD) number of sedentary bouts per day was 85.9 (16.1), with 9.0 (2.4) breaks per sedentary hour. Adjusting for wear time and smoking status, total sedentary time increased and the number of bouts and breaks per sedentary hour decreased as age and BMI increased (P < .001). Most sedentary time occurred in bouts of shorter duration (Table 2). Among the total number of sedentary bouts, the mean (SD) percentage of bouts of at least 30 minutes was 4.8% (2.9%), representing 31.5% (12.4%) of total sedentary time.