Exposure to Suicide Among Post 9/11 Veterans: Prevalence, Correlates and Treatment Needs

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Background: The toll of suicide goes way beyond the death of an individual. Those exposed (defined as knowing the person) to a suicide death are at elevated risk for mental illness, physical disorders, impaired social functioning, and fatal and nonfatal suicide behavior. Conclusions from the handful of studies that have examined this topic among Veterans are limited by distinct samples, limited sample sizes and other methodological issues. Additionally, the numbers of women and minority race/ethnicity service members and Veterans in these studies were too small to examine what are likely critical differences by sex and race. Significance: This study will provide foundational information on an understudied risk factor for suicide in a cohort of Veterans at increased suicide risk – post 9/11 Veterans within six years following military separation. It will provide information to inform suicide postvention strategies that target the population of suicide bereaved post-9/11 Veterans as well as those targeting women and American Indian/Alaskan Native (AI/AN) Veterans. Innovation and Impact: (1) Use of VA data to provide the most reliable prevalence estimates for suicide exposure among Veterans to date; (2) Oversampling of vulnerable but understudied populations -- Women and AI/AN Veterans; (3) inclusion of two comparison groups to elucidate the common and unique contribution of suicide exposure to health outcomes and patterns of VA service utilization; and (4) Assessment of the formal and informal supports Veterans receive for mental health problems associated with suicide using both survey and VA healthcare utilization data. Specific Aims: (1) Evaluate differences in the prevalence of posttraumatic stress disorder (PTSD), prolonged grief disorder (PGD), and in suicidal ideation, attempts and planning among Veterans exposed to suicide compared with those exposed to other causes of sudden death and with unexposed Veterans. We will also evaluate differences by sex and race. (2) Identify modifiable moderating factors for the association between suicide exposure and negative outcomes and modifiable moderating factors for the association between suicide or sudden death exposure and negative outcomes relative to those with neither exposure. (3) Describe treatment experiences, interests, reported suicide attempts, and patterns of VA service utilization among those exposed to a suicide death compared to Veterans exposed to other sudden deaths and to unexposed Veterans. (4) Contextualize quantitative findings through interviews with a purposive sample of Veterans exposed to suicide. The interviews will focus on modifiable factors at each level of the socio-ecological model of suicide prevention to better understand targets for intervention. Methodology: This explanatory sequential mixed methods study examines outcomes associated with suicide exposure in a nationally representative sample of post-9/11 Veterans enrolled in VA healthcare. We will collect data in three waves. Wave 1 will implement a national population probability sample using a brief survey to assess exposure history (suicide, other sudden death, neither) and exposure characteristics (e.g., time since exposure) among 11,400 Veteran respondents. Wave 2 will survey Wave 1 respondents, stratified by exposure history (suicide, sudden death, neither), to assess outcomes and variables of interest among 4,500 Veterans (1,500 respondents per exposure group). Wave 3 involves interviews with a purposive subsample of 32 Waves 2 survey responders who have been exposed to suicide but differ in outcomes. Quantitative analysis is the priority of the study; the qualitative component will contextualize the quantitative findings. Next Steps/ Implementation: This work will direct VA and the field towards an understanding of the most critical outcomes among veterans exposed to suicide, the mechanisms that may lead to deleterious outcomes, and lay a foundation for understanding the effective treatments and supports needed for Veterans who experience a suicide loss, including women and AI/AN Veterans.