An Evaluation of the Complex Relationship between Combat Experiences and Suicide Deaths, Suicide Attempts, and Suicidal Ideation among U.S. Military Veterans.

Abstract

Objective: Combat has been related to suicidal thoughts and behaviors via increased PTSD and depression in prior work; however, such studies have been limited by sample size, reliance on self-report, failure to account for other disorders, and a limited focus on ideation and attempts.

Method: The objective of this study was to overcome these limitations by examining the association between combat and suicide ideation, attempts, and deaths in a large and diverse sample of veterans (N = 324,510) using survey data, electronic health records, and National Death Index data.

Results: As expected, combat was positively associated with PTSD and depression, which were, in turn, positively associated with suicide ideation, attempts, and death. Combat was indirectly associated with all three outcomes via PTSD-depression after accounting for the influence of other psychiatric disorders, although the effects were small in magnitude. Combat exposure, PTSD-depression, and other psychiatric disorders collectively accounted for 30-35% of the variance in suicide attempts and suicidal ideation, respectively. In contrast, combat exposure, PTSD-depression, and other psychiatric disorders collectively accounted for only a small fraction of the variance (2%) in suicide deaths.

Conclusion: Taken together, our findings suggest that combat is primarily associated with suicidal ideation and suicide attempts (as opposed to suicide deaths) via PTSD and depression (as opposed to other psychiatric conditions). More research is needed to identify predictors of suicide death among military veterans.