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

https://doi.org/10.1016/j.jad.2017.03.008Get rights and content

Highlights

  • Underlying mechanisms between PTSD and suicide risk are proposed.

  • PTSD was indirectly related to suicidal behaviors via depression and internal hostility.

  • Anger did not serve as a mediator in the PTSD-suicide risk linkage.

  • Suicide prevention in veterans should focus on internal anger and hostility.

Abstract

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.

Section snippets

Participants

Participants (N=545) in this IRB-approved study were recruited via online invitations distributed to veterans-related social media groups (e.g., military-related Facebook pages) and national organizations (e.g., Veterans of Foreign Wars [VFW] chapters). Participants completed online surveys that were administered through [www.surveymonkey.com]. The sample was primarily male (n=382; 70.1%), White (n=469; 86.1%), Army (n=209; 38.3%), served throughout multiple eras (n=240; 44.0%), received some

Results

Our bivariate hypothesis was supported, as all study variables were significantly associated in the predicted directions (see Table 2). With regard to our dependent variable, PTSD symptoms (r=.45, p<.001), depressive symptoms (r=.48, p<.001), anger (r=.38, p<.001), and internal hostility (r=.45, p<.001) were positively related to suicide risk. Depressive symptoms (r=.77, p<.001), anger (r=.70, p<.001), and internal hostility (r=.71, p<.001) were positively associated with PTSD symptoms. Anger (r

Discussion

In our sample of community veterans, we found, in support of hypotheses, that PTSD symptoms were associated with suicide risk through the following mechanisms: (i) through total effect of all variables (ii) indirectly via higher levels of depressive symptoms in both models; (iii) indirectly via higher levels of depressive symptoms and, sequentially, greater levels of internal hostility; and, (iv) indirectly via increased internal hostility. In other words, we found that PTSD, itself, was

Conclusions

In a sample of community veterans, we found that the relation between PTSD symptoms and suicide risk is influenced by the sequential associations between depression and anger. The experience of trauma may set in motion a cascade of events that includes disruptions to the ability to regulate cognitive (e.g., depression) and emotional (e.g., anger) functioning and which, consequently, contributes to vulnerability to suicidal behavior. Although future research on the interrelations between these

Conflicts of interest

None.

Acknowledgements

None.

References (102)

  • I. Giegling et al.

    Personality and attempted suicide. Analysis of anger, aggression and impulsivity

    J. Psychiatr. Res.

    (2009)
  • J. Gill et al.

    Lower health related quality of life in U.S. military personnel is associated with service-related disorders and inflammation

    Psychiatry Res.

    (2014)
  • E. Harmon-Jones

    Anger and the behavioral approach system

    Personal. Individ. Differ.

    (2003)
  • K.A. Hawkins et al.

    An examination of the relationship between anger and suicide risk through the lens of the interpersonal theory of suicide

    J. Psychiatr. Res.

    (2014)
  • M. Jandl et al.

    Suicide risk markers in major depressive disorder: a study of electrodermal activity and event-related potentials

    J. Affect. Disord.

    (2010)
  • J. Jang et al.

    Predictors of suicidal ideation in a community sample: roles of anger, self-esteem, and depression

    Psychiatry Res.

    (2014)
  • S.J. Janssen et al.

    The relation between self-reported PTSD and depression symptoms and the psychological distance of positive and negative events

    J. Behav. Ther. Exp. Psychiatry

    (2015)
  • C.M. Lemaire et al.

    Factors associated with suicidal ideation in OEF/OIF veterans

    J. Affect. Disord.

    (2011)
  • M.W. Miller et al.

    Internalizing and externalizing subtypes in female sexual assault survivors: implications for understanding of complex PTSD

    Behav. Ther.

    (2007)
  • M.K. Nixon et al.

    Affect regulation and addictive aspects of repetitive self-injury in hospitalized adolescents

    J. Am. Acad. Child Adolesc. Psychiatry

    (2002)
  • B.O. Olatunji et al.

    Fear and loathing: a meta-analytic review of the specificity of anger in PTSD

    Behav. Ther.

    (2010)
  • M. Panagioti et al.

    Post-traumatic stress disorder and suicidal behavior: a narrative review

    Clin. Psychol. Rev.

    (2009)
  • R.H. Pietrzak et al.

    Risk and protective factors associated with suicidal ideation in veterans of operations enduring freedom and Iraqi freedom

    J. Affect. Disord.

    (2010)
  • R.H. Pietrzak et al.

    Suicidal ideation in treatment-seeking veterans of operations enduring freedom and Iraqi freedom: the role of coping strategies, resilience, and social support

    J. Psychiatr. Res.

    (2011)
  • H.J. Ramsawh et al.

    Risk for suicidal behaviors associated with PTSD, depression, and their comorbidity in the U.S. Army

    J. Affect. Disord.

    (2014)
  • M.E. Roley et al.

    The relationship between rumination, PTSD, and depression symptoms

    J. Affect. Disord.

    (2015)
  • D.M. Smits et al.

    The relations between anger, coping with anger, and aggression, and the BIS/BAS system

    Personal. Individ. Differ.

    (2005)
  • M. Strachan et al.

    An integrated approach to delivering exposure-based treatment for symptoms of PTSD and depression in OIF/OEF veterans: preliminary findings

    Behav. Ther.

    (2012)
  • J.D. Acosta et al.

    Mental health Stigma in the Military

    (2014)
  • D.D. Blake et al.

    Post-traumatic stress disorder and coping in veterans who are seeking medical treatment

    J. Clin. Psychol.

    (1992)
  • N. Breslau

    Epidemiologic studies of trauma, posttraumatic stress disorder, and other psychiatric disorders

    Can. J. Psychiatry/Rev. Can. Psychiatr.

    (2002)
  • N. Breslau et al.

    Psychiatric sequelae of posttraumatic stress disorder in women

    Arch. Gen. Psychiatry

    (1997)
  • T.A. Bullman et al.

    Posttraumatic stress disorder and the risk of traumatic deaths among Vietnam veterans

  • F.N. Busch

    Anger and depression

    Adv. Psychiatr. Treat. J. Contin. Prof. Dev.

    (2009)
  • S.P. Cahill et al.

    Effect of cognitive-behavioral treatments for PTSD on anger

    J. Cogn. Psychother.

    (2003)
  • D.T. Castillo et al.

    Externalizing and internalizing subtypes of posttraumatic psychopathology and anger expression

    J. Trauma. Stress

    (2014)
  • R.L. Cautin et al.

    Assessment of mode of anger expression in adolescent psychiatric inpatients

    Adolescence

    (2001)
  • C.M. Chemtob et al.

    Anger, impulsivity, and anger control in combat-related posttraumatic stress disorder

    J. Consult. Clin. Psychol.

    (1994)
  • C.M. Chemtob et al.

    Cognitive-behavioral treatment for severe anger in posttraumatic stress disorder

    J. Consult. Clin. Psychol.

    (1997)
  • K.C. Cukrowicz et al.

    Suicide ideation among college students evidencing subclinical depression

    J. Am. Coll. Health

    (2011)
  • J.M. Currier et al.

    Initial psychometric evaluation of the Moral Injury Questionnaire - Military version

    Clin. Psychol. Psychother.

    (2015)
  • S.S. Daniel et al.

    Trait anger, anger expression, and suicide attempts among adolescents and young adults: a prospective study

    J. Clin. Child Adolesc. Psychol.

    (2009)
  • Department of Veterans Affairs, 2002. Posttraumatic stress disorder: Implications for primary care. Retrieved from:...
  • C.W. Drapeau et al.

    U.S.A. suicide 2014: Official Final Data

    (2015)
  • K.M. Eaton et al.

    Strengthening the validity of population-based suicide rate comparisons: an illustration using U.S. military and civilian data

    Suicide Life-Threat. Behav.

    (2006)
  • J.A. Fairbank et al.

    Patterns of appraisal and coping across different stressor conditions among former prisoners of war with and without posttraumatic stress disorder

    J. Consult. Clin. Psychol.

    (1991)
  • M. Fava et al.

    The importance of irritability as a symptom of major depressive disorder: results from the National Comorbidity Survey replication

    Mol. Psychiatry

    (2010)
  • L.B. Fisher et al.

    From the outside looking in: sense of belonging, depression, and suicide risk

    Psychiatry Interpers. Biol. Process.

    (2015)
  • C.L. Franklin et al.

    Posttraumatic stress disorder and major depressive disorder: Investigating the role of overlapping symptoms in diagnostic comorbidity

    J. Nerv. Ment. Dis.

    (2001)
  • T.E. Galovski et al.

    Changes in anger in relationship to responsivity to PTSD treatment

    Psychol. Trauma Theory Res. Pract. Policy

    (2014)
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