Posttraumatic stress disorder, depression, and ...

Psychiatry Research 265 (2018) 224–230

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Psychiatry Research journal homepage: www.elsevier.com/locate/psychres

Posttraumatic stress disorder, depression, and suicidal ideation in veterans: Results from the mind your heart study

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Melanie B. Arensona,b,1, , Mary A. Whooleya,b, Thomas C. Neylana,b, Shira Maguena,b, ⁎ Thomas J. Metzlera,b, Beth E. Cohena,b, a b

San Francisco VA Medical Center, San Francisco, CA, USA University of California, San Francisco, San Francisco, CA, USA

A R T I C LE I N FO

A B S T R A C T

Keywords: Posttraumatic stress disorder Depression Suicidal ideation Veterans’ health Military

Veterans with PTSD or depression are at increased risk for suicidal ideation. However, few studies have examined that risk in those with comorbid PTSD and depression, instead focusing on these disorders individually. This study investigates the association of suicidal ideation with comorbid PTSD and depression and examines the role of military and psychosocial covariates. We evaluated 746 veterans using the CAPS to assess PTSD and the PHQ-9 to measure depression and suicidal ideation. Covariates were assessed via validated self-report measures. 49% of veterans with comorbid PTSD and depression endorsed suicidal ideation, making them more likely to do so than those with depression alone (34%), PTSD alone (11%), or neither (2%). In multivariate logistic regression models, this association remained significant after controlling for demographics and symptom severity. Anger, hostility, anxiety, alcohol use, optimism and social support did not explain the elevated risk of suicidal ideation in the comorbid group in fully adjusted models. As suicidal ideation is a known risk factor for suicide attempts and completions, veterans with comorbid PTSD and depression represent a vulnerable group who may need more intensive monitoring and treatment to reduce risk of suicide.

1. Introduction According to the Centers for Disease Control and Prevention, between 1999 and 2014 suicide rates in the United States increased by 24% from 10.5 to 13 per 100,000 (Curtin et al., 2016). During that time, suicide rates within the military rose drastically, surpassing civilian rates to around 19 per 100,000 generally and as high as 23.8 per 100,000 in the Army (Kuehn, 2010; Pruitt et al., 2015). Rates were even higher among veterans: 43.13 per 100,000 for men and 10.41 per 100,000 for women in 2001 (McCarthy et al., 2009). The high rates of suicide within military populations may be partially due to the prevalence of mental health disorders in military personnel and a higher risk of suicide among those with a mental health disorder (Farberow et al., 1990; Kang and Bullman, 2008; LeardMann et al., 2013; Pietrzak et al., 2010a; Smith et al., 2016). LeardMann et al. (2013) examined predictors of suicide in over 151,000 current and former military personnel and found that service members who had completed suicide were more likely to have had depression, manic depressive disorder, heavy or binge drinking and other alcohol related problems. Other studies have found increased risk of suicide

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and/or suicidal ideation among those with a diagnosis of PTSD or depression individually (Bryan and Corso, 2011; Freeman et al., 2000; Jakupcak et al., 2009; Pompili et al., 2013; Ramsawh et al., 2014). Beyond creating devastating emotional loss and being a major public health concern, suicidal ideation and behaviors also present an economic concern: an estimated $1 billion was spent in the year 2000 alone on the treatment of self-injury, as well as another $32 billion in lost productivity (Corso et al., 2007). Within the military, the RAND Corporation estimated that the two-year post-deployment cost of PTSD and/or depression for the 1.6 million troops deployed between 2001 and 2007 is approximately $6.2 billion; 36% of that cost is estimated to be the result of loss of life to suicide (Tanielian et al., 2008). Because depression and PTSD commonly occur together, it can be difficult to isolate the effects of one disorder versus the other. Very few studies have examined the combined impact of depression and PTSD on suicidal ideation (instead focusing on each individually) and most of those have focused on non-military populations (Carr et al., 2013; Cougle et al., 2009; Oquendo et al., 2005, 2003). For example, Carr et al. (2013) found a mediating effect of depression on the relationship between PTSD and suicidal ideation among a population of

Corresponding authors at: University of Maryland, 0216 Biology-Psychology Building, College Park, MD 20742, USA. E-mail addresses: [email protected], [email protected] (M.B. Arenson), [email protected] (B.E. Cohen). Present address: University of Maryland, College Park, Maryland.

https://doi.org/10.1016/j.psychres.2018.04.046 Received 26 July 2017; Received in revised form 12 April 2018; Accepted 12 April 2018 Available online 22 April 2018 0165-1781/ Published by Elsevier B.V.


M.B. Arenson et al.

increased social network size, perceived social support, positive affect, and emotion regulation would be associated with decreased suicidal ideation. If there were differences among military populations, we expected those from Vietnam and Iraq or Afghanistan to endorse suicidal ideation at greater rates.

African American women recruited from a public hospital who had attempted suicide within the previous 12 months. However, as this study focuses on a specific civilian female population, these results might not translate to veterans, the majority of whom are male. Posing similar generalizability issues, those studies that have focused on military and veteran populations are usually limited to a single era (Hyer et al., 1990; Ramsawh et al., 2014) or branch (Guerra and Calhoun, 2011; Lemaire and Graham, 2011). For example, Kimbrel et al. (2016) found that Iraq and Afghanistan veterans with comorbid PTSD and depression were significantly more likely than those with either disorder alone to have attempted suicide during 12 months of prospective follow-up, but it is unclear if those results are reflective of the larger current veteran population, many of whom served during other eras. Previous studies have found differences in PTSD treatment outcomes (Yoder et al., 2012), demographic characteristics (such as employment, incarceration rate, and marital status) and disability and/or VA compensation rates among veterans for different eras (Fontana and Rosenheck, 2008). In order to appropriately treat the diverse population of veterans that seek care, it is critical that we understand both the unique characteristics of each branch and era, as well as universal characteristics of the veteran population as a whole. Furthermore, while studies have shown that there is an increased risk for suicidal ideation and attempts among those with comorbid PTSD and depression (Carr et al., 2013; Kimbrel et al., 2016; Oquendo et al., 2003; Richardson et al., 2012; Rojas et al., 2014), there is limited knowledge about additional factors that may worsen or be protective against suicidal ideation in the context of these co-occurring disorders (Kimbrel et al., 2016; Panagioti et al., 2012; Pukay-Martin et al., 2012). Previous research has examined the role of social support, hardiness, coping, and resilience in PTSD, depression, or suicidal ideation among returning veterans individually (Jakupcak et al., 2010; King et al., 1998; Pietrzak et al., 2010a; Tsai et al., 2012). For example, Pietrzak et al. (2010b) examined psychosocial risk factors (such as combat experience, psychosocial functioning, resilience, social support, depression, PTSD and alcohol use) and their relationship with suicidal ideation. They found that decreased social support and social functioning, as well as increased PTSD and depression were associated with increased suicidal ideation. However, they did not examine these factors in the context of suicidal ideation and co-occurring PTSD and depression. As these factors represent potential areas for intervention and reduction in risk of suicidal ideation and behaviors, it is critical to understand how they might impact the relationship between PTSD, depression and suicidal ideation. Finally, while it is known that those with comorbid PTSD and depression have more severe symptoms on average compared to those with either diagnosis alone, it is unclear how much symptom severity accounts for the increased risk of suicidal ideation (Angstman et al., 2016; Bryan and Corso, 2011; Campbell et al., 2007; Marshall et al., 2001). These pieces of information are critical to improving the identification of at-risk veterans and selecting appropriate, targeted treatments to reduce their risk of suicide. In the following study, we address these knowledge gaps by examining the association of comorbid PTSD and depression with suicidal ideation in a large cohort of veterans from different eras and military branches. In addition, we explore how demographic, psychosocial, and military variables are related to this association. Psychosocial measures were chosen based on previous research suggesting they may influence PTSD, depression, or suicidal ideation (Jakupcak et al., 2010; King et al., 1998; Pietrzak et al., 2010a, 2009, 2001; Tsai et al., 2012). Military characteristics were examined to address potential differences in PTSD, depression, and suicidal ideation among veterans from different eras. We hypothesized that those with both PTSD and depression would be more likely to endorse suicidal ideation. Furthermore, we expected that greater alcohol and drug use, hostility, anger, anxiety and physical impairment would be associated with increased suicidal ideation, while

2. Materials and methods 2.1. Participants The Mind Your Heart Study is a prospective cohort study investigating the long-term effects of PTSD on a variety of health outcomes. Between February 2008 and June 2010, 746 patients from two Department of Veterans Affairs (VA) sites (the San Francisco VA Medical Center and Palo Alto VA Medical Center) completed in person baseline examinations. Given the targeted interest in the effects of PTSD, those with the diagnosis were purposefully oversampled during recruitment. Specifically, recruitment letters were mailed to patients who had been seen in the general medical clinics in the last 5 years and had received an International Classification of Diseases, 9th revision (ICD-9) code for a PTSD diagnosis and to patients of a similar age also seen in these clinics but without a PTSD diagnosis. PTSD status was ultimately determined with a gold-standard clinical interview as described below. Participants were also recruited through flyers posted at the VA facilities and through provider referrals. Participants were excluded if they intended to move from the area in the following three years or were unable to provide contact information for follow up. Additionally, due to the fact that participants would undergo a cardiac treadmill test, potential participants were excluded if they were unable to walk one block or had a myocardial infarction in the previous six months. The current analysis focuses on cross-sectional data collected during the baseline assessment. Data for 18 participants were excluded from analysis due to concerns about accuracy of PTSD diagnosis or incomplete data and data for 3 participants were excluded because they were non-veterans. This left 725 participants for our analysis. All participants provided written informed consent; this research was approved by the University of California, San Francisco Institutional Review Board and the San Francisco VA Medical Center Research and Development Committee. 2.2. PTSD We evaluated current PTSD via the Clinician Administered PTSD Scale (CAPS) interview, using criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric Association, 2000). The CAPS is widely used, with excellent test-retest reliability (r = 0.92–0.99) and internal consistency (α = 0.80–0.90; Weathers et al., 2001). All interviews were conducted in person by masters-level clinicians, and supervised by a licensed clinical psychologist with expertise in PTSD assessment. 2.3. Depression We assessed depression using an 8-item version of the 9-item Patient Health Questionnaire (PHQ-9; Kroenke et al., 2001). The 9th item, which asks about “thoughts that you would be better off dead or hurting yourself in some way” was used to determine suicidal ideation, and was therefore excluded from the depression categorization. We used the standard cut-point of ≥10 to indicate probable depression, as it has demonstrated excellent validity when compared to diagnostic algorithm (Kroenke et al., 2009). 2.4. Suicidal ideation Suicidal Ideation was determined using the above-described 9th item of the PHQ-9, which has been previously validated in both general 225


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second yearly follow-up telephone interview for 650 participants. If participants answered both baseline and year two questionnaires, year two answers were used for analysis.

and veteran populations (Louzon et al., 2016; Rossom et al., 2017; Simon et al., 2016). Any positive response to the item was considered current suicidal ideation. If any participant endorsed suicidal ideation, they were assessed for risk with additional questions. Following a preestablished protocol, study team members provided those veterans with mental health contact information or a direct hand-off to the principal investigator or mental health staff, as needed.

2.6. Statistical analysis We examined differences in variables in those who did versus did not endorse suicidal ideation with t-tests for continuous variables and chi-square tests for categorical variables. We constructed logistic regression models with PTSD and depression status as the predictor stratified into four groups (no PTSD/Depression, depression only, PTSD only, comorbid PTSD/depression) and endorsement of suicidal ideation as the outcome. We adjusted for confounders, followed by potential psychosocial variables that were associated with suicidal ideation at p ≤ 0.1 in age, sex, and PTSD/depression status adjusted models. To examine military variables, we constructed logistic regression models with military service era or deployment as the predictor and endorsement of suicidal ideation as the outcome and then adjusted for PTSD/ depression status. We used Stata SE Version 14 (StataCorp; College Station, Texas) for all analyses.

2.5. Covariates We administered a self-report questionnaire to all participants to determine age, sex, race, ethnicity, education, and military service history. Additionally, participants completed a number of validated self-report measures. 2.5.1. Risk The 4-item Anger Temperament subscale of the State-Trait Anger Expression Inventory (STAXI) assesses one's general propensity to experience and express anger without specific provocation (Spielberger, 1988). All items are rated on a scale of 1 (almost never) to 4 (almost always). The Anxiety subscale of the Hospital Anxiety and Depression Scale (HADS-A), consisting of 7 items on a 0 (not at all) to 3 (most of the time) scale, was used to assess anxiety (Zigmond and Snaith, 1983). We administered 43 items from the Cook-Medley Hostility Scale: the 13-item Cynicism subscale (minus one question about sexuality that was eliminated), the Hostile Affect subscale (5 items), the Aggressive Responding subscale (9 items), the Hostile Attribution subscale (12 items) and the Social Avoidance subscale (4 items; Cook and Medley, 1954). We assessed physical function using the physical functioning component of The Medical Outcomes Study Short Form Health Survey: Physical Functioning (SF-36), which consists of 10 items rated on a 3-point scale of 1 (yes, limited a lot) to 3 (no, not limited at all; Ware and Sherbourn, 1992). The Alcohol Use Disorders Identification Test consumption questions (AUDIT-C) was used to determine alcohol use; it consists of 3 items and yields a total score of 0–12, of which a score of 3 or higher in women and 4 or higher in men is determined to be probable alcohol use disorder (Bush et al., 1998). Drug Use was measured using a one-item question, asking “Have you used illicit drugs, such as cocaine, opiates, barbiturates, or LSD?” and respondents indicated use in the past year; use in the lifetime, but not in the last year; or never.

3. Results Of the 725 participants evaluated, 59 (8%) met criteria for depression only, 113 (16%) for PTSD only, 138 (19%) for comorbid PTSD and depression, and 415 (57%) had neither. 110 (15%) participants endorsed suicidal ideation. Table 1 describes the characteristics of participants by suicidal ideation status. Veterans with comorbid PTSD and depression were significantly more likely to endorse suicidal ideation (p < 0.001, see Fig. 1); of those who met criteria for both PTSD and depression, 49% (n = 68) endorsed SI, as compared to 34% (n = 20) with depression alone, 11% (n = 12) with PTSD alone, and 2% (n = 10) with neither. Using logistic regression, this association remained significant, even after controlling for age, sex, and PTSD and depression severity scores (OR = 8.2, CI [2.2–29.8] p = 0.002, see Table 2). Participants who endorsed suicidal ideation had significantly higher levels of anger, anxiety, hostility, and physical dysfunction and lower Table 1 Characteristics of participants by suicidal ideation.

2.5.2. Resiliency The Berkman-Syme Social Network Index (SNI) assesses four domains of social relationships (marital status, sociability, church group membership, and membership in other community organizations) and then categorizes participants into four levels of social connection (socially isolated, moderately isolated, moderately integrated, and socially integrated; Berkman and Kawachi, 2000). The Positive Affect Schedule subscale of the Positive and Negative Affect Schedule (PANAS) is a 10-item mood scale, upon which respondents rate their experience of a particular emotion on a 5-point scale ranging from 1 (not at all) to 5 (extremely; Watson et al., 1988). The Emotion Regulation Questionnaire (ERQ) consists of 10 items rated on a scale of 1 (strongly disagree) to 5 (strongly agree; Gross and John, 2003). The Revised Life Orientation Test (LOT-R) is an 8-item measure (plus 4 filler items) designed to assess optimism. Respondents rate on a scale from 0 (strongly disagree) to 4 (strongly agree; Scheier and Carver, 1985). The Multidimensional Scale of Perceived Social Support (MSPSS) is a 12-item scale that measures perceived social support from family, friends, and a significant other, using a 5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree; Kazarian and McCabe, 1991). 2.5.3. Military Factors related to military service were self-report. They were collected during baseline interviews for 145 participants and during the 226

Variable

SI− (n = 615)

SI+ (n = 110)

p

Age Sex: Male Female Ethnicity: White Non-white Education: No college degree College degree Social networks Anger Positive affect Anxiety Hostility Emotion regulation Optimism Physical functioning Drug Use: Never Yes, not in last year Yes, in last year Alcohol use disorder: No Yes Perceived social support Combat exposure

58.6 (11.4)

58.3 (10.4)

0.84

589 (96%) 26 (4%)

98 (89%) 12 (11%)

0.004

255 (42%) 350 (58%)

40 (36%) 70 (64%)

0.26

426 (70%) 188 (31%) 3.6 (2.7) 6.2 (2.6) 31.3 (8.0) 6.8 (3.6) 18.1 (7.8) 33.4 (5.2) 14.9 (4.2) 24.7 (5.2)

82 (75%) 28 (25%) 2.7 (1.9) 8.6 (3.5) 27.0 (7.6) 10.9 (3.6) 24.5 (8.1) 33.6 (6.1) 10.6 (4.3) 22.5 (5.3)

0.28

313 (51%) 236 (39%) 62 (10%)

52 (48%) 41 (38%) 16 (15%)

0.37

349 (58%) 249 (42%) 42.1 (12.7) 9.3 (12.1)

58 (56%) 46 (44%) 35.6 (11.3) 13.6 (13.1)

0.62