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Military Sexual Trauma and Suicide Mortality

  • Rachel Kimerling
    Correspondence
    Address correspondence to: Rachel Kimerling, PhD, VA Palo Alto Health Care System, 795 Willow Road, PTSD-324, Menlo Park CA 94025
    Affiliations
    National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California

    Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California

    National MST Support Team, VA Mental Health Services, Department of Veterans Affairs, Menlo Park, California
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  • Kerry Makin-Byrd
    Affiliations
    National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California

    National MST Support Team, VA Mental Health Services, Department of Veterans Affairs, Menlo Park, California
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  • Samantha Louzon
    Affiliations
    VA Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health Operations, Department of Veterans Affairs, Ann Arbor, Michigan
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  • Rosalinda V. Ignacio
    Affiliations
    VA Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health Operations, Department of Veterans Affairs, Ann Arbor, Michigan
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  • John F. McCarthy
    Affiliations
    VA Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health Operations, Department of Veterans Affairs, Ann Arbor, Michigan

    VA Center for Clinical Management Research, Ann Arbor, Michigan

    Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
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Published:December 14, 2015DOI:https://doi.org/10.1016/j.amepre.2015.10.019

      Introduction

      The Veterans Health Administration health system uses a clinical reminder in the medical record to screen for military sexual trauma. For more than 6 million Veterans, this study assessed associations between military sexual trauma screen results and subsequent suicide mortality.

      Methods

      For Veterans who received Veterans Health Administration services in fiscal years 2007–2011 and were screened for military sexual trauma (5,991,080 men; 360,774 women), proportional hazards regressions evaluated associations between military sexually trauma and suicide risk. Models were adjusted for age, rural residence, medical morbidity, and psychiatric conditions, obtained from medical records at the year military sexual trauma screening occurred. Analyses were conducted in 2014.

      Results

      Military sexual trauma was reported by 1.1% of men and 21.2% of women. A total of 9,017 Veterans completed suicide during the follow-up period. Hazard ratios for military sexual trauma were 1.69 (95% CI=1.45, 1.97) among men and 2.27 (95% CI=1.76, 2.94) among women. Suicide risk associated with military sexual trauma remained significantly elevated in adjusted models.

      Conclusions

      Study results are among the first population-based investigations to document sexual trauma as a risk factor for suicide mortality. Military sexual trauma represents a clinical indicator for suicide prevention in the Veterans Health Administration. Results suggest the importance of continued assessments regarding military sexual trauma and suicide risks and of collaboration between military sexual trauma–related programs and suicide prevention efforts. Moreover, military sexual trauma should be considered in suicide prevention strategies even among individuals without documented psychiatric morbidity.

      Introduction

      Suicide prevention is a national public health priority

      2012 National Strategy for Suicide Prevention: Goals and Objectives for Action. Washington, DC: DHHS, Office of the Surgeon General and the National Action Alliance for Suicide Prevention; September 2012.

      and a priority of the Veterans Health Administration (VHA) system.
      • Katz I.
      Lessons learned from mental health enhancement and suicide prevention activities in the Veterans Health Administration.
      Veterans are at increased risk of suicide relative to the general adult U.S. population,
      • McCarthy J.
      • Valenstein M.
      • Kim H.M.
      • Ilgen M.
      • Zivin K.
      • Blow F.
      Suicide mortality among patients receiving care in the Veterans Health Administration health system.
      • Blow F.C.
      • Bohnert A.S.
      • Ilgen M.A.
      • et al.
      Suicide mortality among patients treated by the Veterans Health Administration from 2000 to 2007.
      • Hoffmire C.A.
      • Kemp J.E.
      • Bossarte R.M.
      Changes in suicide mortality for veterans and nonveterans by gender and history of VHA service use, 2000–2010.
      prompting a focus on the conditions and experiences that account for this excess risk among Veterans. Mental health conditions, including substance use disorders, mood and anxiety disorders, post-traumatic stress disorder (PTSD), and schizophrenia are reliably associated with suicide risk among Veterans and recent-era service members.
      • Ilgen M.A.
      • Bohnert A.S.B.
      • Ignacio R.V.
      • et al.
      Psychiatric diagnoses and risk of suicide in veterans.
      • Nock M.K.
      • Stein M.B.
      • Heeringa S.G.
      • et al.
      Prevalence and correlates of suicidal behavior among soldiers: results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).
      • Ilgen M.A.
      • McCarthy J.F.
      • Ignacio R.V.
      • et al.
      Psychopathology, Iraq and Afghanistan service, and suicide among Veterans Health Administration patients.
      The risks posed by deployment to Iraq or Afghanistan are less clear: Deployment has been associated with elevated risk for suicide during active-duty Army service,
      • Schoenbaum M.
      • Kessler R.C.
      • Gilman S.E.
      • et al.
      Predictors of suicide and accident death in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS): results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).
      but does not emerge as a risk factor in comprehensive studies of service members or recent-era Veterans.
      • Reger M.A.
      • Smolenski D.J.
      • Skopp N.A.
      • et al.
      Risk of suicide among US military service members following operation enduring freedom or operation Iraqi freedom deployment and separation from the US military.
      • Kang H.K.
      • Bullman T.A.
      • Smolenski D.J.
      • Skopp N.A.
      • Gahm G.A.
      • Reger M.A.
      Suicide risk among 1.3 million veterans who were on active duty during the Iraq and Afghanistan wars.
      Little is known about other military experiences that may increase risk for suicide mortality, such as military sexual trauma (MST). Veterans who have experienced MST show elevated rates mental health conditions and non-fatal suicide attempts,
      • Kimerling R.
      • Gima K.
      • Smith M.W.
      • Street A.
      • Frayne S.
      The Veterans Health Administration and military sexual trauma.
      and further research on suicide risk can yield important insights to inform suicide prevention efforts.
      In the VHA, the term MST is used to refer to sexual assault or repeated, threatening sexual harassment during military service (Title 38 U.S. Code 1720D). Universal screening documents that 24.3% of women and 1.3% of men who received services in fiscal year 2013 (FY2013) reported MST.
      Military Sexual Trauma Support Team
      Military Sexual Trauma (MST) Screening Report, fiscal year 2012.
      Veterans who report MST are at greater age-adjusted risk for suicide attempts and self-injury, as well as the mental health conditions that are also risk factors for suicide.
      • Kimerling R.
      • Gima K.
      • Smith M.W.
      • Street A.
      • Frayne S.
      The Veterans Health Administration and military sexual trauma.
      • Klingensmith K.
      • Tsai J.
      • Mota N.
      • Southwick S.M.
      • Pietrzak R.H.
      Military sexual trauma in U.S. veterans: results from the National Health and Resilience in Veterans Study.
      In FY2013, VHA provided specialized MST-related mental health care to 58.7% of women Veterans and 44.3% of men who reported MST, representing care to more than 71,000 individuals.
      Military Sexual Trauma Support Team
      Summary of Military Sexual Trauma-Related Outpatient Care, Fiscal Year 2013.
      These services represent potential points of intervention for preventive interventions targeted to Veterans where MST experiences may increase suicide risks.
      Studies of MST and suicide risk could inform a gender-related vulnerability observed among military and Veteran populations. Among Veterans, men have higher rates of suicide as compared with women,
      • Katz I.R.
      • McCarthy J.F.
      • Ignacio R.V.
      • Kemp J.
      Suicide among veterans in 16 states, 2005 to 2008: comparisons between utilizers and nonutilizers of Veterans Health Administration (VHA) services based on data from the National Death Index, the National Violent Death Reporting System, and VHA Administrative Records.
      but the increased suicide risk relative to non-Veterans is substantially greater among women than men, even when accounting for the lower risk for suicide associated with VHA utilization.
      • McCarthy J.
      • Valenstein M.
      • Kim H.M.
      • Ilgen M.
      • Zivin K.
      • Blow F.
      Suicide mortality among patients receiving care in the Veterans Health Administration health system.
      • Hoffmire C.A.
      • Kemp J.E.
      • Bossarte R.M.
      Changes in suicide mortality for veterans and nonveterans by gender and history of VHA service use, 2000–2010.
      Similarly, mental health conditions pose a stronger risk for suicide among women VHA users as compared with men.
      • Ilgen M.A.
      • Bohnert A.S.B.
      • Ignacio R.V.
      • et al.
      Psychiatric diagnoses and risk of suicide in veterans.
      Among the active-duty Army, deployment is associated with significantly greater increase in suicide for women as compared with men,
      • Gilman S.E.
      • Bromet E.J.
      • Cox K.L.
      • et al.
      Sociodemographic and career history predictors of suicide mortality in the United States Army 2004-2009.
      which is attenuated after accounting for past-year reported sexual assaults.
      • Street A.E.
      • Gilman S.E.
      • Rosellini A.J.
      • et al.
      Understanding the elevated suicide risk of female soldiers during deployments.
      The current study is the first large-scale, population-based study of sexual trauma and suicide mortality, examining risks associated with MST among male and female Veterans receiving care in the VHA. The study had two aims: (1) to determine the rate of suicide among men and women Veterans in VHA who reported MST and (2) to evaluate whether MST is associated with suicide risks among VHA users and to estimate the magnitude of this risk accounting for other suicide risk factors. As an exploratory aim, the relationship between suicide and receipt of mental health services for MST-related conditions was examined.

      Methods

      A retrospective cohort design was used to assess associations between MST screen results and subsequent suicide mortality among all Veterans who received VHA outpatient services between October 1, 2007, and September 30, 2011 (FY2007–2011), and were screened for MST (6,010,893 men; 363,680 women). Observations were excluded from the analyses (0.4%) owing to incomplete or out-of-range values for age (9,523) or rural/urban residence (13,196). VHA users who were excluded from the analyses had significantly higher likelihood of substance abuse disorder, anxiety, PTSD, and MST, and a lower likelihood of schizophrenia and medical comorbidities as compared with those who were retained. Suicide mortality was assessed until death or the end of calendar year 2011. Study analyses were conducted in 2014 as program evaluation activities of the VHA Office of Mental Health Operations and VHA Mental Health Services.

      Data Sources and Measures

      Data from the Veteran Affairs (VA) National Patient Care Database (NCPD)

      VA Information Resource Center. Research User Guide: FY2002 VHA Medical SAS Outpatient Datasets. Hines, IL: VA Information Resource Center, Health Services Research and Development Service, Edward J. Hines Jr. VA Hospital; 2003.

      and the MST Support Team Data Archive were used to identify the cohort. These data were linked to National Death Index data collected as part of VA suicide monitoring to provide information on causes of death using established methods.
      • Blow F.C.
      • Bohnert A.S.
      • Ilgen M.A.
      • et al.
      Suicide mortality among patients treated by the Veterans Health Administration from 2000 to 2007.
      The primary outcome was death by suicide as indicated by the National Death Index, considered the most sensitive population-based data source.
      • Cowper D.C.
      • Kubal J.D.
      • Maynard C.
      • Hynes D.M.
      A primer and comparative review of major U.S. mortality databases.
      Consistent with prior work,
      • McCarthy J.
      • Valenstein M.
      • Kim H.M.
      • Ilgen M.
      • Zivin K.
      • Blow F.
      Suicide mortality among patients receiving care in the Veterans Health Administration health system.
      • McCarthy J.F.
      • Blow F.C.
      • Ignacio R.V.
      • Ilgen M.A.
      • Austin K.L.
      • Valenstein M.
      Suicide among patients in the Veterans Affairs Health System: rural urban differences in rates, risks, and methods.
      suicide deaths were identified using the ICD-10
      International Classification of Diseases.
      codes X60–X84, Y87.0.
      The VHA uses a clinical reminder in the electronic medical record to screen for MST. During the observation period, the screening instrument contained two items: While you were in the military: (a) Did you receive uninvited and unwanted sexual attention, such as touching, cornering, pressure for sexual favors, or verbal remarks?; (b) Did someone ever use force or threat of force to have sexual contact with you against your will? These items have been validated against psychometrically sound assessment instruments, yielding a sensitivity of 0.92 and specificity of 0.89 for item “a,” and a sensitivity of 0.89 and specificity of 0.90 for item “b.”
      • Kimerling R.
      • Gima K.
      • Smith M.W.
      • Street A.
      • Frayne S.
      The Veterans Health Administration and military sexual trauma.
      • McIntyre L.M.
      • Butterfield M.I.
      • Nanda K.
      • et al.
      Validation of a trauma questionnaire in veteran women.
      This performance is comparable to other widely used VA mental health screens for depression
      • Lowe B.
      • Kroenke K.
      • Grafe K.
      Detecting and monitoring depression with a two-item questionnaire (PHQ-2).
      and PTSD.
      • Prins A.
      • Ouimette P.
      • Kimerling R.
      • et al.
      The primary care PTSD screen (PC-PTSD): development and operating characteristics.
      An affirmative response to either item is entered as a positive screen; negative responses to both items are entered as negative screens; Veterans who decline to respond are screened again within 1 year, with an interim response coded as declined. Among Veterans with positive screens, providers can document care for MST-related conditions at each healthcare encounter. This information was obtained from the NCPD for all mental health encounters to derive a dichotomous indicator of MST-related mental health care.
      Age in years was categorized as 18–29, 30–39, 40–49, 50–59, 60–69, 70–79, and ≥80 years. ICD-9 diagnoses were obtained from the NCPD, and grouped into non-overlapping categories of substance use disorder, bipolar disorder, schizophrenia, depression, PTSD, and anxiety disorders.
      • Ilgen M.A.
      • Kleinberg F.
      • Ignacio R.V.
      • et al.
      Noncancer pain conditions and risk of suicide.
      The Charlson comorbidity index score
      • Charlson M.E.
      • Pompei P.
      • Ales K.L.
      • MacKenzie C.R.
      A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
      was calculated from ICD-9-CM diagnoses of medical conditions obtained from the NCPD and used as an indicator of medical morbidity, coded as 0, 1, and ≥2.

      Statistical Analysis

      Proportional hazards regression models were used to assess associations between MST and suicide, stratified by gender. Age-adjusted models and fully adjusted models that included age group, medical morbidity, rural residence, and mental health diagnoses (substance use disorder, bipolar disorder, depression, other anxiety, PTSD, and schizophrenia) were also calculated. Risk time began at the first outpatient encounter during FY2007–2011 with documentation of MST screening (i.e., the first outpatient encounter or, for Veterans without prior use, the screening date).
      Covariance sandwich estimators adjusted for the clustered nature of the data, with Veterans nested within VHA facilities. Age, sex, medical morbidity, rurality, and mental health diagnoses were assessed based on records during the first year of observation for each Veteran. Population-attributable fractions of suicide deaths associated with MST were estimated from the age-adjusted (for comprehensive estimates) and fully adjusted models (for conservative estimates) using the punafcc package in Stata, version 12. The number of suicides was multiplied by the population-attributable fraction to obtain the number of suicides during the observation period associated with MST.

      Results

      Table 1 presents the demographic characteristics of the sample. Overall, 2.2% of Veterans in the study reported MST when screened (1.1% of men; 21.2% of women), 97.4% reported no MST, and 0.3% declined to complete the screen. Significant differences by MST screen status were observed across all Veteran characteristics, where Veterans who reported MST were more likely to be female, younger, have lower Charlson scores, less likely to live in rural areas, and more likely to receive a diagnosis of each mental health condition. There were 9,017 completed suicides during the follow-up period, with a crude suicide rate of 37.4/100,000 person-years (Table 2). Among both men and women, suicide rates were higher among those with positive MST screens as compared to those with negative screens. Rates were high among women who declined MST screening (90.4), though there were wide CIs and relatively few suicides (six) in this group.
      Table 1Characteristics of Veterans Affairs Outpatients by MST Status: 2007–2011
      MST Status
      All,Yes,No,Declined,
      n (%)n (%)n (%)n (%)
      All6,351,854 (100.0)142,152 (2.2)6,189,474 (97.4)20,228 (0.3)
      Gender
       Male5,991,080 (94.3)65,792 (46.3)5,907,300 (95.4)17,988 (88.9)
       Female360,774 (5.7)76,360 (53.7)282,174 (4.6)2,240 (11.1)
      Age
       18–29435,996 (6.9)17,144 (12.1)417,594 (6.7)1,258 (6.2)
       30–39389,911 (6.1)19,119 (13.4)369,623 (6.0)1,169 (5.8)
       40–49709,873 (11.2)36,220 (25.5)671,394 (10.8)2,259 (11.2)
       50–591,603,344 (25.2)41,054 (28.9)1,557,743 (25.2)4,547 (22.5)
       60–691,285,687 (20.2)15,204 (10.7)1,267,185 (20.5)3,298 (16.3)
       70–791,190,785 (18.7)8,493 (6.0)1,178,456 (19.0)3,836 (19.0)
       ≥80736,258 (11.6)4,918 (3.5)727,479 (11.8)3,861 (19.1)
      Charlson Index category
       03,356,208 (52.8)87,870 (61.8)3,258,713 (52.6)9,625 (47.6)
       11,479,502 (23.3)30,329 (21.3)1,444,480 (23.3)4,693 (23.2)
       ≥21,516,144 (23.9)23,953 (16.9)1,486,281 (24.0)5,910 (29.2)
      Rural residence
       Urban4,003,707 (63.0)97,223 (68.4)3,892,828 (62.9)13,656 (67.5)
       Rural2,348,147 (37.0)44,929 (31.6)2,296,646 (37.1)6,572 (32.5)
      Psychiatric conditions
       Substance use disorder569,804 (9.0)22,848 (16.1)544,546 (8.8)2,410 (11.9)
       Bipolar disorder133,046 (2.1)12,659 (8.9)119,663 (1.9)724 (3.6)
       Depression1,110,272 (17.5)62,613 (44.0)1,043,118 (16.9)4,541 (22.4)
       Other anxiety453,261 (7.1)25,633 (18.0)425,877 (6.9)1,751 (8.7)
       PTSD599,882 (9.4)45,172 (31.8)552,433 (8.9)2,277 (11.3)
       Schizophrenia103,925 (1.6)6,104 (4.3)96,796 (1.6)1,025 (5.1)
      Note: χ2 tests for differences across MST status were statistically significant at p<0.0001 for all Veteran characteristics.MST, military sexual trauma; PTSD, posttraumatic stress disorder.
      Table 2Suicide Deaths by Gender and MST Screen Status, VHA Outpatients, 2007–2011
      Suicide deaths, n (%)Person-years of risk timeRate per 100,000 person-years (95% CI)
      Total9,017 (0.1)24,085,489.937.4 (36.7, 38.2)
      Men
       MST yes159 (0.24)246,019.364.6 (55.3, 75.5)
       MST no8,573 (0.15)22,425,850.738.2 (37.4, 39.0)
       Declined screening26 (0.14)50,002.252.0 (35.4, 76.4)
      Women
       MST yes97 (0.13)290,829.333.4 (27.3, 40.7)
       MST no156 (0.06)1,066,148.414.6 (12.5, 17.1)
       Declined screening6 (0.27)6,64090.4 (40.6, 201.1)
      MST, military sexual trauma; VHA, Veterans Health Administration.
      As shown in Table 3, MST was significantly associated with increased risk for suicide among both men (hazard ratio [HR]=1.69, 95% CI=1.45, 1.97) and women (HR=2.27, 95% CI=1.76, 2.94) in unadjusted models. Even when adjusting for age, medical morbidity, rural residence, and mental health conditions, MST remained a significant risk factor for both men (HR=1.19, 95% CI=1.02, 1.39) and women (HR=1.36, 95% CI=1.01, 1.83). For men, the attributable fractions of suicide associated with MST ranged from 0.29% (fully adjusted) to 0.69% (age adjusted), or between 25 and 61 suicide deaths during the observation period. Among women, the range was 10.1% to 19%, or 26–49 suicide deaths during the observation period. Figure 1 displays the survival curve illustrating the probability of suicide mortality by sex and MST status.
      Table 3MST and Proportional Hazards Regression Analyses of Suicide Deaths, VHA Outpatients, 2007–2011
      HR (95% CI)p-valueAttributable fraction due to MST, PAF (95% CI)
      Men
       MST1.69 (1.45, 1.97)<0.0001
       Age-adjusted model1.62 (1.39, 1.89)<0.00010.69% (0.52, 0.87)
       Fully adjusted model
      Fully adjusted model is adjusted for age group, Charlson score, rural residence, and psychiatric conditions (substance use disorders, bipolar disorder, depression, posttraumatic stress disorder, anxiety disorders). HR, hazard ratio; MST, military sexual trauma; PAF, population-attributable fraction; VHA, Veterans Health Administration.
      1.19 (1.01, 1.39)0.0290.29% (0.05, 0.53)
      Women
       MST2.27 (1.76, 2.94)<0.0001
       Age-adjusted model1.97 (1.53, 2.56)<0.000119% (13.8, 23.8)
       Fully adjusted model
      Fully adjusted model is adjusted for age group, Charlson score, rural residence, and psychiatric conditions (substance use disorders, bipolar disorder, depression, posttraumatic stress disorder, anxiety disorders). HR, hazard ratio; MST, military sexual trauma; PAF, population-attributable fraction; VHA, Veterans Health Administration.
      1.35 (1.01, 1.83)0.04510.1% (1.3, 18.2)
      Note: Boldface indicates statistical significance (p<0.05).
      a Fully adjusted model is adjusted for age group, Charlson score, rural residence, and psychiatric conditions (substance use disorders, bipolar disorder, depression, posttraumatic stress disorder, anxiety disorders).HR, hazard ratio; MST, military sexual trauma; PAF, population-attributable fraction; VHA, Veterans Health Administration.
      Figure thumbnail gr1
      Figure 1Suicide-specific survival curves as a function of sex and military sexual trauma screen results.
      MST, military sexual trauma.
      Among individuals who reported MST, those who died by suicide were significantly more likely to be treated for mental health conditions determined by their provider to be related to MST experiences (men, 49.7% vs 35.8%, OR=1.77, 95% CI=1.30, 2.41; women, 67.0% vs 47.5%, OR=2.24, 95% CI=1.47, 3.43).

      Discussion

      This large population-based study was conducted to inform VHA suicide prevention activities and ascertain associations between MST screen results and suicide risks among men and women receiving VHA health services. Results indicated an increased risk for suicide among Veterans who reported MST. Study findings add to the literature regarding increased suicide risks associated with military service and military stressors.
      • Schoenbaum M.
      • Kessler R.C.
      • Gilman S.E.
      • et al.
      Predictors of suicide and accident death in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS): results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).
      • Kang H.K.
      • Bullman T.A.
      • Smolenski D.J.
      • Skopp N.A.
      • Gahm G.A.
      • Reger M.A.
      Suicide risk among 1.3 million veterans who were on active duty during the Iraq and Afghanistan wars.
      • Street A.E.
      • Gilman S.E.
      • Rosellini A.J.
      • et al.
      Understanding the elevated suicide risk of female soldiers during deployments.
      This was the first study to document that sexual trauma during military service heightens subsequent risks of suicide. VHA has undertaken a number of initiatives to enhance cross-collaboration between suicide prevention and mental health programs for individuals who report MST. These include ongoing training on MST-related mental health issues for staff at the VHA national suicide prevention crisis hotline, which serves Veterans and their families. VHA has enhanced referral pathways by facilitating communication between MST coordinators and suicide prevention coordinators, who are located at each VHA medical center. In addition, recent VA suicide prevention predictive modeling
      • McCarthy J.F.
      • Bossarte R.M.
      • Katz I.R.
      • et al.
      Predictive modeling and concentration of the risk of suicide: implications for preventive interventions in the U.S. Department of Veterans Affairs.
      has included MST as part of a large array of model components. VHA mental health enhancement initiatives and suicide prevention programs may underlie the relatively lower excess risk for suicide among VHA users as compared with Veteran non-users,
      • Hoffmire C.A.
      • Kemp J.E.
      • Bossarte R.M.
      Changes in suicide mortality for veterans and nonveterans by gender and history of VHA service use, 2000–2010.
      • Katz I.R.
      • McCarthy J.F.
      • Ignacio R.V.
      • Kemp J.
      Suicide among veterans in 16 states, 2005 to 2008: comparisons between utilizers and nonutilizers of Veterans Health Administration (VHA) services based on data from the National Death Index, the National Violent Death Reporting System, and VHA Administrative Records.
      and the present work supports the importance integrating MST into VHA suicide prevention initiatives, as well as suicide prevention into care for MST.
      Although the observed effect sizes for suicide risks associated with MST were attenuated following adjustment for mental health diagnoses and other risk factors, MST remained a significant independent risk factor among both women and men. Mental health conditions have previously demonstrated a robust risk for suicide mortality among Veterans, with stronger effects among women.
      • Ilgen M.A.
      • Bohnert A.S.B.
      • Ignacio R.V.
      • et al.
      Psychiatric diagnoses and risk of suicide in veterans.
      The attenuation of effects for MST after adjusting for mental health conditions suggests that mental health conditions may partially account for the observed relationship of MST to suicide, especially among women. Given the increased risk for mental health conditions associated with MST,
      • Kimerling R.
      • Gima K.
      • Smith M.W.
      • Street A.
      • Frayne S.
      The Veterans Health Administration and military sexual trauma.
      • Kimerling R.
      • Street A.E.
      • Pavao J.
      • et al.
      Military-related sexual trauma among Veterans Health Administration patients returning from Afghanistan and Iraq.
      and the substantial proportions of suicide decedents in the cohort who were treated for mental health conditions related to MST, MST-related mental health care may be an important avenue to reduce the associated suicide risk. Because this study addressed only suicide mortality, analyses could not determine whether treatment of MST-related conditions may have influenced more-proximal suicide risk factors. For example, sexual trauma is a risk factor for repeated suicide attempts.
      • Beghi M.
      • Rosenbaum J.F.
      • Cerri C.
      • Cornaggia C.M.
      Risk factors for fatal and nonfatal repetition of suicide attempts: a literature review.
      Examination of mental health quality indicators such as treatment intensity and continuity of care, which may influence suicide risks,
      • Desai R.A.
      • Dausey D.J.
      • Rosenheck R.A.
      Mental health service delivery and suicide risk: the role of individual patient and facility factors.
      is also important for further research regarding MST-related mental health treatment. However, because MST exerted a significant independent effect on suicide mortality that was not accounted for by medical or mental health conditions, sexual trauma should be considered in suicide prevention strategies, even among individuals without documented psychiatric morbidity. Further assessments regarding suicide ideation and attempts among Veterans who have experienced MST will help to inform optimal points of intervention, such as primary care, to address suicide risk in these Veterans.
      Consideration of gender differences is important to the implications of the current results. In the VHA system, women are under-represented, accounting for 5.7% of the study population. MST was significantly more common among women, and absolute effects for MST (as indicated by the population-attributable fraction) were substantially higher among women. However, crude suicide rates among men who reported MST were approximately twice those of women (64.6 vs 33.4), owing to the higher rates of suicide among men. The result is that the total numbers of suicide deaths during the observation period that could be attributed to MST were comparable for men and women (ranging from 25 to 61 for men and 26 to 49 for women). These results support targeting both men and women in efforts to prevent MST among those in active duty or to prevent suicide among Veterans exposed to MST. Another way to consider gender in the risk for suicide posed by MST is examination of the survival curve. These data suggest that MST may negate the protective effect of female gender on suicide risk, where women who experienced MST showed similar risk of suicide over time as the average male VA user. Comprehensive women’s health services in VA have potential to provide a platform for gender-tailored, indicated, suicide prevention strategies: Coordinated primary care and mental health services are a strategic priority for VA Women’s Health Services, where services at each facility include women Veteran program managers and designated women’s primary care providers with expertise in women’s health.
      Among women, the small proportion who declined MST screening demonstrated a substantial risk for suicide, which remained after adjusting for other suicide risk factors. However, this finding represents only six suicide observations and should be interpreted with caution. The MST clinical reminder is automated to re-screen Veterans who decline screening 1 year following the original screen. The screens not subsequently replaced with positive or negative screen values therefore tend to represent Veterans that used relatively fewer VHA services following screening. Inspection of the data indicates that the declined values among the suicide decedents in this group were not due to suicide mortality within a year of screening. VHA health care faces significant challenges in suicide prevention among Veterans who are not regular users, and community outreach and education may be especially valuable in these cases.

      Limitations

      The results of this evaluation should be interpreted in the context of several limitations. The study was limited to Veterans who received VA health care and may not generalize to Veterans who do not use VHA services. In addition, a portion of the population (less than 0.5%) was excluded owing to data quality, which may have affected the results. In VHA, screening is used to detect clinical need and to document eligibility for receipt of MST-related services without cost sharing, and represent conservative prevalence estimates.
      • Perez-Stable E.
      • Miranda J.
      • Munoz R.F.
      • Ying Y.
      Depression in medical outpatients.
      • Magruder K.M.
      • Yeager D.E.
      Patient factors relating to detection of posttraumatic stress disorder in Department of Veterans Affairs primary care settings.
      • Barth S.K.
      • Kimerling R.E.
      • Pavao J.
      • et al.
      Military sexual trauma among recent veterans: correlates of sexual assault and sexual harassment.
      However, experiences of MST among women and men with negative screen values would bias results towards the null, lending confidence to the observed effects. Study analyses were focused on the VHA health system, and so suicide risk was assessed beginning at the time of MST detection in VHA, rather than during active or reserve duty when the sexual trauma occurred. Unobserved suicide mortality may have occurred following exposure but prior to screening, leading study results to underestimate the true risk associated with MST, especially among those with more-distal military service. Finally, the authors are unable to determine the order of onset among MST and mental health conditions. By definition, MST occurred during military service, and health conditions were observed among Veterans (separated from military service). Some chronic conditions could have predated MST, despite other mental health conditions judged to be related to MST experiences by treating providers. Further study is needed to help define the extent to which MST-related conditions may partially account for the observed relationship of MST to suicide risk.

      Conclusions

      This study provides novel and important evidence for the impact of military experiences on the risk of suicide among Veterans. Women and men who reported MST demonstrated an increased risk for suicide, and MST remained an independent risk factor even after adjusting for other known risk factors for suicide among Veterans, including mental health conditions, medical morbidity, and demographic characteristics. Suicide decedents who reported MST were more likely to receive mental health services for MST-related conditions, highlighting these services as a point of intervention for prevention. The results highlight the benefits of continued collaboration among primary care, MST-related mental health programs, and suicide prevention efforts. Because of the universal screening practice for MST, this investigation of VHA users also represents one of the first population-based studies to establish sexual trauma as a risk factor for suicide in both women and men. Study findings have informed VHA approaches to MST services and suicide prevention.

      Acknowledgments

      This work was supported by the Department of Veterans Affairs, Veterans Health Administration, Mental Health Services, and Office of Mental Health Operations. Input from Mental Health Services and Mental Health Operations helped shape the design of the study; the collection and interpretation of the data; and the preparation, review, and approval of the manuscript. The views expressed in this report are those of the authors and do not necessarily represent those of the Veterans Health Administration.
      Data were acquired for program planning and evaluation purposes, not for research.
      No financial disclosures were reported by the authors of this paper.

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