The Sexual Harassment–Suicide Connection in the U.S. Military: Contextual Effects of Hostile Work Environment and Trusted Unit Leaders

Sexual harassment has been associated with suicidal behaviors, and with the rise in suicides in the U.S. military, sexual harassment's role in suicide has been of growing interest. Lacking are studies that examine group‐ or unit‐level variables in the relationship of sexual harassment to suicidal behaviors (thoughts, plans, and attempts). In this study, survey data from soldiers (12,567 soldiers in 180 company‐sized units) who completed the Unit Risk Inventory administered during calendar year 2010 were analyzed using hierarchical linear modeling. At the individual level, sexual harassment was associated with a fivefold increase for risk of suicide. Reporting that leaders could be trusted was associated with a decreased suicide risk by about one‐third. There was no statistically significant interaction between sexual harassment and trusted leaders in predicting the suicidal behaviors. At the group level, units or companies having higher levels of sexual harassment also had soldiers three times more at risk for suicide. A cross‐leveling effect was also observed: Among units having higher levels of sexual harassment, the negative correlation (buffering effect of unit leaders on suicidal behaviors) was diminished. Implications of findings for preventing sexual harassment and suicide risk are discussed.     

Combat Stressors Predicting Perceived Stress Among Previously Deployed Soldiers

While combat exposures are considered principle stressors in developing mental health problems, research suggests social support can reduce this risk. Using data from 1,592 previously deployed soldiers, we found five classes of soldiers based on their patterns of responses to items measuring perceived stress. In subsequent analyses, we found increased combat exposure predicted membership in classes with greater combat-related stress, while greater unit cohesion predicted membership in classes with lower perceived stress. Also, greater willingness to report misconduct predicted greater unit cohesion. Results suggest that unit cohesion plays a vital role in the reduction of perceived stress among soldiers.     

Race,Offense Type,and Suicide Ideation: Tests of the Interpersonal‐Psychological Theory in Juvenile Offenders

This study evaluated the synergy hypothesis of the Interpersonal‐Psychological Theory of Suicide (IPTS ), which argues thwarted belongingness and perceived burdensomeness are positively interactive in their association with suicide ideation, in a group of juvenile offenders. It also examined whether this prediction is differentially applicable across race/ethnicity or offense type. Participants included 590 adjudicated and confined male juveniles. Regression was used to test the association between suicide ideation and thwarted belongingness, perceived burdensomeness, and their interaction term. Subsequent analyses included tests of group interactions related to race/ethnicity and offense type. No interaction between thwarted belongingness and perceived burdensomeness was observed, despite adequate power. No significant group interactions were observed for race/ethnicity or offense type. However, results did show significant linear relationships between thwarted belongingness, perceived burdensomeness, and ideation, highlighting their potential utility as intervention targets in this at‐risk population. Thus, although the current results are the first to show the basic IPTS risk factors generalize across race/ethnicity and offense type, they also failed to support that those factors were interactive, a primary IPTS claim. The absence of an interaction between thwarted belongingness and perceived burdensomeness suggests their role in suicide ideation for juvenile offenders may be more parsimonious than the IPTS proposes.     

Suicide Crisis Syndrome: A review of supporting evidence for a new suicide‐specific diagnosis

Suicide is a major public health problem, and suicide rates are still on the rise. Current strategies for identifying individuals at risk for suicide, such as the use of a patient's self‐reported suicidal ideation or evidence of past suicide attempts, have not been sufficient in reducing suicide rates. Recently, research groups have been focused on determining the acute mental state preceding a suicide attempt. The development of an acute suicidal diagnosis, the Suicide Crisis Syndrome (SCS), is aimed at capturing this state to better treat individuals. The SCS has five main evidence‐based components—entrapment, affective disturbance, loss of cognitive control, hyperarousal, and social withdrawal. The SCS may provide clinicians with the ability to identify individuals who are experiencing an acute pre‐suicidal mental state, regardless of their self‐reported suicidal ideation. Future research leading to the incorporation of this diagnosis into clinical practice could improve the quality of care and reduce the personal, societal, and legal burden of suicide.     

The Army's New Unit Personnel Replacement and Its Relationship to Unit Cohesion and Social Support

A recent concern of the U.S. Army's top leadership has been the deterioration of morale and cohesion in combat arms units. High personnel turnover in U.S. Army units has been viewed as a primary factor contributing to decreased unit cohesiveness. The current and traditional U.S. Army Indi- vidual Replacement (IR) System trained, assigned, and deployed soldiers to units as individuals. As a result, IR units have had as much as 45% personnel turnover annually. The new Unit Replacement (UR) System trained, assigned, and deployed soldiers as intact groups for the entire first-term soldier's enlistment. The objective of the study was to examine the effects of unit replacement on cohesion and to elaborate on the function of cohesion by examining the relationship between cohesion and social support in a sample of 3,245 soldiers in 43 line companies matched by type of replacement, type of combat arms, and stateside/overseas deployment. Soldiers in UR units in which soldiers had previously undergone Basic and Advanced Individual Training together or had their personnel stabilized reported a significantly higher level of cohesion than did soldiers in IR units. This difference persisted even when personal and unit characteristics were held constant in compari- sons. In terms of social support, UR soldiers cited more support providers in their units than did IR soldiers. Perceived satisfaction with social support and perceived helpfulness of social support provided by unit members were significantly and positively correlated with the cohesion measures, irrespective of the type of replacement. Whereas reciprocity was significantly and positively related to cohesion in commonly trained UR and IR units, it was nonsignificantly related to cohesion in personnel-stabilized UR units. Impli- cations of results for the expected effects of cohesion on the quality of interpersonal relations among unit members are discussed.     

Sexual Self‐Concept Ambiguity and the Interpersonal Theory of Suicide Risk

Mechanisms (i.e., thwarted belongingness, perceived burdensomeness, hopelessness) derived from the interpersonal theory of suicide which are hypothesized to account for the relation between sexual orientation self‐concept ambiguity and active suicide ideation were examined. Participants included 349 women, among whom 42% currently self‐ascribed a non‐exclusively heterosexual sexual identity. Among women reporting higher levels of sexual self‐concept ambiguity, greater risk for active suicide ideation is found when perceptions of burden and feelings of thwarted belonging co‐occur with feelings of hopelessness. Results support relevant theory useful for understanding suicide risk among sexual minority women who acknowledge ambiguity with regard to their sexual orientation.     

Suicide Crisis Syndrome Mediates the Relationship Between Long‐term Risk Factors and Lifetime Suicidal Phenomena

In recent years, there has been growing attention to the distinction between acute and long‐term suicidal risk factors. We have previously characterized an acute, negative affect state, termed the suicide crisis syndrome (SCS ), as a marker of near‐term suicidal risk. Here, we test whether documented long‐term risk factors (i.e., trait vulnerabilities), including perfectionism, impulsivity, chronic substance abuse, insecure attachment, poor social support, and childhood trauma, associate to suicidal phenomena through a pathway of the SCS . A sample of 207 psychiatric inpatients were administered a battery of eight scales, including the Suicide Trigger Scale (STS ‐3) as a measure of the SCS . While both STS ‐3 and all trait vulnerabilities were associated with lifetime suicidal ideation and attempts, only STS ‐3 was related to pre‐admission suicide attempts. The STS ‐3 significantly mediated the effect of each trait vulnerability on lifetime suicidal phenomena (combining ideation and behavior), with the proportion of mediating effect ranging from .29 to .56. Reverse mediation analyses were only significant for insecure attachment, supporting a largely unidirectional mediation effect. The SCS appears to serve as an acute risk factor for suicidal behavior in psychiatric inpatients and may act as a mechanism by which long‐term risk factors increase suicidal risk.     

Meaning Made of Stress among Veterans Transitioning to College: Examining Unique Associations with Suicide Risk and Life‐Threatening Behavior

Meaning made of stress has been shown to be a unique predictor of mental and physical health. In this study, we examined the unique associations between two facets of meaning made of stress (comprehensibility and footing in the world) and suicide risk and life‐threatening behavior among military veterans who have transitioned to college were examined, controlling for demographic factors, religiousness, combat‐related physical injury, combat exposure, depressive symptoms, and posttraumatic stress symptoms. Findings suggest that comprehensibility (having “made sense” of a stressor) is uniquely associated with lower suicide risk and a lower likelihood of driving under the influence of drugs or alcohol and engaging in self‐mutilating behaviors.     

Current and Military‐Specific Gender Minority Stress Factors and Their Relationship with Suicide Ideation in Transgender Veterans

Research suggests the prevalence of suicide ideation and suicide attempts in the transgender veteran community may be upwards of 20 times higher than nontransgender veterans, who are known to be at increased risk than the general US population. This study aimed to understand the potential influence of external and internal minority stress experienced during and after military service on past‐year and recent suicide ideation in a sample of 201 transgender veterans. Nonparametric bootstrapping analyses indicated past‐year transgender‐specific discrimination and rejection (external minority stress) indirectly predicted frequency of both past‐year and past 2‐week suicide ideation through past‐year shame related to gender identity (internal minority stress). This result was significant when controlling for symptoms of depression and demographics. Similar patterns emerged when examining relationships among military external and internal minority stress on suicide outcomes. These results suggest that attempts to reduce both the experience and impact of minority stressors related to gender identity during and after military service may be an important avenue for suicide prevention.     

Combat Exposure and Risk for Suicidal Thoughts and Behaviors Among Military Personnel and Veterans: A Systematic Review and Meta‐Analysis

Due to seemingly mixed empirical results, questions persist about the possible role of deployments and combat exposure. We conducted a narrative review and meta‐analysis of 22 published studies to integrate findings regarding the relationship of deployment‐related predictors (i.e., deployment, deployment to a combat zone, combat experience, and exposure to specific combat events) with suicide‐related outcomes (i.e., suicide ideation, attempt, and death). Across all predictors and outcomes, the combined effect was small and positive, r = .08 [0.04, 0.13], and marked by significant heterogeneity, I² = 99.9%, Q(21)=4880.16, p < .0001, corresponding to a 25% increased risk for suicide‐related outcomes among those who have deployed. Studies examining the relationship between exposure to killing and atrocities (k = 5) showed the largest combined effect, r = .12 [0.08, 0.17], and less heterogeneity, I² = 84.4%, Q(4)=34.96, p < .0001, corresponding to a 43% increased risk for suicide‐related outcomes among those exposed to killing or atrocity. Implications for theory, research, and clinical practice are discussed.     

Thwarted Belongingness in Relation to Face‐to‐Face and Online Interactions

Suicide is ranked as the tenth leading cause of death for all ages in the United States (Centers for Disease Control and Prevention, 2012). Joiner's (2005) interpersonal theory of suicide stated thwarted belongingness—the feeling of being alienated from others—and perceived burdensomeness—the feeling of being a liability to others—are the primary proximal factors leading to suicidal desire. The current study focused on thwarted belongingness and examined its relationship to face‐to‐face interactions and online interactions in both an undergraduate and community sample. We hypothesized that negative face‐to‐face and online interactions would be independently associated with higher levels of thwarted belongingness. Furthermore, we hypothesized that face‐to‐face interactions would moderate the relationship between online interactions and thwarted belongingness and that online interactions would moderate the relationship between face‐to‐face interactions and thwarted belongingness. Three hundred eighty‐seven participants (79.6% female) at a southern university and 209 (62.7% male) participants recruited from Amazon's Mechanical Turk website completed an online survey. Results only partially supported hypotheses, with only face‐to‐face interactions shown to be independently related to higher levels of thwarted belongingness. These findings indicated that negative face‐to‐face interactions may contribute to higher levels of risk factors for suicide ideation and highlighted the importance of assessing for negative interactions across all contexts.     

Trajectories of Suicide Ideation,Nonsuicidal Self‐Injury,and Suicide Attempts in a Nonclinical Sample of Military Personnel and Veterans

Nonsuicidal self‐injury (NSSI) is a risk factor for suicide attempts, but little is known about NSSI among military personnel and veterans, or about the temporal sequencing of NSSI relative to suicide ideation and attempts. This study evaluates trajectories of suicide ideation, NSSI, and suicide attempts in a sample of 422 military personnel and veterans. Of those with a history of NSSI, 77% also experienced suicide ideation. Suicide ideation emerged before NSSI (67%) more often than the reverse (17%). Of those with a history of suicide attempt, 41% also engaged in NSSI. NSSI emerged prior to the first suicide attempt (91%) more often than the reverse (9%). The length of time from suicide ideation to suicide attempt was longer for those who first engaged in NSSI (median = 3.5 years) compared with those who did not engage in NSSI (median = 0.0 years), Wald χ²(1) = 11.985, p = .002. Age of onset was earlier for participants reporting NSSI only compared with those reporting both NSSI and suicide attempts (16.71 vs. 22.08 years), F(1, 45) = 4.149, p = .048. NSSI may serve as a “stepping stone” from suicide ideation to attempts for 41% of those who attempt suicide.     

The Effects of the Family Bereavement Program to Reduce Suicide Ideation and/or Attempts of Parentally Bereaved Children Six and Fifteen Years Later

Findings concerning the long‐term effects of the Family Bereavement Program (FBP) to reduce suicide ideation and/or attempts of parentally bereaved children and adolescents are presented. Parental death is a significant risk factor for suicide among offspring (Guldin et al., 2015). This study is a long‐term follow‐up of 244 children and adolescents who had participated in a randomized trial of the FBP, examining the intervention effects on suicide ideation and/or attempts as assessed through multiple sources. Results indicate a significant effect of the FBP to reduce suicide ideation and/or attempts at the 6‐ and 15‐year follow‐up evaluation. The findings support the potential benefits of further research on “upstream” suicide prevention.     

Predictors of suicide ideation and depression in Hong Kong adolescents: perceptions of academic and family climates

The unique dimensions of perceptions of school and family contributing to depression and suicide ideation in Hong Kong adolescents were examined in two studies. In Study 1, among 327 Hong Kong Chinese female students ages 13-18, 47% reported some suicide ideation. Suicide ideation was significantly associated with depression, test anxiety, academic self-concept, and adolescents' perceived parental dissatisfaction with academic performance. The correlation between test anxiety and depression was especially high (r = .51). Study 2 examined how three different aspects of perceived family relationship were associated with depression and suicide ideation. Among 371 Hong Kong Chinese adolescents ages 14-20, 52.6% reported suicide ideation. Low levels of family cohesion and support and high levels of parent-adolescent conflict were positively related to depression and suicide ideation in both genders. Across both studies, depression mediated associations between academic- and family-related variables and suicide ideation. Findings underscore the importance of both academic and family climate in understanding depression and suicide ideation among Chinese adolescents.     

Suicide ideation and depression in university students in Botswana

The study aimed at exploring suicide ideation and its relationship to depression in university students in Botswana. Data were collected from 122 undergraduate students (68.9% females, 31.1% males) with a mean age of 20.02 years. Depressive symptoms were measured with an adapted version of Beck's Depression Inventory-II. In total, 47.5% of the respondents reported suicide ideation, 28.7% reported previous suicide attempts, and the mean depression score was 19.14. Suicide ideation correlated strongly with total depression scores. The level of depression severity was linearly related to suicide ideation but 14.3% of respondents who scored at the level of minimal depression and 53.8% of those who scored at the level of mild depression had also contemplated suicide. The level of education of respondents’ mothers had an inverse relationship with suicide ideation and with depression in that those whose mothers had a tertiary level education were less likely to engage in suicide ideation and had significantly lower depression scores. The results are discussed from within the specific social ecological context of Botswana.     

Determinants and Predictive Value of Clinician Assessment of Short‐Term Suicide Risk

We examine the interrelations among clinicians' judgment of patients' suicide risk, clinicians' emotional responses, and standard risk factors in the short‐term prediction of suicidal thoughts and behaviors. Psychiatric outpatients (n = 153) with a lifetime history of suicide ideation/attempt and their treating clinicians (n = 67) were evaluated at intake. Clinicians completed a standard suicide risk instrument (modified SAD PERSONS scale), a 10‐point Likert scale assessment of judgment of patient suicide risk (Clinician Prediction Scale), and a measure of their emotional responses to the patient (Therapist Response Questionnaire‐Suicide Form). The Columbia Suicide Severity Rating Scale and the Beck Scale for Suicide Ideation were administered at a one‐month follow‐up assessment (n = 114, 74.5%). Clinician judgment of risk significantly predicted suicidal thoughts and behaviors at follow‐up. Both the standard suicide risk instrument and clinician emotional responses contributed independently to the clinician assessment of risk, which, in turn, mediated their relationships with suicidal thoughts and behaviors. Our findings validate the importance of clinical judgment in assessing suicide risk. Clinical judgment appears to be informed both by concrete risk factors and clinicians' emotional responses to suicidal patients, highlighting emotional awareness as a promising area for research and training.     

Nonlinear Change Processes During Psychotherapy Characterize Patients Who Have Made Multiple Suicide Attempts

Research suggests that multiple suicide attempters experience considerable variability in suicide ideation and longer‐duration suicidal crises, which suggests the possibility of two states of stability (one low risk and one high risk). To date, however, few studies have examined nonlinear change processes in suicide ideation among patients. In a sample of 76 active duty U.S. Army soldiers receiving brief cognitive behavioral therapy for acute suicide risk, we examined differences in the ebb and flow of suicide ideation among multiple attempters, first‐time attempters, and ideators. Results indicated that multiple attempters were characterized by two states of stability corresponding to low and high intensity suicide ideation; these states were separated by a region of instability corresponding to moderate intensity suicide ideation. In contrast, ideators and first‐time attempters were characterized by only a single state of stability corresponding to low intensity suicide ideation. Among patients who have made multiple suicide attempts, suicide ideation may function as a bimodal rather than a continuous construct.     

Empirically Derived Subgroups of Self‐Injurious Thoughts and Behavior: Application of Latent Class Analysis

Latent class analysis was applied to the sample data to identify homogenous subtypes or classes of self‐injurious thoughts and behavior (SITB) based on indicators indexing suicide ideation, suicide gesture, suicide attempt, thoughts of nonsuicidal self‐injury (NSSI), and NSSI behavior. Analyses were based on a sample of 1,809 healthy adults. Associations between the emergent latent classes and demographic, psychological, and clinical characteristics were assessed. Two clinically relevant subtypes were identified, in addition to a class who reported few SITBs, and were labeled as follows: low SITBs (25.8%), NSSI and ideation (25%), and suicidal behavior (29.2%). Several unique differences between the latent classes and external measures emerged. For instance, those belonging to the NSSI and ideation class compared with the suicidal behavior class reported lower levels of entrapment, burdensomeness, fearlessness about death, exposure to the attempted suicide or self‐injury of family members and close friends, and higher levels of goal disengagement and acute agitation. SITBs are best explained by three homogenous subgroups that display quantitative and qualitative differences. Profiling the behavioral and cognitive components of suicidal and nonsuicidal self‐injury is potentially useful as a first step in developing tailored intervention and treatment programs.     

The Suicidal Narrative and Its Relationship to the Suicide Crisis Syndrome and Recent Suicidal Behavior

In this study, we introduce the construct of the suicidal narrative, a hypothetical personal narrative linked to imminent suicide, and explore its relationship to near‐term suicidal risk and the suicide crisis syndrome (SCS). Psychiatric outpatients (N = 289) were administered the Columbia Suicide‐Severity Rating Scale (C‐SSRS), Suicide Crisis Inventory (SCI), and Suicide Narrative Inventory (SNI), a novel instrument combining the documented risk factors of Thwarted Belongingness, Perceived Burdensomeness, Humiliation, Social Defeat, Goal Disengagement, and Goal Reengagement. Dimensional measures of past month, lifetime, and past suicidal phenomena, incorporating ideation and behavior, were calculated from the C‐SSRS. Structural equation modeling was used to explore the interaction among variables. Factor analysis of the SNI yielded two orthogonal factors, termed Interpersonal and Goal Orientation. The former factor was comprised of Perceived Burdensomeness, Social Defeat, Humiliation, and Thwarted Belongingness, the latter of Goal Disengagement and Goal Reengagement. The Interpersonal factor correlated with both SCS severity and suicidal phenomena in each time frame and the Goal Orientation factor with no other variable. As hypothesized, the proposed model was significant for the past month only. Our findings support the construct of the suicidal narrative and its function as a near‐term suicidal risk factor.     

Cultural orientation, family cohesion, and family support in suicide ideation and depression among African American college students

This study extends previous research by examining the role of communalism, family cohesion, and family support in suicide ideation and depression in African American college students. Participants were 188 African American introductory psychology students (126 female, 61 male) from a historically black college. (1) Results showed that communalism, family cohesion, and family support were positively associated with each other. Higher levels of family cohesion and family support were associated with lower levels of suicide ideation and depression. Linear regression analyses showed a main effect for communalism and family support. Having strong communal values was positively related to suicide ideation and depression. Having strong family support was associated with fewer experiences of suicide ideation and depression. Stepwise regression analyses indicated that family support explained more variance in suicide ideation and depression than family cohesion. Implications of these results for future research and practice are discussed.