Suicidal Behavior in Posttraumatic Stress Disorder: Focus on Combat Exposure


Populations

Suicidal ideation/suicidal ideation with plan

Suicide attempt

Death from suicide

General population [13]

13.5/3.9%

4.6%

0.015%

General population with chronic PTSD [38, 66]

38.3/8.5%

9.6%

0.4%

Veterans with PTSD [79]

44/36%

14%

0.6–11.8%

OEF/OIF returning veterans [15, 54, 126]

12.5% [54]–21/6% [15]

9% [19]

0.022% [126]





Relationship Between PTSD and Suicidal Ideation


Numerous large studies representing North American, European, and South African general populations have demonstrated a robust correlation between PTSD and suicidal ideation [3, 43, 44]. Even after Marshall et al. [45] applied partial diagnostic criteria to PTSD, a strong association emerged, with a proportion of subjects with suicidal ideation increasing from 9% with no PTSD symptoms to 33% for those with four PTSD symptoms. It is a correlation that appears to nearly equally affect patients with different demographic characteristics and traumatic experiences, evidenced by studies on sheltered women traumatized by domestic abuse, adolescents exposed to street or jail violence, and Israeli students exposed to the trauma of terrorism [4651].

Numerous studies in combat veterans, active duty military, or police personal exposed to combat violence have also demonstrated a strong, positive association between PTSD and suicidal ideation [51]. Bell et al. [52] found that reexperiencing symptom cluster of PTSD was strongly associated with suicidal ideation in Vietnam combat veterans , and veterans of Iraq and Afghanistan wars carrying the diagnosis of PTSD were several times more likely to endorse suicidal ideation when compared to controls [53]. Veterans from the Operation Enduring Freedom and Operation Iraq freedom (OEF/OIF) who endorsed suicidal ideation were found to be more likely to suffer from symptoms of PTSD [54]. In the Norwegian peacekeepers, suicidal ideation jumped from 6% to 17% when PTSD symptoms were factored in the analysis [55], and Maia et al. [56] found police officers with a history of violent trauma exposure and full PTSD diagnosis to have a sevenfold increase in the lifetime prevalence of suicide ideation compared to a well-matched control group without PTSD.


PTSD and Suicide Attempt


Considering the high rate of suicidal ideation in traumatized subjects, it is not surprising that up to 29% of combat veterans and up to 40% of civilians diagnosed with PTSD will make a suicide attempt, some more than once [2, 57]. It’s a behavioral trend observed and noted as early as 1950s when World War II veterans returned home [58]. Both Hyer et al. [11] and Hendin et al. [10] separately demonstrated that up to 20% of combat-exposed Vietnam veterans carrying a diagnosis of chronic PTSD attempted suicide, with persistent combat action and survival guilt as well as symptoms of depression mediating the self-destructive behavior. Brenner and colleagues [59] found that the risk of suicide attempt in veterans with PTSD is significantly higher than for controls and is further increased by a comorbidity with TBI.

Similarly, several large studies involving civilian subjects demonstrated a robust association between PTSD and the risk of suicide attempt compared to a demographically matched control groups [2, 8, 36, 60]. Sareen and colleagues [43], for example, found that PTSD was the only anxiety disorder independently correlated to suicide attempts, and the European Study of the Epidemiology of Mental Disorders (ESEMED ) which analyzed 21,425 adults from six European countries found that 10.7% of subjects suffering from PTSD has attempted suicide [3].


Contribution of PTSD to Death from Suicide


Although established rates of suicidal ideation and attempts carry some utility in predicting death rates from suicide, data on specific population is the best tool for this task. For example, suicide rate among veterans with PTSD was found to be more than three times the rate in the general population expected by the Center for Disease Control and Prevention [61]. Bullman and colleagues [62] found increased risks of suicide in Vietnam veterans diagnosed with PTSD, when compared to the general population and veterans without PTSD, and Watanabe et al. [63] demonstrated that death from suicide in combat-exposed Vietnam marines exceeded that of demographically matched control group not exposed to combat action in Vietnam. Boscarino et al. [64] further showed that the risk of death from suicide in Vietnam combat veterans with PTSD is elevated, even after controlling effects of combat trauma, and Farbero and colleagues [65] demonstrated that veterans who died from suicide are more likely to experience PTSD symptoms in the past than matched veterans who died from motor vehicle accidents. A large nationwide Danish study found a high degree of association between PTSD and suicide, with comorbid depression further elevating the risk [66].

Interestingly, not every study demonstrated a positive correlation between PTSD and suicide rate. Krysinka et al. [67] reviewed 52 papers on the relationship between completed suicide rate and PTSD and found no positive association. A large Veteran Affairs National Registry for Depression study by Zivin and colleagues [68], for example, found suicide rate among veterans diagnosed with PTSD to be lower compared to veteran group without the diagnosis. The discrepancy could potentially be accounted by differences in study designs, populations, treatment quality, and diagnostic tools and highlights the need to refine research methodology in the fields of suicide, PTSD, and trauma.


The Role of Comorbid Psychiatric Conditions in Suicidal Behavior of PTSD


Mood, anxiety, substance abuse, and personality disorders often co-occur with PTSD [52, 6972], with some estimates that up to 99.8% of patients with PTSD carry another psychiatric diagnosis [8]. A comorbidity can both contribute to the suicidal behavior of combat-exposed as well as civilian patients and artificially inflate data on suicide rates in PTSD [12, 16] (see Table 8.2). The explanations for the high rate of co-occurrences vary from psychiatric disorders predisposing to trauma and PTSD, to depression, anxiety, and substance use disorders being the effect of PTSD symptoms. Additionally, certain symptom clusters of PTSD overlap with symptoms of common psychiatric diagnoses, and common biological and psychological factors are shared by both PTSD and other psychiatric disorders.


Table 8.2
Relative risk of suicidal behavior in PTSD comorbid with different psychiatric disorders












































































PTSD + mood disorder

Risk of suicidal behavior

PTSD + anxiety disorder

Risk of suicidal behavior

PTSD + other disorders

Risk of suicidal behavior

Combination of disorders

Risk of suicidal behavior

Major depressive disorder

++

Alcohol abuse

+

Personality disorders

+

2 + disorders combined

+

Dysthymia

+

Alcohol dependence

+

TBI

+

3 + disorders combined

++

Mania

++

Drug abuse

+

Generalized anxiety disorder

+

4 + disorders combined

+++

Any mood disorder

++

Drug dependence

+

Panic disorder

+

5 + disorders combined

++++
   
Any substance disorder

+

Any anxiety

+
   
       
PTSD

+
   


+ represents an approximate degree of suicidal behavior risk. Table was constructed using data from [8, 12, 15]


PTSD, Mood Disorders, and Suicidal Behavior


Lifetime PTSD, even subthreshold diagnosis , is strongly associated with mood disorders. The comorbidity is especially prominent with the major depressive disorder (MDD) and, with an exception of dysthymia, usually precedes the symptoms of depression [45, 73]. In the traumatic events of Oklahoma City bombing, a large proportion of victims with pre-disaster MDD developed PTSD, and a large proportion of victims with pre-event PTSD developed new-onset MDD, highlighting the complexity of the interaction between PTSD and depressive disorders [47, 74, 75]. Fullerton et al. [76] also found that preexisting MDD increases susceptibility to the development of acute and chronic PTSD, and Shalev with colleagues [77] demonstrated that up to 44.5% of people develop a comorbidity between PTSD and a major depressive disorder after a traumatic event, with a positive synergistic effect on suicidality and clinical impairment compared to either disorder alone.

Approximately 56–87% of individuals who commit suicide are diagnosed with MDD [78], but numerous well-controlled studies involving subjects traumatized by combat have demonstrated that comorbidity between PTSD and MDD increases suicidal behavior compared to either diagnosis alone [7982]. Freeman et al. [56] showed that patients with chronic, combat-related PTSD and a history of suicide attempt were more likely to have suffered from comorbid symptoms of depression, and Wunderlich et al. [83] demonstrated that depression in young adults diagnosed with PTSD was a major contributor to the risk of suicide attempt.

Studies have also found a correlation between bipolar disorder and PTSD leading to an elevated risk of suicidal [84]. Lu and colleagues [85] demonstrated, for example, that history of bipolar illness interacts with trauma to increase the risk of developing PTSD and suicide attempt, and Lucas et al. [86] showed that patients with comorbid PTSD and bipolar type 1 disorder are at higher risk of suicide attempt than bipolar-only group or patients diagnosed with bipolar who have been exposed to trauma but without the diagnosis of PTSD.


PTSD, Primary Psychotic Disorders, and Suicidal Behavior


Trauma and PTSD also appear to increase the chance of suicidal behavior in patients with a psychotic disorder [87, 88]. Strauss et al. [89] found comorbid PTSD to be associated with a higher risk of suicide ideation and behavior in veterans with schizophrenia and schizoaffective disorders. Terrier and colleagues [90] showed that in response to the trauma of first psychotic episode, approximately 40% of patients developed PTSD with an increased risk of suicidal ideation. Finally, the same investigators also demonstrated that patients with schizophrenia suffering from comorbid PTSD showed elevated suicidal ideation, plan, and attempts compared to subjects without comorbid PTSD [85].


PTSD, Anxiety Disorders, and Suicidal Behavior


A number of large national representative studies have demonstrated that anxiety disorders are often comorbid with PTSD diagnosis, and the comorbidity appears to increase the risk of suicidal behavior [34, 45, 9193]. Capron and colleagues [94] suggested that excessive sensitivity to anxiety symptoms of PTSD is associated with an increased rate of suicide attempt, and Hapke et al. [95] concluded that symptoms of anxiety predispose to the development of PTSD. Ferrada-Noli et al. [96] found that out of 149 refugee subjects traumatized by torture, 117 were diagnosed with PTSD. Out of the subjects positive for PTSD, 29% got labeled with another anxiety disorder, and the comorbid group demonstrated risk of suicidal attempt that was even higher than PTSD comorbid with depression group.


PTSD, Borderline Personality Disorder, and Suicidal Behavior


In a large study, Pietrzak and colleagues [97] reported that PTSD is frequently comorbid with several personality disorders, including the borderline personality disorder (BPD) . Many other researchers have also validated this association, with estimates that nearly 60% of PTSD patients suffer from BPD [98, 99].

In exploring this relationship, Pagura and colleagues [100] suggested that despite being separated categorically by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), both BPD and PTSD share a relationship to trauma with higher risk of suicidal behavior as a result. Some studies even hypothesize that BPD should be viewed as part of a posttraumatic stress “syndrome” or complex PTSD [10, 101105]. Oquendo and colleagues [81] suggested that the increased suicidal behavior in patients suffering from PTSD and depressive disorders is mediated by cluster B personality traits, while Bell et al. [52] showed that reexperiencing symptoms of trauma were predictive of suicidal behavior and overlap with experiences of patients with BPD.

Despite an incompletely understood mechanism, the co-occurrence of BPD and PTSD elevates the risk of suicidal behavior compared to either disorder alone [106, 107]. Data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Wave II, for example, showed that the comorbid group suffered from a higher psychiatric burden, a lower quality of life, and a higher rate of suicide attempts than either group alone [99]. A study by Harned and colleagues [108], however, suggested that comorbid PTSD and BPD in women actually lowered the suicide intent and lethality from suicide attempts, a controversial conclusion given the data that suggest otherwise.


PTSD and Alcohol and Drug Abuse Disorders


Data shows a strong association between trauma, PTSD, and illicit substance and alcohol use [60, 109], including in veteran and active military personnel. The National Comorbidity Survey, for example, found that subjects with an alcohol or drug use disorders were more likely to have co-occurring PTSD compared to controls [96], and the analysis of the Epidemiologic Catchment Area (ECA) data by Cottler et al. [110] found that individuals with a history of cocaine and opioid use were at increased risk of trauma exposure and PTSD, compared to controls.

Suicide rate in subjects with comorbid PTSD and substance dependence has also been shown to exceed either one of these disorders alone [111113] and appears to vary with different disorders [114]. A study by Harned et al. [115] demonstrated that women diagnosed with PTSD and substance dependence are at higher risk of suicide as well as non-suicidal self-injury, and a large, retrospective, Australian study looking at the relationship between opioid dependence disorder and suicide attempt and ideation found that opioid-dependent subjects had higher rates of PTSD and BPD which were believed to raise rates of attempted suicide [116].

Longitudinal analysis of co-occurrence of PTSD and substance or alcohol suggests a mechanism behind this association. Brown et al. [73] demonstrated that PTSD often precedes substance and alcohol use disorders, most likely as a self-medication of PTSD symptoms, and Chapman et al. [46] as well as Pietrzak et al. [53] suggested that substance and alcohol abuse mediates an increased risk of suicidal behavior in traumatized patients. Data from a large Australian National Survey of Mental Health and Well-Being showed that patients with trauma and PTSD had a high rate of substance use disorder, most commonly alcohol. They showed that in 8.7% of the cases, trauma preceded the onset of substance use; for 33.8% the traumatic event occurred simultaneous to the onset of substance use disorder symptoms, suggesting that substance use could predispose to as well as complicate trauma and PTSD [111].


Trauma, PTSD, and Suicidal Behavior


Most of the subjects in civilian and military populations experience at least one traumatic event in their lifetime, but fewer than 10% develop PTSD [117], and even a smaller fraction engages in suicidal behavior [118]. PTSD, comorbid psychiatric disorders, trauma , or a combination of these factors could potentially mediate the association between trauma and suicidal behavior . Several well-controlled studies in civilian populations, including large, nationally representative data sets, have demonstrated that trauma leads to suicidal behavior with and without PTSD [119122]. Numerous studies have shown that symptoms other than classic symptom clusters of PTSD are responsible for mediating suicidal behavior in subjects with PTSD. Several investigators, for example, demonstrated that instability in paternal relationship, combat guilt, and depression were predictive of suicide in Vietnam veterans with PTSD [10, 11], and Kotler et al. [37] suggested that post traumatic symptoms of avoidance or intrusion were not significantly correlated with the suicide risk in subjects diagnosed with PTSD, but anger and impulsivity were.

Nelson and colleagues [123] showed combat trauma and not PTSD mediated that association between combat exposure and suicidal behavior in Canadian Forces personnel, and Kang and Bullman [13] found that suicidal behavior was directly proportional to the degree of combat trauma exposure.

Numerous studies also argue that it is in fact symptoms of PTSD that are responsible for suicidal behavior, in traumatized civilian as well as combat populations [46, 47, 5052, 62, 96, 124126]. For example, Cox and colleagues [124] isolated and characterized the group that developed PTSD after trauma exposure and demonstrated that symptoms of PTSD and not trauma experience was associated with suicide attempt, highlighting its role in the development of suicidal behavior.


Protective Factors, Management, and Future Research in PTSD and Suicidal Behavior



Social Support


Social support , both objective and perceived, appears to decrease the chances of PTSD as well as the risk of suicidal behavior in the civilian and the military populations [37, 123, 125, 127129]. For OEF/OIF veterans diagnosed with PTSD, post-deployment social support system in the form of marriage, family, and friends and access to medical care as well as greater sense of purpose, control, leadership, and satisfaction with social safety net appeared protective against the risk of suicide [54, 130]. For example, being service connected to a VA hospital health-care system appears to decrease the risk of suicidal behavior in war veterans with PTSD [68].

Additionally, considering findings by Kessler and colleagues [8] that 90% of first suicide attempts happened rapidly after formation of ideation, research into appropriate ways of providing social support to high-risk war veterans should be a top priority. The US Department of Defense, for example, has started instituting ways of screening for PTSD, comorbid psychiatric disorder, and other suicide risk factors in returning veterans, with a goal of decreasing growing suicidal activity observed in returning combat personnel and veterans [131].


Coping Mechanisms


Coping mechanisms modulate the symptoms of PTSD and can be exploited to reduce the risk of suicidal behavior associated with it. A study by Amira and colleagues [132] has shown that the risk of suicide was significantly associated with decreased use of minimization, replacement, and mapping psychological strategies and significantly related to increased suppression in patients diagnosed with PTSD, suggesting that diminished ability to deal with trauma and emotional impairment increases the risk of suicidal behavior. Solomon et al. [133] demonstrated that veterans who used more problem-solving and less emotion- and distance-based coping mechanisms were less likely to manifest symptoms of PTSD. Finally, an innovative study that looked at approximately 15,000 subjects demonstrated that trauma and PTSD can actually function as a coping strategy and reduce the risk of suicidal behavior [134], exemplifying a novel application of psychotherapy to treat the symptoms of PTSD and lower suicidal behavior.


Psychotherapy


Sareen et al. [135] has shown that military personnel exposed to combat trauma endorsed increased need for mental health service, such as counseling and therapy, and Shalev et al. [136] demonstrated that immediate and delayed prolonged exposure cognitive behavioral therapy (CBT) prevented PTSD in some traumatized patients. Jakupcak and Varra [137] recommend identifying veterans with PTSD at high risk for suicide and treating them with CBT, arguably the most popular psychotherapy technique currently employed in this patient population [138]. Refinement of the current and innovation of novel psychotherapeutic techniques to target the symptoms of PTSD, comorbid psychiatric conditions, and associated impairment, including suicidality, is a promising direction for future research. Psychodynamic psychotherapy, hypnotherapy, and eye movement desensitization and reprocessing [140] are all examples of psychotherapeutic techniques that hold a promise for patients with PTSD.


Pharmacology in PTSD


As discussed by Chen and colleagues [27], immediate psychopharmacological intervention might mitigate some aspects of the psychiatric impairment associated with trauma exposure and PTSD, including suicidal behavior. Numerous studies have supported the use of selective serotonin reuptake inhibitors (SSRIs) in treating the symptoms of PTSD and associated psychiatric morbidities, and the Federal Drug Administration (FDA) has even approved two members of its class, fluoxetine and paroxetine [139140, 143]. Nagy et al. [144], for example, has demonstrated that fluoxetine is efficacious in reducing PTSD symptoms of reexperiencing, avoidance, and hyperarousal, and Zohar et al. [145] have shown sertraline to be effective in reducing anger and emotional dysregulation in combat-traumatized PTSD veterans. Data on efficacy of SSRIs in PTSD has been inconsistent, however. For example, Martenyi and colleagues [146] suggested that fluoxetine might not be efficacious in veteran with PTSD, and Shalev and colleagues [136] demonstrated that escitalopram might not be useful in preventing PTSD symptoms in traumatized patients. Finally, a small study using only male subjects, by Hetzberg and colleagues [82], did not find fluoxetine to be more effective than placebo in reducing symptoms of PTSD in combat veterans.

Other classes of antidepressants have demonstrated some efficacy in reducing symptoms of PTSD, including in combat veteran populations, but unfavorable side effects make these medications less popular than SSRIs [139, 142, 147]. Similarly, antipsychotics, anticonvulsants, and benzodiazepines are not commonly employed on long-term basis due to an unclear cost-benefit analysis of these medications [141, 148]. Scarcity of data on pharmacological interventions in combat-traumatized PTSD patients should fuel a search for novel biological targets for psychotropic agents such as monoamine, glutamate and endocannabinoid neurotransmitter systems, neuropeptides, and components of the HPA axis as well as other neuroactive endocrine factors [14, 147151]. Successful treatment of PTSD may reduce suicidality in patients with PTSD.


Conclusion


Nationally managed mental health-care access for the military personnel and veterans traumatized in combat can improve the quality of life and reduce suicidal behavior in this patient population [152]. Keuhn correctly noted that the cultural and logistical barriers in the military often impede proper mental health-care delivery to a patient population, often with complex psychiatric presentation [13]. Zamorsky et al. [153] emphasized proper screening, improvement of mental health recourses, and awareness of psychological problems as the fundamental tactics in decreasing suicidality among military personnel and veterans. “The Joshua Omvig Veterans Suicide Prevention Act” of 2007 [126] and the US House of Representatives Committee on Veterans’ Affairs [154] acknowledged the issue of the increasing suicidal behavior and its relationship to PTSD and offered several sensible approaches to stabilizing the worrisome trend of increasing rate of death from suicide in the military. Screening for psychiatric symptoms before, during, and post-deployment, training staff, increasing regular and emergency mental health-care access, and educating families and friends of veterans and active duty personnel on the risk factors of suicide are all examples of innovative approaches the military is undertaking in order to tackle the growing problem of self-destructive behavior in its ranks (see Table 8.3).
Feb 25, 2018 | Posted by in PSYCHOLOGY | Comments Off on Suicidal Behavior in Posttraumatic Stress Disorder: Focus on Combat Exposure

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