DEPRESSION AND ANXIETY 27 : 1001–1005 (2010) Research Article DOES PTSD MODERATE THE RELATIONSHIP BETWEEN SOCIAL SUPPORT AND SUICIDE RISK IN IRAQ AND AFGHANISTAN WAR VETERANS SEEKING MENTAL HEALTH TREATMENT? Matthew Jakupcak, Ph.D.,1,2 Steven Vannoy, Ph.D.,2 Zac Imel, Ph.D.,1,2 Jessica W. Cook, Ph.D.,3 Alan Fontana, Ph.D.,4,5 Robert Rosenheck, M.D.,4,5 and Miles McFall, Ph.D.1,2 Objective: This study examined posttraumatic stress disorder (PTSD) as a potential moderating variable in the relationship between social support and elevated suicide risk in a sample of treatment-seeking Iraq and Afghanistan War Veterans. Method: As part of routine care, self-reported marital status, satisfaction with social networks, PTSD, and recent suicidality were assessed in Veterans (N 5 431) referred for mental health services at a large Veteran Affairs Medical Center. Logistic regression analyses were conducted using this crosssectional data sample to test predictions of diminished influence of social support on suicide risk in Veterans reporting PTSD. Results: Thirteen percent of Veterans were classified as being at elevated risk for suicide. Married Veterans were less likely to be at elevated suicide risk relative to unmarried Veterans and Veterans reporting greater satisfaction with their social networks were less likely to be at elevated risk relative to Veterans reporting lower satisfaction. Satisfaction with social networks was protective for suicide risk in PTSD and non-PTSD cases, but was significantly less protective for veterans reporting PTSD. Conclusions: Veterans who are married and Veterans who report greater satisfaction with social networks are less likely to endorse suicidal thoughts or behaviors suggestive of elevated suicide risk. However, the presence of PTSD may diminish the protective influence of social networks among treatment-seeking Veterans. Depression and Anxiety 27:1001–1005, 2010. Published 2010 Wiley-Liss, Inc.y Key words: suicide; social support; PTSD; Iraq; Afghanistan INTRODUCTION Recent findings suggest that returning Veterans of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) who are diagnosed with psychiatric 1 VISN 20 Northwest Mental Illness Research, Education, and Clinical Center, Seattle, Washington 2 Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington 3 Center for Tobacco Research and Intervention, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin 4 VISN 1 New England Mental Illness Research, Education, and Clinical Center, New England 5 Yale University School of Medicine, New Haven, Connecticut Published 2010 Wiley-Liss, Inc. Correspondence to: Matthew Jakupcak, Deployment Health Clinic, Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108. E-mail: matthew.jakupcak@va.gov The authors report they have no financial relationships within the past 3 years to disclose. This work was performed at VA Puget Sound Health Care SystemSeattle Division. y This article is a US Government work and, as such, is in the public domain in the United States of America. Received for publication 19 February 2010; Revised 27 May 2010; Accepted 29 May 2010 DOI 10.1002/da.20722 Published online 18 August 2010 in Wiley Online Library (wiley onlinelibrary.com). 1002 Jakupcak et al. disorders are at increased risk for suicide.[1] The onset of suicidal ideation or attempting suicide may represent preliminary steps toward completed suicide.[2] Hence, active suicidal ideation or recent suicide attempts are often used as markers of elevated suicide risk.[3–8] To prevent suicides, it is critical to identify and understand the risk and protective factors for elevated suicide risk among OEF/OIF Veterans with mental disorders. The positive association between social support and mental health functioning is well established[9,10] and the presence of social support is inversely related to risk for suicidality.[11–13] Support drawn from social networks (spouses, family members, and friendships) may buffer psychological distress in persons with mental disorders,[9,10] thus decreasing risk for suicide.[11] Prior research indicates that marital status is protective for suicide in community samples of Veterans[14,15] and Veterans recently discharged from inpatient psychiatric care are less likely to complete suicide if they reside in a cohesive community.[16] A recent study found that in a community sample of OEF/OIF Veterans, PTSD was associated with an increased risk for suicidal ideation while post-deployment social support was protective for suicidal ideation.[17] Although social support may be protective for suicide risk in OEF/OIF Veterans, the presence of PTSD may influence how individuals interact within social networks to cope with stressors, thus mitigating the protective mechanisms of social support. Prior research suggests that Veterans with PTSD are more likely to seek out social support than Veterans without PTSD; however, Veterans with PTSD are also less likely to use active problem solving and may instead rely on maladaptive coping strategies, such as emotional avoidance or self-blame that can decrease the benefit of close relationships.[18,19] Accordingly, although Veterans with PTSD may have access to social support, they may be less likely to benefit from it. The purpose of this study was to examine whether PTSD diminishes the buffering effects of social support on elevated suicide risk in OEF/OIF Veterans seeking mental health treatment. We tested a moderation model, in which marital status and satisfaction with social networks were hypothesized to be less protective for suicide risk among OEF/OIF Veterans reporting PTSD relative to Veterans without PTSD. METHOD The majority of the subjects were men (88.9%) and the average age was 32.4 years (SD 5 8.95). Two thirds of the sample indicated race/ ethnicity as White (66.4%), 11% African-American, 6.8% Hispanic, 6% Native American or Pacific Islander, 4.2% Asian, and 5.6% indicated ‘‘other.’’ More than half of the sample (56.4%) indicated they were applying for service-connected disability and 10.7% indicated they were currently service-connected for PTSD. The majority of the subjects were not married (55.5%) while 44.5% indicated they were married or remarried. MEASURES Veterans were assessed using the Veteran Affairs Military Stress Treatment Assessment (VAMSTA),[19] a multi-measure assessment packet used to assess pre- and post-treatment functioning for Veterans referred for treatment of military-related traumatic stress. The VAMSTA includes a number of well-established self-report instruments and has demonstrated good internal and test–retest reliability.[20] Each of the measures used in this study (described below) are included in the VAMSTA. The military version of the posttraumatic checklist (PCL-M)[21] was used to assess PTSD. Screening criteria for PTSD required a PCL-M global score of 50 and the presence of the symptoms endorsed at a moderate or high levels across the three symptom clusters per the DSM-IV algorithm for diagnosing PTSD. Marital status (married/unmarried) and ratings of satisfaction with social networks were used as measures of social support. Both marital status and subjective ratings of satisfaction with social relationships have been shown to influence clinical outcomes in trauma-exposed populations.[22] Satisfaction with social networks was measured using three items drawn from the Quality of Life Interview.[23] Items ask respondents to rate their satisfaction (1 5 Terrible, 2 5 Unhappy, 3 5 Mostly Dissatisfied, 4 5 Mixed, 5 5 Mostly Satisfied, 6 5 Pleased) in three domains of their social networks: (1) amount of time spent with other people, (2) quality of relationships with family members, and (3) amount of friendship in life. We created an operational definition for elevated suicide risk, based on the report of recent active and/or frequent suicidal ideation or a recent suicide attempt. Current suicidal ideation was assessed using three items drawn from the Scale for Suicidal Ideation (SSI).[24] The three items from the SSI asked respondents to rate, within the past month: (1) their desire to make an active suicide attempt (1 5 no desire, 2 5 weak desire, 3 5 moderate-to-strong desire), the frequency of suicidal ideation (1 5 never, 2 5 rarely/occasionally, 3 5 off and on, 4 5 persistently or continuously), and control over suicidal ideation (1 5 no thoughts of suicide, 2 5 sure of control over attempting, 3 5 unsure of control over attempting, 4 5 no sense of control over attempting). A single yes/no item in the VAMSTA asked respondents if they had made a suicide attempt in the 4 months before seeking VA care. Veterans were classified in the elevated suicide risk group if they indicated a score of 3 or more on any of the SSI items suggestive of active or prominent suicidal ideation or if they endorsed a recent suicide attempt. PARTICIPANTS DATA ANALYSIS The sample was drawn from OEF/OIF Veterans (N 5 466) who were consecutively assessed and subsequently referred for mental health services at VA Puget Sound Health Care System (VAPSHCS) from 2004 to 2007. Cases that were missing key variables were omitted (n 5 35), resulting in a final sample of 431 participants. The study protocol included a waiver of informed consent to use de-identified clinic data and was approved by the University of Washington Internal Review Board and the Research and Development Committee of VAPSHCS. We used SPSS Version 13 and conducted preliminary chi-square tests, Spearman’s rho correlation, and analyses of variance for categorical and continuous variables in order to identify potential covariates. Thirteen percent (n 5 56) of the sample were classified as being at elevated suicide risk. There were no significant associations between sociodemographic variables (i.e., gender, age, race/ethnicity, years of education, disability-seeking status) and elevated suicide risk. Surprisingly, we found no significant association between marital status and Veteran’s ratings of satisfaction with their social networks, Depression and Anxiety Research Article: Does PTSD Moderate the Relationship? r 5 –0.003, P4.50. Veterans who were unmarried (n 5 239) were no more likely to screen positive for PTSD than were married Veterans (n 5 192), Wald 5 0.71, P 5.398, OR 5 1.17. However, Veterans in the PTSD group (n 5 214) reported significantly less satisfaction with their social networks (M 5 3.7, SD 5 1.13) relative to Veterans in the non-PTSD group (n 5 217) (M 5 4.9, SD 5 1.09), F(1,429) 5 141.2, Po.001). Logistic regression analysis was planned to test the hypothesis that PTSD status moderates the relationship between social support and elevated suicide risk. As the marital status and satisfaction with social networks variables were not significantly interrelated, we conducted two separate hierarchical logistical regression models following methods recommended for testing for moderation and interpreting interaction effects.[25,26] Main effect variables are entered into the first step of a regression model and the interaction terms are entered into the second step. Specifically, PTSD and marital status were entered into the first step of the model predicting group classification for elevated suicide risk and the interaction term (Marital Status  PTSD) was entered into the second step of the regression model. A second regression model was conducted to test for moderation using satisfaction with social networks. The satisfaction variable was centered and standardized using a Z-score transformation and entered into the first step of the model with PTSD; the interaction term (Satisfaction with Social Networks  PTSD) was entered into the second step of the model. RESULTS The results of the two regression models testing moderation are presented in Table 1. In the first step of the Model 1, both marital status and PTSD were significantly related to elevated suicide risk. Veterans reporting PTSD were more likely to be classified in the elevated suicide risk group relative to non-PTSD Veterans, whereas married Veterans were 53% less likely to be in the elevated suicide risk group relative to unmarried Veterans. However, the interaction term (Marital Status  PTSD) did not significantly predict group classification for elevated suicide risk (see Table 1). Accordingly, marital status did not differentially protect against elevated suicide risk in Veterans with and without PTSD. TABLE 1. Logistic regression models showing predictors of elevated suicide risk Wald’s Z Model 1 (marital status) PTSD 31.28 Marital status 6.32 PTSD 22.35 Marital status 1.40 PTSD  Marital Status 0.27 Model 2 (satisfaction with social networks) PTSD 14.38 Social networks 14.01 PTSD 14.59 Social networks 10.75 PTSD  Social Network 4.74 Po.05; Po.01. OR CI (95%) 11.98 0.47 10.46 0.27 1.82 5.02–28.59 0.26–0.85 3.95–27.69 0.03–2.35 0.19–17.28 5.29 0.51 9.37 0.18 3.38 2.36–14.85 0.36–0.73 2.97–29.51 0.06–0.50 1.13–10.10 1003 In the first step of Model 2, both PTSD and satisfaction with social networks were significantly associated with elevated risk for suicide. Veterans reporting satisfaction ratings one standard deviation above the mean were 49% less likely to be classified in the elevated suicide risk group. In the second step of Model 2, the interaction term was a significant predictor of elevated suicide risk. Simple effects analyses showed that satisfaction with social networks was less protective for suicide risk in the PTSD group (OR 5 0.61, Po.01) relative to the non-PTSD group (OR 5 0.20, Po.01). A one standard deviation increase in satisfaction ratings corresponded to a 39% reduction in the likelihood of being classified in the elevated suicide risk group in Veterans reporting PTSD compared to the 80% decrease in likelihood observed in the non-PTSD group. DISCUSSION Marital status and Veterans’ ratings of satisfaction with social networks were independently protective for suicide risk in this sample of OEF/OIF Veterans referred for mental health services. As predicted, satisfaction with social networks reduced suicide risk in OEF/OIF Veterans, but was less protective for Veterans reporting symptoms of PTSD. The presence of PTSD in OEF/OIF Veterans may interfere with how Veterans utilize social networks, thus lessening the beneficial effects of social support. Further research is needed to explore specific help-seeking and interpersonal coping behaviors associated with PTSD to elucidate the mechanisms through which PTSD impacts use of social support. However, the current findings suggest that clinicians addressing PTSD should not overrate the protective aspect of social networks. Not only are OEF/OIF Veterans with PTSD likely to be less satisfied with their social networks, it seems their satisfaction has less impact on distress evidenced by suicide ideation and/or recent suicide attempts. Clinicians are encouraged to introduce interpersonal skills training and promote Veterans’ positive engagement in their social networks,[27] especially among OEF/OIF Veterans who report limited or strained social support. We did not find support for our hypothesized moderation model when examining the interaction between PTSD and marital status. Regardless of PTSD status, married Veterans may benefit from a live-in spouse who can readily provide assistance addressing psychosocial stressors, thus preventing the onset of suicidal thoughts or behaviors. Surprisingly, we found no association between marital status and satisfaction with social networks, perhaps suggesting that the instrumental support offered by spouses is protective for suicide risk through mechanisms independent of subjective relationship satisfaction. Marital status may also represent a perceived sense of responsibility for Depression and Anxiety 1004 Jakupcak et al. others that protects OEF/OIF Veterans from suicidal impulses, irrespective of PTSD. Future research is needed to explore the ways in which objective and subjective features of social support interrelate in OEF/ OIF Veterans. The current findings should be considered within the context of study limitations. First, this study relied on self-report measures in a treatment-seeking sample. Veterans may have either minimized or inflated reports of specific symptoms due to stigma or compensation seeking. Thus, these results may not generalize to nontreatment-seeking OEF/OIF Veterans. Second, the data used for this study is cross-sectional, and causal relationships between PTSD, social support, and risk for future suicidal behaviors cannot be assumed. Although we found partial support for our proposed moderation model, it is also plausible that symptoms of PTSD contribute to a Veteran’s progressive strain on social relationships,[28–30] thus increasing Veterans’ social withdrawal and perceived burden on others, markers of risk that can portend suicide.[31] Alternatively, hereditary factors may inform a biological vulnerability in each domain, such that individuals who are predisposed to develop PTSD following traumatic life events are also predisposed to experience interpersonal difficulties or suicidal ideation. Largescale prospective studies are needed to further test moderation and meditational models to determine the longitudinal course of PTSD, social support, and suicide risk in OEF and OIF Veterans. Finally, we relied on marital status and single-item ratings of satisfaction specific to social access (i.e., time spent with other people), and the amount and quality of friendships and family relationships. Because social support is a complex construct with multifaceted features,[9,10,32] future research should use comprehensive measures of social integration and objective and subjective appraisals of social support to identify mechanisms that may inform elevated suicide risk in OEF and OIF Veterans with mental health concerns. CONCLUSIONS Iraq and Afghanistan War Veterans, who are married and report greater satisfaction with their social support networks, are less likely to endorse thoughts or behaviors suggestive of elevated suicide risk. Although protective for suicide risk in Veterans with and without PTSD, the buffering effects of social networks may be less pronounced in Veterans reporting symptoms of PTSD. Clinicians should assess for satisfaction with social networks and consider promoting positive interpersonal coping skills and greater social integration, especially for Veterans with PTSD. Veterans’ friends and family members should be educated to detect warning signs of suicide and be informed of VA and community mental health resources in order to prevent Veteran suicide. Depression and Anxiety Acknowledgments. This material is the result of work supported by resources from the VA Puget Sound Health Care System, Seattle, Washington. Conflict of Interest: The authors declare there are no conflicts of interest. REFERENCES 1. Kang HK, Bullman TA. Risk of suicide among US Veterans after returning from the Iraq and Afghanistan War zones. J Am Med Assoc 2008;300:652–653. 2. Stillion JM, McDowell EE. 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However, users may print, download, or email articles for individual use. Journal of Traumatic Stress April 2014, 27, 244–248 BRIEF REPORT Traumatic Brain Injury, PTSD, and Current Suicidal Ideation Among Iraq and Afghanistan U.S. Veterans Blair E. Wisco,1,2 Brian P. Marx,1,2 Darren W. Holowka,1,2 Jennifer J. Vasterling,1,2 Sohyun C. Han,1 May S. Chen,1 Jaimie L. Gradus,1,2,3 Matthew K. Nock,4 Raymond C. Rosen,5 and Terence M. Keane1,2 1 National Center for PTSD at VA Boston Healthcare System, Boston, Massachusetts, USA Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA 3 Department of Epidemiology, Boston University School of Public Health, Boston Massachusetts, USA 4 Department of Psychology, Harvard University, Cambridge, Massachusetts, USA 5 New England Research Institutes, Watertown, Massachusetts, USA 2 Suicide is a prevalent problem among veterans deployed to Iraq and Afghanistan. Traumatic brain injury (TBI) and psychiatric conditions, such as posttraumatic stress disorder (PTSD), are potentially important risk factors for suicide in this population, but the literature is limited by a dearth of research on female veterans and imprecise assessment of TBI and suicidal behavior. This study examined 824 male and 825 female U.S. veterans who were enrolled in the baseline assessment of the Veterans After-Discharge Longitudinal Registry (Project VALOR), an observational registry of veterans with and without PTSD who deployed in support of the wars in Iraq and Afghanistan and were enrolled in the Veterans Affairs healthcare system. Results indicated that current depressive symptoms, PTSD, and history of prior TBI were all significantly associated with current suicidal ideation (Cohen’s d = 0.91, Cramers’ Vs = .19 and .08, respectively). After adding a number of variables to the model, including psychiatric comorbidity, TBI history was associated with increased risk of current suicidal ideation among male veterans only (RR = 1.55). TBI is an important variable to consider in future research on suicide among veterans of the wars in Iraq and Afghanistan, particularly among male veterans. Suicide occurs at an alarming rate among Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) veterans (LeardMann et al., 2013). Suicidal ideation is a primary target of the Department of Veterans Affairs’ (VA) suicide screening efforts. A better understanding of factors associated with suicidal ideation among OEF/OIF/OND veterans accessing VA services is critically important to informing suicide prevention. Posttraumatic stress disorder (PTSD), depression, and substance abuse are well-established risk factors for suicidal ideation among OEF/OIF veterans (Pietrzak et al., 2010). Traumatic brain injury (TBI), a “signature injury” of OEF/OIF, may confer further risk. Although small studies suggest that the association between TBI and suicidal behavior is explained by comorbid PTSD (Barnes, Walter, & Chard, 2012), a large study of veterans found that TBI predicted suicide, even after adjusting for psychiatric comorbidity (Brenner, Ignacio, & Blow, 2011). Importantly, there is comparatively little research on suicidal behavior among women veterans, a growing yet understudied group. Female veterans are a vulnerable population who are at increased suicide risk relative to female civilians (McCarthy et al., 2009). The association between TBI and suicidal ideation may be particularly important among female veterans, as women who serve in the military are at increased risk of TBI relative to female civilians (Tanielian & Jaycox, 2008). This study examined associations between current suicidal ideation and self-reported TBI history, lifetime PTSD, and other deployment-related factors in a large sample of male and female OEF/OIF/OND veterans accessing VA mental health care. We hypothesized that suicidal ideation would be associated with TBI history, psychiatric conditions, combat and Dr. Wisco is now at the University of North Carolina at Greensboro. Funding was provided by the U.S. Department of Defense Awards W81XWH08-2-0100 and W81XWH-08-2-0102. Dr. Wisco was supported by Award Number T32MH019836 from the National Institute of Mental Health. The funding organizations for this study had no role in the design or conduct of the study; in the collection, management, analysis, and interpretation of the data or in preparation, review, or approval of the manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Department of Defense, Department of Veterans Affairs, or the National Institute of Mental Health. Correspondence concerning this article should be addressed to Brian P. Marx, National Center for PTSD, VA Boston Healthcare System, 150 South Huntington Ave., 116B-4, Boston, MA 02130. E-mail: brian.marx@va.gov 2014. This article is a US Government work and is in the public domain in the USA. View this article online at wileyonlinelibrary.com DOI: 10.1002/jts.21900 244 245 TBI, PTSD, and Suicidal Ideation in OEF/OIF/OND Veterans postbattle experiences, and lower levels of postdeployment social support. We further hypothesized that TBI history would be related to suicidal ideation even after adjusting for psychiatric comorbidity. Finally, we predicted that similar risk and protective factors would be observed for female and male veterans. Method Participants and Procedure Participants were United States Army or Marine veterans enrolled in the baseline assessment of the Veterans AfterDischarge Longitudinal Registry (Project VALOR), a registry of VA mental health care users with and without PTSD who deployed in service of OEF/OIF/OND (Rosen et al., 2012). Veterans with probable PTSD according to medical records were oversampled at a 3:1 ratio to create the PTSD registry; women (underrepresented among veterans) were sampled at a 1:1 ratio. Potential participants (n = 4,391) were contacted by phone; 2,712 (61.8%) consented to participate. Of consented participants, 1,649 completed questionnaires online or by mail and a telephone interview with a doctoral-level clinician (1,214 with probable PTSD and 436 with no PTSD, according to administrative records), yielding a response rate of 37.6%. Responders were slightly older (M = 38.50 years, SD = 9.74) than nonresponders (M = 35.79 years, SD = 9.73; t(4,389) = 8.94, p < .001, Cohen’s d = 0.28) and more likely to be Caucasian (56.0% vs. 48.9%, respectively, χ2 (4, N = 4391) = 40.60, p < .001, Cramer’s V = .09). There was no difference in military branch, χ2 (1, N = 4,391) = 1.73, p = .188, Cramer’s V = .02). To ensure safety, 42 participants at high suicide risk (total score > 17 on measure described below) were excluded. All procedures were approved by the VA Boston Healthcare System Institutional Review Board. Measures Age and sex were derived from participants’ medical record. Ethnicity and race were obtained by self-report. A modified Deployment Risk and Resilience Inventory (DRRI; King, King, Vogt, Knight, & Samper, 2006) was used to assess combat intensity (16-item combat experiences scale), other warzone stressors (16-item postbattle experiences scale), and social support (15-item postdeployment social support scale). TBI history was assessed using structured interview questions reflecting current classification standards (American Congress of Rehabilitation Medicine, Head Injury Interdisciplinary Special Interest Group, 1993). Participants were asked if they ever had a head injury or blast exposure that led to altered consciousness, memory loss, seizures, or brain surgery. If so, up to five injuries were queried. For each injury, participants were asked when the injury occurred, whether it occurred during deployment, whether they were “dazed, confused, or seeing stars” (altered mental state) immediately afterwards, presence and duration of loss of consciousness, whether they could recall the event immediately afterwards, and how long after the injury they began remembering new things (posttraumatic amnesia). Participants were classified as having probable TBI if they reported at least one head injury with either altered mental state, loss of consciousness, or posttraumatic amnesia. For additional analyses, participants were further classified according to these TBI characteristics: (a) number, (b) loss of consciousness, (c) single or multiple, (d) occurred on or off deployment, and (e) the number of months since the most recent TBI. One hundred interviews were coded for interrater agreement (κ = .97). PTSD diagnostic status for all participants was confirmed using the Structured Clinical Interview for DSM-IV, PTSD module (SCID; Spitzer, Williams, Gibbon, & First, 1992), a wellvalidated clinician administered interview. Interrater agreement among the three raters, based on a randomly selected subsample of 5% of interviews, was high (κs > .85). Lifetime PTSD status (any current or past PTSD diagnosis) determined by SCID was used in all analyses. The total score on the 8-item version of Prime-MD Patient Health Questionnaire (PHQ-8; Wells, Horton, LeardMann, Jacobson, & Boyko, 2013) was our measure of current depressive symptoms (Cronbach’s α = .90). The Alcohol Use Disorders Identification Test (AUDIT; Saunders, Aasland, Babor, Fuente, & Grant, 1993), a 10-item questionnaire (Cronbach’s α = .87), was used to classify participants with the suggested ranges of 8 to 16 for moderate and > 16 for high alcohol problems. The Mini-International Neuropsychiatric Interview, English version 5.0 (M.I.N.I., Sheehan et al., 1998) is a brief structured diagnostic interview assessing suicidality within the past month. Participants who endorsed any of four items assessing suicidal ideation were classified as ideators. Data Analysis We conducted χ2 analyses and t tests examining whether those with and without suicidal ideation differed on variables of interest. We then conducted multivariate Poisson regressions predicting suicidal ideation status using a hierarchical approach; the first multivariate model included demographics, the second model added combat and postbattle experiences, and the third model included all variables. To examine possible gender differences, these three multivariate models were conducted in the full sample and separately among males and females, yielding a total of nine analyses. As a sensitivity analysis, multivariate regressions were repeated excluding participants reporting moderate-to-severe TBI (defined as at least one TBI with loss of consciousness > 30 minutes or posttraumatic amnesia > 24 hours). Complete data were not available for all variables; analyses were completed on all available data. Results Bivariate analyses are provided in Table 1. Hispanic ethnicity, PTSD, high levels of alcohol problems, TBI history, more Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies. 246 Wisco et al. Table 1 Characteristics of Veterans With and Without Current Suicidal Ideation Variable Female Hispanic Race White Black Asian AI/AN NH/PI Multiracial Lifetime PTSD Alcohol problems Moderate High TBI ࣙ 1 reported No LOC LOC Single Multiple Off deployment On deployment On/off deployment Age Combat experiences PB experiences PD social support Current depression Months since last TBI Combined No suicidal ideation n or M % or SD n or M % or SD 825 211 50.1 13.0 625 141 50.8 11.6 1238 261 15 18 5 61 1250 77.5 16.3 0.9 1.1 0.3 3.8 77.1 943 181 11 13 2 45 875 336 168 20.5 10.3 896 339 557 452 443 304 390 201 37.49 32.88 33.08 49.57 20.40 100.9 55.8 21.1 34.7 28.2 27.6 18.9 24.3 12.5 9.88 12.70 13.03 11.23 6.40 87.46 Suicidal ideation n or M % or SD V or d 200 70 48.0 17.2 .03 .07** .07 78.9 15.1 0.9 1.1 0.2 3.8 72.4 295 80 4 5 3 16 375 73.2 19.9 1.0 1.2 0.7 4.0 91.0 .19*** 248 104 20.3 8.5 88 64 21.2 15.4 .03 .12*** 643 251 392 342 300 221 288 133 36.98 32.36 32.65 50.91 19.08 99.98 53.5 20.9 32.6 28.5 25.0 18.4 24.0 11.1 9.84 12.62 12.99 11.06 6.16 88.77 62.6 21.8 40.8 27.2 35.4 20.5 25.2 16.8 9.86 12.83 13.09 10.81 5.38 83.62 .08** .05 .10** .04 .12*** .07* .06 .12*** 0.21*** 0.16** 0.13* 0.48*** 0.91*** 0.04 253 88 165 110 143 83 102 68 39.02 34.39 34.32 45.61 24.34 103.69 Note. AI/AN = American Indian/Alaska Native; NH/PI = Native Hawaiian/Pacific Islander; PTSD = posttraumatic stress disorder; TBI = traumatic brain injury; LOC = loss of consciousness; PB = postbattle; PD = deployment. Data on suicidal ideation were not available for two participants, who are excluded from this table. Ns ranged from 1,598 to 1,647 for the combined sample, 1,195 to 1,230 for individuals with no suicidal ideation, and 403 to 417 for individuals with suicidal ideation. Cramer’s V was used as the effect size index for continuous variables; Cohen’s d was used for categorical variables. Chi−square tests for alcohol variables reflect comparisons to the no alcohol control group; χ2 tests for the TBI variables reflect comparisons to the no TBI control group. *p < .05. **p < .01. ***p < .001. severe depressive symptoms, older age, greater exposure to combat and postbattle experiences, and lower levels of social support were associated with current suicidal ideation. There was no effect of gender on suicidal ideation. A history of multiple TBIs and TBI with loss of consciousness were more strongly associated with suicidal ideation than a history of a single TBI or TBI without loss of consciousness. Multivariate Poisson regression (Table 2) revealed that, after adjusting for effects of other variables, risk of suicidal ideation higher among veterans with more severe depressive symptoms and with PTSD diagnoses, and among veterans of Hispanic ethnicity. In follow-up multivariate models stratified by gender, TBI was associated with significantly increased risk among men but not women. PTSD, depressive symptoms, and Hispanic ethnicity were associated with increased risk of suicidal ideation for men and women. The sensitivity analysis indicated that TBI associations remained the same when participants with moderate-to-severe TBI (n = 160, 17.8% of participants with TBI) were excluded. Discussion History of TBI, a common experience of veterans deployed in service of OEF/OIF/OND, emerged as a noteworthy correlate of current suicidal ideation. Specific TBI characteristics, loss of consciousness and multiple injuries, were associated with greater suicidal ideation risk at the bivariate level. After Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies. 247 TBI, PTSD, and Suicidal Ideation in OEF/OIF/OND Veterans Table 2 Hierarchical Multivariate Models Accounting for Suicidal Ideation among Males, Females, and Full Sample Male Variable Model 1: Demographics Gender (male) Age Hispanic Race Black Other Female Combined RR 95% CI RR 95% CI RR 95% CI – 1.01 1.43* [1.00, 1.02] [1.02, 1.99] – 1.02* 1.77* [1.01, 1.03] [1.32, 2.36] 1.06 1.01* 1.59* [0.97, 1.15] [1.01, 1.02] [1.27, 1.98] 1.37 1.14 [0.98, 1.92] [0.69, 1.88] 1.26 1.26 [0.95, 1.68] [0.82, 1.92] 1.30* 1.19 [1.05, 1.61] [0.86, 1.64] – 1.02* 1.78* [1.01, 1.03] [1.33, 2.39] 1.01 1.01* 1.62* [0.92, 1.11] [1.01, 1.02] [1.30, 2.03] 1.26 1.21 1.00 1.00 [0.94, 1.68] [0.78, 1.90] [0.99, 1.02] [0.99, 1.01] 1.27* 1.16 1.01 1.00 [1.02, 1.59] [0.82, 1.62] [1.00, 1.02] [0.99, 1.01] – 1.01 1.56* [1.00, 1.03] [1.14, 2.12] 1.09 1.01 1.52* [0.99, 1.19] [1.00, 1.02] [1.22, 1.89] 1.05 1.13 0.98 0.98 0.99 1.09* 1.85* [0.79, 1.40] [0.72, 1.78] [0.97, 1.00] [0.99, 1.01] [0.98, 1.00] [1.06, 1.11] [1.16, 2.94] 1.08 1.01 0.99 0.99 0.99 1.09* 2.00* [0.87, 1.34] [0.73, 1.41] [0.99, 1.00] [0.98, 1.00] [0.98, 1.00] [1.07, 1.11] [1.41, 2.83] 1.01 1.19 0.95 [0.72,1.42] [0.80, 1.77] [0.74, 1.22] 1.02 1.17 1.17 [0.83, 1.26] [0.98, 1.40] [0.98, 1.40] Model 2: Demographics and deployment-related stressors Gender (male) – Age 1.01 [1.00, 1.02] Hispanic 1.46* [1.04, 2.06] Race Black 1.30 [0.92, 1.84] Other 1.13 [0.67, 1.91] Combat experiences 1.01 [1.00, 1.03] Postbattle experiences 1.00 [0.99, 1.01] Model 3: All variables Gender (male) – Age 1.00 [0.99, 1.02] Hispanic 1.45* [1.05, 1.99] Race Black 1.18 [0.84, 1.64] Other 0.94 [0.58, 1.50] Combat experiences 1.00 [0.99, 1.01] Postbattle experiences 0.99 [0.98, 1.00] Postdeployment support 0.99 [0.98, 1.00] Depressive symptoms 1.10* [1.07, 1.12] PTSD 2.16* [1.29, 3.61] Alcohol problems Moderate 1.04 [0.79, 1.37] High 1.28 [0.95, 1.71] TBI 1.55* [1.16, 2.09] Note. RR = relative risk; CI = confidence interval; PTSD = posttraumatic stress disorder; TBI = traumatic brain injury. Models 1, 2, and 3 were each run three times: among males only, among females only, and in the combined sample. Confidence intervals not including one indicate statistical significance at α = .05. Age, combat experiences, postbattle experiences, postdeployment social support, and depressive symptoms were entered into the models as continuous variables. Prevalence ratios for alcohol variables reflect risk in reference to a no-alcohol control group; ratios for race reflect risk in reference to a White control group. adjusting for covariates, TBI was significantly associated with current suicidal ideation among male, but not female veterans. Our results do not explain why suicidal ideation is higher among veterans reporting prior TBI or whether the association is due to neural causes. One possibility is that TBI leads to cognitive deficits that impair cognitive control and mood regulation, although there is little evidence of long-lasting cognitive deficits in mild TBI (Vasterling et al., 2006). Nonetheless, these results indicate that TBI assessment may be important to include in future suicide screening research, particularly in male veterans. Consistent with prior research, depression, lifetime PTSD, high levels of alcohol problems, and low levels of social support were associated with current suicidal ideation at the bivariate level. After adjusting for covariates, depression and PTSD remained significantly associated with suicidal ideation. Key deployment-related factors (combat and postbattle experiences) were weakly related to suicidal ideation, and were not significant after adjusting for demographics. These findings suggest that assessment of combat exposure is less valuable than assessment of psychiatric conditions in determining suicide risk (LeardMann et al., 2013). Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies. 248 Wisco et al. Unfortunately, due to the observational and retrospective nature of our study, we cannot determine causal relationships. The generalizability of our findings is potentially limited by aspects of our sample, which was self-selected, restricted to deployed OEF/OIF/OND veterans seeking mental healthcare within VA, and excluded participants at highest suicide risk in the interest of safety. Finally, we did not verify TBI independently with eye witnesses or medical records, a limitation common in deployed samples. Strengths include the large sample of both female and male veterans and the use of structured interviews for assessment of TBI, PTSD, and suicidal ideation. Therefore, psychiatric disorders are important markers of suicidal ideation among both male and female OEF/OIF/OND veterans accessing VA mental health care. Among male veterans in this cohort, self-reported TBI is also an important suicidal ideation marker. Our results offer initial support for including TBI history, in addition to psychiatric history, in suicide risk assessment, especially for male veterans. References American Congress of Rehabilitation Medicine, Head Injury Interdisciplinary Special Interest Group. (1993). Definition of mild traumatic brain injury. Journal of Head Trauma Rehabilitation, 8, 86–87. doi:10.1097/00001199199309000-00010 McCarthy, J. F., Valenstein, M., Kim, H. M., Ilgen, M., Zivin, K., & Blow, F. C. (2009). Suicide mortality among patients receiving care in the Veterans Health Administration health system. American Journal of Epidemiology, 169, 1033–1038. doi:10.1093/aje/kwp010 Pietrzak, R. H., Goldstein, M. B., Malley, J. C., Rivers, A. J., Johnson, D. C., & Southwick, S. M. (2010). Risk and protective factors associated with suicidal ideation in veterans of Operations Enduring Freedom and Iraqi Freedom. Journal of Affective Disorders, 123, 102–107. doi:10.1016/ j.jad.2009.08.001 Rosen, R. C., Marx, B. P., Maserejian, N. N., Holowka, D. W., Gates, M. A., Sleeper, L. A., . . . Keane, T. M. (2012). Project VALOR: Design and methods of a longitudinal registry of post-traumatic stress disorder (PTSD) in combat-exposed veterans in the Afghanistan and Iraqi military theaters of operations. International Journal of Methods in Psychiatric Research, 21, 5–16. doi:10.1002/mpr.355 Saunders, J. B., Aasland, O. G., Babor, T. F., Fuente, J. R., & Grant, M. (1993). Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption-II. Addiction, 88, 791–804. doi:10.1111/j.13600443.1993.tb02093.x Sheehan, D. V., Lecrubier, Y., Sheehan, K, H., Amorim, P., Janavs, J., Weiller, E., . . . Dunbar, G. C. (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59, 22–33. Barnes, S. M., Walter, K. H., & Chard, K. M. (2012). Does a history of mild traumatic brain injury increase suicide risk in veterans with PTSD? Rehabilitation Psychology, 57, 18–26. doi:10.1037/a0027007 Spitzer, R. L., Williams, J. B., Gibbon, M., & First, M. B. (1992). The Structured Clinical Interview for DSM-III-R (SCID). I: History, rationale, and description. Archives of General Psychiatry, 49, 624–629. doi:10.1001/archpsyc.1992.01820080032005 Brenner, L. A., Ignacio, R. V., & Blow, F. C. (2011). Suicide and traumatic brain injury among individuals seeking Veterans Health Administration Services. Journal of Head Trauma Rehabilitation, 26, 257–264. doi:10.1097/HTR.0b013e31821fdb6e Tanielian, T., & Jaycox, L. H. (2008). Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica, CA: RAND Center for Military Health Policy Research. King, L. A., King, D. W., Vogt, D. S., Knight, J., & Samper, R. E. (2006). Deployment Risk and Resilience Inventory: A collection of measures for studying deployment-related experiences of military personnel and veterans. Military Psychology, 18, 89–120. doi:10.1207/s15327876mp1802_1 Wells, T. S., Horton, J. L., LeardMann, C. A., Jacobson, I. G., & Boyko, E. J. (2013). A comparison of the PRIME-MD PHQ-9 and PHQ-8 in a large military prospective study. Journal of Affective Disorders, 148, 77–83. doi:10.1016/j.jad.2012.11.052 LeardMann, C. A., Powell, T. M., Smith, T. C., Bell, M. R., Smith, B., Boyko, E. J., . . . , Hoge, C. W. (2013). Risk factors associated with suicide in current and former military personnel. Journal of the American Medical Association, 310, 496–506. doi:10.1001/jama.2013.65164 Vasterling, J. J., Proctor, S. P., Amoroso, P., Kane, R., Heeren, T., & White, R. F. (2006). Neuropsychological outcomes of army personnel following deployment to the Iraq War. Journal of the American Medical Association, 296, 519–529. doi:10.1001/jama.296.5.519 Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies. Copyright of Journal of Traumatic Stress is the property of John Wiley & Sons, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. Corridor Business Journal Jan. 1 - 7, 2018 17 COLUMN | HEALTH CARE Veteran suicide – a problem solved with community solutions As we enter the new year, the holidays are behind us and the gatherings with friends and family are receding into memories. Our vigilance about suicide, however, needs to remain sharp. People who struggle during the holiday season are still struggling today, many even more so. Veterans who have served our country with pride need our help now more than ever. It is time to know the signs of veterans in crisis and know how to help when the time comes. The VA is here to assist in that effort and we know that we cannot do it alone. This is a problem that will only be solved with the whole community involved. The U.S. Department of Veterans Affairs (VA) and the VA Health Care System in Iowa City are on a mission to end suicide among veterans in communities across America, including here in Eastern Iowa and Western Illinois. As a part of that, we have launched the #bethere campaign to connect communities with valuable resources for helping those in crisis. Approximately 14 of the 20 veterans who die by suicide each day are not receiving care from the Veterans Health Administration. We need your help to reach them. We invite you to share your insights, experiences and resources to shape public health initiatives that support veterans at risk. One veteran suicide is one too many. VA works with hundreds of organizations and corporations at the national and local levels, including veterans service organizations, local businesses and religious organizations, to raise awareness about suicide prevention programs. These partners have regular contact with veterans as well as active duty service members, One veteran suicide is one too many. reservists, National Guard members and their families. By reaching out to help, communities can send the message that they value these individuals and their service. Organized events are a great way for our partners to advance the critical national goal of ending veteran suicide. By promoting vet- eran-focused resources in your community at events such as job fairs and wellness expos, you can help us reach all veterans. Connecting with fellow veterans to spread the word about mental health and suicide prevention resources makes veteran wellness a community priority. If you are hosting a community event in your area, the VA would love to partner with you. Reach out to us at (319) 338-0581, ext. 7104 if you are interested in developing our partnership to #bethere for veterans and service members who are struggling. Veterans, family members and care providers can initiate a free and confidential conversation with an experienced and caring VA responder by calling the Veterans Crisis Line. If you are concerned about the safety and well-being of a veteran, call (800) 273-8255 and press 1. Chat online at VeteransCrisisLine.net/Chat to get support anonymously. A text message can also be sent to 838255 to connect to a VA responder. These resources can be used even if a veteran is not registered with VA or enrolled in VA health care. Veteran suicide is preventable, and suicide prevention is everyone’s business. Visit www. va.gov/nace/myVA/ or www.iowacity.va.gov for more information. • Judith Johnson-Mekota is director of the Iowa City VA Health Care System. COLUMN | CONSULTING Set a ‘HARD’ goal in 2018 Gale Mote is a trainer, organizational development catalyst and coach in Cedar Rapids. Contact her at galemote@ galemoteassociates.com I admit that I gave up on New Year’s resolutions a long time ago. I stuck with them for about 12 hours and then, like a rubber band, the forces of habit snapped me back to my comfort zone. Goal-setting is different than making a half-hearted commitment over a champagne toast. To really accomplish anything worthwhile, you need to have a goal – to know where you are going and why, and, most importantly, to know when you have arrived. Effective goals bring greater clarity to our decision-making. We have the courage to say “no” to what is not urgent or important, and to focus our time, energy and resources on activities that move us in the direction of the finish line. You’ve probably heard of setting SMART Goals: Specific, Measurable, Attainable, Relevant and Time Oriented. These are all classic principles important to incorporate into your goal-setting tool kit. I would like to offer another model from Mark Murphy and Leadership IQ called HARD Goals: Heartfelt, Animated, Required and Difficult. Let’s explore each in more detail. Heartfelt means that you really care about the goal – it’s important to you. Murphy says, “A HARD goal has to be something which promises you more value than any other goal imaginable and therefore you are not going to let anything get in the way of making it happen.” In the year ahead, what is something you want really badly? How passionate are you about this goal? Is it a nice-to-have or a must? Get passionate! Do you remember interviewing for your dream job? You practiced the interview questions. On the day of the interview, you stoked your brain with positive affirmations – “I am confident,” “I am an awesome fit for this role.” You could literally see yourself shaking hands with the interviewer and smiling as you walked away from the building, knowing the job was yours. Animation is making your goals come to life in your imagination. As an example, when Howard Schultz founded Starbucks, he visualized it as a “third place between work and home.” Steve Jobs referred to the iPod as “1,000 songs in your pocket.” To do this, you must first create a vision of what it will feel like to accomplish your goal. Then you need to animate it with a vivid mental picture that might include color, emotions, size, shape and movement. Finally, you need to write down what you imagine. Writing imprints in the brain and will reinforce the mental image you’ve created. Tomorrow is the killer for most goals. While it worked to keep little Orphan Annie optimistic, procrastination will not help you realize your goals. Required means exactly that – achieving your goal is a necessity, not an option. The anticipation of achieving the goal has to be so much more attractive that what you are doing today. Make a list of all the benefits of achieving the goal and bring them closer to you. Stay focused on them as you move confidently, one step at a time, in the direction of your vision. Change is not easy. There will be obstacles. Identify what might get in the way of you achieving your goal and think about how you will meet that challenge. Create a sense of urgency to keep the momentum. Difficult means setting a goal that will force you to tap into your inner strength and bring the best of yourself to the task at hand. Of course, you don’t want it to be so hard that you quit before you even start. Think about the accomplishments that you are most proud of in your life. Did they come easy or were they difficult to achieve? When you reach a HARD goal, you will say I gave it my all and it was worth it. I put in the time, made the sacrifices, paid the price and now I feel this tremendous sense of accomplishment. It’s a natural high. Best wishes for an amazing year ahead where your HARD goals become a reality! • Copyright of Corridor Business Journal is the property of Corridor Media Group and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. 
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