Anger Mediates the Relationship Between Posttraumatic Stress Disorder and Suicidal Ideation in Veterans

TRANSLATING RESEARCH INTO PRACTICE (TRIP) REPORT

Military REACH’s review of ANGER MEDIATES THE RELATIONSHIP BETWEEN POSTTRAUMATIC STRESS DISORDER AND SUICIDAL IDEATION IN VETERANS

Dillon, K. H., Van Voorhees, E. E., Dennis, P. A., Glenn, J. J., Wilks, C. R., Morland, L. A., Beckham, J. C., & Elbogen, E. B. (2020). Anger mediates the relationship between posttraumatic stress disorder and suicidal ideation in veterans. Journal of Affective Disorders, 269, 117-124. https://doi.org/10.1016/j.jad.2020.03.053

BRIEF SUMMARY: Experiencing posttraumatic stress disorder (PTSD) symptoms increases one’s risk for suicide, but the nature of the association between PTSD symptoms and suicidal ideation for Veterans is less understood. The fluid vulnerability theory of suicide suggests that acute risk factors, such as the sudden triggering of anger, may increase suicidal ideation. In particular, aggressive impulses (i.e., urges to engage in physically destructive behavior) and difficulty managing anger (i.e., struggle to calm down or control one’s behavior when upset) are components of anger that may explain the association between PTSD symptoms and suicidal ideation. The interpersonal-psychological theory of suicide also supports the proposed influence of anger in suicidal ideation, as anger may trigger feelings of being a burden or a lack of social connection that may lead to increased suicidal ideation. Longitudinal data from post-9/11-era Veterans (N = 298) collected at three waves (baseline, six-month follow-up, 12-month follow-up) were used to analyze how anger may explain the connection between PTSD symptoms and suicidal ideation. The results indicated that anger partially explained the association between PTSD symptoms and suicidal ideation, even after accounting for Veterans’ demographic characteristics and depressive symptoms.

KEY FINDINGS – PTSD symptoms, depressive symptoms, and anger were all significantly associated with suicidal ideation at all three waves. – Aggressive impulses were the most significant predictor of suicidal ideation at baseline, whereas the most significant predictor of suicidal ideation at the six- and 12-month follow-up periods was depressive symptoms. – Increased PTSD symptoms were associated with concurrent increases in anger across each wave. These increases in anger linked PTSD symptoms at baseline and six-month follow-up with higher levels of suicidal ideation at six- and 12-month follow-ups, respectively. – Increased PTSD symptoms were associated with stronger aggressive impulses and increased difficulty in managing anger. However, only the increase in aggressive impulses was associated with higher levels of suicidal ideation.

IMPLICATIONS FOR FAMILIES – Work together as a family to learn anger management skills, such as practicing mindfulness, meditation, and healthy conflict management strategies.

IMPLICATIONS FOR HELPING PROFESSIONALS – Include assessments of anger and aggression when screening Veterans for suicide risk, as these may be time-sensitive markers of suicide risk. – Help Veterans battling PTSD manage aggressive impulses to address suicide risk.

IMPLICATIONS FOR POLICY MAKERS AND MILITARY LEADERSHIP – Expand military and Veteran health insurance to cover interventions that include distress tolerance, emotion regulation, and anger management so that Service members and Veterans may access necessary resources to manage their PTSD-related emotions.

www.MilitaryREACH.org | 334.844.3299 | [email protected] SAMPLE CHARACTERISTICS 298 post-9/11-era Veterans at baseline; 198 (66.4%) completed the 12-month follow up survey 22 to 67 years old, with a mean age at baseline of 39.9 Most participants were male (83.5%). 52.7% identified as African American, and 39.2% identified as Caucasian. METHODOLOGY – Secondary data were analyzed from a larger, three-wave longitudinal study. Participants were post-9/11- era Veterans who were recruited via advertisements, mailings to Veterans Affairs (VA)-registered Veterans, clinical referrals, and a VA study database. Data were collected at baseline (wave 1), a six-month follow up (wave 2), and a 12-month follow up (wave 3). Study participants were offered compensation at each data collection period. – Participants completed self-report measures of posttraumatic stress disorder (PTSD), anger, suicidal ideation, and depressive symptoms at the Durham VA Healthcare System at each wave of data collection. – Bivariate correlations were computed to examine the associations between the baseline variables and suicidal ideation at both six- and 12-month follow-ups. – Multilevel structural equation models examined anger as a mediator between PTSD (at the same time point as anger) and suicidal ideation at six-month intervals (baseline to six-month follow-up and six- month follow-up to 12-month follow-up). STRENGTHS – This study’s hypotheses were informed by both the fluid vulnerability theory of suicide and the interpersonal-psychological theory of suicide. Through these theoretical frameworks, this study was able to develop a more nuanced explanation of suicide risks for Veterans. – The use of longitudinal data allows for the identification of the order in which PTSD, anger, and suicidal ideation interact over time. LIMITATIONS – This study only assessed suicidal ideation, not suicidal behavior, so the association between anger and Veterans’ actual suicide attempts cannot be inferred from the findings. – The sample consisted mostly of males and overrepresented racial minority groups, thus indicating that the sample may not be representative of the military population overall, which limits the generalizability of the findings.

ASSESSMENT OF THE STUDY CREDIBLE

CONTRIBUTORY

COMMUNICATIVE CAUTIONARY ADEQUATE COMMENDABLE EXEMPLARY

DIMENSIONS OF ASSESSMENT ADDITIONAL INFORMATION — CREDIBLE: Research that is rigorous, transparent, consistent, Underlined terms in red font are linked to the definition in the and generalizable. This dimension reflects an evaluation of the Military REACH Dictionary. To explore more terms visit: https:// study’s scientific methodology. militaryreach.auburn.edu//DictionaryResult. Terms in blue font — CONTRIBUTORY: Research that is original, applicable, and has are linked to additional resources. the potential to enhance the well-being of military families. This dimension examines the impact of the study. PARTNERSHIP — COMMUNICATIVE: Research that is coherent, understandable, This work is result of a partnership funded by the Department and readable. This dimension assesses how effectively the of Defense (DoD) between the DoD’s Office of Military Family authors convey the content of the study. Readiness Policy and the U.S. Department of Agriculture/National * These dimensions are adapted from the work of Mårtensson Institute of Food and Agriculture (USDA/NIFA) through a grant/ et al. (2016). For more information on the REACH evaluation cooperative agreement with Auburn University. USDA/NIFA Award framework and rubric visit: MilitaryREACH.org No. 2017-48710-27339, PI, Mallory Lucier-Greer.

HUMAN SCIENCES