Issues & Insights on Context and Causes Related to Early Mortality due to Suicide and Self-harm Among Veterans – Lesson from Operation Deep Dive Operation Deep Dive (OpDD)

Presenter: Karl Hamner, PhD, OpDD Scientific Principal Investigator & Christopher M. Gill, OpDD Graduate Research Assistant, The University of Alabama College of Education

Grants/Research Support: Bristol-Myers Squibb Foundation Research Grant INTRODUCTION Agenda

OPERATION DEEP DIVE (OpDD) OVERVIEW

STATUS OF LITERATURE REVIEW AND THOUGHTS ON DIRECTIONS FOR FUTURE RESEARCH Why OpDD? Why Karl and Chris? Veteran Suicide Vignette: Case One

Joshua Markel, a Marine veteran: Joshua had been mentor for his fire team, had seemed unshakable in Afghanistan. Back home he appeared solid, had a job with a sheriff’s office, a new truck, was married and had time to hunt deer with his father. But one day, while watching football on TV with friends, he wordlessly went to his room, picked up a pistol and killed himself. He was 25. https://inmilitary.com/a-marine-unit-stalked-by-suicide-trying-to-save-itself/ Veteran Suicide Vignettes: Case Two

John Watts, a Navy veteran with a long history of homelessness and substance abuse who had been in and out of treatment with the US VA, went to the Georgia State Capital building wearing a vest lined with firecrackers and flammable devices, then doused himself with flammable liquid and lit the fireworks. A safety officer doused the flames; he died a week later from his injuries. He was 58. https://www.nbcnews.com/news/veterans/air-force-veteran-sets-himself-fire-protest-treatment-va-n886796 Veteran Suicide Vignettes: Case Three

Peter Kaisen, a Navy Veteran: Peter was a loving grandfather and he worked hard to ensure his daughters were well cared for. After serving in the military, he joined the police and received a serious back injury at work, leading to years of medication. He regularly went to his local VA for care. The last time he was seen alive he went to the VA emergency center and was turned away. He returned to his vehicle and shot himself. His family reported they thought he was suffering from depression, but had not been diagnosed or treated for it. He was 76. https://www.longislandpress.com/2016/08/26/northport-va-vet-suicide-life-of-love-devotion-ends-with-questions/ Urgency vs. Complexity

20 VETERAN SUICIDES A DAY!!! The urgency of prevention is real and drives our research. Yet the tyranny of urgency means we turn to reductionist answers in the hope of finding THE CURE, the elusive key to prevention. Yet our issues (suicide/early mortality and prevention) are deeply complex. Purpose of OpDD

 What is the connection between community and veteran suicide? • Four-year (2018-2021) community-based veteran suicide prevention study in 14 communities across the county • Conducted by America’s Warrior Partnership and The University of Alabama, funded by Bristol Myers-Squibb Foundation • Examines impact of community environments on veteran suicide/death from deliberate self-harm • Results will guide development of evidence-based programs for reducing suicide and self-harm among veterans OpDD Research Questions

 What is the impact of a less than honorable military discharge on the suicide/death from deliberate self-harm among veterans?  What is the relationship between military service experience and suicide/death from deliberate self-harm for all veterans to the suicide rate among veterans who are not receiving VA services?  What role do differences in community context and engagement play in preventing suicides and self-harm among those who have served?  Why do some former service members die from suicide/death from deliberate self-harm while others do not? The OpDD Team

Karl Hamner, PhD Phillip N. Smith, PhD Krystal Garcia The University of Alabama University of South Alabama America’s Warrior Partnership OpDD Scientific Principal Investigator OpDD Consultant & Suicide Research Expert Program Associate

Cheree Tham, LCSW Kate Hendricks Thomas, PhD, MCHES Christopher Gill America’s Warrior Partnership OpDD Consultant & Veteran Resiliency The University of Alabama OpDD Community Principal Investigator Expert PhD Graduate Student

Matthew Hudnall, PhD Yana Melnykov, PhD Hailah Said The University of Alabama The University of Alabama The University of Alabama Co-Principle Investigator & OpDD Data Analytics Co - Investigator Project Manager and Data Security Expert Xin Yang, PhD Eric Caine, MD The University of Alabama University of Rochester Co-Investigator OpDD Consultant & Suicide Research Expert Sierra Rodgers-Farris Ramya Sundararaman, MD The University of Alabama CALIBRE Systems Research Assistant OpDD Consultant & Suicide Research Expert OpDD Literature Review Team

Karl Hamner, PhD - The University of Alabama Eric Caine, MD - University of Rochester,

James Thompson, MD – Veterans Affairs, Canada Kate Hendricks Thomas, PhD, MCHES

Phillip N. Smith, PhD - University of South Alabama Matthew Hudnall, PhD - The University of Alabama

Suzette Bremault-Phillips, PhD – University of Alberta Alexandra Heber, MD – Veterans Affairs, Canada

Christopher Gill, BS - The University of Alabama Nicholas Fadior, MS - University of South Alabama

Sierra Rodgers-Farris - The University of Alabama Natasha Busa, BS - University of South Alabama

Matthew Story – The University of Alabama Communities Our “Top of the Mountain”

We want to know:

• Amongst the array of veterans who have died from suicide/self-injury, what spaces did they traverse in the last year of their lives?

• “We want to be able to find veterans when they are a mess, before they decide they cannot live with the mess.” – Dr. Eric Caine, sometime recently.

• Where might communities be able to make a difference? Conceptual Foundation for OpDD – Context Matters, Especially for Prevention!

- OpDD is based on the ecological model to explore contextual factors that influence Veterans at the relational, communal, and societal levels.

Caine et al. (2018) Comprehensive, integrated approaches to suicide prevention: practical guidance. Societal Community Relationship* Individual* Premature Death from Suicide & Self-Harm: Common Developmental Contexts for Different Adverse Outcomes

MV Death & SUICIDE HOMICIDE Self-inflicted Poisoning Prevention & (DDSI) Legal System Involvements Intervention Emergency Room Visits Opportunities Mental Health & Chemical Dependency Treatment Contacts Indicated & Clinical

Emerging Behavioral Problems & Mental Health Disturbances Selective School Difficulties & Indicated Alcohol and Substance Misuse

Universal & Disruptive Family Factors Selective Disadvantaged Economic & Social Factors Prevention Focused

 The clinical/treatment based approach to prevention is inadequate to create large scale reduction in suicide rates.

• “The field has pervasively emphasized high-risk individuals … (yet) most suicides come from the general population” (Caine, 2013; p. 823). • “Based on the existing literature, all STB [suicide thoughts and behaviors] risk (and protective) factors are weak and inaccurate” (Franklin, et al., 2017). • Trying to predict which individuals will die by suicide in the coming year is like trying to find the needle in a stack of needles – the overwhelming majority of “at-risk” individuals will NOT die from suicide (Caine,2018).

 We need to move “upstream to discern distal common risk factors that underpin multiple aetiologically related forms of premature death, including suicide, deaths from drug intoxication and deaths from risk-related medical disorders.” (Caine, 2018; p. i39) Domains of Well-being VAC Model of Transition

- To accommodate the state of current literature it was necessary to move away from Milner et al. grouping system to one that reflects the direction of recent suicide literature.

- Modified “Health” to “Health/Mental Health”.

- Additional domains were created to account for the full body of literature on military and Veteran research:

• Transition • Spiritual • Identity • Social Media Thompson et al. (2019). Life course well-being framework for suicide prevention in Canadian • Place/Spatial Armed Forces Veterans. Journal of Military, Veteran and Family Health. doi:10.3138/jmvfh.2018-0020 • Prevention. Context and Location Matter CDCD Hotspot in 16 States

Logan et al. (2016) Foundation of OpDD Literature Review

Milner, A. , Hjelmeland, H. , Arensman, E. & Leo, D. (2013). Social- Environmental Factors and Suicide Mortality: A Narrative Review of over 200 Articles. Sociology Mind, 3, 137-148. doi: 10.4236/sm.2013.32021.

• “Results of the review indicated that rates of suicide mortality … were sensitive to a wide range of social factors.” (p. 137) • Milner et al. “only examined studies explicitly considering social and environmental influences on suicide mortality.” (p. 138) • None of the studies reviewed addressed suicide among military service members or veterans. Allison Milner

University of Melbourne Associate Professor Allison Milner, PhD.

1983-2019 Suicide Mortality Suicide Rates Economy Income Unemployment Relationship Status Fertility Rate Birth Rate Female Labour Force Gender Role Participation Search Strategy Religion Migration Rural Modernization Milner et al. used Alcohol Access to Means Media the following - English Peer-reviewed terms: - Empirically based - Included only articles considering social and environmental influences

- Findings grouped by subject area (search terms)

- Criteria inherently excluded almost all military/veteran articles Suicide Mortality Suicide Rates Economy Income Unemployment Relationship Status Fertility Rate Birth Rate Female Labor Force Gender Role Participation Religion Migration Rural Modernization Search Strategy Alcohol Access to Means Media OpDD Additional Terms Veteran Service Members Post-traumatic Moral Injury OpDD added the Stress Disorder & (PTSD) Transition Military Transition Military Identity Veteran Identity following terms: Warrior Identity Social Media

- Search parameters set for 2000 – 2018 to capture Military/Veteran literature excluded by Milner et al.

- English Peer-reviewed

- Empirically based

- Included articles considering individual factors and review for military and Veteran

- Grouped by modified Domains of Well-being (Thompson et al., 2019) Search Strategy (con’t)

Suicide Mortality Suicide Rates Suicide Mortality Suicide Rates Economy Income Unemployment Relationship Economy Income Unemployment Relationship Status Status Fertility Rate Birth Rate Female Labor Gender Role Fertility Rate Birth Rate Female Labour Gender Role Force Participation Force Religion Migration Rural Modernization Participation Alcohol Access to Means Media Religion Migration Rural Modernization OpDD Additional Terms Veteran Service Post-traumatic Moral Injury Alcohol Access to Media Members Stress Disorder & Means (PTSD) Transition Military Military Identity Veteran Identity Transition Warrior Social Media Identity Search Results

Domains Non- Mil/Vet Mil/Vet Total Work/Purpose 41 4 45 Transition 0 7 7 Original search yielded: 911 ecological Spiritual 2 11 13 papers Social Integration 32 4 36 Soc. Media 2 3 5 Secondary military search: 403 papers Place/Spatial 27 0 27 Life Skill/Preparedness 4 0 4 Identity 0 6 6 Initial review for inclusion: 374 papers Housing/Physical Env. 2 40 42 Health/Mental Health 0 58 58 Final: 195 Non-Mil/Vet, 143 Mil/Vet, & Finance 39 0 39 36 supporting articles Cultural/Social Env. 46 7 53 Prevention 0 3 3 195 143 338 Supporting articles 36 Total 374 Literature Review: The literature on socioeconomic Initial Findings factors on suicide at the moment appears to be more informative less by what is reporting than by what it is not investigating. We are continuing the practices already shown by Franklin et al. (2017) to be insufficient for prevention. Literature Review:  Despite having a lot more published research since Milner et al., the picture has not changed much on social and Initial Findings economic “risk” factors.

 Suicide causation is understood to be multifactorial, complex, varying individually, and due to interacting factors rather than linear causal chains.

 Much of the epi research on suicide has focused on a narrow range of risk indicators.

 There is a great deal of data supporting the importance of socioeconomic factors in suicide.

 Most theories proposed for suicide recognize the importance of life stressors, beyond just mental illness. Domain: Employment/Purposeful Activity & Finance

Much of the findings related to employment and finance were consistent with Milner and largely focused on the 2008 recession. The major factors were being male (middle aged) and unemployment. However, much of these findings were confounded or modified by social factors or mental health. Also, rates were actually found to have spiked just prior to the recession indicating an individual level ”crisis effect”. Military literature found that personal factors were more closely related to higher rates than employment.  General Findings . Higher rates of unemployment among men (Fountoulakis, 2015). . Effects of unemployment on suicide were moderated by Durkheimian social factors: social meaning, marriage, etc. (Kim, 2017). . Heavily confounded by other factors, drinking, MH, anxiety (Haw, 2015). . Occupational factors have correlations that can also be explained by education and income factors (Kolves, 2013). . Causal links found in other studies were modified by “crisis effect” (Laanani, 2015).  Military Specific Findings . Loss of meaning for veterans was associated with increased suicide rates irrespective of employment status (Reger, 2015). . Early discharge, low rank, and deployment status had greater associations to suicide rates than the accompanied unemployment and financial concerns (Kesslar, 2015). Domain: Health/Mental Health

Milner’s criteria inherently omitted clinical factors. As such the findings came from the military/veterans literature. Research focused on a retinue of clinical factors attempting to build prediction models for suicide. Across the health and mental health literature, no one factor rises to consistent significance with most being low levels of significance among otherwise unrelated factors in (or limited associations with) suicide. While the body of literature focused on clinical risk factors is robust, many of the associations are confounded by factors that reside outside of the clinical realm.

 Military Specific Findings . Males with multiple suicide attempts were more likely to have problem substance use and a mood disorder diagnosis, while females with a multiple attempt history were more likely to have a history of childhood sexual trauma. . TBI is found to be a significant risk factor for suicidal behavior (Barnes, 2012). . Veterans with severe pain were more likely to die by suicide than patients experiencing none, mild, or moderate pain. Domain: Life Skills and Knowledge

Education is a consistent protective factor against suicide across the literature. Consistent with Milner, developmental factors have some association to suicide rates with risk being more pronounced at certain stages of development. In military and veteran literature, there is a burgeoning interest in understanding the alternate pathways of development in emerging adulthood that occurs in the military. Understanding how the institution of the military effects this period of development may help to shed light on why the differentiation of life skills like communication and emotion regulation are so disparate in the veteran community.  General Findings . High education levels associated with lower risk for suicide. . Risk of dying by suicide relative to other violent deaths may be more pronounced at certain developmental stages for each gender. . Identified three developmental issues in young men: unsuccessful in becoming independent; (b) weakened competence to deal with shame; and (c) trapped in anger in young with higher rates.  Military Specific Findings . The development of personal autonomy and identity achievement appear to lag in emerging adults that join the military. Domain: Housing/Physical Environment

Milner’s findings on higher risks in rural areas have held in the most recent studies. Greater firearm access, higher local suicide rates (clustering), and less access to mental health providers and facilities were associated with higher rates. The military literature is consistent with these findings, however, There is very little research on firearm access control among veterans that is both practical, for local authorities and mental health providers, and palatable for veterans.  General Findings . Areas with less access to firearms have lower rates of suicide by firearm and in general. Rates decrease after restrictions are places. (Anestis: 2016). . Living in an area with higher suicide rates increases individual risk and households with gun ownership increase risk for individuals in house. . Increase in available facilities and professionals linked to less risk (Nakanishi, 2017).  Military Specific Findings . Rural individuals at higher risk, mostly men and older individuals and mostly by firearms. Results stand after controlling for mental health access. Female veterans are more likely than other women to use a firearm (McCarthy, 2012). Domain: Place Spatial

Consistent with other domains, spatial analysis suggests that rural, compared to urban, areas have higher rates of suicide. While there is very little spatial analysis of suicide among military and veterans, a CDC study found major hotspots of veteran suicide across 16 states, indicating the need to examine the contextual and social characteristics of these areas and their interaction with the veteran community. Bottom line: “Place matters”.  General Findings . Rural locations show a higher rate of suicide than urban areas. . High or very high-density locations also have a high risk, with distinct clustering in some (mostly wealthy) urban areas. . Social isolation related to higher risk.  Military Specific Findings . Within the National Violent Death Reporting System participating states, an estimated 262(33%) current military suicides occurred in just ten (1.0%) counties, and 391 (33%) Veteran suicides occurred in 33 (3.4%) counties. Domain: Social Integration

Consistent with Milner, research was focused on macro-level societal factors that may influence rates. The concept of social capital is a growing sector of research that suggests a given area’s level of social capital is related to suicide rates. While the idea is promising, a clear definition has not emerged and there is little agreement as to how to measure and areas social capital. Military/veteran literature points to the social context as a pathway to prevention of veteran suicide, but there is little understanding about how veterans might access social capital or how to help them engage.  General Findings . Both ‘economic/employment’ and ‘social/welfare’ dimensions of social exclusion significantly influence suicide mortality among males. . Suicide mortality rates were related to the measure of perceived social capital. . Social support may have a protective effect against suicide on a regional level. . The findings support classic sociological arguments that the risk of suicide is influenced by the social milieu and cannot explained by the aggregation of individual characteristics.  Military Specific Findings . Veterans who are married and who report greater satisfaction with social networks are less likely to endorse suicidal thoughts or behaviors suggestive of elevated suicide risk. Domain: Cultural/Social Environment

Social capital was also an important feature in the cultural/social environment domain. This research measured high social capital as including marriage, family, group membership, etc., where as corruption, social unrest, poverty, etc. were indicators of low social capital. Attendance of religious services and proximity of in-group members were protective factors against suicide. Interestingly, there was very little research impact of the military culture on the life course of veterans. Much of the work that does exist has tremendous overlap across the domains that guide the framework of this article is treated in the areas of transition and identity.  General Findings . Social capital related to lower risk, specifically marriage, family, and group membership . . Social upheaval and government corruption can increase risk. . Frequent religious service attendance is a protective factor (Vanderweele, 2016.  Military Specific Findings . N/A Domain: Spiritual

The body of research in spirituality found several positive correlations to well-being related to spiritual health. Religiosity, religious belief, and religious practice were found to be protective factors among those subscribing to a religious faith. In military and veteran research in spirituality, an inverse relationship was found between spiritual and existential well-being, and suicidality, with the ability to sustain meaning rooted in spiritual well- being.  General Findings . Religiosity as a protective factor. . Rates among intrinsically religious groups with Judaism as a baseline, finding lower rates than Christians, but not Muslims. Found higher rates among military age males, but still lower than non- religious cultures. Of note: there is no WHO data available from Muslims countries since 1985 (Witztum, 2012).  Military Specific Findings . Inverse relationship of spiritual well-being, existential well-being, and suicidality. The ability to sustain meaning is rooted in spiritual well-being. . Building spiritual strength produces a reduction in PTSD symptoms/severity comparable to other approaches, Domain: Transition

Transition is an emerging area of research where findings seem to go against the grain of past assumptions. For instance, the relationship of suicide to combat trauma is not as strong as previously thought, nor is it as closely related as transition to civilian life. Transitioning veterans are at higher risk if they are lower rank, served less than 4 years, or have a less than honorable discharge. Some found the persistence of the military identity is a major barrier to transition conferring high risk of suicide, likely, due to the sense existential isolation. These findings indicate a deeper issue for veterans than trauma or employment, as previously assumed.

 Military Specific Findings . Deployment not associated w/ rates of suicide. Increased rates associated w/ separation from the military. Higher rates for > four years or > honorable discharge. . Struggles in transition into civilian life due to identity disturbance, the destabilization effects of trauma, and persistence of warrior identity, etc. Non-traditional factors: less than expected time served (medical, disciplinary, MH factors). Highlight institutional factors, expectations, and suggests that research fails to connect factors such as maturity or developmental problems, or social issues (Kapur, 2009). Domain: Identity

Several studies have explored the enduring characteristics of the military identity that may be contributing to the sense of existential isolation experienced by veterans, leading to suicidal behavior. These enduring traits are powerful and are often misidentified and as mental health issues among veterans. Whelan (2014) suggests that the traits generally used to diagnose depression are actually a description of daily life in the military institution: “black and white thinking, perfectionist standards and mental rigidity, emotional suppression, over developed sense of responsibility, self-blame, generally negative view, and intolerance for ambiguity” (pg. 15). These traits are descriptive of everyday life in the military, and may be an enduring part of the military identity, related to post-service strain that is often associated with trauma.  Military Specific Findings . In discourses of loss and separation with some had achieved closure with their past military selves, others struggled and became stuck in a liminal space between civilian and military lives that perpetuated feelings of isolation (Herman, 2014). . Correlational analyses indicated that the domains of military identity were strongly related to post- deployment adjustment as well as other indicators of psychosocial health (Lancaster, 2018). . Transition causes adverse mental health effects that stem from contrasts between the military’s demands for deindividuation, obedience, chain-of-command, and dissociation and the civilian identity expectations of autonomy, self-advocacy, and being relational (Smith, 2014).  Contextual factors arising from the literature include (Berkman et al., 2000): • Social capital (# of organizations in community) • Social integration (e.g. belonging to an organization) • Social fragmentation (e.g. economic stratification) The Challenge of • Social depravation (e.g. lack of access to jobs, Context and healthcare, etc.)  The contextual factors contribute to isolation (physical, promising Areas psychological, existential), which may, in turn, lead to crisis For Further and/or suicide.  We do not have commonly accepted definitions of contextual Inquiry: Social factors such as Social Capital, let alone a clear understanding of how such factors interface with individuals experiencing Isolation and stress. Loneliness Existential Isolation

Existential Isolation (EI) describes the ‘‘unbridgeable gap between oneself and any other being” (Yalom, 1980, p. 355).

 Distinct from social isolation & loneliness (Helm et al., 2018). . Social Isolation - physical separation from immediate context. . Loneliness – A feeling of isolation regardless of immediate context. . Existential Isolation – A feeling of being fundamentally different from others.

 Threats to worldview, in-group identity, close relationships, and bases of self-worth increases the accessibility of death-related thoughts (Helm et al., 2019).

 EI may be a crucial concept for better understanding and preventing veteran suicide.

 We believe it is a key issue at interface of individual and contextual risk. Concept related to a common refrain among Veterans that often feel “alone in a crowd of people”. Social Connection/Identity/Capital

 Growing body of research shows that the three concepts of social connectedness, social identity, and social capital are all related better life and health outcomes and lower risk for suicide/early mortality.

 These concepts overlap throughout the literature.

 Gross measures of each need to be explored in greater depth, with a focus for us on what they mean for veterans.

 Jetten et al. (2014) argue that social connection and social capital are subordinate concepts to social identity. . “The social identity approach starts from the assumption that to understand individuals’ thoughts, beliefs and actions, we need to understand how they categorize themselves in relation to others.”

 Regardless, these concepts have been shown to be protective and there is a growing body of general literature on designing interventions based on these. We need to know how these concepts play out for veterans. Sense of Purpose

 A growing literature has demonstrated that people with a sense of purpose live longer. For example, Alimujiang et al. (2019) found “a stronger purpose in life was associated with lower all-cause mortality” and noted that a number of interventions which had been developed to give people a stronger sense of people were shown to have positive outcomes on quality of life and other health promoting outcomes.

 Similarly, research from Japan (Sone et al., 2008) has shown that having “ikigai” – Japanese for the sense of “life worth living” and “why I get up in the morning” – has a significant protective role. Specifically, they found that those who reported not having ikigai were at significantly greater risk for all-cause mortality.

 Numerous published articles, essays and books about military-civilian transitions postulate that the loss of a greater sense of purpose is a significant cause of transition difficulty.

 We have not yet found a study that demonstrates this yet.  We must stop treating suicide/“veteran” suicide as monolithic. All suicides are not the same. Per Tatz (2017), we need to know what kinds of suicide we are trying to prevent in order to Thoughts and do so. . How is suicide different for different types of veterans? Is Research the nature of the suicides by older veterans the same as those of younger veterans? Are all older veteran suicides Recommendations a result of chronic illnesses? (con’t)  Following Caine et al. (2018), we need to move up-stream to study factors that will allow preventing crises before they happen, rather than trying to predict suicide among those “on the ledge”.

 This means we first need to understand the social geography of our communities and the social ecology of those groups at enhanced risk of early mortality within .  We typically view suicide either with a microscope (the clinical view of individual cases typically of people considering suicide ) or a telescope (epidemiological Thoughts and surveillance data of deaths determined to be suicides). Yet either view distorts the larger picture. Research  Within the biopscyhosocial model that dominates our western Recommendations discourse, we emphasize the Bio and the Psycho to the (con’t) detriment of the Social when we need all three equally.  Consistent with the ecological model of suicide, we need to “focus on understanding suicide at the individual level in different contexts” (Hjelmaland, 2013). We need more rich Thoughts and data, not less.  We need more multi-method research. Clinical work/research Research can identify potentially important suicidal pathways, but then we need epidemiological research to see if they are more widespread. Epidemiological studies are critical in identifying real Recommendations patterns of suicide correlates, yet qualitative deep dives in to those patterns are needed to understand if those patterns are (con’t) important and what they mean.  We need less focus on theory and need more and better data, not just better models and analytic tools (e.g., Big Data).  This starts with improving our suicide surveillance system. . Garbage In = Garbage Out! Levels of Suicide Research: Refocusing our Lens on the Meso Level

•State/Province, National, International •Studies quantitative/epidemiological MACRO •Suicide research with a telescope

•County/Community •Mostly quantitative, some mixed methods •This is the least studied yet most important area for prevention because is where meso the individual and context come together

•Individual/Family •Predominantly clinical/qualitative MICRO •Suicide research with microscope  We need to focus more on the intersection of the individual Levels of with the context (individual life domains, family, community, etc.) if we want to prevent premature mortality for veterans or Suicide others.

Research  When thinking about concepts/constructs such as social capital and their relationship to suicide and self harm deaths, (Con’t) we need to ask: 1. Why are we concerned about the concept? 2. How are we operationalizing it? 3. How do real people experience/live it? 4. Is this something we can impact? We Need to  Suicide and suicide prevention meet virtually every condition for a “wicked” problem. Change the Way . Wicked problems are “complex, ever changing societal and organizational planning problems that you haven't We Approach been able to treat with much success, because they won't keep still. They're messy, devious, and they fight Suicide and back when you try to deal with them” (Ritchey, 2013).  Wicked problems require complex responses yet for suicide Suicide we continue to approach it with single factor or, at best, multifactorial, linear solutions. This won’t work. To address this Prevention particularly wicked problem, “we must move beyond the multidimensional and multifactorial linear thinking to consider complexity theory as a more adequate model for understanding” (Borrell-Carrió, Suchman & Epstein, 2004; p.581) and adopt a systems focus/complexity science approach to suicide prevention.  The issues we have raised above to improve our understanding of suicide fit within the complexity science paradigm.

. “Complexity science expands on the reductionistic framework by not only understanding the parts that Complexity contribute to the whole but by understanding how each part interacts with all the other parts and emerges into a Science and new entity, thus having a more comprehensive and complete understanding of the whole.” (Tuner and Baker, Suicide 2019; p. 2). Prevention  Complexity science has begun to make it’s way into public health. Researchers at the University of Victoria have done research on improving health systems in Canada using complexity science. The potential for complexity science in suicide research needs to be explored. QUESTIONS?

Karl Hamner, Ph.d. Principle Investigator, [email protected] References:

Alimujiang A, Wiensch A, Boss J, et al. (2019). Association Between Life Purpose and Mortality Among US Adults Older Than 50 Years. JAMA Net Open.; 2(5):e194270. http://doi.org/10.1001/jamanetworkopen.2019.4270. Álvaro-Meca, A., Kneib, T., Gil-Prieto, R., & de Miguel, A.G., (2013) Epidemiology of suicide in Spain, 1981–2008: A spatiotemporal analysis. Public Health. 127:4, 380-385 https://doi.org/10.1016/j.puhe.2012.12.007. Anestis, M.D., Khazem, L.R., Mohn, R.S., & Green, B.A., (2015A). Testing the main hypotheses of the interpersonal psychological theory of suicidal behavior in a large diverse sample of United States military personnel. Comprehensive Psychiatry. 60: 78-85 https://doi.org/10.1016/j.comppsych.2015.03.006. Anestis, M.D., & Anestis, J.C., (2015B) Suicide Rates and State Laws Regulating Access and Exposure to Handguns. American Journal of Public Health. 105:2049-2058 https://doi.org/10.2105/AJPH.2015.302753. Anestis, M., & Capron, D.W., (2016). The associations between state veteran population rates, handgun legislation, and statewide suicide rates. Journal of Psychiatric Research. 74: 30-34 https://doi.org/10.1016/j.jpsychires.2015.12.014. Arenson, M.B., Whooley, M.A., Neylan, T.C., Maguen, S., Metzler, T.J., Cohen, B.E. (2018). Posttraumatic stress disorder, depression, and suicidal ideation in veterans: Results from the mind your heart study. Psychiatry Research, 265, 224-230, https://doi.org/10.1016/j.psychres.2018.04.046. Baker, J.R., and Rose, R.M. (2019). Complexity Theory: An Overview with Potential Applications for the Social Sciences. Systems. 7:4 http://doi.org/10.3390/systems7010004. Balint, L., Dome, P., Daroczi, G., Gonda, X., & Rihmer, Z. (2014) Investigation of the marked and long-standing spatial inhomogeneity of the Hungarian suicide rate: A spatial regression approach. Journal of Affective Disorders. 155:180-185, https://doi.org/10.1016/j.jad.2013.10.047. Bando, D.H., Brunoni, A.R., Fernandes, T.G., Benseñor, I.M., & Lotufo, P.A., (2012). Suicide rates and trends in São Paulo, Brazil, according to gender, age and demographic aspects: a join point regression analysis. Brazilian Journal of Psychiatry. 34:3, 286-293 https://dx.doi.org/10.1016/j.rbp.2012.02.001. References:

Balestra, S. (2018). Gun prevalence and suicide. Journal of Health Economics. 61:163-177 https://doi.org/10.1016/j.jhealeco.2018.08.003. Batticarte, J.J.S., Rubio, B.M., & Castillo-Patton, A.E. (2017). Analysis of Official Suicide Statistics in Spain (1910-2011). Centro de Investigaciones Sociológicas. 160:19, 95-113 https://doi.org/10.5477/cis/reis.160.95. Berkman, L.F., Glass, T., Brissette, I., Seeman, T.E. (2000) From social integration to health: Durkheim in the new millennium. Social Science & Medicine. 51:6, 843-857, https://doi.org/10.1016/S0277-9536(00)00065-4 Blakely, S.M., Wagner, R., Naylor, J., Brancu, M., et al., (2018). Chronic Pain, TBI, and PTSD in Military Veterans: A Link to Suicidal Ideation and Violent Impulses? The Journal of Pain. 19:7,797-806. https://doi.org/10.1016/j.jpain.2018.02.012. Bolzam-Macente, L., & Zandonade, E. (2012) Spatial distribution of suicide incidence rates in municipalities in the state of Espírito Santo (Brazil), 2003-2007: spatial analysis to identify risk areas. Brazilian Journal of Pschiatry. 34:3 http://dx.doi.org/10.1016/j.rbp.2011.11.001. Bozzay, M.L., Liu, R.T., & Kleinman, E.M., (2014). Gender and age differences in suicide mortality in the context of violent death: Findings from a multi-state population-based surveillance system. Comprehensive Psychiatry. 55:1077-1084 https://doi.org/10.1016/j.comppsych.2014.03.017. Braden, A., Overholser, J., Fisher, L., & Ridley, J. (2015), Life Meaning Is Associated with Suicidal Ideation Among Depressed Veterans. Death Studies. 39:1, 24-29. https://doi.org/10.1080/07481187.2013.871604. Brenner, L., Ignacio, R.V., & Blow, F., (2011). Suicide and Traumatic Brain Injury Among Individuals Seeking Veterans Health Administration Services. Journal of Head Trauma Rehabilitation. 26:4,257-264. http://dio.org/10.1097/HTR.0b013e31821fdb. Brewin, C.R., Garnett, R., and Andrews, B. (2011). Trauma, identity and mental health in UK military veterans. Psychological Medicine. 41, 1733–1740. https://doi.org/10.1017/S003329171000231XP. References:

Caine, E.D. (2018). Predicting Risk of Suicide Among Individuals Who are Members of Higher-Risk Populations: Finding THE Needle in a Stack of Needles! Administration and Policy in Mental Health and Mental Health Services Research. 45: 696 https://doi.org/10.1007/s10488-018 0886-6. Caine E.D., Reed J., Hindman J, Quinlan, K., (2018) Comprehensive, integrated approaches to suicide prevention: practical guidance. Injury Prevention. 24, 38–45. http://doi:10.1136/injuryprev-2017-042366 Carcach, C. (2017). A spatio-temporal analysis of suicide in El Salvador. BMC Public Health. 17:339 https://doi.org/10.1186/s12889-017-4251-6. Chan CH, Caine ED, You S, et al., (2015). Changes in South Korean urbanicity and suicide rates, 1992 to 2012. BMJ Open. 5;5 http://dx.doi.org/10.1136/bmjopen-2015-009451. Cheong, K. S., Choi, M. H., Cho, B. M., Yoon, T. H., Kim, C. H., Kim, Y. M., & Hwang, I. K. (2012). Suicide rate differences by sex, age, and urbanicity, and related regional factors in Korea. Journal of preventive medicine and public health. 45:2,70–77. http://doi.org/10.3961/jpmph.2012.45.2.70. Cheung, Y.D., Spittal, M.J., Pirkis, J., & Yip, P. S., (2012) Spatial analysis of suicide mortality in Australia: Investigation of metropolitan-rural-remote differentials of suicide risk across states/territories. Social Science & Medicine. 75:8,1460-1468, https://doi.org/10.1016/j.socscimed.2012.04.008. Crifasi, C.K., Meyers, J.S., Vernick, J.S., & Webster, D.W., (2015). Effects of changes in permit-to-purchase handgun laws in Connecticut and Missouri on suicide rates. Preventive Medicine. 79:43-49, https://doi.org/10.1016/j.ypmed.2015.07.013. Currier, J. M., Smith, P. N., & Kuhlman, S. (2017). Assessing the unique role of religious coping in suicidal behavior among U.S. Iraq and Afghanistan veterans. Psychology of Religion and Spirituality. 9:1,118–123. https://doi.org/10.1037/rel0000055. References:

Denney, J.T., Wadsworth, T., Rogers, R.G. and Pampel, F.C. (2015). Suicide in the City: Do Characteristics of Place Really Influence Risk? Social Science Quarterly. 96: 313-329 https://doi.org/10.1111/ssqu.12165. Durkheim, E. (1897) Suicide: a Study in Sociology. Free Press, NY, New York. Fontanella, C.A., Saman, D.M., Campo, J.V., Hiance-Steelesmith, D.L., Bridge, J.A., et al., (2018). Mapping suicide mortality in Ohio: A spatial epidemiological analysis of suicide clusters and area level correlates. Preventive Medicine. 106: 177-184 https://doi.org/10.1016/j.ypmed.2017.10.033. Fountoulakis, K.N, Savopoulos, C., Apostolopoulou, M., Dampali, R., Zaggelidou, E., Karlafti, E., et al. (2015). Rate of suicide and suicide attempts and their relationship to unemployment in Thessaloniki Greece (2000–2012), Journal of Affective Disorders.174:131-136, https://doi.org/10.1016/j.jad.2014.11.047. Gilman, S., Bromet, E., Cox, K., Colpe, L., Fullerton, C., et al., (2014). Sociodemographic and career history predictors of suicide mortality in the United States Army 2004–2009. Psychological Medicine. 44:12, 2579-2592. http://doi.org/10.1017/S003329171400018X. Harris, J.I., Usset, T., Voecks, C., Thuras, P., Currier, J., & Erbes, C., (2018) Spiritually integrated care for PTSD: A randomized controlled trial of “Building Spiritual Strength. Psychiatry Research. 267:420-428, https://doi.org/10.1016/j.psychres.2018.06.045. Haw, C., Hawton, K., Gunnell, D., & Platt, S. (2015). Economic recession and suicidal behavior: Possible mechanisms and ameliorating factors. International Journal of Social Psychiatry. 61;1 pg.73 –81. https://doi.org/10.1177/0020764014536545. Helm, P. J., Greenberg, J., Park, Y. C., & Pinel, E. C. (2018). Feeling alone in your subjectivity: Introducing the state trait existential isolation model (STEIM). Journal of Theoretical Social Psychology. 1, 1–12. https://doi.org/10.1002/jts5.41 References:

Helm, P.J., Lifshin, U., Chau, R., Greenberg, J. (2019) Existential isolation and death thought accessibility. Journal of Research in Personality, Volume 82, 103845, https://doi.org/10.1016/j.jrp.2019.103845 Hjelmaland, H. (2013). Suicide research and prevention: The importance of culture in “biological times”. In E. Colucci & D. Lester (Eds.), Suicide and Culture: Understanding the Context, pp. 3-23. Cambridge, MA, Hogrefe Publishing. Herman, A. & Yarwood, R. (2014) From services to civilian: The geographies of veterans' post-military lives. Geoforum. 53, pp. 41-50. http://dx.doi.org/10.1016/j.geoforum.2014.02.001 Hodwitz, O., & Frey, K., (2016). Anomic suicide: A Durkheimian analysis of European normlessness, Sociological Spectrum, 36:4, 236-254 https://doi.org/10.1080/02732173.2016.1148652. Houirani, L.L., Williams, J., Forman-Hoffman, V., Lane, M.E., Weimer, B., & Bray, R.M. (2012) Influence of Spirituality on Depression, Posttraumatic Stress Disorder, and Suicidality in Active Duty Military Personnel. Depression Research and Treatment. 2012 https://doi.org/10.1155/2012/425463. Hsu, C., Chang, S., Lee, E.S.T., Yip, P.S.F., (2015) Geography of suicide in Hong Kong: Spatial patterning, and socioeconomic correlates and inequalities. Social Science & Medicine.130:190-203 https://doi.org/10.1016/j.socscimed.2015.02.019. Ilgen, M.A., Zivin, K., Austin, K.L., Bohnert, A.S.B., Czyz, E.K., et al., (2010). Severe Pain Predicts Greater Likelihood of Subsequent Suicide. Suicide and Life-Threatening Behavior. 40:6, 597-608. http://doi.org/10.1521/suli.2010.40.6.597. References:

Jakupcak, M., Vannoy, S., Imel, Z., Cook, J.W., Fontana, A., Rosenheck, R. and McFall, M. (2010), Does PTSD moderate the relationship between social support and suicide risk in Iraq and Afghanistan War Veterans seeking mental health treatment?. Depression Anxiety. 27:1001-1005 https://doi.org/10.1002/da.20722. James, Strom, T.Q., & Leskela, J., Risk-Taking Behaviors and Impulsivity Among Veterans With and Without PTSD and Mild TBI. Military Medicine. 179:4,357–363 https://doi.org/10.7205/MILMED-D-13-00241. Kaplan, M.S., McFarland, B.H., Huguet, N., & Valenstein, M. (2012). Suicide Risk and Precipitating Circumstances Among Young, Middle-Aged, and Older Male Veterans. American Journal of Public Health 102:1;131-137, https://doi.org/10.2105/AJPH.2011.300445. Kapur, N., While, D., Blatchley, N., Bray, I., & Harrison, K. (2009). Suicide after leaving the UK Armed Forces—A cohort study. PLoS Medicine. 6:3 http://doi.org/10.1371/journal.pmed.1000026. Kaufman, E.J., Morrison, C.N., Branas, C.C., & Wiebe, D.J., (2018). State Firearm Laws and Interstate Firearm Deaths From Homicide and Suicide in the United States: A Cross-sectional Analysis of Data by County. JAMA Intern Med. 178:5, 692–700. http://doi.org/10.1001/jamainternmed.2018.0190. Kessler, R., Stein, M., Bliese, P., Bromet, E., Chiu, et al.,(2015). Occupational differences in US Army suicide rates. Psychological Medicine. 45:15, 3293-3304. http://doi.org/10.1017/S0033291715001294. Kim, W., Jang, S., Chun, S.Y., Lee, T., Han, K., & Park, E. (2017) Mortality in Schizophrenia and Other Psychoses: Data from the South KoreaNational Health Insurance Cohort, 2002–2013. Korean Med Sci. 32: 835-842. https://doi.org/10.3346/jkms.2017.32.5.835. References:

Kimura, T., Iso, H., Honjo, K., Ikehara, S., Sawada, N., et al. (2016) Educational Levels and Risk of Suicide in Japan:The Japan Public Health Center Study (JPHC) Cohort I. Journal Epidemiol. 26:6,315-321 http://doi.org/10.2188/jea.JE20140253. Kochanski-Ruscio, K.M., Carreno-Ponce, J.T., DeYoung, K., Grammer, G., & Ghahramanlou_Holloway, M. (2015) Diagnostic and psychosocial differences in psychiatrically hospitalized military service members with single versus multiple suicide attempts. Comprehensive Psychiatry. 55:3,450-456, https://doi.org/10.1016/j.comppsych.2013.10.012. Kolves, K., Milner, A., & Varnik, P. (2013). Suicide rates and socioeconomic factors in EasternEuropean countries after the collapse of the SovietUnion: trends between 1990 and 2008. Sociology of Health & Illness. 35:6, pp. 956–970. https://doi.org/10.1111/1467-9566.12011. König, D., Swoboda, P., Cramer, R., Krall, C., Postuvan, V., & Kapusta, N. (2018). Austrian firearm legislation and its effects on suicide and homicide mortality: A natural quasi-experiment amidst the global economic crisis. European Psychiatry. 52:104-112 http://doi.org/10.1016/j.eurpsy.2018.04.006. Kposowa, A.J. (2013). Association of suicide rates, gun ownership, conservatism and individual suicide risk. Social Psychiatry & Psychiatric Epidemiology. 48:1467–1479 https://doi.org/10.1007/s00127-013-0664-4. Kunst, A.E., van Hooijdonk, C., Droomers, M. et al. (2013) Community social capital and suicide mortality in the Netherlands: a cross- sectional registry-based study. BMC Public Health. 13:969 https://doi.org/10.1186/1471-2458-13-969 Laanani, M., Ghosn, W., Jougla, E., Rey, G. (2015). Impact of unemployment variations on suicide mortality in Western European countries (2000–2010). J Epidemiol Community Health 69:103-109. http://dx.doi.org/10.1136/jech-2013-203624. References:

Lahti, A., Keränen, S., Hakko, H. et al. (2014). Northern excess in adolescent male firearm suicides: a register-based regional study from Finland, 1972–2009. Eur Child Adolesc Psychiatry. 23:45–52 https://doi.org/10.1007/s00787-013-0422-x. Lancaster, S.L., Kintzle, S., and Castro, C.A. (2018) Validation of the Warrior Identity Scale in the Chicagoland Veterans Study. Journal of Theory and Research. 18:. https://doi.org/10.1080/15283488.2017.1410157 Li, H., Hsiao, Y., Tang, C., & Miao, N. (2014) Nursing Inequalities in Elderly Suicides: An Empirical Study of Taiwan. International Journal of Gerontology. 8:1, 27-30, https://doi.org/10.1016/j.ijge.2013.10.005. Liu, S., Page, A., Yin, P., Astell-Burt, T., Feng, X., Liu, Y et al., (2015). Spatiotemporal variation and social determinants of suicide in China, 2006–2012: Findings from a nationally representative mortality surveillance system. Psychological Medicine. 45:15,3259-3268. http://doi.org/10.1017/S0033291715001269. Logan, J.E., Fowler, K.A., Patel, N.P., Holland, K.M., (2016) Suicide Among Military Personnel and Veterans Aged 18–35 Years by County—16 States American Journal of Preventive Medicine. 51(5S3):S197–S208. http://creativecommons.org/licenses/by-nc- nd/4.0/ Lucia Smith, N.D., & Kawachi, I., (2014) State-level social capital and suicide mortality in the 50 U.S. states. Social Science & Medicine.120:269-277 https://doi.org/10.1016/j.socscimed.2014.09.007. Lusk, J., Dobscha, S.K., Kopacz, M., Ritchie, M.F., & Ono, S. (2018). Spirituality, Religion, and Suicidality Among Veterans: A Qualitative Study, Archives of Suicide Research, 22:2, 311-326 http://doi.org/10.1080/13811118.2017.1340856. References:

McCarthy, M.D., Thompson, S.J., & Knox, K.L., (2012) Use of the Air Force Post- Deployment Health Reassessment for the Identification of Depression and Posttraumatic Stress Disorder: Public Health Implications for Suicide Prevention. American Journal of Public Health. 102:1,60-65. https://doi.org/10.2105/AJPH.2011.300580. McCormack, L., & Ell, L. (2017). Complex psychosocial distress post-deployment in veterans: Reintegration identity disruption and challenged moral integrity. Traumatology, 23:3, 240–249. https://doi.org/10.1037/trm0000107. Milner, A., Hjelmaland, H., Arensman, E., De Leo, D. (2013) Social-Environmental Factors and Suicide Mortality: A Narrative Review of over 200 Articles. Sociology Mind. Vol.3, No.2, 137-148. http://dx.doi.org/10.4236/sm.2013.32021 Nad, S., Marcinko, D., Vuksan-Aeusa, B., Jakovljevic, M. & Jakoljevic, G., (2008). Spiritual Well-Being, Intrinsic Religiosity, and SuicidalBehavior in Predominantly Catholic Croatian War Veterans With Chronic Posttraumatic Stress Disorder. The Journal of Nervous and Mental Disease. 196:1,79-83 http://doi.org/10.1097/NMD.0b013e31815faa5f. Nakanishi, M., & Endo, K. (2017). National suicide prevention, local mental health resources, and suicide rates in Japan. Crisis: The Journal of Crisis Intervention and Suicide Prevention. 38:6,384–392 https://doi.org/10.1027/0227-5910/a000469. Nicholas L. Recker & Matthew D. Moore (2016) Durkheim, social capital, and suicide rates across US counties, Health Sociology Review, 25:1, 78-91, DOI: 10.1080/14461242.2015.1101703 Opoliner, A., Azrael, D., Barber, C. et al., (2014) Explaining geographic patterns of suicide in the US: the role of firearms and antidepressants. Injury Epidemiol. 1:6 https://doi.org/10.1186/2197-1714-1-6. References:

Phillips, J.A. (2013). Factors Associated With Temporal and Spatial Patterns in Suicide Rates Across U.S. States, 1976–2000. Demography. 50”591–614 https://doi.org/10.1007/s13524-012-0176-y. Rasmussen, M.L., Haavind, H., Dieserud, G., & Dyregrov, K., (2014) Exploring Vulnerability to Suicide in the Developmental History of Young Men: A Psychological Autopsy Study. Death Studies. 38:9,549-556, http://dio.org/10.1080/07481187.2013.780113. Recker, N.L., & Moore, M.D., (2016) Durkheim, social capital, and suicide rates across US counties. Health Sociology Review. 25:1,78-91, http://doi.org/10.1080/14461242.2015.1101703. Reger, M. A., Smolenski, D. J., Skopp, N.S., Metzger-Abamukang, M.J., Kang, H.K., Bullman, T.A., Perdue, S., Gahm, G.A. (2015) Risk of Suicide Among US Military Service Members Following Operation Enduring Freedom or Operation Iraqi Freedom Deployment and Separation From the US Military. JAMA Psychiatry. 2015;72(6):561-569. https://doi:10.1001 Reger, M. A., Tucker, R. P., Carter, S. P., & Ammerman, B. A. (2018). Military Deployments and Suicide: A Critical Examination. Perspectives on Psychological Science, 13:6, 688–699. https://doi.org/10.1177/1745691618785366 Rossen, L.M., Hedegaard, H., Khan, D., & Warner, M., (2018) County-Level Trends in Suicide Rates in the U.S., 2005–2015. American Journal of Preventive Medicine. 55:1,72-79 https://doi.org/10.1016/j.amepre.2018.03.020. Sedivy, N.Z., Podlogar, T., Kerr, D.C.R., & De Leo, D., (2017).Community social support as a protective factor against suicide: A gender- specific ecological study of 75 regions of 23 European countries. Health & Place. 48:40-46 https://doi.org/10.1016/j.healthplace.2017.09.004. Smith, R. T., & True, G. (2014). Warring Identities: Identity Conflict and the Mental Distress of American Veterans of the Wars in Iraq and Afghanistan. Society and Mental Health, 4:2, 147–161. https://doi.org/10.1177/2156869313512212 References:

Stack, S. (2000). Suicide: A 15-year review of the sociological literature. Part II: Modernization and social integration perspectives. Suicide & Life-Threatening Behavior. 30, 163-176. https://doi.org/10.1111/j.1943-278X.2000.tb01073.x Tatz, C. (2017). Suicide and sensibility. Death Studies, 41:8, 542-550. Thompson, J.M., Heber, A., VanTil, L., Simkus, K., Carrese, L., Sareen, J., and Pedlar, D. Life course well-being framework for suicide prevention in Canadian Armed Forces Veterans. Journal of Military, Veteran and Family Health. https://doi:10.3138/jmvfh.2018-002 Too, L.S., Spittal, M.J., Bugeja, L. et al. (2016). Individual and community factors for railway suicide: a matched case–control study in Victoria, Australia. Social Psychiatry and Psychiatric Epidemiology. 51, 849–856 https://doi.org/10.1007/s00127-016-1212-9 Torok, M., Konings, P., Batterham, P.J. et al. (2017) Spatial clustering of fatal, and non-fatal, suicide in new South Wales, Australia: implications for evidence-based prevention. BMC Psychiatry 17:339 https://doi.org/10.1186/s12888-017-1504-y. Tsai AC, Lucas M, Sania A, et al. Social Integration and Suicide Mortality Among Men: 24-Year Cohort Study of U.S. Health Professionals. Annals Internal Medicine. 161:85–95 https://doi.org/10.7326/M13-1291. VanderWeele, T.J., Li, S., Tsai, A.C., & Kawachi, I. (2016). Association Between Religious Service Attendance and Lower Suicide Rates Among US Women. JAMA Psychiatry. 73:8,845–851 http://doi.org/10.1001/jamapsychiatry.2016.1243. Whelan, J.J. (2016). Ghost in the Ranks: Forgotten Voices & Military Mental Health. The Ingram Book Company. Victoria, BD, Canada. Wilson, G., Hill, M., Kiernan, M.D. (2018). Loneliness and social isolation of military veterans: systematic narrative review, Occupational Medicine, 68:9, 600–609, https://doi.org/10.1093/occmed/kqy160 Witztum, E., Stein, D., (2012). Suicide in Judaism with a Special Emphasis on Modern Israel. Religions. 3:3,725-738 https://doi.org/10.3390/rel3030725. References:

Yalom, I. D. (1980). Existential psychotherapy. New York: Basic Books. Yamamura, E., Andrés, A.R. & Katsaiti, M.S. Does Corruption Affect suicide? Econometric Evidence from OECD Countries. Atlantic Economic Journal. 40:133–145 https://doi.org/10.1007/s11293-012-9313-7. Yip, P.S.F., Chen, Y., Yousuf, S., Lee, C.S.M., Kawano, K., et al., (2012). Towards a reassessment of the role of divorce in suicide outcomes: Evidence from five pacific rim populations. Social Science & Medicine.75: 2, 358-366 https://doi.org/10.1016/j.socscimed.2012.03.009. Yur’yev, A., Värnik, P., Sisask, M., Leppik, L., Lumiste, K., & Värnik, A. (2013). Some aspects of social exclusion: Do they influence suicide mortality? International Journal of Social Psychiatry. 59:3,232–238. https://doi.org/10.1177/0020764011431792. Yur'yev, A., Yur'yeva, L., Värnik, P., Lumiste, K. & Värnik, A. (2015) The Complex Impact of Risk and Protective Factors on Suicide Mortality: A Study of the Ukrainian General Population. Archives of Suicide Research. 19:2, 249-259 http://doi.org/10.1080/13811118.2015.1004471.