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Posttraumatic Cognitions and Suicidal Ideation Among Veterans Receiving PTSD Treatment

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Abstract

With approximately 20 veteran suicide deaths per day, suicidal ideation (SI) among veterans is an important concern. Posttraumatic stress disorder (PTSD) is associated with SI among veterans, yet mechanisms of this relationship remain unclear. Negative posttraumatic cognitions contribute to the development and maintenance of PTSD, yet no studies have prospectively examined the relationship between posttraumatic cognitions and SI. Veterans (N = 177; 66% Male) participating in a 3-week intensive outpatient program for PTSD completed assessments of PTSD severity, depressive symptoms, SI, and posttraumatic cognitions. Negative posttraumatic cognitions about the self significantly predicted SI at posttreatment, controlling for pretreatment levels of SI, depression, and PTSD symptom severity. Self-blame and negative posttraumatic cognitions about others/world did not predict SI prospectively. Negative posttraumatic cognitions about the self appear to be an important factor in the manifestation of SI among veterans with PTSD and should be monitored as a potential indicator of suicide risk.

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References

  • Beck, A. T., Brown, G. K., Steer, R. A., Dahlsgaard, K. K., & Grisham, J. R. (1999). Suicide ideation at its worst point: A predictor of eventual suicide in psychiatric outpatients. Suicide & Life-Threatening Behavior, 29(1), 1–9. https://doi.org/10.1111/j.1943-278X.1999.tb00758.x.

    Article  CAS  Google Scholar 

  • Black, S. A., Gallaway, M. S., Bell, R., & Ritchie, E. C. (2011). Prevalence and risk factors associated with suicides of army soldiers 2001–2009. Military Psychology, 23(4), 433–451. https://doi.org/10.1080/08995605.2011.590409.

    Article  Google Scholar 

  • Bovin, M. J., Marx, B. P., Weathers, F. W., Gallagher, M. W., Rodriguez, P., Schnurr, P. P., & Keane, T. M. (2016). Psychometric properties of the PTSD checklist for diagnostic and statistical manual of mental disorders–fifth edition (PCL-5) in veterans. Psychological Assessment, 28(11), 1379–1391. https://doi.org/10.1037/pas0000254.

    Article  PubMed  Google Scholar 

  • Brewin, C. R., & Holmes, E. A. (2003). Psychological theories of posttraumatic stress disorder. Clinical Psychology Review, 23(3), 339–376. https://doi.org/10.1016/S0272-7358(03)00033-3.

    Article  PubMed  Google Scholar 

  • Brown, G. K., Beck, A. T., Steer, R. A., & Grisham, J. R. (2000). Risk factors for suicide in psychiatric outpatients: A 20-year prospective study. Journal of Consulting and Clinical Psychology, 68(3), 371–377. https://doi.org/10.1037//0022-006X.68.3.371.

    Article  PubMed  CAS  Google Scholar 

  • Centers for Disease Control and Prevention. (2017). Web-based injury statistics query and reporting system (WISQARS). Retrieved December 6, 2017, from http://www.cdc.gov/injury/wisqars/index.html.

  • Cox, K. S., Mouilso, E. R., Venners, M. R., Defever, M. E., Duvivier, L., Rauch, S. A. M., … Tuerk, P. W. (2016). Reducing suicidal ideation through evidence-based treatment for posttraumatic stress disorder. Journal of Psychiatric Research, 80, 59–63. https://doi.org/10.1016/j.jpsychires.2016.05.011.

    Article  PubMed  Google Scholar 

  • Dalgleish, T. (2004). Cognitive approaches to posttraumatic stress disorder: The evolution of multirepresentational theorizing. Psychological Bulletin, 130(2), 228–260. https://doi.org/10.1037/0033-2909.130.2.228.

    Article  PubMed  Google Scholar 

  • Department of Veterans Affairs. (2016). Suicide among veterans and other Americans 2001–2014. Washington, DC: Office of Suicide Prevention.

    Google Scholar 

  • Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behavior Research and Therapy, 38, 319–345. https://doi.org/10.1016/S0005-7967(99)00123-0.

    Article  CAS  Google Scholar 

  • Foa, E. B., Ehlers, A., Clark, D. M., Tolin, D. F., & Orsillo, S. M. (1999). The posttraumatic cognitions inventory (PTCI): Development and validation. Psychological Assessment, 11(3), 303–314. https://doi.org/10.1037/1040-3590.11.3.303.

    Article  Google Scholar 

  • Foa, E. B., & Rauch, S. A. M. (2004). Cognitive changes during prolonged exposure versus prolonged exposure plus cognitive restructuring in female assault survivors with posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 72(5), 879–884. https://doi.org/10.1037/0022-006X.72.5.879.

    Article  PubMed  Google Scholar 

  • Fulton, J. J., Calhoun, P. S., Wagner, H. R., Schry, A. R., Hair, L. P., Feeling, N., … Beckham, J. C. (2015). The prevalence of posttraumatic stress disorder in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans: A meta-analysis. Journal of Anxiety Disorders, 31, 98–107. https://doi.org/10.1016/j.janxdis.2015.02.003.

    Article  PubMed  Google Scholar 

  • Gallagher, M. W., & Resick, P. A. (2012). Mechanisms of change in cognitive processing therapy and prolonged exposure therapy for ptsd: Preliminary evidence for the differential effects of hopelessness and habituation. Cognitive Therapy and Research, 36(6), 750–755. https://doi.org/10.1007/s10608-011-9423-6.

    Article  Google Scholar 

  • Gradus, J. L., Suvak, M. K., Wisco, B. E., Marx, B. P., & Resick, P. A. (2013). Treatment of posttraumatic stress disorder reduces suicidal ideation. Depression and Anxiety, 30(10), 1046–1053. https://doi.org/10.1002/da.22117.

    Article  PubMed  Google Scholar 

  • Harvey, M. M., Rauch, S. A., Zalta, A. K., Sornborger, J., Pollack, M. H., Rothbaum, B. O., … Simon, N. M. (2017). Intensive treatment models to address posttraumatic stress among post-9/11 warriors: The Warrior Care Network. Focus, 15(4), 378–383.

    Article  Google Scholar 

  • Horwitz, A. G., Berona, J., Czyz, E. K., Yeguez, C. E., & King, C. A. (2017). Positive and negative expectations of hopelessness as longitudinal predictors of depression, suicidal ideation, and suicidal behavior in high-risk adolescents. Suicide and Life-Threatening Behavior, 47, 168–176. https://doi.org/10.1111/sltb.12273.

    Article  PubMed  Google Scholar 

  • Horwitz, A. G., Czyz, E. K., Berona, J., & King, C. A. (2018). Prospective associations of coping styles with depression and suicide risk among psychiatric emergency patients. Behavior Therapy, 39, 225–236.

    Article  Google Scholar 

  • Horwitz, A. G., Miron, L., & Maieritsch, K. P. (2019). Prospective associations between DSM-5 PTSD symptom clusters and suicidal ideation in treatment seeking veterans. Psychological Services.

  • Jakupcak, M., Cook, J., Imel, Z., Fontana, A., Rosenheck, R., & McFall, M. (2009). Posttraumatic stress disorder as a risk factor for suicidal ideation in Iraq and Afghanistan war veterans. Journal of Traumatic Stress, 22(4), 303–306. https://doi.org/10.1002/jts.20423.

    Article  PubMed  Google Scholar 

  • Kabat-Zinn, J. (2003). Mindfulness-based stress reduction (MBSR). Constructivism in the Human Sciences, 8(2), 73–107.

    Google Scholar 

  • Kang, H. K., Natelson, B. H., Mahan, C. M., Lee, K. Y., & Murphy, F. M. (2003). Post-traumatic stress disorder and chronic fatigue syndrome-like illness among gulf war veterans: A population-based survey of 30,000 veterans. American Journal of Epidemiology, 157(2), 141–148. https://doi.org/10.1093/aje/kwf187.

    Article  PubMed  Google Scholar 

  • Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 593–602. https://doi.org/10.1001/archpsyc.62.6.593.

    Article  PubMed  Google Scholar 

  • Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., Nelson, C. B., & Bromet, E. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52(12), 1048–1060. https://doi.org/10.1001/archpsyc.1995.03950240066012.

    Article  PubMed  CAS  Google Scholar 

  • Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9. Journal of General Internal Medicine, 16(9), 606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  • Kroenke, K., Strine, T. W., Spitzer, R. L., Williams, J. B. W., Berry, J. T., & Mokdad, A. H. (2009). The PHQ-8 as a measure of current depression in the general population. Journal of Affective Disorders, 114(1), 163–173.

    Article  PubMed  Google Scholar 

  • Krysinska, K., & Lester, D. (2010). Post-traumatic stress disorder and suicide risk: A systematic review. Archives of Suicide Research, 14(1), 1–23. https://doi.org/10.1080/13811110903478997.

    Article  PubMed  Google Scholar 

  • Kulka, R. A., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Jordan, B. K., Marmar, C. R., & Weiss, D. S. (1990). Trauma and the Vietnam war generation: Report of findings from the National Vietnam Veterans Readjustment Study. Philadelphia, PA: Brunner/Mazel.

    Google Scholar 

  • Maguen, S., Luxton, D. D., Skopp, N. A., Gahm, G. A., Reger, M. A., Metzler, T. J., & Marmar, C. R. (2011). Killing in combat, mental health symptoms, and suicidal ideation in Iraq war veterans. Journal of Anxiety Disorders, 25(4), 563–567.

    Article  PubMed  Google Scholar 

  • McLean, C. P., Zang, Y., Zandberg, L., Bryan, C. J., Gay, N., Yarvis, J. S., & Foa, E. B. (2017). Predictors of suicidal ideation among active duty military personnel with posttraumatic stress disorder. Journal of Affective Disorders, 208, 392–398. https://doi.org/10.1016/j.jad.2016.08.061.

    Article  PubMed  Google Scholar 

  • Miranda, R., & Nolen-Hoeksema, S. (2007). Brooding and reflection: Rumination predicts suicidal ideation at 1-year follow-up in a community sample. Behaviour Research and Therapy, 45(12), 3088–3095. https://doi.org/10.1016/j.brat.2007.07.015.

    Article  PubMed  PubMed Central  Google Scholar 

  • Nock, M. K., Borges, G., Bromet, E. J., Alonso, J., Angermeyer, M., Beautrais, A., … Williams, D. (2008). Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. British Journal of Psychiatry, 192(2), 98–105. https://doi.org/10.1192/bjp.bp.107.040113.

    Article  PubMed  Google Scholar 

  • Norris, F. H., & Slone, L. B. (2007). The epidemiology of trauma and PTSD. In Handbook of PTSD: Science and practice (pp. 78–98). New York, NY: Guilford Press.

    Google Scholar 

  • Panagioti, M., Gooding, P. A., & Tarrier, N. (2012). A meta-analysis of the association between posttraumatic stress disorder and suicidality: The role of comorbid depression. Comprehensive Psychiatry, 53(7), 915–930. https://doi.org/10.1016/j.comppsych.2012.02.009.

    Article  PubMed  Google Scholar 

  • 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(1–3), 102–107. https://doi.org/10.1016/j.jad.2009.08.001.

    Article  PubMed  Google Scholar 

  • Resick, P. A., Monson, C. M., & Chard, K. M. (2016). Cognitive processing therapy for PTSD: A comprehensive manual. New York, NY: Guilford Press.

    Google Scholar 

  • Rogers, M. L., & Joiner, T. E. (2017). Rumination, suicidal ideation, and suicide attempts: A meta-analytic review. Review of General Psychology, 21(2), 132–142. https://doi.org/10.1037/gpr0000101.

    Article  Google Scholar 

  • Rudd, D. M., Berman, A. L., Joiner, T. E., Nock, M. K., Silverman, M. M., Mandrusiak, M., … Witte, T. (2006). Warning signs for suicide: Theory, research, and clinical applications. Suicide and Life-Threatening Behavior, 36(3), 255–262. https://doi.org/10.1521/suli.2006.36.3.255.

    Article  PubMed  Google Scholar 

  • Scher, C. D., Suvak, M. K., & Resick, P. A. (2017). Trauma cognitions are related to symptoms up to 10 years after cognitive behavioral treatment for posttraumatic stress disorder. Psychological Trauma: Theory, Research, Practice, and Policy, 9(6), 750–757. https://doi.org/10.1037/tra0000258.

    Article  Google Scholar 

  • Schumm, J., Dickstein, B. D., Walter, K. H., Owens, G. P., & Chard, K. M. (2015). Changes in posttraumatic cognitions predict changes in posttraumatic stress disorder symptoms during cognitive processing therapy. Journal of Consulting and Clinical Psychology, 83(6), 1161–1166. https://doi.org/10.1037/ccp0000040.

    Article  PubMed  Google Scholar 

  • Simon, G. E., Rutter, C. M., Peterson, D., Oliver, M., Whiteside, U., Operskalski, B., & Ludman, E. J. (2013). Does response on the PHQ-9 depression questionnaire predict subsequent suicide attempt or suicide death? Psychiatric Services, 64(12), 1195–1202.

    Article  PubMed  Google Scholar 

  • Smith, N. B., Mota, N., Tsai, J., Monteith, L., Harpaz-Rotem, I., Southwick, S. M., & Pietrzak, R. H. (2016). Nature and determinants of suicidal ideation among U.S. veterans: Results from the national health and resilience in veterans study. Journal of Affective Disorders, 197, 66–73. https://doi.org/10.1016/j.jad.2016.02.069.

    Article  PubMed  Google Scholar 

  • Ten Have, M., De Graaf, R., Van Dorsselaer, S., Verdurmen, J., Van’t Land, H., Vollebergh, W., & Beekman, A. (2009). Incidence and course of suicidal ideation and suicide attempts in the general population. Canadian Journal of Psychiatry, 54(12), 824–833.

    Article  PubMed  Google Scholar 

  • Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S. R., Selby, E. A., & Joiner, T. E. (2010). The interpersonal theory of suicide. Psychological Review, 117(2), 575–600. https://doi.org/10.1037/a0018697.

    Article  PubMed  PubMed Central  Google Scholar 

  • Weathers, F. W., Bovin, M. J., Lee, D. J., Sloan, D. M., Schnurr, P. P., Kaloupek, D. G., … Marx, B. P. (2017). The Clinician-Administered PTSD Scale for DSM–5 (CAPS-5): Development and initial psychometric evaluation in military veterans. Psychological Assessment. https://doi.org/10.1037/pas0000486.

    Article  PubMed  Google Scholar 

  • Weathers, F. W., Litz, B. T., Keane, T. M., Palmieri, P. A., Marx, B. P., & Schnurr, P. P. (2013). The PTSD checklist for DSM-5 (PCL-5). National Center for PTSD. https://doi.org/10.1037/t02622-000.

    Article  Google Scholar 

  • 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, the Millennium Cohort Study. Journal of Affective Disorders, 148(1), 77–83.

    Article  PubMed  Google Scholar 

  • Wenzel, A., & Beck, A. T. (2008). A cognitive model of suicidal behavior: Theory and treatment. Applied and Preventive Psychology, 12(4), 189–201. https://doi.org/10.1016/j.appsy.2008.05.001.

    Article  Google Scholar 

  • Zalta, A. K., Gillihan, S. J., Fisher, A. J., Mintz, J., McLean, C. P., Yehuda, R., & Foa, E. B. (2014). Change in negative cognitions associated with PTSD predicts symptom reduction in prolonged exposure. Journal of Consulting and Clinical Psychology, 82(1), 171–175. https://doi.org/10.1037/a0034735.

    Article  PubMed  Google Scholar 

  • Zalta, A. K., Held, P., Smith, D. L., Klassen, B. J., Lofgreen, A. M., Normand, P. S., … Karnik, N. S. (under review). Evaluating patterns and predictors of symptom change during a three-week intensive outpatient treatment for veterans with PTSD.

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Acknowledgements

We thank the Wounded Warrior Project for their support of the Warrior Care Network and the resulting research. We would also like to thank the participating veterans and their families. We also wish to acknowledge the administrators, research assistants, and clinicians in the Road Home Program.

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  1. Department of Psychiatry, Rush University Medical Center, 1645 W. Jackson Blvd., Chicago, IL, 60612, USA

    Adam G. Horwitz, Philip Held, Brian J. Klassen, Niranjan S. Karnik, Mark H. Pollack & Alyson K. Zalta

  2. Department of Behavioral Sciences, Rush University Medical Center, 1645 W. Jackson Blvd., Chicago, IL, 60612, USA

    Alyson K. Zalta

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  1. Adam G. Horwitz
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Correspondence to Adam G. Horwitz.

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Conflict of Interest

Philip Held receives grant support from the Boeing Company and the American Psychological Association. Niranjan Karnik receives grant support from the Wounded Warrior Project; Welcome Back Veterans, an initiative of the McCormick Foundation and Major League Baseball; and the National Center for Advancing Translational Science of the National Institutes of Health (UL1TR002389). Mark Pollack receives funding from the Wounded Warrior Project, National Institute of Health, and Janssen Pharmaceuticals. Dr. Pollack serves on advisory boards for Aptinyx, Bracket Global, Palo Alto Health Sciences and has equity from Doyen Medical, Argus, Medavante, Mensante Corporation, Mindsite, and Targia Pharmaceuticals and receives royalties from SIGH-A, SAFER interviews. Alyson Zalta is supported by a career development award from the National Institute of Mental Health (K23 MH103394).

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All study procedures were approved by the Institutional Review Board with a waiver of consent because all assessments were collected as part of routine clinical care procedures.

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Horwitz, A.G., Held, P., Klassen, B.J. et al. Posttraumatic Cognitions and Suicidal Ideation Among Veterans Receiving PTSD Treatment. Cogn Ther Res 42, 711–719 (2018). https://doi.org/10.1007/s10608-018-9925-6

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