Journal of Affective Disorders 148 (2013) 3741

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Journal of Affective Disorders

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Research report

Guilt is more strongly associated with suicidal ideation among military personnel with direct combat exposure
Craig J. Bryan a,n, Bobbie Ray-Sannerud a, Chad E. Morrow b, Neysa Etienne c
a

National Center for Veterans Studies, 260 S. Central Campus Dr., Room 205, Salt Lake City, UT 84112, United States Hurlburt Field, FL 32544, United States c Maxwell Air Force Base, 50 S Lemay Plaza Montgomery, AL 36112, United States
b

a r t i c l e i n f o
Article history: Received 18 October 2012 Received in revised form 7 November 2012 Accepted 20 November 2012 Available online 8 December 2012 Keywords: Suicide Military Suicidal ideation Guilt Combat

abstract
Background: Suicide rates in the U.S. military have been rising rapidly in the past decade. Research suggests guilt is a signicant predictor of suicidal ideation among military personnel, and may be especially pronounced among those who have been exposure to combat-related traumas. The current study explored the interactive effect of direct combat exposure and guilt on suicidal ideation in a clinical sample of military personnel. Methods: Ninety-seven active duty U.S. Air Force personnel receiving outpatient mental health treatment at two military clinics completed self-report symptom measures of guilt, depression, hopelessness, perceived burdensomeness, posttraumatic stress disorder, and suicidal ideation. Results: Generalized multiple regression analyses indicated a signicant interaction of guilt and direct combat exposure (B .124, SE .053, p .020), suggesting a stronger relationship of guilt with suicidal ideation among participants who had direct combat exposure as compared to those who had not. The interactions of direct combat exposure with depression (B .004, SE .040, p .926), PTSD symptoms (B .016, SE .018, p .382), perceived burdensomeness (B .159, SE .152, p .300) and hopelessness (B .069, SE .036, p .057) were nonsignicant. Conclusions: Although guilt is associated with more severe suicidal ideation in general among military personnel, it is especially pronounced among those who have had direct combat exposure. & 2013 Elsevier B.V. All rights reserved.

1. Introduction The suicide rate in the United States Armed Forces has doubled since the initiation of military operations in Afghanistan and Iraq, recently surpassing the age- and gender-adjusted suicide rate for the U.S. general population despite historical trends for decreased risk for suicide (Department of Defense [DOD], 2011). Within the U.S. Air Force, a dramatic increase in suicides has occurred in recent years, with 2010 marking the highest suicide rate in 17 years (Department of Defense, 2011). Given these temporal trends, questions have been raised about the possible role of deployment and combat exposure on increased suicide rates in the military as a whole. Data to date indicate that only onequarter of active duty Air Force personnel who die by suicide have ever deployed to a combat zone, however, and less than 7% have directly experienced combat (Department of Defense, 2011), suggesting that direct combat exposure might not be a signicant contributor to suicidal behaviors suicides among Air Force personnel.

Corresponding author. E-mail address: craig.bryan@utah.edu (C.J. Bryan).

Military data from other branches of the military also indicate that history of deployment and direct combat exposure are not overrepresented among military suicides (Department of Defense, 2011). Among military veterans, studies have similarly failed to support an association between direct combat exposure with suicide attempts, although signicant associations with increased rates and severity of suicidal ideation have been noted, especially among military veterans with elevated levels of trauma symptoms (Maguen et al., 2012; Rudd, in press; Sareen et al., 2007). Evidence for a relationship between direct combat exposure and suicide risk has also been indirectly inferred from studies demonstrating that signicantly higher rates of death by suicide (Boscarino, 2006; Drescher et al., 2003; Farberow et al., 1990), suicide attempts (Freeman et al., 2000; Kramer et al., 1994; Nad et al., 2008), and suicidal ideation (Buttereld et al., 2005) are observed among combat veterans with posttraumatic stress disorder (PTSD) relative to combat veterans without PTSD. In light of these ndings, Bryan and colleagues (in press) have recently suggested that guilt might be an important contributor to suicide risk among military personnel. Guilt is typically conceptualized as a controllable psychological state that is linked to a specic action or behavior, and often entails a sense of regret or

0165-0327/$ - see front matter & 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.jad.2012.11.044

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C.J. Bryan et al. / Journal of Affective Disorders 148 (2013) 3741

remorse, or feeling bad about what I did (Kim et al., 2011; Tangney and Dearing, 2002). Guilt is a common experience of trauma victims, including combat veterans, and is believed to be a core affective feature of combat-related PTSD (Litz et al., 2009). The central role of guilt in PTSD is further supported by clinical trials demonstrating that guilt decreases for trauma victims who receive trauma-focused therapies for PTSD (i.e., prolonged exposure and cognitive processing therapy), but does not decrease for trauma victims who do not receive these therapies (Resick et al., 2002). Guilt has also been proposed to be a central cognitive-affective state for many suicidal individuals (e.g., Orbach, 1997), including military and veteran samples. For instance, combat-related guilt was the most signicant predictor of suicidal ideation and suicide attempts among Vietnam combat veterans (Hendin and Haas, 1991), and was signicantly correlated with suicidal ideation in a clinical sample of Iraq and Afghanistan combat veterans with combat-related PTSD (McLean et al., 2012). In a more general clinical sample of military personnel, guilt was signicantly associated with severity of suicidal ideation among military personnel beyond the effects of other robust risk factors such as hopelessness, past suicide attempts, and depression (Bryan et al., in press). Unfortunately, these studies did not consider how the relationship of guilt with suicidal ideation might differ according to history of direct combat exposure. Given that guilt might be especially salient among those military personnel and veterans who have been exposed to combat-related traumas, the primary aim of the current study was to determine if guilt was differentially associated with suicidal ideation according to history of direct combat exposure in a clinical sample of active duty Air Force personnel. We specically hypothesized that military personnel who had direct combat exposure would report a stronger relationship of guilt and suicidal ideation as compared to military personnel who had not been in direct combat.

2.2. Procedures Participants were recruited from two outpatient military mental health clinics, one located in the South U.S. and the second located in the West U.S. All current patients and new patients were invited to participate by clinic staff following their regularly-scheduled mental health appointments or intake appointments, without exclusion. The only inclusion criterion was to be currently accessing outpatient mental health treatment; there were no exclusion criteria. Patients voluntarily provided informed consent for the study and then completed an anonymous survey packet in the waiting room immediately following invitation and agreement to participate. Completed packets were returned to collection boxes located at the checkin desks of each clinic. The current study was reviewed and approved as exempt research by the WrightPatterson Air Force Base Institutional Review Board. 2.3. Measures 2.3.1. Beck scale for suicidal ideation (BSSI) Severity of current suicidal ideation was assessed with the Beck scale for suicidal ideation (BSSI; Beck et al., 1988), which is a 19-item self-report measure of the individuals beliefs and attitudes about suicide such as frequency and duration of ideation, specicity of planning, and preparations for death. Responses are summed to a total score ranging from 0 to 38, with higher scores indicating more severe suicidal ideation. The BSSI has very good internal consistency and convergent validity, and has been found to predict future suicide attempts and death by suicide (Beck and Steer, 1991). Internal consistency for the BSSI in the current sample was .89. 2.3.2. Self-injurious thoughts and behaviors interview (SITBI) Past suicide attempts were assessed using the self-injurious thoughts and behaviors interview (SITBI; Nock et al., 2007), which is a structured interview that assesses the presence, frequency, and characteristics of self-injurious thoughts and behaviors over the individuals lifespan. The interview has good interrater reliability (k .99), test-retest reliability over six months (k .70), and demonstrates strong convergent validity with other measures of suicidal ideation (k .54; Nock et al., 2007). 2.3.3. Future dispositions inventory (FDI) The negative focus subscale of the FDI (Osman et al., 2010) was used to assess intensity of hopelessness and pessimism. The negative focus subscale consists of 8 items (e.g., I worry that things will never go well for me no matter what I do, I doubt whether things will ever get better for me in life, I fear that I will run into more difculties in the years ahead) that respondents rate on a 5-point Likert scale ranging from 1 (not at all true) to 5 (extremely true). The scale is reliable ( 4 .83), correlates strongly in the expected directions with measures of hopelessness, adaptive coping, and psychological symptoms, and can differentiate between suicidal and nonsuicidal groups (Osman et al., 2010). 2.3.4. Patient health questionnaire-9 (PHQ-9) The PHQ-9 (Kroenke et al., 2001) was used to assess depression symptom severity. The PHQ-9 directs respondents to indicate the frequency of experiencing the nine symptoms of major depressive disorder during the past two weeks, with total scores ranging from 0 to 36. The PHQ-9 is widely used in clinical and research settings, and has demonstrated good internal consistency and sensitivity and specicity for major depressive disorder

2. Method 2.1. Participants Participants included 97 active duty Air Force personnel (58.8% male, 39.2% female, 2.1% unknown) ranging in age from 21 to 54 years (M 34.13, SD 8.69) who were currently receiving outpatient mental health treatment at two military clinics in the South and West U.S. Consistent with this age range, rank distribution was junior enlisted (E1E4, 23.7%), noncommissioned ofcer (E5E6, 42.2%), senior noncommissioned ofcer (E7E9, 14.4%), and ofcer (O1O6, 19.6%). Racial distribution was 68.0% Caucasian, 19.6% African American, 2.1% Asian, 1.0% Native American, 1.0% Native Hawaiian/Pacic Islander, and 4.1% other. Eight participants (8.2%) endorsed Hispanic or Latino ethnicity. Reective of a general outpatient mental health clinic patient population, participants were diagnosed with a range of DSM-IV diagnoses (M 1.19, SD .64, range: 0 to 4) by a licensed psychiatrist, psychologist, or social worker: 27.8% posttraumatic stress disorder, 22.7% major depressive disorder, 19.6% adjustment disorder, 9.3% generalized anxiety disorder, 6.2% depression not otherwise specied, 6.2% anxiety not otherwise specied, 4.1% dysthymic disorder, 4.1% panic disorder, 3.1% bipolar II disorder, 3.1% alcohol dependence, and several additional Axis I conditions occurring in less than 1.0% of participants. Eleven participants were additionally diagnosed with an Axis II personality disorder: 5.2% borderline personality disorder, 2.1% personality disorder not otherwise specied, and 1.0% each of schizotypal, antisocial, histrionic, and dependent personality disorders.

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39

Table 1 Means, standard deviations, and intercorrelations of all variables (n 97). 1. Gender Age Suicide attempt PTSD Hopelessness Depression Burdensomeness Combat exposure Suicidal ideation M SD
n

2.

3.

4.

5.

6.

7.

8.

9.

.10 .03 .16 .07 .22* .06 .03 .06

.18 .17 .19 .11 .03 .30** .01 34.13 8.69

.35** .31** .30** .37** .03 .51**

.46** .74** .48** .17 .34** 43.12 19.41

.57** .58** .18 .33** 10.26 7.63

.53** .08 .27** 10.66 7.17

.03 .56** 1.28 1.66

.12

2.58 4.36

nn

p o .05. p o .01.

(Kroenke et al.). Internal consistency for the PHQ-9 in the current sample was.92. 2.3.5. Posttraumatic stress disorder checklist (PCL) The PTSD checklist (PCL; Weathers et al., 1993) was used to assess PTSD symptom severity. The PCL directs respondents to consider the most stressful experience in their lives and to indicate the severity with which each symptom of PTSD has been experienced within the past 30 days. The scale has demonstrated excellent reliability, validity, and diagnostic utility (Blanchard et al., 1996; Weathers et al., 1993). Internal consistency for the PCL in the current sample was .97. 2.3.6. Interpersonal needs questionnaire (INQ) The perceived burdensomeness subscale of the interpersonal needs questionnaire (INQ; Van Orden et al., 2012) was used to assess the extent of respondents belief that others would be better off without them. The scale contains six statements (e.g., The people in my life would be better off if I were gone, I think I make things worse for the people in my life) that are rated on a scale ranging from 1 (not at all true for me) to 7 (very true for me). The scale has been found to be reliable across diverse clinical and nonclinical samples, correlates with measures of selfliking and perceived self-competence, and has been found to signicantly predict suicidal ideation and suicide attempts beyond the effects of other risk factors, thereby establishing it as a particularly robust predictor of suicide risk. Internal consistency for the current sample was .92. 2.3.7. Personal feelings questionnaire-2 (PFQ2) The PFQ2 (Harder et al., 1993) was used to measure guilt. The PFQ2 directs respondents to indicate how frequently they experience six different emotional or cognitive states (e.g., mild guilt, worry about hurting or injuring someone, regret, remorse) on a scale ranging from 0 (never) to 4 (continuously or almost continuously). The guilt subscale has good internal consistency ( 4 .72) and testretest stability ( 4 .85) and correlates strongly with other measures of guilt, shame, self-derogation, and social anxiety (Harder et al., 1993; Harder and Zalma, 1990). Internal consistency for the PFQ2 guilt scale in the current sample was .85. 2.4. Data analysis Generalized linear modeling with robust maximum likelihood was utilized to test the associations of direct combat exposure and guilt with severity of suicidal ideation. The following variables were entered as predictors: gender, age, history of suicide attempts, PTSD symptoms, depression symptoms, hopelessness, perceived

burdensomeness, direct combat exposure, and guilt. In terms of power, the current study was sufciently powered (.80) to detect a moderately small effect (f2 .08) for a two-tailed test of signicance with a p-value o .05.

3. Results Fifty-nine (61.5%) participants had deployed to Iraq and/or Afghanistan, of which approximately half (n 25; 25.8% of sample) reported having direct combat exposure. Almost half of participants (n 54; 44.3% of sample) reported some level of suicidal ideation or desire within the past week, with total BSSI scores ranging from 0 to 20. Nine (9.3%) reported making a suicide attempt in the past. Means, standard deviations, and intercorrelations of all variables are displayed in Table 1. As would be expected in a clinical setting psychological symptoms were elevated and intercorrelated with each other. Suicidal ideation was positive correlated with previous suicide attempts, PTSD symptoms, hopelessness, depression, and perceived burdensomeness. Direct combat exposure was positively correlated with age, indicating that older military personnel were more likely to have been in combat. 3.1. Is the association of guilt and suicidal ideation stronger among military personnel with direct combat exposure? Generalized regression analyses were conducted in two steps. In the rst step, all predictors were entered simultaneously, the results of which are summarized in Table 2. Guilt was signicantly associated with more severe suicidal ideation (B .130, SE .044, p .003) above and beyond the effects of all covariates, but direct combat exposure was not (B .046, SE .303, p .880). In the second step, the interaction of guilt with direct combat exposure was added to the model, resulting in a signicant interaction (B .124, SE .053, p .020). The form of the interaction is plotted in Fig. 1, and indicates that for military personnel with no direct combat exposure, guilt was not signicantly associated with suicidal ideation (t .529, p .598), but for military personnel with direct combat exposure, suicidal ideation became more severe as guilt increased (t 3.144, p .002). To determine if a similar pattern existed for other clinical risk factors, we repeated the regression analyses several times, replacing the interaction of combat exposure and guilt with the following variables: depression, PTSD symptoms, and hopelessness. The interactions of depression with direct combat exposure (B .004, SE .040, p .926), PTSD symptoms with direct combat exposure (B .016, SE .018, p .382), and perceived burdensomeness with direct combat exposure (B .158, SE .152,

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Table 2 Generalized regression coefcients predicting severity of suicidal ideation. Step 1 B Gender Age Suicide attempt PTSD Hopelessness Depression Burdensomeness Combat Guilt Combat guilt .172 .039 1.156 .011 .007 .096 .206 .046 .130 SE .301 .017 .395 .011 .029 .034 .107 .303 .044 p .569 .023 .003 .318 .807 .005 .055 .880 .003 Step 2 B .307 .041 1.346 .015 .003 .103 .174 1.282 .098 .124 SE .312 .018 .407 .012 .030 .035 .108 .649 .048 .053 p .326 .021 .001 .204 .912 .004 .107 .048 .041 .020

0.8 0.7 Dependent Variable 0.6 0.5 0.4 0.3 0.2 0.1 0 Low guilt High guilt Combat No combat

Fig. 1. Interaction of guilt and combat exposure on severity of suicidal ideation among 97 Air Force personnel receiving outpatient mental health treatment.

p .300) were not signicant, but the interaction of hopelessness with direct combat exposure (B .069, SE .036, p .057) showed a strong trend towards signicance, with hopelessness showing a somewhat stronger association with increased suicidal ideation among military personnel who had been in direct combat.

or cognitive processing therapy (Resick et al., 2002) could potentially reduce suicide risk and prevent suicidal behavior in military personnel and veterans who have been involved in direct combat. Clinical trials are needed to explicitly test this possibility. In the current study, the interaction of hopelessness and direct combat exposure demonstrated a nonsignicant trend towards signicance, with hopelessness showing a stronger relationship with suicidal ideation among veterans who have been involved in direct combat than among military personnel without direct combat exposure. It is possible that hopelessness, too, might be more strongly associated with suicidal ideation among veterans who have been involved in direct combat although with a much smaller effect than guilt. As noted above, because our study was only sufciently powered to detect moderately small effect sizes (f2 4 .08), it seems likely that the current sample was too small, implicating the need to conduct additional studies with larger sample sizes to explore this possibility. In addition to the limitation of small sample size, conclusions might not generalize to personnel in other Branches of the military with more frequent and higher intensity exposure to combat. Along these same lines, our study did not assess for exposure to different dimensions of combat (e.g., going on patrols, killing, witnessing injury), which could be differentially related to suicide risk. Future studies with larger samples from both clinical and nonclinical settings are necessary to determine the generalizability of our ndings. The current study is additionally limited by self-report methodology, which can be vulnerable to response bias, although the fact that data were collected via anonymous surveys from military personnel who had already self-identied for mental health treatment likely reduces the impact of stigma on response patterns. Nonetheless, follow-up studies using structured diagnostic interviews (especially for PTSD) would contribute considerably to our understanding of guilt, direct combat exposure, and suicidal ideation. Despite these limitations, results of the current study suggest that some risk factors for suicidal ideation might be augmented by direct exposure to combat, highlighting the importance of recognizing different subgroups of military personnel and veterans that might warrant different types of clinical interventions or prevention programs.

4. Discussion Consistent with expectations, results of the current study indicated that guilt is differentially associated with suicidal ideation among those military personnel according to history of direct combat exposure. Specically, although guilt was signicantly associated with more severe suicidal ideation in general, it was especially pronounced among those military personnel who had direct combat exposure. In comparison, depression, PTSD symptomatology, and perceived burdensomeness did not show a differential relationship with suicidal ideation according to direct combat exposure, suggesting that guilt might be a relatively stronger risk factor for increased suicidal ideation among military personnel who have been in direct combat. This aligns with previous ndings that guilt is an especially strong predictor of suicidal ideation among veterans who have been involved in direct combat (Hendin and Haas, 1991; McLean et al., 2012), and might provide an explanation for the increased rates of suicidal ideation and intent observed in several studies among veterans involved in direct combat (Maguen et al., 2012; Rudd, in press; Sareen et al., 2007). From a clinical perspective, these results suggest that assessing guilt might be especially important when conducting suicide risk assessments with veterans who have been involved in direct combat. Similarly, treatments that have been shown to reduce trauma-related guilt such as prolonged exposure

Role of funding source This study received no nancial support. The views expressed in this article are those of the authors and do not necessarily represent the ofcial position or policy of the U.S. Government, the Department of Defense, or the U.S. Army.

Conict of interest None of the authors have any actual or potential conicts of interest.

Acknowledgement The authors would like to acknowledge the contributions and assistance of TSgt (Ret) AnnaBelle Bryan on this project.

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