Journal of Psychiatric Research 46 (2012) 843e848

Contents lists available at SciVerse ScienceDirect

Journal of Psychiatric Research

journal homepage: www.elsevier.com/locate/psychires

Life stressors, emotional distress, and trauma-related thoughts occurring

in the 24 h preceding active duty U.S. Soldiers suicide attempts
Craig J. Bryan*, M. David Rudd
National Center for Veterans Studies, The University of Utah, 260 S. Central Campus Dr., Room 205, Salt Lake City, UT 84112, USA

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 25 January 2012
Received in revised form
7 March 2012
Accepted 8 March 2012

External life events and internal experiences (i.e., emotional distress and trauma-related thoughts)
occurring in the 24 h preceding suicide attempts were examined in a sample of active duty U.S. Soldiers.
Seventy-two Soldiers (66 male, 6 female; 65.3% Caucasian, 9.7% African-American, 2.8% Asian, 2.8%
Pacic Islander, 4.2% Native American, and 9.7% other; age M 27.34, SD 6.50) were interviewed
using the Suicide Attempt Self Injury Interview to assess the occurrence of external events and internal
experiences on the day of their suicide attempts, and to determine their associations with several
dimensions of suicide risk: suicidal intent, lethality, and deliberation about attempting. Multiple external
stressors and internal states were experienced by Soldiers in the 24 h preceding their suicide attempts,
with emotional distress being the most common. Trauma-related thoughts were much less frequently
reported in the 24 h preceding suicide attempts. Emotional experiences were directly associated with
suicidal intent, and explained the relationship between external events and suicidal intent. Lethality was
unrelated to any external events, emotional experiences, or trauma-related thoughts. Greater emotional
distress and trauma-related thoughts were associated with shorter deliberation about whether or not to
attempt suicide. Soldiers experience multiple sources of distress in the period immediately preceding
their suicide attempts. Soldiers who experience more negative emotional experiences have a stronger
desire for suicide and spend less time deliberating before an attempt.
2012 Elsevier Ltd. All rights reserved.

Keywords:
Suicide
Suicide attempt
Military
Army
Trauma

1. Introduction
Suicide consistently ranks within the top ten causes of death
within the U.S., accounting for over 30,000 deaths per year (Centers
for Disease Control, 2012). Nonfatal suicide attempts, with an
estimated prevalence rate of 2.7%, are much more common than
suicide deaths (Nock and Kessler, 2006), and are the most robust
risk factor for death by suicide even in the presence of other wellestablished risk factors for suicide (e.g., Joiner et al., 2005). Suicidal
behaviors among members of the U.S. Armed Forces have been of
particular concern for given their rapid rise in frequency since 2004
(Department of the Army, 2010; Ramchand et al., 2011). As the
closest behavioral pattern to completed suicide, better understanding of suicide attempts could potentially provide important
clues for understanding completed suicide.
Empirical data and clinician experience have identied
a considerable number of risk factors for suicidal behaviors that can
be generally organized into external and internal experiential

* Corresponding author. Tel.: 1 210 621 8300, 1 210 621 8300 (mobile).
E-mail addresses: craig.bryan@utah.edu, craig.bryan@psych.utah.edu (C.J. Bryan).
0022-3956/$ e see front matter 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jpsychires.2012.03.012

domains. External risk factors include life stressors such as relationship problems, nancial strain, legal problems, and injury or
illness, and internal risk factors include mood disturbance, specic
thought processes such as hopelessness, and physiological disturbances such as insomnia. Within the military, epidemiological data
have identied a number of relevant external and internal factors
associated with suicidal behaviors. In terms of external factors, for
instance, 82% of active duty suicide deaths within the Army have
been found to be associated with at least one signicant life
stressor, of which relationship problems are the most frequentlyoccurring (Center for Health Promotion and Preventive Medicine
[CHPPM], 2010). Specic to internal factors, 48% of Soldiers who
died by suicide were diagnosed with mental health condition at the
time of death (CHPPM, 2010). These data are mirrored within the
other Branches of Service, indicating some consistencies across the
entire military (Department of Defense, 2010). Posttraumatic stress
disorder (PTSD) is of particular concern in light of recent evidence
that 9.1% of Soldiers who die by suicide have been diagnosed with
PTSD (CHPPM, 2010) and a growing body of literature supporting
the contributory role of PTSD on suicide risk among military
personnel and veterans (Jakupcak et al., 2009; Rudd et al., 2011;
Sareen et al., 2007). Unfortunately, these epidemiological data are

844

C.J. Bryan, M.D. Rudd / Journal of Psychiatric Research 46 (2012) 843e848

limited by cross-sectional designs or long follow-up periods that

can be impractical or of limited utility to clinicians, who tend to
operate with much shorter frames of reference.
A considerable challenge facing clinicians is the dynamic nature
of suicide risk, which uctuates over time concurrent with both
external events (e.g., life stressors) and internal experiences (e.g.,
mood and cognitions). In many cases, these uctuations in risk can
occur extremely rapidly, making suicidal behaviors extremely
difcult to predict with reliability, especially in the short-term.
Recent discussions of short-term indicators of suicidal behaviors,
referred to as warning signs for suicide, have highlighted the
general lack of evidence for acute indicators and the resulting
difculties in identifying and disseminating reliable warning signs
that are meaningful to clinicians (i.e., occurring within hours or
days of suicidal behavior; Mandrusiak et al., 2006; Rudd et al.,
2006). The dynamic nature of suicide risk has been noted by
Rudd (2006), who proposed the suicidal mode theory as a model
for understanding the process of suicide risk over time. The suicidal
mode is a network of cognitive (e.g., hopelessness, perceived burdensomeness), behavioral (e.g., substance abuse, social withdrawal), emotional (e.g., depression, shame), and physical (e.g.,
insomnia, concentration impairment) experiences that are simultaneously activated in the presence of a triggering event (e.g., life
stressors). The suicidal mode is maintained by the mutual inuence
of these internal experiences, which in turn interact with external
life events. In the presence of triggering events, the suicidal mode is
activated and the individual experiences an acute suicidal crisis.
These suicidal crises resolve subsequent to the deactivation of the
individuals internal cognitive, behavioral, emotional, and physical
experiences, at which point the individual returns to their baseline
level of risk.
To our knowledge, no studies currently exist that explore the
external and internal contextual factors occurring within Soldiers
lives within the period of time immediately preceding (i.e., within
24 h of) suicidal behavior. Indeed, rigorous empirical data on such
near-term contextual factors is limited in general (Rudd et al.,
2006). The primary aim of the current study was therefore to
describe external and internal contextual factors experienced by
Soldiers within 24 h immediately preceding their suicide attempts,
and to examine the relationships of these factors with several
dimensions of suicidal behavior: suicidal intent, lethality, and
deliberation. Two primary hypotheses were tested: (1) a greater
number of external events and internal experiences (both emotions
and trauma-related thoughts) occurring on the day of Soldiers
suicide attempts would be associated with more severe suicidal
intent and shorter deliberation about attempting; and (2) external
and internal (i.e., emotions and trauma-related thoughts) contextual factors would be unrelated to attempt lethality.

2. Method
2.1. Participants
Participants were 72 active duty Soldiers (66 male, 6 female) age
19e44 years (M 27.34, SD 6.50) reporting at least one suicide
attempt within the past month. These 72 participants were drawn
from a larger sample of 93 Soldiers referred for a standardized
evaluation as part of a randomized clinical trial testing a brief
psychotherapy to reduce suicide attempts. Participants had been in
the military an average of 5.45 years (SD 4.01, range: 1e19 years),
and self-reported the following racial status: Caucasian (65.3%),
African-American (9.7%), Asian (2.8%), Pacic Islander (2.8%), Native
American (4.2%), and other (9.7%). Separate from race, 22.2%
reported Hispanic or Latino ethnicity. The majority of participants

were married (53.5%), followed by single (18.3%), separated (14.1%),

dating/engaged (7.0%), divorced (5.6%), and widowed (1.4%).
2.2. Procedure
Data were obtained from comprehensive evaluations administered to all Soldiers providing informed consent to participate in
a clinical trial testing an outpatient treatment to reduce suicidal
behaviors. Participants were referred upon discharge from inpatient hospitalization due to acute suicide risk, and completed selfreport measures and structured interviews at intake and at 3and 6-month follow-ups. The study was approved by the Institutional Review Boards of the Madigan Army Medical Center and the
University of Utah in accordance with the latest version of the
Declaration of Helsinki.
2.3. Measures
2.3.1. Suicide attempt
The Suicide Attempt Self-Injury Interview (SASII; Linehan et al.,
2006) is a structured clinical interview designed to assess the
factors involved in nonfatal suicide attempts and intentional selfinjury, which can be used to differentiate suicide attempts from
nonsuicidal self-injury and/or other forms of deliberate self-harm.
The SASII assesses factors including method, lethality, duration of
deliberation, subjective versus objective intent, reasons for the
attempt, and consequences of the attempt. On the basis of all
information obtained, the evaluator classied the behavior as
a suicide attempt (whether ambivalent or not) versus nonsuicidal
self-injury, based primarily on the assessed level of subjective and/
or objective intent. A suicide attempt was dened as a nonfatal,
self-directed, potentially injurious behavior with any intent to die
as a result of the behavior, regardless of outcome (cf. Crosby, Ortega,
& Melanson, 2011; Silverman et al., 2007). The SASII has high
interrater reliability (.871e.978, Mdn .956) across the assessorrelated items. Very high consistency has been found between
retrospective (4 months) report of suicide attempts by patients as
compared to weekly reports (ICC .91), suggesting that retrospective report is comparable to regular, ongoing reports of suicide
attempts. Comparison of reports on the SASII relative to medical
record verication has additionally supported the instruments
validity in assessing medical lethality and outcome. In the current
study, the SASII was used to assess up to three distinct suicide
attempts made during the assessment period: the rst attempt, the
worst point suicide attempt (i.e., the episode during which the
patient most strongly desired death), and the most recent suicide
attempt. In the current study, interrater agreement was assessed
via review of assessment notes by a second rater. Raters agreed on
the classication of suicide attempts in all cases in the current
study.
Suicidal intent was assessed by asking participants to self-rate
the intensity of their desire for suicide during each attempt on
a scale ranging from 0 (not at all) to 6 (I was extremely serious,
intended to die, and was not ambivalent at all). Medical lethality
was rated by the evaluator using standardized criteria on a scale
ranging from 1 (very low; e.g., less than or equal to 5 pills,
scratching, head banging, etc.) to 6 (severe; e.g., pulling trigger of
loaded gun aimed at a vital area, jumping from a high place,
hanging). Extent of deliberation was rated by the evaluator on
a scale ranging from 1 (commitment to act, followed by very
careful or elaborate plan carried out over time) to 7 (no active
planning; occurred impulsively, with no forethought and with very
strong emotion). To assess situational factors occurring during the
24 h preceding each suicide attempt, participants were presented
with a list of 46 potential experiences and then asked if each factor

C.J. Bryan, M.D. Rudd / Journal of Psychiatric Research 46 (2012) 843e848

occurred within the 24 h immediately preceding each suicide

attempt using a dichotomous (yes/no) format. These factors are
organized into three clusters: external events (i.e., things that
happened in the environment; a .71), emotional experiences
(i.e., things you felt; a .89), and traumatic thoughts (i.e., things
you thought about; a .46). Due to low reliability of the traumatic
thoughts cluster, we repeated all analyses with each individual item
from the scale. Because results did not differ when considering each
individual item versus the aggregated items, we maintained (and
report) only results using the full subscale.
2.3.2. Clinical diagnosis
The Structured Clinical Interviews for DSM-IV (SCID-IV; First
et al., 2002) was used to determine participants clinical diagnoses. The SCID-IV-TR was administered by a trained evaluator
during the initial, baseline assessment. Ninety-seven percent of
participants met criteria for at least one Axis I disorder, and 69.0%
met criteria for more than one Axis I diagnosis. Axis I clinical
disorders for the current sample were as followed: major depressive disorder (89.3%), posttraumatic stress disorder (39.3%),
substance dependence (26.2%), alcohol dependence (23.8%), social
phobia (10.7%), panic disorder (8.3%), alcohol abuse (7.1%), body
dysmorphic disorder (3.6%), substance abuse disorder (3.6%),
depressive disorder not otherwise specied (2.4%), acute stress
disorder (2.4%), dysthymic disorder (2.4%), binge eating disorder
(2.4%), specic phobia (1.2%), and anxiety disorder not otherwise
specied (1.2%).
2.4. Data analytic strategy
Frequency analyses and measures of central tendency were rst
used to describe the sample. To test the association of contextual
factors with suicidal intent, lethality of attempt, and duration of
deliberation, a series of generalized linear regression analyses
(negative binomial distributions) were analyzed in a series of steps
using robust estimation. In the rst step, the dependent variables
were regressed onto each individual contextual factor. In the
second step, the contextual factors were entered into the regression
equation simultaneously. To test for mediation effects, the test of
indirect effects with bootstrapping was utilized consistent with the
recommendations of Preacher and Hayes (2004). Because the
dependent variables (intent, lethality, and deliberation) all
demonstrated signicant negative skew and negative binomial
regression models require positive skew, scores were rst reversekeyed for the purposes of analysis. Results are presented and
interpreted using untransformed scores, however (i.e., higher
scores indicate more severe pathology). Analyses were repeated
with gender, age, and diagnosis (i.e., PTSD, depression, substance
abuse, and alcohol abuse) entered as covariates due to these variables associations with suicidal behaviors, which did not change
results.
3. Results
The72 participants attempted suicide a total of 138 times
(M 1.85, SD .89, Mdn 2), with a range from one (42.3%) to ve
(1.4%) lifetime suicide attempts. Because a maximum of three
suicide attempts per participants was assessed, consistent with the
rst-worst-most recent approach, only 136 out of the 138 total
suicide attempts were assessed. The methods of suicide attempt
were, in descending order of frequency: drugs/medication overdose
(36.0%); scratching/cutting (20.6%); rearm (18.4%); hanging (8.8%);
transportation-related (4.4%); jumping (2.9%); alcohol consumption
(2.9%); asphyxiation (2.2%); drowning (1.5%); and poisoning/caustic
substance, stepping into trafc, and other (.7% each).

845

3.1. Contextual factors occurring in the 24 h before suicide attempts

On average, participants reported a mean total of 15.02
(SD 7.65, range: 0e33) contextual factors occurring in the 24 h
before each suicide attempt. Approximately two-thirds of these
factors (M 10.32, SD 5.51) were emotional experiences, followed by external events (M 4.06, SD 2.73) and then traumatic
thoughts (M .65, SD .90). The frequencies of each self-reported
situational factor are listed in Table 1, organized according to the
three categories. The most frequently-reported contextual factors
were emotional in nature: feeling depressed (83.1%); upset,
miserable or distressed (75.7%); overwhelmed (66.9%); and lonely,
isolated, or abandoned (62.5%). The most frequently-endorsed

Table 1
Frequency of contextual factors occurring within 24 h of 136 suicide attempts by 72
active duty Soldiers.
Item

Things that happened in the environment (a .71)

1.
You had an argument or conict with another person
79 58.1
4.
Someone was angry with you, criticized you, or put
67 49.3
you down
9.
You were isolated or alone more than you wanted to be
54 39.7
3.
Someone was disappointed with you
44 32.4
6.
Someone rejected you
44 32.4
21.
Other important negative events happened which could
38 27.9
have triggered your suicide attempt
16.
You saw things you could use to harm yourself or attempt 36 26.5
suicide with
2.
You tried to spend time with someone but couldnt
32 23.5
5.
Someone let you down or broke a promise
31 22.8
10.
You had nancial problems
31 22.8
7.
You lost someone important (even if temporary loss)
30 22.1
14.
You tried to get (or continue) something you wanted
29 21.3
but couldnt
12.
You had health problems or physical discomfort
16 11.8
19.
You had a therapy session before your suicide attempt
9 6.6
15.
You heard of someone else attempting suicide or harming
6 4.4
themselves
13.
You had a new demand
5 3.7
17.
You talked to someone about sexual abuse or rape
5 3.7
20.
You had a therapy session scheduled for later in the day
4 2.9
18.
You talked with your therapist about sexual abuse or rape
3 2.2
8.
Therapist went out of town or took a break from
2 1.5
having sessions
11.
You lost a job
2 1.5
Things you felt (a .89)
36.
Depressed
113 83.1
22.
Upset, miserable or distressed
103 75.7
25.
Overwhelmed
91 66.9
38.
Lonely, isolated, or abandoned
85 62.5
31.
Like a failure or inferior
78 57.4
35.
Sad or disappointed
78 57.4
40.
Discouraged or hopeless
73 53.7
24.
Anxious, afraid, or panicked
72 52.9
39.
Trapped or helpless
66 48.5
29.
Self-hatred or shame, or thought you were bad
65 47.8
33.
Felt bad about yourself
63 46.3
27.
Angry, frustrated or enraged at someone else
61 44.9
32.
Like a burden to others
59 43.4
42.
Emotionally empty or numb
58 42.6
23.
Out of control
56 41.2
37.
Tired or exhausted
56 41.2
28.
Angry frustrated or enraged at yourself
53 39.0
41.
Confused
49 36.0
30.
Like you deserved to be punished or hurt
43 31.6
34.
Guilty
43 31.6
26.
Angry, frustrated or enraged unspecied
38 27.9
Things you thought about (a .46)
45.
Combat
21 15.4
46.
Had ashbacks or nightmares
21 15.4
44.
Physical abuse or assault
19 14.0
43.
Sexual abuse or rape
11 8.1

846

C.J. Bryan, M.D. Rudd / Journal of Psychiatric Research 46 (2012) 843e848

external events were interpersonally-oriented: an argument or

conict with someone (58.1%); being the target of someones anger
or criticism (49.3%); and being isolated or alone (39.7%). Thoughts
about traumatic events were much less common, being endorsed in
less than 16% of suicide attempts.

Exp(b) 1.02 [.94, 1.09]; emotional experiences: b .03, SE .02,

p .162, Exp(b) 1.03 [.99, 1.07]; traumatic thoughts: b .01,
SE .10, p .919, Exp(b) .99 [.78, 1.19]).

3.2. Means, standard deviations, and intercorrelations of variables

A greater number of emotional experiences (b .08, SE .03,

p .007, Exp(b) 1.08 [1.02, 1.15]) and traumatic thoughts (b .46,
SE .12, p < .001, Exp(b) 1.58 [1.25, 1.99]) were associated with
less deliberation, but external events were unrelated to deliberation (b .05, SE .05, p .337, Exp(b) 1.05 [.95, 1.15]). When
considered together, results did not change; more emotional
experiences (b .08, SE .03, p .024, Exp(b) 1.08 [1.01, 1.16])
and traumatic thoughts (b .40, SE .12, p .001, Exp(b) 1.49
[1.18, 1.89]) were associated with more deliberation, but external
events were not (b .06, SE .05, p .208, Exp(b) .94 [.85,
1.04]).
Because the highest score (7) on the SASIIs deliberation scale
explicitly probes for emotional distress in addition to objective
duration of deliberation (i.e., no active planning; occurred
impulsively, with no forethought and with very strong emotion), it
is possible that this might contaminate ndings. We therefore
recoded all values of 7 to the value 6, which corresponds to the
same objective duration of deliberation but without the explicit
inclusion of emotion (i.e., no active planning; occurred impulsively, with no forethought but without strong emotion). The
regression analyses were repeated, but no change in ndings
resulted; more emotional distress and traumatic thoughts
remained signicantly associated with less deliberation, and
external events remained unassociated with deliberation.

Descriptive statistics and zero-order correlations for all variables

are reported in Table 2. Mean suicidal intent was high (M 4.92,
SD 1.46, range: 0e6) and positively correlated with external
events (r .24, p .006) and emotional experiences (r .33,
p < .001), but was not correlated with traumatic thoughts (r .09,
p .292). Mean lethality was high (M 4.21, SD 1.74, range: 1e6)
and was not correlated with other variables. Deliberation was also
very high (M 5.75, SD 1.99, range: 0e6) and positively correlated with suicidal intent (r .21, p .013), emotional experiences
(r .24, p .005), and traumatic thoughts (r .32, p < .001), but
not with external events (r .07, p .403). Emotional experiences
correlated positively with both external events (r .54, p < .001)
and traumatic thoughts (r .29, p .001), but external events and
traumatic thoughts were uncorrelated (r .16, p .064).
3.3. Associations with suicidal intent
A greater number of external events (b .13, SE .05, p .007,
Exp(b) 1.14 [1.04, 1.23]) and emotional experiences (b .08,
SE .02, p < .001, Exp(b) 1.09 [1.04, 1.13]) occurring in the 24 h
before suicide attempts were associated with higher levels of
suicidal intent, but traumatic thoughts were not (b .14, SE .13,
p .304, Exp(b) 1.15 [.89, 1.41]). When considered together, only
emotional experiences (b .07, SE .03, p .011, Exp(b) 1.08
[1.02, 1.13]) were signicantly associated with higher intent, and
the direct effect of external events lost signicance (b .04,
SE .06, p .478, Exp(b) 1.04 [.93, 1.16]), suggesting a possible
mediation effect. A test for mediation was therefore conducted,
resulting in a statistically signicant model (F (2, 133) 8.605,
p < .001, f2 .12) with the indirect effect of external events on
suicidal intent through emotional experiences being signicant
(b .08, SE .03, z 2.79, p .005). Results suggest that suicidal
Soldiers emotional experiences explain the relationship of external
events with suicidal intent.
3.4. Associations with lethality of attempt
None of the contextual factors were independently associated
with attempt lethality (external events: b .04, SE .03, p .209,
Exp(b) 1.04 [.98, 1.11]; emotional experiences: b .03, SE .02,
p .072, Exp(b) 1.03 [1.00, 1.06]; traumatic thoughts: (b .04,
SE .10, p .740, Exp(b) 1.04 [.83, 1.24]). An absence of association was similarly found when all contextual factors were
considered together (external events: b .02, SE .04, p .695,
Table 2
Means, standard deviations, and intercorrelations for all variables.

1. Intent
2. Lethality
3. Deliberation
4. External events
5. Emotional experiences
6. Traumatic thoughts
M
SD
**p < .01, *p < .05.

1.

2.

3.

4.

5.

6.

.15
.21*
.24**
.33**
.09
4.92
1.46

.04
.10
.15
.03
4.21
1.74

.07
.24**
.32**
5.75
1.99

.54**
.16
4.06
2.73

.29**
10.32
5.51

.65
.9

3.5. Associations with suicidal deliberation

4. Discussion
Results of the current study suggest that active duty Soldiers
experience multiple external stressors and negative internal (both
emotional and trauma-related) experiences in the 24 h before their
suicide attempts. Emotional distress was more commonly endorsed
than external events, and traumatic thoughts were the least
frequently endorsed. Of the external events occurring in the 24 h
before the Soldiers suicide attempts, the majority were interpersonal in nature, consistent with prior research supporting the
importance of interpersonal and relationship stressors occurring
within the time immediately preceding suicidal behaviors among
both non-military (Appleby et al., 1999; Bastia and Kar, 2009;
Wyder et al., 2009) and military samples (Department of the Army,
2010; Department of Defense, 2010). The differential associations of
external events and emotional experiences with various dimensions of suicide risk have particular clinical implications for
understanding suicidal behavior among Soldiers.
Soldiers who reported experiencing a greater number of
emotional experiences on the day of their suicide attempt also
reported more severe suicidal intent. Although experiencing
a greater number of life stressors in the 24 h before their suicide
attempts was associated with more severe suicidal intent, this
relationship occurred only indirectly through Soldiers emotional
distress. This suggests that the relationship between life stressors
and suicidal intent is explained by co-occurring emotional distress,
thereby partially supporting our initial hypothesis. Previous
research has similarly found positive correlations between
emotional distress and subjective suicidal intent, but an absence of
association between life events and intent (Horesh et al., in press).
This pattern is consistent with the tenets of uid vulnerability
theory (Rudd, 2006), which posits that external events serve to
trigger or activate the suicidal mode, whereas suicidal intent and
emotional distress are both direct manifestations of the active

C.J. Bryan, M.D. Rudd / Journal of Psychiatric Research 46 (2012) 843e848

mode itself. Suicidal intent and emotional experiences should

therefore be more closely associated with each other than external
events. These results suggest that clinicians might enhance the
accuracy of risk assessments by emphasizing Soldiers emotional
experiences in response to stressful events, instead of emphasizing
the total number of stressful events experienced by Soldiers.
Lethality was unrelated to the number of life stressors,
emotions, or traumatic thoughts experienced on the day of the
Soldiers attempts. Although we were unable to identify any other
studies considering the explicit link between emotional distress
and lethality, several previous studies have found that the lethality
of an attempt has only a weak relationship with subjective suicidal
intent (Beck et al., 1975; Brown et al., 2004; Pirkola et al., 2003;
Swahn and Potter, 2001), which was associated with emotional
distress in the current study. This particular nding additionally
aligns with recent theorizing about suicide risk (i.e., the
interpersonal-psychological theory; Joiner, 2005), which argues
that the desire for suicide, which is inuenced by emotional and
cognitive distress, is conceptually distinct from the capability to
engage in highly lethal suicidal behaviors. Our ndings therefore
suggest that clinicians would be mistaken in assuming that the
number of life stressors and/or severity of emotional distress or
trauma could serve as predictors of the lethality of a Soldiers
suicide attempt.
Finally, the amount of deliberation over a suicide attempt is
associated with internal but not external factors. Specically, our
data indicate that Soldiers reporting more emotional distress and
(especially) traumatic thoughts on the day of their suicide attempts
spent more time thinking about whether or not to attempt suicide.
In other words, Soldiers reporting less emotional experiences acted
more quickly and deliberated for less time. This pattern remained
even when considering clinical diagnosis, indicating that emotional
and traumatic experiences are related to suicide deliberation
regardless of clinical diagnosis. Given the primary purpose of selfinjurious and suicidal behavior is to reduce emotional distress
(Nock and Prinstein, 2004; Brown et al., 2002; Bryan and Rudd,
2012), it is not surprising that more intense negative emotional
experiences are associated with longer deliberation. Results also
align with previous research nding that longer deliberation about
suicide is associated with more emotional distress and desire for
death (Simon et al., 2001; Wyder and DeLeo, 2007). Clinicians
should therefore be mindful that rapid decisions to act upon
suicidal impulses can occur even among those patients reporting
lower levels of emotional distress.
The current study is limited by its relatively small sample size
restricted to active duty Soldiers who survived nonlethal suicide
attempts. Results therefore might not generalize to other samples,
and should be replicated with larger military and civilian populations. Our study is also limited by the retrospective design,
which could be affected by biases or inaccuracies in memory.
Furthermore, we are unable to determine if the observed relationships would apply to future suicidal behaviors. Additional
research using prospective designs is therefore warranted to better
understand which contextual factors are most robustly linked to
future suicide attempts, especially in the very short term.
Prospective research would also help to determine if our ndings
similarly apply to suicide deaths in addition to suicide attempts.
Finally, our study is unable to distinguish between those events and
experiences that were occurring in participants lives for more
extended periods of time preceding the suicide attempts (e.g.,
ongoing stressors and issues) versus those that occurred exclusively in the day preceding the suicide attempts (e.g., emergence of
new problems or distress). Additional research that can more
accurately differentiate such time-related factors would further
advance our understanding of acute versus chronic factors

847

associated with risk. Despite these limitations, this study provides

useful information on Soldiers life events and psychological
experiences occurring in the period of time immediately preceding
their suicide attempts.
Role of funding source
This work was supported by a grant to M. David Rudd from the
United States Department of Defense (W81XH-09-1-0569). 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.
Contributors
Craig J. Bryan, PsyD, ABPP, was responsible for the daily operations of the study, the research question, data analysis, and
manuscript preparation.
M. David Rudd, PhD, ABPP, was responsible for the design of the
clinical trial from which data were used, and assisted with manuscript preparation.
Conict of interest
None of the authors have any actual or potential conicts of
interest.
Acknowledgment
None.
References
Appleby L, Cooper J, Amos T, Faragher B. Psychological autopsy study of suicides by
people aged under 35. British Journal of Psychiatry 1999;175:148e74.
Bastia BK, Kar N. A psychological autopsy study of suicidal hanging from Cuttack,
India: focus on stressful life situations. Archives of Suicide Research 2009;13:
100e4.
Beck AT, Beck R, Kovacs M. Classication of suicidal behaviors: I. Quantifying intent
and medical lethality. American Journal of Psychiatry 1975;132:285e7.
Brown GK, Henriques GR, Sosdjan D, Beck AT. Suicide intent and accurate expectations of lethality: predictors of medical lethality of suicide attempts. Journal
of Consulting and Clinical Psychology 2004;72:1170e4.
Brown MZ, Comtois KA, Linehan MM. Reasons for suicide attempts and nonsuicidal
self-injury in women with borderline personality disorder. Journal of Abnormal
Psychology 2002;111:198e202.
Bryan CJ, Rudd MD. Reasons for attempting suicide among active duty Soldiers:
clinical implications. In: Presentation at the annual DoD/VA Suicide prevention
conference, Washington, DC, 2012.
Center for Health Promotion and Preventive Medicine. Analyses of army suicides,
2003e2009. Epidemiological Report No. 14-HK-0BW9-10c; 2010.
Centers for Disease Control. 10 leading causes of death by age group, United States
e 2008. Retrieved 25.01.12, from: http://www.cdc.gov/Injury/wisqars/pdf/
10LCD-Age-Grp-US-2008-a.pdf; 2012.
Crosby AE, Ortega L, Melanson C. Self-directed violence surveillance: uniform
denitions and recommended data elements, Version 1.0. Atlanta, GA: Centers
for Disease Control and Prevention; 2011.
Department of Defense. The challenge and the promise: strengthening the force,
preventing suicide, and saving lives: nal report of the department of defense
task force on the prevention of suicide by members of the armed forces.
Washington, DC: Department of Defense; 2010.
Department of the Army. Army health promotion suicide prevention risk reduction:
report 2010. Washington, DC: Department of the Army; 2010.
First MB, Spitzer RL, Gibbon M, Williams JBW. Structured clinical interview for
DSM-IV-TR axis I disorders, research version, research version (SCID-RV). New
York, NY: Biometrics Research: New York State Psychiatric Institute; 2002.
Horesh N, Levi Y, Apter A. Medically serious versus non-serious suicide attempts:
relationships of lethality and intent to clinical and interpersonal characteristics.
Journal of Affective Disorders. in press.
Jakupcak M, Cook J, Imel Z, Fontana A, Rosenheck R, McFall M. Posttraumatic stress
disorder as a risk factor for suicidal ideation in Iraq and Afghanistan war
veterans. Journal of Traumatic Stress 2009;22:303e6.
Joiner TE. Why people die by suicide. Cambride, MA: Harvard University Press;
2005.

848

C.J. Bryan, M.D. Rudd / Journal of Psychiatric Research 46 (2012) 843e848

Joiner TE, Conwell Y, Fitzpatrick KK, Witte TK, Schmidt NB, Berlim MT, et al. Four
studies on how past and current suicidality relate even when everything but
the kitchen sink is covaried. Journal of Abnormal Psychology 2005;114:
291e303.
Linehan MM, Comtois KA, Brown MZ, Heard HL, Wagner A. Suicide attempt self
injury interview (SASII): development, reliability, and validity of a scale to
assess suicide attempts and intentional self-injury. Psychological Assessment
2006;18:303e12.
Mandrusiak M, Rudd MD, Joiner TE, Berman AL, Van Orden KA, Witte T. Warning
signs for suicide on the internet: a descriptive study. Suicide and LifeThreatening Behavior 2006;36:263e71.
Nock MK, Kessler RC. Prevalence of and risk factors for suicide attempts versus
suicide gestures: analysis of the national comorbidity survey. Journal of
Abnormal Psychology 2006;115:616e23.
Nock MK, Prinstein MJ. A functional approach to the assessment of self-mutilative
behavior. Journal of Consulting and Clinical Psychology 2004;72:885e90.
Pirkola S, Isomets E, Lnnqvist J. Do means matter? Differences in characteristics of
Finnish suicide completers using different methods. Journal of Nervous &
Mental Disease 2003;191:745e50.
Preacher KJ, Hayes AF. SPSS and SAS procedures for estimating indirect effects in
simple mediation models. Behavior Research Methods, Instruments, &
Computers 2004;36:717e31.
Ramchand R, Acosta J, Burns RM, Jaycox LH, Pernin CG. The war within: preventing
suicide in the U.S. military. Santa Monica, CA: RAND Corporation; 2011.
Rudd MD. Fluid vulnerability theory: a cognitive approach to understanding the
process of acute and chronic suicide risk (p. 355e368). In: Ellis TE, editor.

Suicide and cognition: theory, research, and therapy. Washington, DC: American Psychological Association; 2006.
Rudd MD, Berman AL, Joiner TE, Nock MK, Silverman MM, Mandrusiak M, et al.
Warning signs for suicide: theory, research, and clinical applications. Suicide and
Life-Threatening Behavior 2006;36:255e62.
Rudd MD, Goulding J, Bryan CJ. Student veterans: a national survey exploring
psychological symptoms and suicide risk. Professional Psychology: Research
and Practice 2011;42:354e60.
Sareen J, Cox BJ, Stein MB, A TO, Fleet C, Asmundson GJ. Physical and mental
comorbidity, disability, and suicidal behavior associated with posttraumatic
stress disorder in a large community sample. Psychosomatic Medicine 2007;69:
242e8.
Silverman MM, Berman AL, Sanddal ND, OCarroll PW, Joiner TE. Rebuilding the
Tower of Babel: a revised nomenclature for the study of suicide and suicidal
behaviors part 2: suicide-related ideations, communications, and behaviors.
Suicide and Life-Threatening Behavior 2007;37:264e77.
Simon TR, Swann AC, Powell KE, Potter LB, Kresnow M, OCarroll PW. Characteristics
of impulsive suicide attempts and attempters. Suicide and Life-Threatening
Behavior 2001;32:49e59.
Swahn MH, Potter LB. Factors associated with the medical severity of suicide
attempts in youths and young adults. Suicide and Life-Threatening Behavior
2001;32:21e9.
Wyder M, De Leo D. Behind impulsive suicide attempts: indications from
a community sample. Journal of Affective Disorders 2007;104:167e73.
Wyder M, Ward P, De Leo D. Separation as a suicide risk factor. Journal of Affective
Disorders 2009;116:208e13.