BACKGROUND/RATIONALE:
The suicide rate among female Veterans increased 63% between 2000 and 2014 - significantly higher than the 30% increase observed among male Veterans during this period. Despite a large volume of work examining risk factors, barriers to care, and care utilization among Veterans, little research has examined these issues as they relate to females. Available research has been limited by small female sample sizes, cross-sectional analysis, and other methodological limitations. As such, we know surprisingly little about the health and psychosocial factors, barriers to care, and healthcare utilization patterns associated with suicidal behaviors among female Veterans. Data on female risk for suicide and their healthcare utilization is needed to direct valuable suicide prevention resources and help VHA address this growing concern.

OBJECTIVE(S):
In a large, national sample of female and male Veterans with recent non-fatal suicidal self-directed violence (SSV: fatal and non-fatal suicide attempts), we aim to: 1) Develop and test explanatory models of female and male risk for repeat SSV over 12 months, and 2) Identify similarities and differences in patterns of healthcare utilization, coping strategies, and symptom change over time between female and male Veterans at risk for SSV.

METHODS:
This is a mixed-methods, longitudinal cohort study of Veterans with a history of SSV, guided by a public health, social-ecological framework to facilitate examination of the range of proximal and distal risks for SSV. First, we will identify and enroll 30 female and 30 male Veterans for whom a non-fatal SSV event was recorded in a suicide behavior report in VA's Corporate Data Warehouse (CDW). These 60 Veterans will participate in qualitative interviews to gather data on Veterans' perspectives and experiences with suicidal thoughts and SSV, their recovery needs and experiences with the recovery process, barriers and facilitators to care, and how clinicians and the healthcare system could better identify and address the needs of Veterans like them. We will use a grounded theory approach to analyze transcripts to develop a theoretical model of risk for SSV among female Veterans, directly informing survey construct selection, quantitative analysis plans, and interpretation of quantitative findings. For the longitudinal survey, we will use suicide behavior reports in CDW to identify and enroll at least 480 female and 480 male Veterans, who will complete health and psychosocial measures at baseline, 6- and 12-month follow up. Self-report questionnaires will be informed by the qualitative findings and include psychosocial and health-related measures such as coping efficacy, interpersonal conflict, positive relations with others, trauma, occupational problems, barriers to care, and mental health symptoms. Participants will be followed for 12 months to assess and document all SSV events (primary outcome: an SSV event following baseline), which will be ascertained via multiple sources. Health and utilization data will be obtained from CDW and medical record progress notes. Main quantitative analyses will use a latent variable modeling framework to simultaneously model males and females in a multi-group format to test models of female and male Veteran suicide risk. We will then use latent class and latent transition analysis to identify differential responses to healthcare utilization and how certain health and psychosocial variables cluster together by gender.

FINDINGS/RESULTS:
None to date.

IMPACT:
Findings from this study will provide previously unavailable evidence to support the selection of intervention targets as well as identify high-priority services and barriers to care to direct programing and research priorities for female Veterans at risk for SSV. This work has the potential to also benefit the broader population of female Veterans with mental health conditions or other risk factors for SSV.

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External Links for this Project

NIH Reporter

Grant Number: I01HX002434-01A1
Link: https://reporter.nih.gov/project-details/9505253

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PUBLICATIONS:

Journal Articles

1. Hoffmire CA, Monteith LL, Denneson LM, Holliday R, Park CL, Mazure CM, Hoff RA. A sex-stratified analysis of suicidal ideation correlates among deployed post-9/11 veterans: Results from the survey of experiences of returning veterans. Journal of affective disorders. 2021 Nov 1; 294:824-830. [view]
2. Hoffmire CA, Denneson LM, Monteith LL, Dichter ME, Gradus JL, Cappelletti MM, Brenner LA, Yano EM. Accelerating Research on Suicide Risk and Prevention in Women Veterans Through Research-Operations Partnerships. Medical care. 2021 Feb 1; 59:S11-S16. [view]
3. Chen JI, Cameron DC, Laliberte AZ, Hooker ER, Niederhausen M, Denneson LM. Assessment of Suicidal Intent in Self-directed Violence and Subsequent Care Received Among Military Veterans: A National Study of Gender Differences. Medical care. 2021 Feb 1; 59:S17-S22. [view]
4. Denneson LM, McDonald K, Tompkins KJ, Meunier CC. Elucidating the chronic, complex nature of suicidal ideation: A national qualitative study of veterans with a recent suicide attempt. Journal of affective disorders reports. 2020 Dec 15; 2(10030):https://doi.org/10.1016/j.jadr.2020.100030. [view]
5. Denneson LM, Tompkins KJ, McDonald KL, Britton PC, Hoffmire CA, Smolenski DJ, Carlson KF, Dobscha SK. Gender Differences in Recovery Needs After a Suicide Attempt: A National Qualitative Study of US Military Veterans. Medical care. 2021 Feb 1; 59:S65-S69. [view]
6. Denneson LM, Smolenski DJ, McDonald KL, Shull S, Hoffmire CA, Britton PC, Carlson KF, Dobscha SK. Gender differences in risk and resilience for suicidal thoughts and behaviors: A national longitudinal survey study of United States veterans with a recent suicide attempt. Journal of affective disorders. 2024 Sep 1; 360:412-420. [view]
7. Denneson LM, Tompkins KJ, McDonald KL, Hoffmire CA, Britton PC, Carlson KF, Smolenski DJ, Dobscha SK. Gender differences in the development of suicidal behavior among United States military veterans: A national qualitative study. Social science & medicine (1982). 2020 Sep 1; 260:113178. [view]
8. Spark TL, Reid CE, Adams RS, Schneider AL, Forster J, Denneson LM, Bollinger M, Brenner LA. Geography, rurality, and community distress: deaths due to suicide, alcohol-use, and drug-use among Colorado Veterans. Injury epidemiology. 2023 Feb 10; 10(1):8. [view]
9. Krishnamurti LS, Denneson LM, Agha A, Beyer N, Mitchell S, Dichter ME. Improving suicide prevention for women veterans: Recommendations from VHA suicide prevention coordinators. General hospital psychiatry. 2023 May 27; 84:67-72. [view]
10. Denneson LM, Hannon SA, McDonald KL, Chen JI, O'Neil ME. Inactivation of high-risk flags for suicide in the Veterans Health Administration: Association of documentation variation with suicide attempts. Psychological Services. 2023 Nov 2. [view]
11. Smolenski DJ, McDonald KL, Hoffmire CA, Britton PC, Carlson KF, Dobscha SK, Denneson LM. Informing measurement of gender differences in suicide risk and resilience: A national study of United States military veterans. Journal of Clinical Psychology. 2023 May 1; 79(5):1371-1385. [view]
12. Chen JI, Mastarone GL, Denneson LM. It's Not Easy - Impacts of Suicide Prevention Research on Study Staff. Crisis. 2019 May 1; 40(3):151-156. [view]
13. Somohano V, Vasquez A, Shank T, Irrgang M, Newman AG, Evans C, Wyse JJ, Denneson LM, O'Neil ME, Lovejoy TI. Perceptions of women with comorbid PTSD and SUD on mechanisms underlying mindfulness-based interventions. Cognitive and behavioral practice. 2024 Feb 1; 31(1):https://doi.org/10.1016/j.cbpra.2022.05.003. [view]
14. Tompkins KJ, Roth B, Wu T, Somohano VC, Denneson LM. Perspectives on military culture among veterans with a recent suicide attempt: Illustrating gender differences and informing suicide prevention. Armed forces and society. 2022 Sep 16; https://doi.org/10.1177/0095327X221123375. [view]
15. Conner KR, Kearns JC, Denneson LM. Qualitative analysis of hospital patient narratives of warning signs on the day of their suicide attempt. General hospital psychiatry. 2022 Nov 9; 79:146-151. [view]
16. Denneson LM, Cameron DC, Hooker ER, Laliberte AZ, Chen JI. Self-Directed Violence Surveillance in the Veterans Health Administration: A National Examination of Factors Associated with Undetermined Versus Suicide Attempt Classification. Community mental health journal. 2023 Jul 1; 59(5):954-961. [view]

Journal Other

1. Denneson LM, Hoffmire CA, Blosnich JR, Dichter ME, Fitelson E, Holliday R, Monteith LL, Smolenski DJ, Yano EM. Advancing Knowledge of Suicide Risk and Prevention Among Women: Introduction to the Supplement. Medical care. 2021 Feb 1; 59:S1-S3. [view]

HSR&D or QUERI Articles

1. Hoffmire CA, Denneson LM. Concerning Trends in Suicide Among Women Veterans Point to Need for More Research on Tailored Interventions. HSR&D FORUM: Research Highlights. 2018 May 1; Spring(2018). [view]

DRA: Mental, Cognitive and Behavioral Disorders
DRE: Prevention, TRL - Applied/Translational
Keywords: Gender Differences, Suicide
MeSH Terms: none