To examine the role of subjective cognitive difficulties (SCD), posttraumatic stress disorder (PTSD), and their interaction in predicting suicidal ideation and current suicidal intent in middle-aged and older United States (US) military veterans.

Population-based cross-sectional study.

Data were analyzed from the 2019 to 2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 3602 US veterans aged 50 years and older (mean age = 69.0).

Questionnaires including the Medical Outcomes Study Cognitive Functioning Scale (SCD), PTSD Checklist for DSM-5 (PTSD), Patient Health Questionnaire-9 (suicidal ideation in the previous two weeks), and the Suicide Behaviors Questionnaire-Revised (current suicidal intent).

A total of 154 (4.4%) veterans screened positive for current PTSD, 239 (6.7%) reported past two-week suicidal ideation, and 37 (1.0%) reported current suicidal intent. The probability of suicidal ideation among veterans with both SCD and PTSD was more than six times higher than that observed in the full sample (44.5% vs. 6.7%) and more than 2.5 times higher than that observed in veterans with SCD and no PTSD (44.5% vs. 17.5%). Veterans with both subjective memory and concentration difficulties were more likely to report suicidal intent, though the interaction between SCD and PTSD was not significantly associated with suicidal intent.

Middle-aged and older U.S. veterans with subjective cognitive impairment and PTSD report higher rates of suicidal ideation than those with SCD alone. Interventions targeting SCD and PTSD may mitigate suicide risk among middle-aged and older veterans.

Little is known about environmental factors that may influence associations between genetic liability to suicidality and suicidal behavior.

This study examined whether a suicidality polygenic risk score (PRS) derived from a large genome-wide association study (N = 122,935) was associated with suicide attempts in a population-based sample of European-American US military veterans (N = 1664; 92.5% male), and whether cumulative lifetime trauma exposure moderated this association.

Eighty-five veterans (weighted 6.3%) reported a history of suicide attempt. After adjusting for sociodemographic and psychiatric characteristics, suicidality PRS was associated with lifetime suicide attempt (odds ratio 2.65; 95% CI 1.37–5.11). A significant suicidality PRS-by-trauma exposure interaction emerged, such that veterans with higher levels of suicidality PRS and greater trauma burden had the highest probability of lifetime suicide attempt (16.6%), whereas the probability of attempts was substantially lower among those with high suicidality PRS and low trauma exposure (1.4%). The PRS-by-trauma interaction effect was enriched for genes implicated in cellular and developmental processes, and nervous system development, with variants annotated to the DAB2 and SPNS2 genes, which are implicated in inflammatory processes. Drug repurposing analyses revealed upregulation of suicide gene-sets in the context of medrysone, a drug targeting chronic inflammation, and clofibrate, a triacylglyceride level lowering agent.

Results suggest that genetic liability to suicidality is associated with increased risk of suicide attempt among veterans, particularly in the presence of high levels of cumulative trauma exposure. Additional research is warranted to investigate whether incorporation of genomic information may improve suicide prediction models.

Homelessness is a major public health problem among U.S. military veterans. However, contemporary, population-based data on the prevalence, correlates, and mental health burden of homelessness among veterans are lacking.

Data were analyzed from the 2019–2020 National Health and Resilience in Veterans Study, a nationally representative survey of veterans (n = 4069). Analyses examined the prevalence and correlates of homelessness, as well as the independent associations between homelessness and current probable psychiatric conditions, suicidality, and functioning.

The lifetime prevalence of homelessness was 10.2% (95% confidence interval 9.3–11.2). More than 8-of-10 veterans reported experiencing their first episode of homelessness following military service, with a mean of 10.6 years post-discharge until onset (s.d. = 12.6). Adverse childhood experiences (ACEs), cumulative trauma burden, current household income, younger age, and drug use disorder emerged as the strongest correlates of homelessness (49% of total explained variance). Veterans with a history of homelessness had elevated odds of lifetime suicide attempt, attempting suicide two or more times, and past-year suicide ideation [odd ratios (ORs) 1.3–3.1]. They also had higher rates of current probable posttraumatic stress disorder, major depressive, generalized anxiety, and drug use disorders (ORs 1.7–2.4); and scored lower on measures of mental, physical, cognitive, psychosocial functioning (d = 0.11–0.15).

One in ten U.S. veterans has experienced homelessness, and these veterans represent a subpopulation at substantially heightened risk for poor mental health and suicide. ACEs were the strongest factor associated with homelessness, thus underscoring the importance of targeting early childhood adversities and their mental health consequences in prevention efforts for homelessness in this population.

Exposure to potentially morally injurious events (PMIEs) is associated with increased risk for substance use disorders (SUDs), although population-based studies remain limited. The goal of this study was to better understand the relationships between PMIE exposure and lifetime and past-year alcohol use disorder (AUD), drug use disorder (DUD), and SUD.

Data were analyzed from the 2019–2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 1321 combat veterans. Multivariable analyses examined associations between three types of PMIE exposure (perpetration, witnessing, and betrayal), and lifetime and past-year AUD, DUD, and SUD, adjusting for sociodemographic variables, combat exposure severity, prior trauma, and lifetime posttraumatic stress disorder and major depressive disorder.

Perpetration was associated with increased odds of lifetime AUD (OR 1.15; 95% CI 1.01–1.31) and lifetime SUD (OR 1.18; 95% CI 1.03–1.35). Witnessing was associated with greater odds of past-year DUD (OR 1.20; 95% CI 1.04–1.38) and past-year SUD (OR 1.14; 95% CI 1.02–1.28). Betrayal was associated with past-year AUD (OR 1.20; 95% CI 1.03–1.39). A large proportion of the variance in past-year AUD was accounted for by betrayal (38.7%), while witnessing accounted for 25.8% of the variance in past-year DUD.

Exposure to PMIEs may be a stronger contributor to SUDs among veterans than previously known. These findings highlight the importance of targeted assessment and treatment of moral injury among veterans with SUDs, as well as attending to specific types of morally injurious experiences when conceptualizing and planning care.

The coronavirus disease-2019 (COVID-19) pandemic has caused myriad health, social, and economic stressors. To date, however, no known study has examined changes in mental health during the pandemic in the U.S. military veteran population.

Data were analyzed from the 2019–2020 National Health and Resilience in Veterans Study, a nationally representative, prospective cohort survey of 3078 veterans. Pre-to-peri-pandemic changes in psychiatric symptoms were evaluated, as well as pre-pandemic risk and protective factors and pandemic-related correlates of increased psychiatric distress.

The prevalence of generalized anxiety disorder (GAD) positive screens increased from pre- to peri-pandemic (7.1% to 9.4%; p < 0.001) and was driven by an increase among veterans aged 45–64 years (8.2% to 13.5%; p < 0.001), but the prevalence of major depressive disorder and posttraumatic stress disorder positive screens remained stable. Using a continuous measure of psychiatric distress, an estimated 13.2% of veterans reported a clinically meaningful pre-to-peri-pandemic increase in distress (mean = 1.1 standard deviation). Veterans with a larger pre-pandemic social network size and secure attachment style were less likely to experience increased distress, whereas veterans reporting more pre-pandemic loneliness were more likely to experience increased distress. Concerns about pandemic-related social losses, mental health COVID-19 effects, and housing stability during the pandemic were associated with increased distress, over-and-above pre-pandemic factors.

Although most U.S. veterans showed resilience to mental health problems nearly 1 year into the pandemic, the prevalence of GAD positive screens increased, particularly among middle-aged veterans, and one of seven veterans experienced increased distress. Clinical implications of these findings are discussed.

Varied longitudinal courses of suicidal ideation (SI) may be linked to unique sets of risk and protective factors.

A national probability sample of 2291 U.S. veterans was followed over four assessments spanning 7 years to examine how a broad range of baseline risk and protective factors predict varying courses of SI.

Most veterans (82.6%) denied SI at baseline and all follow-ups, while 8.7% had new onset SI, 5.4% chronic SI, and 3.3% remitted SI. Compared to the no-SI group, chronic SI was associated with childhood trauma, baseline major depressive and/or posttraumatic stress disorder (MDD/PTSD), physical health difficulties, and recent traumatic stressors. Remitted veterans had the highest risk of a prior suicide attempt (SA) compared to no-SI [relative risk ratio (RRR) = 3.31] and chronic SI groups (RRR = 4.65); and high rates of MDD/PTSD (RRR = 7.62). New onset SI was associated with recent stressors and physical health difficulties. All symptomatic SI groups reported decrements in protective factors, specifically, social connectedness, trait curiosity/exploration, and purpose in life.

Nearly one-in-five veterans reported SI over a 7-year period, most of whom evidenced new onset or remitted SI courses. Chronic and remitted SI may represent particularly high-risk SI courses; the former was associated with higher rates of prospective SA, and psychiatric and physical distress, and the latter with increased likelihood of prior SA, and isolation from social and mental health supports. Physical disability, MDD/PTSD, and recent stressors may be important precipitating or maintaining factors of SI, while social connectedness may be a key target for suicide prevention efforts.