Traumatic Events and Suicide Attempts

Traumatic Events and Suicide Attempts Findings from a large representative sample of Canadian military personnel Presenter: Shay-Lee Belik Co-Authors: Brian J Cox Gordon JG Asmundson Murray B Stein Jitender Sareen

Background Concern about the mental health of soldiers Suicide 2 nd most common cause of death in US military War/combat operations may lead to exposure to traumatic experiences 38% of SI attributable to exposure to traumatic events Controversy around relationship of combat- related trauma to suicidal behavior Ritchie et al 2003 Mil Med; Goldney et al 2000 Aust NZ J Psych

The Controversy - Combat Increased risk Kaplan et al 2007 >34,000 veterans longitudinal cohort Veterans twice as likely (HR=2.13) to die of suicide compared with non-veterans Decreased risk Desjeux et al. 2004 Longitudinal cohort study Lower suicide risk in army men than in men in rest of population Bullman & Kang 1996 Increasing risk of suicide with increased occurrence of combat trauma

The Controversy - Peacekeeping Increased risk Thorensen et al. 2003 >22,000 veterans longitudinal cohort Increased risk of suicide among former peacekeepers No difference in risk Wong et al. 2001 No increased risk of suicide in peacekeepers

Limitations of previous work Non-representative samples e.g., VA clinical samples Not a wide range of traumatic events Important effect of childhood adversities

Current objectives Does a direct link exist between traumatic events and suicide attempts? Trauma exposure Suicide attempts Psychiatric disorder e.g. PTSD

Measures in the CCHS-CFS CFS Covers a range of traumas Respondents can endorse multiple traumas Can look at impact of each of 28 traumas independently

Analyses Statistical weight employed Multiple logistic regression Stratified by gender AOR 1 Sociodemographics - Age - Marital status - Income - Education - Rank - Type of service AOR 2 Sociodemographics Psychiatric disorders 3 or more disorders

Results

Prevalence of suicide attempts in men and women. No Men 97.8 (97.3-98.2) Women 94.4 (93.2-95.4) Yes 2.2 (1.8-2.7) 5.6 (4.6-6.7)

Association between traumatic events and suicide attempts in men. Men Traumatic Event AOR-1 AOR-2 Deployment-related Combat 1.25 (0.70-2.21) 1.15 (0.62-2.12) Peacekeeping 0.84 (0.51-1.38) 0.82 (0.47-1.43) Witness atrocities 1.97 (1.17-3.31)** 1.68 (0.94-3.01) Kidnapped 3.80 (1.49-9.69)** 3.44 (1.23-9.62)* Witness death 1.34 (0.87-2.08) 1.25 (0.75-2.08) Caused death 2.92 (1.10-7.72)* 2.16 (0.73-6.37) Purposely injured or killed 3.59 (1.60-8.06)** 2.69 (1.09-6.61)* Accident / Other unexpected Auto accident 1.07 (0.64-1.80) 0.91 (0.50-1.68) Other accident 1.78 (1.06-2.99)* 1.59 (0.90-2.81) Toxic chemical exposure 1.87 (1.14-3.06)* 1.86 (1.09-3.18)* Man-made disaster 1.41 (0.79-2.53) 1.35 (0.73-2.50) Natural disaster 1.29 (0.73-2.26) 1.23 (0.65-2.31) Unexpected death 1.41 (0.93-2.16) 1.17 (0.71-1.95) Child illness or injury 1.15 (0.42-3.18) 0.64 (0.18-2.22) Life threatening illness 2.20 (1.05-4.63)* 2.25 (1.04-4.89)* Sexual trauma Raped 8.56 (3.66-19.99)** 4.29 (1.47-12.53)** Sexual assault 6.57 (3.77-11.45)** 3.73 (1.89-7.34)** Other interpersonal Child abuse 6.51 (3.70-11.49)** 4.43 (2.35-8.36)** Spouse abused you 3.49 (0.54-22.59) 2.93 (0.38-22.73) Other person abused you 3.24 (2.04-5.15)** 2.31 (1.34-3.96)** Witness domestic violence 4.01 (2.40-6.72)** 3.43 (1.94-6.04)** Stalked 4.83 (2.36-9.89)** 3.71 (1.56-8.83)** Mugged 2.39 (1.53-3.72)** 2.45 (1.53-3.91)** AOR-1: adjusted for sociodemographic factors, which includes age, marital status, income, education, rank [junior, senior, officer], and type of service [regular vs. reserve]. AOR-2: adjusted for sociodemographic factors, presence of any lifetime mental disorder, comorbidity (3 or more mental disorders). *p<.05. **p<.01.

Association between traumatic events and suicide attempts in women. Women Traumatic Event AOR-1 AOR-2 Deployment-related Combat 1.46 (0.73-2.94) 1.30 (0.63-2.68) Peacekeeping 1.26 (0.73-2.18) 1.15 (0.62-2.16) Witness atrocities 1.43 (0.57-3.58) 0.96 (0.37-2.50) Kidnapped 3.29 (0.88-12.34) 1.49 (0.36-6.11) Witness death 1.50 (0.98-2.29) 1.16 (0.69-1.95) Caused death --- --- Purposely injured or killed --- --- Accident / Other unexpected Auto accident 1.50 (0.88-2.57) 1.28 (0.66-2.48) Other accident 2.43 (1.26-4.70)** 1.91 (0.97-3.77) Toxic chemical exposure 1.21 (0.62-2.36) 1.25 (0.62-2.50) Man-made disaster 2.67 (1.40-5.10)** 2.16 (1.02-4.55)* Natural disaster 1.42 (0.81-2.49) 1.11 (0.55-2.26) Unexpected death 1.47 (1.00-2.16)* 1.03 (0.65-1.63) Child illness or injury 1.42 (0.48-4.18) 1.07 (0.31-3.65) Life threatening illness 1.55 (0.75-3.23) 0.82 (0.30-2.28) Sexual trauma Raped 4.66 (3.05-7.13)** 2.54 (1.55-4.18)** Sexual assault 5.63 (3.68-8.62)** 3.41 (2.09-5.57)** Other interpersonal Child abuse 3.98 (2.29-6.93)** 2.34 (1.15-4.75)* Spouse abused you 4.79 (2.91-7.89)** 3.71 (1.97-6.99)** Other person abused you 4.93 (2.26-10.73)** 3.08 (1.04-9.14)* Witness domestic violence 2.38 (1.54-3.70)** 1.73 (1.00-3.01)* Stalked 2.58 (1.61-4.12)** 1.86 (1.09-3.19)* Mugged 2.40 (1.38-4.17)** 1.71 (0.89-3.29) AOR-1: adjusted for sociodemographic factors, which includes age, marital status, income, education, rank [junior, senior, officer], and type of service [regular vs. reserve]. AOR-2: adjusted for sociodemographic factors, presence of any lifetime mental disorder, comorbidity (3 or more mental disorders). *p<.05. **p<.01.

Association between number of traumatic events and suicide attempts Prevalence of traumatic events Men % Women % (95% CI) (95% CI) Exposure to any of the traumatic events 86.7 80.5 Number of traumatic events No traumatic events 13.3 19.5 1 traumatic event 15.2 19.0 2 traumatic events 13.8 16.4 3 or more traumatic events 57.8 45.2 AOR-1 AOR-2 Men 1.21 (1.14-1.28)** 1.17 (1.09-1.24)** Women 1.26 (1.19-1.34)** 1.18 (1.09-1.27)** AOR-1: adjusted for sociodemographic factors, which includes age, marital status, income, education, rank [junior, senior, officer], and type of service [regular vs. reserve]. AOR-2: adjusted for sociodemographic factors, presence of any lifetime mental disorder, comorbidity (3 or more mental disorders). *p<.05. **p<.01.

Conclusions Few deployment-related traumatic events associated with suicide attempts Relationship appears to be mediated by mental disorders Replication of previous findings Sexual trauma strong association Link with interpersonal trauma Risk of suicide attempts increases with increasing number of events

Limitations Lay interviewers Would be better with clinicians Cross-sectional, sectional, retrospective No causal inference Are these deployment-related events?

Lifetime Exposure to Traumatic Events Deployment-related Prevalence of traumatic events Men % Women % (95% CI) (95% CI) Combat 17.6 6.6 Peacekeeping 39.3 16.3 Witnessed atrocities 14.4 3.6 Kidnapped/held captive 2.5 1.4 Witnessed death 46.6 23.0 Caused death 3.3 --- Purposely injured or killed 4.4 --- Accident / Other unexpected Motor vehicle accident 26.8 14.6 Other accident 18.0 6.1 Toxic chemical exposure 23.4 9.3 Man-made disaster 19.2 12.2 Natural disaster 13.3 5.1 Unexpected death 38.1 36.3 Child illness or injury 5.5 3.7 Life-threatening illness 7.5 6.5

Lifetime Exposure to Traumatic Events Sexual trauma Prevalence of traumatic events Men % Women % (95% CI) (95% CI) Raped 2.4 21.0 Sexual assault 6.5 36.7 Other interpersonal Child abuse 6.3 6.3 Spouse abuse 1.1 7.1 Other person abused you 13.2 3.1 Witnessed domestic violence 11.8 14.6 Stalked 3.8 15.1 Mugged 21.9 7.7 Civilian in war / refugee Civilian in war zone 5.0 2.9 Civilian in religious terror 4.9 2.9 Refugee --- --- Event happened to other 15.9 17.1 Other trauma 8.5 3.4