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The potential negative impact of COVID-19 on mental health has been a significant concern in the wake of the pandemic. Initial studies seemed to support this concern, as they indicate evidence of substantial increases in prevalence of depression and anxiety in the general public during the pandemic (Czeisler et al., 2020; Ettman et al., 2020). However, recent reports on deaths by suicide in the U.S. in 2020 have shown a 5% decline compared to 2019 (Ahmad & Anderson, 2021). Further, a meta-analysis of deaths by suicide in 21 countries have also reported results consistent with the trend in the U.S., with overall stable or declines in deaths by suicide in high- and upper-middle-income countries (Pirkis et al., 2021).

Military veterans may be more vulnerable to the adverse mental health effects of the pandemic due to previous trauma exposures (Marini, Kaiser, Smith, & Fiori, 2020) and higher prevalence of mental and physical health conditions relative to the general population (Villa, Harada, Washington, & Damron-Rodriguez, 2003; Wiechers, Karel, Hoff, & Karlin, 2015). While some studies have found evidence of increases in depressive, anxiety and posttraumatic stress disorder (PTSD) symptoms in veterans with pre-existing psychiatric conditions during the pandemic (Murphy, Williamson, Baumann, Busuttil, & Fear, 2020), there has been little study of longitudinal changes in mental health symptoms in U.S. military veterans. To address this gap, we conducted three separate studies in a nationally representative, prospective cohort of U.S. veterans to assess: 1) prevalence and factors associated with suicidal ideation in U.S. veterans with pre-existing psychiatric conditions; 2) prevalence and factors associated with new-onset and chronic alcohol use disorder (AUD); and 3) association of pandemic-related PTSD symptoms and posttraumatic growth (PTG) during the pandemic.
 
In our first study (Na et al., 2021), we analyzed data from 661 veterans who screened positive for a mental disorder (e.g., major depressive disorder, generalized anxiety disorder, PTSD, and/or substance use disorder) prior to the pandemic, and completed both pre- and peri-pandemic (i.e., one year into the pandemic) surveys as part of the 2019-2020 National Health and Resilience in Veterans Study (NHRVS). Results revealed that 19.2% of veterans endorsed suicidal ideation during the pandemic. Older age, greater pre-pandemic psychiatric symptom severity and psychosocial difficulties, past-year suicidal ideation and suicide attempt history, increase in past-year psychiatric symptom severity, and COVID-19 infection were independent risk factors for peri-pandemic suicidal ideation, whereas greater pre-pandemic purpose in life and higher household income were protective. Notably, among veterans who reported having been infected with COVID-19 and were 45 years or older, more than 40% endorsed peri-pandemic suicidal ideation. Further, a staggering three-quarters of veterans who reported low pre-pandemic purpose in life and were infected with COVID-19 endorsed suicidal ideation one year into the pandemic.

The second study analyzed data from the full sample of 3,078 veterans from the 2019-2020 NHRVS cohort who completed both pre- and peri-pandemic surveys (Na et al., in press). Results revealed that the prevalence of probable AUD, assessed using the Alcohol Use Disorders Identification Test, remained stable during the pandemic (10.2% pre-pandemic vs. 9.6% one year into the pandemic). Younger age, greater pre-pandemic alcohol use severity, and COVID-related stressors were associated with new-onset probable AUD (2.7%; i.e., not screening positive for AUD pre-pandemic, but screening positive peri-pandemic), whereas higher pre-pandemic household income was associated with lower risk of this outcome. Younger age, combat experience, lifetime substance use disorder, greater drug use severity, lower dispositional optimism, and more COVID-related worries and social restriction stress were associated with higher risk of chronic probable AUD (6.9%; i.e., screening positive for both pre- and peri-pandemic AUD).  

In our third study (Pietrzak, Tsai, & Southwick, 2021), we analyzed the same sample from the second study. At one year into the pandemic, we found that 43.3% of veterans reported moderate or greater levels of COVID-19-associated PTG, most commonly greater appreciation of life, improved social relationships and increased personal strength. The prevalence of PTG was markedly higher among the 12.8% of veterans who screened positive for pandemic-related PTSD symptoms, with 71.9% of these veterans reporting PTG. We also evaluated the relationship between different aspects of pandemic-related PTG and suicidal ideation, which was reported by 8.0% of the population, during the pandemic (note: the pre-pandemic prevalence of suicidal ideation was 7.7%). After adjusting for a broad range of pre- and peri-pandemic variables, greater pandemic-related increases in the PTG domains of appreciation of life and social relationships were associated with a 40% reduction in the odds of contemplating suicide during the pandemic.
 
Results of these initial studies support the potential utility of clinical and policy initiatives to help mitigate the pandemic-related psychiatric, psychosocial and financial distress in U.S. veterans. Notably, the prevalence of suicidal ideation and AUD remained stable from pre- to one-year peri-pandemic, suggesting that the majority of veterans remained resilient, at least with regard to these two outcomes, during the pandemic. They further indicated that a considerable proportion of U.S. military veterans, particularly those with pandemic-related PTSD symptoms, experienced positive psychological changes during the pandemic.

Collectively, these results underscore the importance of closely monitoring veterans with greater pre-pandemic psychological distress and substance use severity, and who endorse greater COVID-related stressors, as they may have increased risk for psychological distress during the pandemic. The results further suggest that clinical interventions targeting traumatic memories (Nijdam et al., 2018), and that promote mindfulness (Zhang et al., 2017), dispositional optimism (e.g., the best possible self-intervention [Carillo et al., 2019]) and purpose in life (e.g., acceptance and commitment therapy [Hayes, Luoma, Bond, Masuda, & Lillis, 2006] and logotherapy [Marshall & Marshall, 2012]), may help mitigate distress and foster PTG and resilience to pandemic-related stress.
 
Further research is needed to replicate and extend these initial results, identify biopsychosocial mechanisms underlying risk for adverse mental health effects of the pandemic, and evaluate the efficacy of prevention and treatment efforts to mitigate risk and bolster salutogenic factors that promote psychological resilience in the face of the pandemic in veterans and other at-risk populations.

About the Authors

Peter Na, MD, MPH, is an addiction psychiatry fellow at Yale University. His research interests include the genetic and psychosocial epidemiology of substance use disorders, suicidal behavior and Asian American mental health. 
 
Jack Tsai, PhD, is research director for the U.S. Department of Veterans Affairs National Center on Homelessness Among Veterans as well as campus dean and professor of public health at University of Texas Health Science Center at Houston. His research interests focus on trauma and resilience, psychiatric rehabilitation, and homelessness.
 
Robert H. Pietrzak, PhD, MPH, is director of the Translational Psychiatric Epidemiology Laboratory in the Clinical Neurosciences Division of the U.S. Department of Veterans Affairs National Center for PTSD, professor of psychiatry at Yale School of Medicine, and professor of public health (social and behavioral sciences) at Yale School of Public Health. His research interests include the psychosocial and genetic epidemiology of traumatic stress and resilience, military and veteran mental health, and dimensional models of stress-related psychopathology.

Reference Articles

Na, P. J., Tsai, J., Hill, M. L., Nichter, B., Norman, S. B., Southwick, S. M., & Pietrzak R.H. (2021). Prevalence, risk and protective factors associated with suicidal ideation during the COVID-19 pandemic in US military veterans with pre-existing psychiatric conditions. J Psychiatr Res, 137, 351-359.

Na, P.J., Norman, S.B., Nichter, B., Hill, M.H., Rosen, M.I., Petrakis, I.L., Pietrzak, R.H. Prevalence, risk, and protective factors of alcohol use disorder during the COVID-19 pandemic in US military veterans. Drug Alcohol Depend. In press.

Pietrzak, R. H., Tsai, J., & Southwick, S. M. (2021). Association of symptoms of posttraumatic stress disorder with posttraumatic psychological growth among US veterans during the COVID-19 pandemic. JAMA Netw Open, 4, e214972.

References

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Carillo, A., Rubio-Aparicio, M., Molinari, G., Enrique, A., Sanchez-Meca, J., & Banos, R. M. (2019). Effects of the best possible self intervention: A systematic review and meta-analysis. PLOS One, 14(9), e0222386.

Czeisler, M. E., Lane, R. I., Petrosky, E., Wiley, J. F., Christensen, A., Njai, R., . . . Rajaratnam, S. M. W. (2020). Mental health, substance use, and suicidal ideation during the COVID-19 pandemic - United States, June 24-30, 2020. MMWR Morb Mortal Wkly Rep, 69(32), 1049-1057.

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Na, P. J., Norman, S. B., Nichter, B., Hill, M. H., Rosen, M. I., Petrakis, I. L., & Pietrzak, R. H. (In press). Prevalence, risk and protective factors of alcohol use disorder during the COVID-19 pandemic in U.S. military veterans. Drug Alcohol Depend.

Na, P. J., Tsai, J., Hill, M. L., Nichter, B., Norman, S. B., Southwick, S. M., & Pietrzak R.H. (2021). Prevalence, risk and protective factors associated with suicidal ideation during the COVID-19 pandemic in US military veterans with pre-existing psychiatric conditions. J Psychiatr Res, 137, 351-359.

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Pietrzak, R. H., Tsai, J., & Southwick, S. M. (2021). Association of symptoms of posttraumatic stress disorder with posttraumatic psychological growth among US veterans during the COVID-19 pandemic. JAMA Netw Open, 4, e214972.

Pirkis, J., John, A., Shin, S., DelPozo-Banos, M., Arya, V., Analuisa-Anguilar, P., & Appleby, L. (2021). Suicide trends in the early months of the COVID-19 pandemic: an interrupted time-series analysis of preliminary data from 21 countries. Lancet Psychiatry, Published: April 13, 2021. doi:10.1016/S2215-0366(21)00091-2

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