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Despite concerted prevention efforts, military suicide rates have risen for more than a decade (Armed Forces Health Surveillance Center [AFHSC], 2014; Psychological Health Center of Excellence [PHCoE], 2020). While many risk and protective factors for suicide have been recognized, researchers and clinicians still struggle to accurately identify individuals who are at high risk (Franklin et al., 2017). As such, novel approaches to the investigation of risk factors for suicide are critically needed. Emerging evidence suggests that suicide exposure, or knowing someone who died by suicide, warrants further investigation as a potential risk factor for suicide among military personnel (Borges et al., 2017; Bryan et al., 2017; Hom et al., 2017). Approximately half of adults in the U.S., including military personnel, have known someone who died by suicide (Bryan et al., 2017; Cerel et al., 2016; Cerel et al., 2015; Feigelman et al., 2018; van de Venne et al., 2020), yet most research on the psychological impact of exposure stems from studies of veterans who are no longer serving, civilians, or combined groups of active duty personnel and veterans. A lack of data on the impact of suicide exposure specific to active duty service members is problematic because it limits our ability to determine how this population is affected while in service, and it impedes the development of tailored postvention efforts that could be delivered by the military or by community providers working with service members.   
In the present study, our research team from San Diego State University, in collaboration with the Naval Health Research Center, sought to address this knowledge gap by exploring the links among exposure to suicide, suicide ideation, and other psychological symptoms among a large clinical sample of active duty service members (N = 1,565). Using existing survey records from the Military Suicide Consortium’s Common Data Elements dataset (Gai et al., 2021), our team first evaluated the relationship between prior suicide exposure and symptoms of posttraumatic stress disorder, anxiety, insomnia, alcohol use, thwarted belongingness, and suicide ideation. We then evaluated whether characteristics of the exposure (e.g., degree of closeness to the deceased) related to psychological symptoms among only those personnel who reported knowing someone who died by suicide (N=985). 
Our results confirmed the devastating reach of suicide within the military, as most participants (N=985, 62.9%) reported the suicide death of at least one person in their lives, including many (n=176, 18.4%) who lost a comrade. Study findings showed that among all participants, suicide exposure was associated with increased PTSD, anxiety, and insomnia symptom severity. However, when examining the relationship between suicide exposure and suicide ideation, our results demonstrated that psychological health outcomes of suicide exposure differed based on the service members’ personal characteristics. Specifically, among servicewomen aged 25 and older, suicide exposure was associated with lower suicide ideation; however, among men and women under 25, suicide exposure was not significantly associated with suicidality.
When examining the psychological health outcomes only among the personnel who reported suicide exposure, characteristics of the exposure were found to play a role. There was no difference in suicide ideation between service members who lost a comrade versus those who lost a partner or close family member, and suicide ideation was significantly higher among service members who lost a comrade compared to those who lost a close friend. Interestingly, these findings suggest  an inverse relationship between degree of closeness to the decedent and suicide ideation.  
As the number of service members who die by suicide rises, so does the number of service members who are exposed. These results show that the psychological impact of suicide exposure can be profound and varied among SM, and they also indicate that additional research may be needed to determine who may be most impacted, in what ways, and why. Individuals providing postvention support, military leaders, and even SMs should be educated on the various ways suicide exposure may affect the exposed.

Target Article

Schmied, E. A.,  Jun, H.-J.,  Glassman, L. H.,  Pippard, N., &  Walter, K. H. (2023).  Investigating the effects of suicide exposure among a clinical sample of active duty service members. Journal of Traumatic Stress,  36, 310– 324. https://doi.org/10.1002/jts.22909

Discussion Questions

  1. This study found that suicide ideation was not elevated among individuals who were exposed to suicide, but other psychological health symptoms were. What have you observed in your own research and practice that could explain these findings?
  2. Study results found that among women older than 25, suicide exposure was inversely associated with suicide ideation. Could findings from your own research and practice help explain this observation?
  3. Data for this study were taken from an entirely clinical sample; how might the results be different in a non-clinical sample?
  4. Insomnia symptoms were found to be elevated among individuals who were exposed to suicide, a finding that has not previously been reported. How do you think suicide exposure might impact sleep health? 

About the Authors

Emily A. Schmied, MPH, PhD, is a behavioral scientist and Assistant Professor in the School of Public Health at San Diego State University, and a Core Investigator at the Institute for Behavioral and Community Health. The primary focus of her research is the identification of risk and protective factors for adverse mental health outcomes in military personnel and the development of health promotion interventions.  Dr. Schmied can be contacted at eschmied@sdsu.edu. 
Kristen H. Walter, PhD, is a clinical research psychologist and division head of the Clinical Research Program at the Naval Health Research Center in San Diego, California. Her research focuses on the treatment of posttraumatic stress disorder (PTSD) and conditions that commonly co-occur with PTSD, such as major depressive disorder, traumatic brain injury, and suicidality among active duty service members and veterans.
Lisa H. Glassman, PhD, is a clinical research psychologist and Leidos contractor at the Naval Health Research Center in San Diego, California. Dr. Glassman’s research is dedicated to increasing access to care, enhancing quality of life, and improving the clinical effectiveness and efficiency of evidence-based interventions. Dr. Glassman has clinical expertise in the delivery of evidence-based psychological interventions for mood, anxiety, and trauma-related conditions, including suicidality, via in-person and telehealth modalities.
Hee-Jin Jun, ScD, is an Adjunct Assistant Professor in the School of Public Health at San Diego State University and a Core Investigator at the Institute for Behavioral and Community Health. Dr. Jun's research focuses on reducing health disparities, sexual minority health, and adolescent health research. 
Nicole Pippard, MPH, is a pre-doctoral research assistant at San Diego State University. She is currently pursuing her doctorate in Public Health from the University of California, San Diego-San Diego State University joint doctoral program.  

References Cited

Armed Forces Health Surveillance Center (2014). Surveillance snapshot: Manner and cause of death, active component, U.S. Armed Forces, 1998-2013. Medical Surveillance Monthly Report, 21(10), 21. 
Borges, G., Bagge, C. L., Cherpitel, C. J., Conner, K. R., Orozco, R., & Rossow, I. (2017). A meta-analysis of acute use of alcohol and the risk of suicide attempt. Psychological Medicine, 47(5), 949–957. https://doi.org/10.1017/S0033291716002841
Bryan, C. J., Cerel, J., & Bryan, A. O. (2017). Exposure to suicide is associated with increased risk for suicidal thoughts and behaviors among National Guard military personnel. Comprehensive Psychiatry, 77, 12–19. https://doi.org/10.1016/j.comppsych.2017.05.006
Cerel, J., Maple, M., van de Venne, J., Moore, M., Flaherty, C., & Brown, M. (2016). Exposure to suicide in the community: Prevalence and correlates in one U.S. state. Public Health Reports, 131(1), 100–107. https://doi.org/10.1177/003335491613100116
Cerel, J., van de Venne, J. G., Moore, M. M., Maple, M. J., Flaherty, C., & Brown, M. M. (2015). Veteran exposure to suicide: Prevalence and correlates. Journal of Affective Disorders, 179, 82–87. https://doi.org/10.1016/j.jad.2015.03.017 
Feigelman, W., Cerel, J., McIntosh, J. L., Brent, D., & Gutin, N. (2018). Suicide exposures and bereavement among American adults: Evidence from the 2016 General Social Survey. Journal of Affective Disorders, 227, 1–6. https://doi.org/10.1016/j.jad.2017.09.056
Franklin, J. C., Ribeiro, J. D., Fox, K. R., Bentley, K. H., Kleiman, E. M., Huang, X., Musacchio, K. M., Jaroszewski, A. C., Chang, B. P., & Nock, M. K. (2017). Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychological Bulletin, 143(2), 187–232. https://doi.org/:10.1037/bul0000084
Gai, A. R., Ringer, F., Schafer, K., Dougherty, S., Schneider, M., Soberay, K. A., Gutierrez, P. M., Joiner, T. E., Comtois, K. A., & Plant, E. A. (2021). The nature and structure of the Military Suicide Research Consortium’s common data elements. Military Behavioral Health, 9(2), 129–138. https://doi.org/10.1080/21635781.2020.1812454
Psychological Health Center of Excellence. (2020). DoDSER: Department of Defense Suicide Event Report, calendar year 2019 annual report. https://health.mil/Reference-Center/Publications/2021/07/06/2019-DoDSER-Annual-Report
van de Venne, J., Cerel, J., Moore, M., & Maple, M.(2020). Sex differences in mental health outcomes of suicide exposure. Archives of Suicide Research, 24(2), 158–185. https://doi.org/10.1080/13811118.2019.1612800