A 3-year longitudinal study examining the effect of resilience on suicidality in veterans
Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham VA Medical Center, Durham, NC, USA
Durham VA Medical Center, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham VA Medical Center, Department of Psychiatry and Behavioral Sciences Duke University Medical Center, Durham, NC, USAEric B. Elbogen, PhD
Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham VA Medical Center, Durham, NC, USA, Department of Psychiatry, UNC-Chapel Hill School of Medicine, Chapel Hill, NC, USA
BACKGROUND: This study prospectively evaluated the correlation and role of resilience and resilience factors in predicting suicidal ideation and attempts in veterans.
METHODS: In this 3-year longitudinal study, 178 Iraq and Afghanistan war veterans were evaluated for a number of clinical and demographic variables. Longitudinal follow-up was performed at approximately 3 years.
RESULTS: Resilience at the initial assessment predicted lower suicidality at follow-up, controlling for suicidality at the initial assessment, suggesting a protective effect for resilience. With respect to specific domains of resilience, secure relationships and positive acceptance of change significantly predicted lower suicidality.
CONCLUSIONS: These findings have important implications for clinical care and for guiding future research efforts to increase resilience among returning soldiers.
KEYWORDS: suicidality, psychological resilience, veterans, resilience factors, secure relationships
ANNALS OF CLINICAL PSYCHIATRY 2013;25(1):59-66
Studies indicate high rates of mental health problems1-6 and suicidality7 among returning soldiers. As military troops return from Iraq and Afghanistan, addressing postdeployment adjustment problems, including suicidality, is an important priority.1,2,8
Suicide risk factors in veteran populations have been studied extensively. Studies have indicated that psychiatric disorders, particularly depression and substance use disorders, are strong risk factors for suicide in most cases.9 Other important risk factors include posttraumatic stress disorder (PTSD),10,11 previous suicide attempts, and demographic factors such as age, sex, and ethnicity.9 Additionally, combat trauma12 and childhood abuse13 have been found to be risk factors for suicide. Some of these factors are modifiable, such as reducing or controlling symptoms of psychiatric disorders, while others, such as age, sex, and history of suicide attempts, are not.
Despite extensive literature on understanding and treating risk factors for suicide, little empirical progress has been made toward preventing suicide in military service members, among whom there has been an alarming increase in suicide.14 In 1 study, the risk of death from disease in general did not differ between veterans and nonveterans. However, veterans were twice as likely (adjusted hazard ratio, 2.13; 95% CI, 1.14 to 3.99) to die of suicide compared with nonveterans in the general population.7
Clinical and research data from other disciplines have indicated that reducing risk factors should be paired with boosting protective factors. For example, if eliminating risk factors for myocardial infarction (eg, smoking cessation) is augmented with protective factors (eg, physical exercise), marked reduction in rates of myocardial infarction could be achieved. The same approach could help reduce suicide rates.
However, limited data are available on protective factors against suicide, especially among veterans. One possible protective factor is resilience. Resilience is a construct that has received more attention in recent years. It is defined by Connor and Davidson15 as “qualities that enable one to thrive in the face of adversity.” It also has been measured and defined by the well-validated Connor-Davidson Resilience Scale (CD-RISC)15,16 and has been suggested to be multidimensional.17-20 Resilience can improve in patients with PTSD, with significant reduction in CD-RISC scores after pharmacotherapeutic and psychotherapeutic interventions.21,22
Studies that have examined resilience and suicidality assessed this relationship cross-sectionally. These studies suggested that resilience might be a protective factor against suicide risk.23-27
However, assessment of resilience longitudinally is needed to understand this relationship across time. Moreover, there is no study that has examined which factor(s) (of 5 factors of resilience described by the Connor and Davidson factor analysis15) are correlated with suicide.
Understanding the relationship between resilience and suicide in returning veterans is helpful for many reasons. First, it could help identify individuals who are at the highest risk for suicide, therefore providing further training or excluding these individuals from situations associated with high trauma exposure. Second, interventions that have the most resilience-enhancing effect could be further examined to determine if they could lower the suicide rate. Finally, examining which factor(s) are correlated with resilience might help in psychotherapeutic and psychosocial treatment development to boost resilience and has implications for treatment policy. This study extends our previous work.25,27 Our a priori hypothesis is that across time, higher resilience would predict lower suicidality. Second, we also explored how the 5 individual factors of resilience15 predicted protection against suicidality across time.
Participants and procedures
In this longitudinal study, 176 Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans were interviewed at the Veterans Integrated Service Network (VISN) 6 Mental Illness Research, Education, and Clinical Center (MIRECC). The MIRECC houses a research registry of veterans who served in the US Armed Forces after September 11, 2001, and volunteered to be considered for research. All veterans were separated from active duty or were in the National Guard or Reserve.
Independent variables on veteran risk factors were gathered at baseline interviews, which occurred between 2005 and 2008. This was designated at time 1 (T1). Veterans in the MIRECC registry were recruited through mailings, advertisements, and clinician referrals. Veterans completed informed consent procedures that were approved by Veterans Affairs (VA) institutional review boards at multiple sites in North Carolina and Virginia and afterward were administered questions concerning postdeployment adjustment. Veterans were compensated for their time and travel expenses.
Dependent variables on veterans’ suicidality were gathered from follow-up interviews, designated as time 2 (T2). An average of 3 years after the baseline interview, veterans in the MIRECC registry were contacted and asked to participate in a National Institute of Mental Health study, which served as the follow-up interview for the current study. Because this study is part of a registry database with a 3-year follow-up, the raters did not know the outcome measures or the purpose of this analysis while evaluating participants. Veterans were compensated for their time and travel expenses after the interviews.
Beck Scale for Suicide Ideation (BSI): Suicidality was assessed using the 21-item, self-report BSI.28 Severity of suicidal thoughts, intent, and plans are assessed in items 1 to 19. The number of previous suicide attempts and the seriousness of the attempt to die associated with the last attempt are assessed in items 20 and 21. Item responses are rated on a 3-point scale ranging from 0 to 2 and then summed to arrive at a total score. The BSI has demonstrated strong internal reliability (reported α coefficient between 0.90 and 0.9729,30). BSI has reasonable convergent, discriminative, and predictive validity.29,31-33 Brown et al32 used a cutoff score of 3 to create a dichotomous index of suicidality, using survival analyses. They determined that a cutoff score of 3 on the BSI yielded the highest hazard ratio in prediction of suicide risk. Given this data, as well as the fact that the BSI deviated markedly from normality in our sample, we employed this cutoff score in our current study to create a dichotomous index (≤2 OR ≥3) of suicidality.
Connor-Davidson Resilience Scale (CD-RISC): The CD-RISC is a reliable (Cronbach α=0.96 in the current sample) and valid15 instrument for measuring resilience. The scale was administered and validated in several different populations, including a community sample, primary care outpatients, general psychiatric outpatients, participants with generalized anxiety disorder, and participants with PTSD.
Items on the CD-RISC assess resilience and include items such as “can deal with whatever comes,” “past success gives confidence for new challenge,” “see the humorous side of things,” “coping with stress strengthens,” “tend to bounce back after illness or hardship,” “things happen for a reason,” “best effort no matter what,” “not easily discouraged by failure,” “think of self as strong person,” “strong sense of purpose,” and “in control of your life.”
The scale demonstrated sound psychometric properties.15 The CD-RISC has demonstrated sensitivity to treatment effects with several therapies (including sertraline, paroxetine, venlafaxine, and cognitive-behavioral therapy) in PTSD patients over time.21,22 This scale consists of 25 items. Each item is rated on a 5-point Likert scale with a possible score from 0 to 100. Higher scores reflect greater resilience. This was used to measure global resilience.
Factor analysis as performed by Connor and Davidson yielded 5 factors. These factors were interpreted in the following manner: factor 1 reflects personal competence, high standards, and tenacity; factor 2 relates to trust in one’s instincts, tolerance of negative affect, and strengthening effects of stress; factor 3 corresponds to the positive acceptance of change and secure relationships; factor 4 relates to control; and factor 5 relates to the effect of spirituality. The 5 factors’ eigenvalues were 7.47, 1.56, 1.38, 1.13, and 1.07, respectively.15 In this study, we examined how the 5 factors of resilience at T1 predicted suicidality at T2.
Davidson Trauma Scale (DTS): PTSD severity was assessed using the DTS.34,35 The DTS is a brief global assessment scale for PTSD symptoms. It includes 17 items corresponding to DSM-IV symptoms of PTSD. The 17 items are rated by frequency and severity. Reliability and validity of the DTS has been demonstrated in veterans who have served since September 11, 2001.35
Alcohol Use Disorders Identification Test (AUDIT): AUDIT is a 10-item, self-report screening questionnaire used to identify individuals with problematic patterns of alcohol consumption.36 AUDIT is divided into 3 domains: hazardous alcohol use (questions 1 to 3), dependence symptoms (questions 4 to 6), and harmful alcohol use (questions 7 to 10). Each response has a score ranging from 0 to 4. A total score of ≥8 in men (or ≥7 in women) indicates a strong likelihood of hazardous and harmful alcohol use, as well as possible alcohol dependence. The AUDIT has been validated for DSM-IV alcohol use disorders.
All statistical analyses were performed using SAS, version 9.2 for Windows (SAS Institute). Univariate analyses were used to describe the sample. Spearman correlation analyses were conducted to ascertain bivariate relationships between T2 suicidality and T1 variables. Analyses by multiple logistic regression were subsequently subjected to stepwise deletion to obtain a reduced model; exclusion criteria were set at a conservative level of P < .05. Specifically, T2 suicidality was regressed on T1 suicidality, T1 resilience, and other clinical and demographic covariates. A parallel analysis was conducted that included multiple domains of resilience derived from previous factor analyses.15
Demographic and clinical characteristics are shown in TABLE 1. Participants (N=176) were mean age 39 (SD=10.6) and were primarily white (63%). The study sample was largely men (82%), and the majority completed post–high school education (57%).
Demographics and clinical characteristics at baseline
||Total sample (N=176)
|Education post high school (%)
|Sex, male (%)
|Race, white (%)
|Days between baseline and follow-up visit
| Baseline BSS
| Follow-up BSS
|Alcohol use disorder (AUDIT)
Resilience factors protective against suicidality
TABLE 2 displays Spearman correlation coefficients between suicidality and resilience factors. There was a significant negative correlation between suicidality and secure relationships (rs= -0.34; P < .0001) and control (rs=-0.29; P=.0004). A trend was found between suicidality and tolerance (rs= -0.16; P=.049). There was no significant correlation between suicidality and tenacity, or suicidality and spirituality.
We also examined resilience factors15 most predictive of suicidality across time using multivariate regression. The factor corresponding to secure relationships and positive acceptance of change (r2=0.04; F=8.19, P=.005) was most predictive both in the bivariate analysis (TABLE 2) and in the multivariate regression (TABLE 3). Although control (factor 4 of resilience) was correlated with suicidality in the bivariate correlation, it was not correlated when examined in the multivariate model.
Spearman correlation coefficients between suicidality and resilience factors
|Tenacity (factor 1)
|Tolerance (factor 2)
|Secure relationships (factor 3)
|Control (factor 4)
|Spiritual (factor 5)
Forward stepwise regression of the total sample for resilience factors on follow-up suicidalitya
|Baseline secure relationshipsb
Resilience is protective against suicidality in multivariate model
The results of the multivariate forward stepwise regression are summarized in TABLE 4. Resilience at baseline (T1) was found to be predictive of suicidality at follow-up (T2) (R2=0.17; F=3.95; P=.0485), controlling for several demographic and clinical variables (TABLE 4) including suicidality at baseline (R2=0.X; F=X; P < .0001).15 Low resilience was a stronger predictor of suicidality than alcohol misuse (on the AUDIT) and PTSD.
Forward stepwise regression of the total sample for baseline resilience score on follow-up suicidality (BSS)a
In this study, suicidality and resilience have been shown to be inversely related across time. Longitudinal follow-up was performed at approximately 3 years. This suggests a protective effect of resilience on suicidality. Of the 5 factors of resilience, the factor corresponding to secure relationships and positive acceptance of change was most significantly predictive of lower suicidality.
To our knowledge, this is the first study to examine the relationship between suicidality and resilience longitudinally. Our result of an inverse relationship between global resilience and suicidality is in agreement with and extends the results of the few cross-sectional studies that examined this relationship.23-27 One of these cross-sectional studies is by Roy et al23 who examined the relationship between suicidality and resilience. Their sample included 20 abstinent substance abuse patients who had attempted suicide, and another sample of 166 prisoners who had attempted suicide and matched control groups.23 In these samples, those who had never attempted suicide had significantly higher CD-RISC resilience scores compared with those who had attempted suicide. The authors reported that the study results “suggest that resilience may be a protective factor mitigating the risk of suicidal behavior associated with childhood trauma.”23
Another study included 272 Iraq and Afghanistan war veterans who were assessed cross-sectionally with a survey that contained measures of resilience. Thirty-four participants (12.5%) reported that they were contemplating suicide in the 2 weeks prior to the survey. Suicide contemplators had lower scores of resilience on CD-RISC. The investigators also found that suicide risk associated with childhood trauma was associated with lower resilience. Of relevance to our study, the investigators found that “sense of purpose and control were negatively associated with suicidal ideation.”24
Moreover, a study by Green et al25 showed that resilience is inversely related to PTSD in veterans and to functional response to PTSD. In another study by our group, resilience has been shown to mitigate the effect of depression and suicidal ideation in Iraq and Afghanistan war veterans cross-sectionally.27
Although a study by Nrugham et al26 examined this relationship in a longitudinal study, they measured resilience cross-sectionally. The study examined a subset sample of 252 participants from eighth and ninth grade. The participants were followed up after 1 year and reassessed 5 years later. Resilience was assessed using the CD-RISC only at the last visit of the study (T3). The investigators found high resilience to be negatively associated with suicide attempts even if the adolescents were victims of violent life events and had been depressed at age 15.
It should be noted that secure relationships were significantly correlated with lower suicidality in the bivariate and multivariate model. However, in the multivariate model, secure relationships contributed to a small portion of the variance of approximately 13%. It is not clear why that is so and needs to be further validated in future studies. Possible explanations could be moderation due to other variables. Potential interacting and moderating effects that are worth examining in future studies are sex, age, and clinical variables such as PTSD diagnosis.37,38
Several investigators have stated that longitudinal studies are needed to increase the robustness of the relationship between resilience and suicidality, and to examine the relationship across time.39 The current study fills this gap and confirms the previous finding suggesting the protective effect of resilience across time. This is the first study to examine the relationship between suicidality and global resilience longitudinally, and the first to examine the factors of resilience individually across time. Interestingly, our longitudinal study results suggest that low resilience was a stronger predictor of suicidality than alcohol misuse and PTSD.
Increasing the confidence that this relationship between resilience and suicidality still holds across time paves the way for development of further programs and interventions to address and boost resilience as an important target for reducing suicidality above and beyond reducing risk factors for suicidality.
These interventions would best address psychosocial aspects that can bolster resilience, improve acceptance to change, and improve relationships. In addition, initial clinical trials of psychopharmacological agents have provided early evidence that resilience can be enhanced pharmacologically.21,22 In addition, an exploratory study has found pretreatment resilience to be a predictor of positive treatment response to the antidepressant venlafaxine.40 Therefore, further examination of this line of research might lead to important interventional modalities for both preventive and treatment purposes above and beyond symptom control.
However, these results should be interpreted with caution in light of the study’s limitations. For example, the possibility of other confounding effects could not be eliminated because of the observational design of the study. Potential confounders such as schizophrenia or bipolar disorder diagnosis also are limitations of this observational study. However, these disorders generally have a low base rate among military veterans because they are screened out during military admission evaluations. Another limitation of the present study is that it included a convenience sample of those who completed the interviews and rating scales. Baseline assessment consisted of self-selected veterans. As a result, participants were not initially approached at baseline. With respect to the follow-up, approximately one-quarter of initial patients had inaccurate contact information and could not be followed. Another limitation is that suicidality (suicidal ideation and attempts)—not completed suicide—was examined in this study. However, assessment of suicidality is the standard of clinical care and a proxy for assessing the risk of suicide.9 Also, a potential limitation is confounding due to psychotropic medications because of the FDA warning of suicidality for antidepressants and anticonvulsants. However, the contribution of antidepressants and anticonvulsants to suicidality (beyond suicidality due to the primary mental illness) recently has been called into question from multiple rigorous studies.41-47
Despite these limitations, initial results from this longitudinal observational study are clinically informative and encouraging and would inform further studies that replicated this work. These results suggest that comprehensive assessment of resilience and its factors among veterans can contribute to understanding their clinical status in terms of suicidality and can inform clinical care. These may be important steps toward development of targeted preventive therapeutics programs, especially toward suicide prevention. In addition, the results could help direct future programs and therapeutics to bolster resilience and reduce suicidal ideation and attempts. Both the VA and the Department of Defense have efforts underway to potentially increase resilience among active duty soldiers48 and veterans.49
This study is the first longitudinal study to establish the protective effect of resilience in veterans with suicidality. However, further longitudinal studies may increase confidence in these findings if the results are replicated in a larger sample and in other populations. Also, further research in this area with candidate interventions is still needed.
ACKNOWLEDGMENTS: We extend thanks to the veterans who volunteered to participate in this study. We thank the diligent Mid-Atlantic Mental Illness Research, Education and Clinical Center Workgroup members and investigators, whose workgroup for this manuscript includes Mira Brancu, PhD, and John A. Fairbank, PhD, Durham Veterans Affairs (VA) Medical Center, Durham, NC; Antony Fernandez, MD, Hunter Holmes McGuire Department of Veterans Affairs Medical Center, Richmond, VA; Harold Kudler, MD, and Christine E. Marx, MD, Durham VA Medical Center, Durham, NC; Scott D. McDonald, PhD, Hunter Holmes McGuire Department of Veterans Affairs Medical Center, Richmond, VA; Scott D. Moore, MD, PhD, and Rajendra A. Morey, MD, Durham VA Medical Center, Durham, NC; Treven C. Pickett, PsyD, Hunter Holmes McGuire Department of Veterans Affairs Medical Center, Richmond, VA; Kristy Straits-Troster, PhD, and Jennifer L. Strauss, PhD, Durham VA Medical Center, Durham, NC; Katherine H. Taber, PhD, W. G. (Bill) Hefner VA Medical Center, Salisbury, NC; Larry A. Tupler, PhD, Elizabeth E. Van Voorhees, PhD, and Richard D. Weiner, MD, PhD, Durham VA Medical Center, Durham, NC; and Ruth E. Yoash-Gantz, PsyD, W. G. (Bill) Hefner VA Medical Center, Salisbury, NC. We also thank the research study staff members at the Durham, Hampton, Richmond, and Salisbury VA Centers for their diligent work and essential contributions to the recruitment of participants and data collection and management of this study. We would also like to acknowledge Mr. Perry Whitted and Ms. Misty Brooks for their extensive administrative contributions on this project, as well as Mr. Jeffery Hoerle for his computer expertise devoted to the project. Mr. Whitted, Ms. Brooks, and Mr. Hoerle report no conflict of interest.
DISCLOSURES: Dr. Elbogen receives grant or research support from the National Institute of Mental Health (NIMH). Drs. Youssef and Beckham and Ms. Green report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products. This work was supported by the Office of Mental Health Services, Department of Veterans Affairs; VISN 6 Mid-Atlantic MIRECC; and Office of Academic Affiliation (OAA), the Department of Veterans Affairs (NAY), NIMH grant R01MH080988 (EBE).
The November 2012 issue contained incorrect data in the “Results” section of “Smoking is associated with greater symptom load in bipolar disorder patients,” by Mohamedlatif Saiyad, MD, et al. (Ann Clin Psychiatry. 2012;24(4):305-309). It should read, “There were no differences in smoking rates between the sexes (men 38.1%, women 32.6%, χ2=.39, P=.54).” The data has been corrected online.
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CORRESPONDENCE: Nagy A. Youssef, MD 508 Fulton Street, MIRECC, Durham, NC 27705 USA, E-MAIL: email@example.com
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