The Effects of Suicide Exposure on Mental Health Outcomes Among Post-9/11 Veterans: Protocol for an Explanatory, Sequential, Mixed Methods Study

Background The toll associated with suicide goes well beyond the individual who died. This study focuses on a risk factor for veteran suicide that has received little previous empirical attention—exposure to the suicide death of another person. Objective The study’s primary objective is to describe the mental health outcomes associated with suicide exposure among veterans who served on active duty after September 2001 (“post-9/11”). The secondary objective is to elucidate why some veterans develop persistent problems following suicide exposure, whereas others do not. Methods This is an explanatory, sequential, mixed methods study of a nationally representative sample of post-9/11 veterans enrolled in Department of Veterans Affairs (VA) health care. Our sampling strategy was designed for adequate representation of female and American Indian and Alaska Native veterans to allow for examination of associations between suicide exposure and outcomes within these groups. Primary outcomes comprise mental health problems associated with trauma and loss (posttraumatic stress disorder and prolonged grief disorder) and suicide precursors (suicidal ideation, attempts, and planning). Data collection will be implemented in 3 waves. During wave 1, we will field a brief survey to a national probability sample to assess exposure history (suicide, other sudden death, or neither) and exposure characteristics (eg, closeness with the decedent) among 11,400 respondents. In wave 2, we will include 39.47% (4500/11,400) of the wave-1 respondents, stratified by exposure history (suicide, other sudden death, or neither), to assess health outcomes and other variables of interest. During wave 3, we will conduct interviews with a purposive subsample of 32 respondents exposed to suicide who differ in mental health outcomes. We will supplement the survey and interview data with VA administrative data identifying diagnoses, reported suicide attempts, and health care use. Results The study began on July 1, 2022, and will end on June 30, 2026. This is the only national, population-based study of suicide exposure in veterans and the first one designed to study differences based on sex and race. Comparing those exposed to suicide with those exposed to sudden death for reasons other than suicide (eg, combat) and those unexposed to any sudden death may allow for the identification of the common and unique contribution of suicide exposure to outcomes and help seeking. Conclusions Integrating survey, qualitative, and VA administrative data to address significant knowledge gaps regarding the effects of suicide exposure in a national sample will lay the foundation for interventions to address the needs of individuals affected by a suicide death, including female and American Indian and Alaska Native veterans. International Registered Report Identifier (IRRID) DERR1-10.2196/51324


HSR4
SAYER, N Veterans exposed to suicide, the mechanisms that may lead to deleterious outcomes, and lay a foundation for understanding the effective treatments and supports needed for Veterans who experience a suicide loss, including women and AI/AN Veterans.

CRITIQUE 1
Exposure to suicide is a significant public health problem.A recent study found that almost half of the US population had been exposed to suicide and among those exposed, over one-third experienced significant distress.Those affected by suicide exposure are at increased risk for psychiatric disorders, impaired social functioning, cirrhosis and sleep disorders, disordered grief, suicide attempts and suicide death.Research on suicide exposure among service members and Veterans is limited to only a handful of studies.One study with Iraq and Afghanistan Veterans showed that 58% of survey responders knew a post-9/11 Veteran who had died by suicide.A study of Veterans in Kentucky found that suicide exposure was associated with depression, anxiety and suicidal ideation and another study of service members and Veterans reported that closeness with the decedent predicted future suicide attempts.Conclusions from these studies are limited because of geographically-limited or nonrepresented samples and there is limited evidence on modifiable risk and protective factors that affect outcomes after exposure to suicide.Furthermore, these studies lack a sufficient number of women and Veterans from diverse racial/ethnic backgrounds to examine differences by sex and race.
The present study addresses these shortcomings through four aims: (1) Evaluate differences in the prevalence of PTSD, PGD, and in suicidal ideation, attempts and planning among Veterans exposed to suicide compared with those exposed to other causes of sudden death and with unexposed Veterans.Assess whether prevalence differs by sex and race.(2) Identify modifiable moderating factors for the association between suicide exposure and negative outcomes and modifiable moderating factors for the association between suicide or sudden death exposure and negative outcomes relative to those with neither exposure.Exploratory aims are: (3) Describe treatment experiences, interests, reported suicide attempts, and patterns of VA service utilization among those exposed to a suicide death compared to Veterans exposed to other sudden deaths and to unexposed Veterans.Differences by sex and race will also be explored.
(4) Elucidate quantitative findings through interviews with a purposive sample of Veterans exposed to suicide who vary in mental health outcomes.The interviews will focus on modifiable factors at each level of the socio-ecological model of suicide prevention to better understand targets for intervention.
This study is consistent with HSR&D priority areas of suicide prevention, mental health (including PTSD and Prolonged Grief Disorder) and women's health.
There are currently no similar studies of suicide bereavement, suicide exposure or suicide survivorship in the VA HSR&D's portfolio, QUERI's portfolio, or in clinicaltrials.govfor suicide bereavement or survivorship.

Innovation and Impact.
The proposed study will significantly advance the current knowledge regarding the impact of suicide exposure on Veterans.Moderately high innovative aspects of the application include: HSR4 SAYER, N 1.Use of VA national data for a population-based study of suicide exposure among post-9/11 Veterans enrolled in VHA. 2. Oversampling of women and American Indian/Alaskan Native (AI/AN) Veterans to allow for the examination of gender and race on suicide exposure.3. Inclusion of two comparison groups to identify the common and unique contributions of suicide exposure to health outcomes and patterns of VA service utilization.4. Assessment of the formal and informal supports Veterans receive for mental health problems associated with suicide using both survey and VA healthcare utilization data.

Strengths:
The overall approach is well developed.The study hypotheses are clearly written and the planned analyses correspond to the hypotheses.
The study is guided by a socio-ecological conceptual framework that considers risk and protective factors at the individual, relational, community, and societal levels.
Uses a nationally representative sample of post-9/11 Veterans within 6 years of military separation (which is high risk timeframe for suicide).
Uses a two-stage, stratified sampling plan (30% women and 12% AI/AN) for the initial wave of data collection.
Uses an explanatory, sequential mixed methods design.
Uses an evidence-based multi-model approach to optimize recruitment rates.
Uses a standardized combat experiences survey.
Measures history of suicide attempts using a self-report, validated questionnaire (Suicide Behaviors Questionnaire-Revised) and suicide attempts reported by VHA clinicians and identified in the Corporate Data Warehouse based on responses to the Comprehensive Suicide Risk Evaluations and the Suicide Behavior and Opioid Reports.

Minor Weaknesses:
Procedures for evaluating the reliability of the classification of VHA provider-reported suicide attempts were not described.
The justification for examining prevalence of self-reported suicide attempts and provider-reported suicide attempts, alone or in combination, is unclear.

Feasibility (including Sampling, Project Timeline and Staffing).
The sampling strategy is well-described and clearly justified.HSR4

SAYER, N
The study appears to be adequately powered to test the primary hypotheses that examines pairwise differences among exposure groups.Additional power calculations were presented for subgroups for Aim 1 and for moderator variables for Aim 2. However, Table 3 did not display power calculations for AI/AN group and were difficult to interpret.
Investigators expect a 60% survey response rate based on prior research conducted by the research team.The study proposes a reasonable action plan if response rates are lower than the anticipated 60% rate; there are specific plans to increase the number of Wave 1 participants if the expected percentages of respondents are not obtained for those with suicide exposure, those with sudden death exposure other than suicide and those with neither type of exposures.
Completion of Project Timeline activities and milestones seem reasonable and feasible.

Implementation.
A The revised application was highly responsive to the concerns raised by the reviewers, including two major design changes.1.The revised application now includes two comparison groups in addition to the suicide exposure group.2. The suicide outcomes have been improved by extracting provider-reported suicide attempts from the VHA medical record.The description and rationale for the study procedures are also more clearly written.

Protection of Human Subjects from Research Risk.
No concerns.

Inclusion of Women and Minorities in Research.
No concerns.
12. Budget and Period of Support.
No comment.

Sharing Research Data (Data Management and Access Plan (DMAP).
No concerns.

Overall Impression.
This project addresses a significant public health problem related to our understanding of the prevalence and the risk and protective factors associated with negative health outcomes (PTSD, Prolonged Grief Disorder, suicidal ideation and suicide attempts) following exposure to suicide for post-911 Veterans in VHA.The revised application was highly responsive to the reviewers' concerns that resulted in improved hypotheses and study design changes.The overall approach is well designed with only a few minor weaknesses.
1. Well-designed study based on a clear conceptual framework and clearly written hypotheses.
2. Addresses a major gap in our understanding of the role of exposure to suicide among post-911 Veterans.
3. Strong research team that is well-suited to carry out the study aims.
4. Uses an explanatory, sequential mixed methods design.
5. Includes a detailed action plan if the expected sample sizes are not obtained.

Significance.
Previous research suggests that exposure to suicide death of a close friend or relative is associated with negative outcomes such as PTSD and suicide attempt in the person exposed; however, little is known about the magnitude of the problem among Veterans and especially among women Veterans and Native American Veterans.While the number of Veterans exposed to suicide death is large, little is known about the magnitude of risk for negative outcome compared to those exposed to other sudden deaths.
The revised design of the study will allow disentangling other sudden loss from suicide loss -an important contribution to advancing research in this area.

Innovation and Impact.
This will be the first population-based study of suicide exposure in Veterans and the only one designed to study differences by sex and race.

Strengths
-Mixed methods design.
-Inclusion of 2 control groups.
-Oversampling hypothesized high risk groups.
-Survey wave design.
-Power analysis section is now clear.

Feasibility (including Sampling, Project Timeline and Staffing).
The feasibility and timeline appear to be appropriate.

Implementation.
The investigators have an adequate plan and have formed an advisory panel.

Investigator Qualifications.
The study team is strong and includes expertise and experience across all the required domains.

Multiple PI Leadership Plan.
Not applicable.

Facilities and Resources.
No concerns.

Adequacy of Response to Previous Feedback Regarding the Proposed Study. HSR4 SAYER, N
The team has been highly responsive.

Protection of Human Subjects from Research Risk.
No concerns.

Inclusion of Women and Minorities in Research.
No concerns.
12. Budget and Period of Support.
No concerns.

Sharing Research Data (Data Management and Access Plan (DMAP).
No concerns.

Overall Impression.
Post-exposure to suicide is under-studied as a risk factor for suicide attempt in the VA.A better understanding of this risk, especially as compared to exposure to other sudden deaths and no exposure might lead to more tailored interventions for suicide prevention (e.g., timely outreach to friends of those whose die by suicide).The application is highly responsive to previous reviews and adequately addresses these critiques.The inclusion of a second control group is a particular strength.
2. Inclusion of 2 control groups -exposed to other sudden loss and not exposed to sudden loss.

CRITIQUE 3 1. Significance.
Inadequate research has been conducted on the influences of death by suicide of a relative/friend on negative mental health outcomes, including exposed-individual PTSD symptoms and suicide risk.This is a particularly relevant problem for Veterans, women Veterans, and Native American Veterans.Without understanding the down-stream effects of suicidal behavior on others, the VA lacks guidance on how to appropriately intervene with suicide-exposed individuals.The aims of the project include evaluating negative mental health outcomes and suicide risk in suicideexposed Veterans versus those not exposed to sudden loss or exposed to non-suicide related HSR4 SAYER, N loss, identifying modifiable moderating factors (e.g., social support, meaning making) that impact negative outcomes, and describing treatment experiences and patterns of VA service utilization.The research focuses on post-9/11 Veterans, which is a group likely to be highly impacted by suicide-exposure.The proposed focus of the project has high clinical importance with potential to inform key clinical HSR&D priority issues including: suicide risk, PTSD, prolonged grief disorder, and women's health.

Innovation and Impact.
The proposed research involves an intensive exploration of the impact of suicide-exposure to ongoing Veteran mental health concerns and is innovative in several ways.The research will help to establish valid and reliable estimates of the number of people exposed (Wave 1) and the impact of exposure to suicide, a key priority of the National Action Alliance for Suicide Prevention.The project will utilize Wave 1 data to identify the relevant sample for additional surveys (Wave 2), and it will include two comparison groups to distinguish between suicide exposure and exposure to other death-related experiences or no exposure to sudden loss.It will also oversample for women and Native American Veterans, providing important information on understudied groups.Wave 3 will conduct qualitative interviews with suicide-exposed Veterans to determine more specifics about the psychological impact of suicide exposure.The study has potential to impact and improve current standards of care, of which there is minimal guidance on how to help suicide-exposed Veterans cope with such loss.

Approach.
The approach will involve three waves of data collection.Appropriate sampling procedures are specified for identification of suicide-exposed Veterans and two control groups (sudden death exposed and no death exposure).Inclusion and exclusion criteria and data sources are appropriately identified across waves.Appropriate plans for ensuring specified participant recruitment and potential barriers are described, as are key analytic issues such as addressing missing data.Wave 3 of the study includes a qualitative interview that will be transcribed and coded to identify key emerging issues reported by Veterans exposed to suicide.The study is feasible and the team outlines an appropriate timeline.
Weaknesses: None identified beyond standard limitations acknowledged by the investigative team (e.g., limited ability to examine those not receiving VHA services).

Feasibility (including Sampling, Project Timeline and Staffing).
The proposed research strategy is well thought out and thorough, with strategic decisions well justified.The issue of power is thoroughly addressed and supports the ability to detect anticipated main effects and interaction analyses.Key issues regarding survey non-response and analytic modeling of missing data are thoroughly outlined.Proposed timeline is appropriate.

Implementation. HSR4 SAYER, N
The research team has established agreements with key partners at the Office of Mental Health and Suicide Prevention (Matthew Miller, PhD., MPH), the Center for PTSD (Craig Rosen, PhD.), and the Rocky Mountain MIRECC (Suzanne McGarity, PhD.& Georgia Gerard, LICSW).These contacts will also serve as a part of the project Advisory Panel, assisting with project guidance and dissemination.The primary deliverables will include a study brief shared with key clinical stakeholders and organizations and a lay summary that can be shared with Veterans and families coping with suicide exposure.

Investigator Qualifications.
The research team is exceptional and well qualified to conduct the proposed research, a strong advisory panel has been established.The PI has substantial experience in leading large-scale VA research projects, mixed methods approaches, and has a stellar support team with the skillset necessary to ensure project success.The study team (and advisory panel) has experience with mixed-methods research and qualitative analyses.

Multiple PI Leadership Plan.
Not applicable.

Facilities and Resources.
The project will take place at the CCDOR of the Minneapolis VAHS and the COIN (Center for Clinical Management Research) at the Ann Arbor VAHS, and both centers have substantial research infrastructures.Appropriate documentation of support agreements has been provided.

Adequacy of Response to Previous Feedback Regarding the Proposed Study.
The project team has thoroughly and appropriately responded to the prior round of reviews, and the quality of the application has improved accordingly.The most important changes include: 1) The addition of two comparison groups (one exposed to sudden death other than suicide and another unexposed to any sudden loss); 2) Better specification of suicide outcome variables (e.g., ideation, planning, & attempts); and 3) The study will oversample women to examine potential sex differences.The project plan now also includes a suicide risk assessment safety plan, troubleshooting for increased survey response rates, and more attention to non-VHA enrollees in examining the data on suicide and PTSD outcomes.Overall, the application is much stronger following revision.

Protection of Human Subjects from Research Risk.
No concerns.

Inclusion of Women and Minorities in Research.
No concerns.
12. Budget and Period of Support.
No concerns.Appropriate.

Overall Impression.
The proposed research examines the important and understudied topic of suicide-exposure among Veterans, and will answer key questions about how exposed Veterans respond with grief and trauma reactions and potential suicide risk concerns of their own.The focus of the study is consistent with HSR& priority areas in suicide prevention.The study will utilize three appropriately powered waves of data collection to (Wave 1) identify suicide exposure incidence and identify the key suicide-exposure group and two relevant control conditions utilized in Wave 2, and the groups will be compared on various measures of clinical function.The study also contains qualitative interviews (Wave 3) meant to help inform the major challenges Veterans exposed to suicide face.Women and Native American Veterans will be oversampled for additional information on these essential groups.Overall, the study has strong potential to increase understanding of down-stream effects of suicide exposure on the mental health of Veterans and will likely result in improved clinical care efforts.Minimal limitations or weaknesses were identified with this revision.