The Relationship Between PTSD and Suicide

William Hudenko, PhD and Tina Crenshaw, PhD

Assessing and Responding to Suicidal Intent: A Fact Sheet for Providers (PDF)

This fact sheet explores the relation between PTSD and suicide and provides information that helps with understanding suicide.

To help prevent suicide

Know about the suicide warning signs and the Suicide Prevention Lifeline: 1-800-273-TALK (1-800-273-8255). (To be routed to the Veterans Crisis Line, dial 1 after being connected). While helping a suicidal person can be a difficult process, remember that the assistance you provide could save someone's life. If you think someone may be suicidal, you should directly ask him or her. You will NOT be putting the idea in their head.

Often the most difficult part of obtaining treatment is the initial call to a mental health professional. It is usually easier for a suicidal individual to accept professional help if they have assistance with this part of the process. For help making referrals see Where to Get Help.

How common is suicide?

It is challenging to determine an exact number of suicides. Many times, suicides are not reported and it can be very difficult to determine whether or not a particular individual's death was intentional. For a suicide to be recognized, examiners must be able to say that the deceased meant to die. Other factors that contribute to the difficulty are differences among states as to who is mandated to report a death, as well as changes over time in the coding of mortality data (1).

Data from the National Death Index, a product of the National Center for Health Statistics of the U.S. Department of Health and Human Services, provide the best estimate of suicides (2). Overall, men have significantly higher rates of suicide than women. This is true whether or not they are Veterans. For comparison:

• In 2005, the suicide rate among male U.S. citizens was 23.19 per 100,000, compared to 5.65 in females.
• In 2005, the suicide rate among male Veteran VA users was 37.19 per 100,000, compared to 13.59 in females.

Does trauma or PTSD increase an individual's suicide risk?

A body of research indicates that there is a correlation between trauma and suicidal behaviors. There is evidence that traumatic events such as childhood abuse and other types of trauma may increase a person's suicide risk (3,4,5,6,7,8). These studies have looked at whether a history of trauma exposure is linked to suicidal behaviors. Studies also suggest that suicide risk is higher in persons with PTSD. For example, research has found that trauma survivors with PTSD have a significantly higher risk of suicide than trauma survivors diagnosed with other psychiatric illness or with no mental pathology (9).

Though considerable research has examined the relation between combat or war trauma and suicide, the relationship is not entirely clear. Some studies have shown a relationship while others have not (1). There is strong evidence, though, that among Veterans who experienced combat trauma, the highest relative suicide risk is observed in those who were wounded multiple times and/or hospitalized for a wound (10). This suggests that the intensity of the combat trauma, and the number of times it occurred, may influence suicide risk in Veterans. This study assessed only combat trauma, not a diagnosis of PTSD, as a factor in the suicidal behavior.

Considerable debate exists about the reason for the heightened risk of suicide in trauma survivors. Whereas some studies suggest that suicide risk is higher due to the symptoms of PTSD (11,12,13), others claim that suicide risk is higher in these individuals because of related psychiatric conditions (14,15). However, a study analyzing data from the National Comorbidity Survey, a nationally representative sample, showed that PTSD alone out of six anxiety diagnoses was significantly associated with suicidal ideation or attempts (16 ). While the study also found an association between suicidal behaviors and both mood disorders and antisocial personality disorder, the findings pointed to a robust relationship between PTSD and suicide after controlling for comorbid disorders. A later study using the Canadian Community Health Survey data also found that respondents with PTSD were at higher risk for suicide attempts after controlling for physical illness and other mental disorders (17).

Some studies that point to PTSD as the cause of suicide suggest that high levels of intrusive memories can predict the relative risk of suicide (11). Anger and impulsivity have also been shown to predict suicide risk in those with PTSD (18). Further, some cognitive styles of coping such as using suppression to deal with stress may be additionally predictive of suicide risk in individuals with PTSD (11).

Other research looking specifically at combat-related PTSD suggests that the most significant predictor of both suicide attempts and preoccupation with suicide is combat-related guilt (19). Many Veterans experience highly intrusive thoughts and extreme guilt about acts committed during times of war. These thoughts can often overpower the emotional coping capacities of Veterans.

Suicide as a traumatic event

Researchers have also examined exposure to suicide as a traumatic event. Studies show that trauma from exposure to suicide can contribute to PTSD. In particular, adults and adolescents are more likely to develop PTSD as a result of exposure to suicide if one or more of the following conditions are true: if they witness the suicide, if they are very connected with the person who dies, or if they have a history of psychiatric illness (20,21,22). Studies also show that traumatic grief is more likely to arise after exposure to traumatic death such as suicide (23,24). Traumatic grief refers to a syndrome in which individuals experience functional impairment, a decline in physical health, and suicidal ideation. These symptoms occur independent of other conditions such as depression and anxiety.

References

1. Knox, K.L. (2008). Epidemiology of the relationship between traumatic experience and suicidal behaviors. PTSD Research Quarterly, 19(4).
2. Statement of the Honorable James B. Peake, MD, Secretary of Veterans Affairs, Before the Committee on Veterans' Affairs, United States House of Representatives, May 6, 2008. Accessed December 10, 2009: http://www.va.gov/OCA/testimony/hvac/08050600.asp
3. Afifi, T.O., Enns, M.W., Cox, B.J., Asmundson, G.J.G., Stein, M.B., & Sareen, J. (2008). Population attributable fractions of psychiatric disorders and suicide ideation and attempts associated with adverse childhood experiences. American Journal of Public Health, 98, 946-952.
4. Brodsky, B.S., Oquendo, M., Ellis, S.P., Haas, G.L., Malone, K.M., & Mann, J.J. (2001). The relationship of childhood abuse to impulsivity and suicidal behavior in adults with major depression. American Journal of Psychiatry, 158, 1871-1877.
5. Ryb, G.E., Soderstrom, C.A., Kufera, J.A., & Dischinger, P. (2006). Longitudinal study of suicide after traumatic injury. Journal of Trauma: Injury, Infection and Critical Care, 61, 799-804.
6. Sarchiapone, M., Jaussent, I., Roy, A., Carli, V., Guillaume, S., Jollant, F., Malafosse, A., & Courtet, P. (2009). Childhood trauma as a correlative factor of suicidal behavior--via aggression traits. Similar results in an Italian and in a French sample. European Psychiatry, 24, 57-62.
7. Nelson, E.C., Heath, A.C., Madden, P.A.F., Cooper, M.L., Dinwiddie, S.H., Bucholz, K.K., Glowinski, A., McLaughlin, T., Dunne, M.P., Statham, D.J., & Martin, N.G. (2002). Association between self-reported childhood sexual abuse and adverse psychosocial outcomes: Results from a twin study. Archives of General Psychiatry, 59, 139-145.
8. Ystgaard, M., Hestetun, I., Loeb, M., & Mehlum, L. (2004). Is there a specific relationship between childhood sexual and physical abuse and repeated suicidal behavior? Child Abuse and Neglect, 28, 863-875.
9. Ferrada-Noli, M., Asberg, M., Ormstad, K., Lundin, T., & Sundbom, E. (1998). Suicidal behavior after severe trauma. Part 1: PTSD diagnoses, psychiatric comorbidity and assessment of suicidal behavior. Journal of Traumatic Stress, 11, 103-112.
10. Bullman, T. A., & Kang, H. K. (1995). A study of suicide among Vietnam veterans. Federal Practitioner, 12(3), 9-13.
11. Amir, M., Kaplan, Z., Efroni, R., & Kotler, M. (1999). Suicide risk and coping styles in posttraumatic stress disorder patients. Psychotherapy and Psychosomatics, 68(2), 76-81.
12. Ben-Yaacov, Y., & Amir, M. (2004). Posttraumatic symptoms and suicide risk. Personality and Individual Differences, 36, 1257-1264.
13. Thompson, M. E., Kaslow, N. J., Kingree, J. B., Puett, R., Thompson, N. J., & Meadows, L. (1999). Partner abuse and posttraumatic stress disorder as risk factors for suicide attempts in a sample of low-income, inner-city women. Journal of Traumatic Stress, 12(1), 59-72.
14. Fontana, A., & Rosenheck, R. (1995). Attempted suicide among Vietnam veterans: A model of etiology in a community sample. American Journal of Psychiatry, 152(1), 102-109.
15. Robison, B. K. (2002). Suicide risk in Vietnam veterans with posttraumatic stress disorder. Unpublished Doctoral Dissertation, Pepperdine University.
16. Sareen, J., Houlahan, T., Cox, B., & Asmundson, G. J. G. (2005). Anxiety Disorders Associated With Suicidal Ideation and Suicide Attempts in the National Comorbidity Survey. Journal of Nervous and Mental Disease. 193(7), 450-454.
17. Sareen, J., Cox, B.J., Stein, M.B., Afifi, T.O., Fleet, C., & Asmundson, G.J.G. (2007). Physical and mental comorbidity, disability, and suicidal behavior associated with posttraumatic stress disorder in a large community sample. Psychosomatic Medicine. 69, 242-248.
18. Kotler, M., Iancu, I., Efroni, R., & Amir, M. (2001). Anger, impulsivity, social support, and suicide risk in patients with posttraumatic stress disorder. Journal of Nervous & Mental Disease, 189(3), 162-167.
19. Hendin, H., & Haas, A. P. (1991). Suicide and guilt as manifestations of PTSD in Vietnam combat veterans. American Journal of Psychiatry, 148(5), 586-591.
20. Andress, V. R., & Corey, D. M. (1978). Survivor-victims: Who discovers or witnesses suicide? Psychological Reports, 42(3, Pt 1), 759-764.
21. Brent, D. A., Perper, J. A., Moritz, G., Friend, A., Schweers, J., Allman, C., McQuiston, L., Boylan, M. B., Roth, C., & Balach, L. (1993b). Adolescent witnesses to a peer suicide. Journal of the American Academy of Child and Adolescent Psychiatry, 32(6), 1184-1188.
22. Brent, D. A., Perper, J. A., Moritz, G., Liotus, L., Richardson, D., Canobbio, R., Schweers, J., & Roth, C. (1995). Posttraumatic stress disorder in peers of adolescent suicide victims: Predisposing factors and phenomenology. Journal of the American Academy of Child and Adolescent Psychiatry, 34(2), 209-215.
23. Melhem, N. M., Day, N., Shear, M. K., Day, R., Reynolds, C. F., & Brent, D. A. (2004). Traumatic grief among adolescents exposed to a peer's suicide. American Journal of Psychiatry, 161(8), 1411-1416.
24. Prigerson, H. G., Shear, M. K., Jacobs, S. C., Reynolds, C. F. I., Maciejewsk, P. K., Davidson, J. R., Rosenheck, R., Pilkonis, P. A., Wortman, C. B., Williams, J. B., Widiger, T. A., Frank, E., Kupfer, D. J., & Zisook, S. (1999). Consensus criteria for traumatic grief: A preliminary empirical test. British Journal of Psychiatry, 174, 67-73.