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Prevalence and Trends in Suicidal Behavior Among US Military Veterans During the COVID-19 Pandemic

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  What is the population-based burden of the COVID-19 pandemic on suicidal behavior among US military veterans?

Finding  In this cohort study of 3078 US military veterans, rates of suicide ideation and suicide attempts did not significantly increase from prepandemic to peripandemic at the population level. However, a small proportion of veterans (2.6%) developed new-onset suicide ideation during the pandemic.

Meaning  These results suggest that despite grim forecasts about the COVID-19 pandemic possibly creating a perfect storm for suicidal behavior, the prevalence of suicidality did not appear to increase among military veterans nearly 10 months into the pandemic.


Importance  The COVID-19 pandemic has raised considerable concerns about increased risk for suicidal behavior among US military veterans, who already had elevated rates of suicide before the pandemic.

Objective  To examine longitudinal changes in suicidal behavior from before the COVID-19 pandemic to nearly 10 months into the pandemic and identify risk factors and COVID-related variables associated with new-onset suicide ideation (SI).

Design, Setting, and Participants  This population-based prospective cohort study used data from the first and second wave of the National Health and Resilience in Veterans Study, conducted from November 18, 2019, to December 19, 2020. Median dates of data collection for the prepandemic and peripandemic assessments were November 21, 2019, and November 14, 2020, nearly 10 months after the start of the COVID-19 public health emergency in the US. A total of 3078 US military veterans aged 22 to 99 years were included in the study.

Main Outcomes and Measures  Past-year SI and suicide attempts.

Results  In this cohort study of 3078 US veterans (mean [SD] age, 63.2 [14.7] years; 91.6% men; 79.3% non-Hispanic White veterans, 10.3% non-Hispanic Black veterans, and 6.0% Hispanic veterans), 233 (7.8%) reported past-year SI, and 8 (0.3%) reported suicide attempts at the peripandemic assessment. Past-year SI decreased from 10.6% prepandemic (95% CI, 9.6%-11.8%) to 7.8% peripandemic (95% CI, 6.9%-8.8%). A total of 82 veterans (2.6%) developed new-onset SI over the follow-up period. After adjusting for sociodemographic and military characteristics, the strongest risk factors and COVID-19-related variables for new-onset SI were low social support (odds ratio [OR], 2.77; 95% CI, 1.46-5.28), suicide attempt history (OR, 6.31; 95% CI, 2.71-14.67), lifetime posttraumatic stress disorder and/or depression (OR, 2.25; 95% CI, 1.16-4.35), past-year alcohol use disorder severity (OR, 1.06; 95% CI, 1.01-1.12), COVID-19 infection (OR, 2.41; 95% CI, 1.41-5.01), and worsening of social relationships during the pandemic (OR, 1.47; 95% CI, 1.16-1.88).

Conclusions and Relevance  The results of this cohort study suggest that despite grim forecasts that the COVID-19 pandemic would exacerbate suicidality among US military veterans, the rate of SI decreased at the population level nearly 10 months into the pandemic. Veterans who were infected with COVID-19 were more than twice as likely to report SI, which suggests the need for future research to examine the potential link between COVID-19 infection and suicidal behavior.

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Article Information

Accepted for Publication: June 27, 2021.

Published Online: August 25, 2021. doi:10.1001/jamapsychiatry.2021.2332

Correction: This article was corrected on October 6, 2021, to fix a sentence in the second paragraph of the Discussion that had erroneously begun with “Third” instead of “Fourth.”

Corresponding Author: Brandon Nichter, PhD, Department of Psychiatry, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA 92093 (bnichter@ucsd.edu).

Author Contributions: Dr Pietrzak had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Nichter, Hill, Kline, Norman, Southwick, Pietrzak.

Acquisition, analysis, or interpretation of data: Nichter, Hill, Na, Krystal, Pietrzak.

Drafting of the manuscript: Nichter, Pietrzak.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Nichter, Pietrzak.

Obtained funding: Krystal, Pietrzak.

Administrative, technical, or material support: Krystal, Pietrzak.

Supervision: Southwick, Pietrzak.

Conflict of Interest Disclosures: Dr Southwick reported receiving financial support from the Glenn H. Greenberg Endowed Professorship of Psychiatry, PTSD, and Resilience, Yale University School of Medicine. Dr Krystal reported being a scientific adviser to Biohaven Pharmaceuticals, BioXcel Therapeutics, Inc, Cadent Therapeutics (Clinical Advisory Board), PsychoGenics, Inc, Stanley Center for Psychiatric Research at the Broad Institute of MIT and Harvard, and Lohocla Research Corporation. Dr Krystal reported owning stock and/or stock options in Biohaven Pharmaceuticals, Sage Pharmaceuticals, Spring Care, Inc, BlackThorn Therapeutics, Inc, and Terran Biosciences, Inc. Dr Krystal reported receiving less than $10 000 in income (consulting fees) per year from AstraZeneca Pharmaceuticals, Biogen, Idec, MA, Biomedisyn Corporation, Bionomics, Limited (Australia), Boehringer Ingelheim International, Concert Pharmaceuticals, Inc, Epiodyne, Inc, Heptares Therapeutics, Limited (UK), Janssen Research & Development, L.E.K. Consulting, Otsuka America Pharmaceutical, Inc, Perception Neuroscience Holdings, Inc, Spring Care, Inc, Sunovion Pharmaceuticals, Inc, Takeda Industries, and Taisho Pharmaceutical Co, Ltd. Dr Krystal reported receiving income of greater than $10 000 per year from Biological Psychiatry as an editor. Dr Krystal reported receiving the drug Saracatinib for use in research studies from AstraZeneca and Mavoglurant from Novartis for research related to the National Institute on Alcohol Abuse and Alcoholism grant “Center for Translational Neuroscience of Alcoholism from AstraZeneca Pharmaceuticals.” Dr Krystal reported having the following patents: (1) Seibyl JP, Krystal JH, Charney DS. Dopamine and noradrenergic reuptake inhibitors in treatment of schizophrenia. US Patent 5447948; September 5, 1995; (2) Coric V, Krystal JH, Sanacora G. Glutamate Modulating Agents in the Treatment of Mental Disorders. US Patent 8778979 B2. July 15, 2014. US Patent Application No. 15/695164; filing date, September 5, 2017; (3) Charney D, Krystal JH, Manji H, Matthew S, Zarate C. Intranasal Administration of Ketamine to Treat Depression. US application 14/197767 filed on March 5, 2014; US Application or Patent Cooperation Treaty International Application 14/306382 filed on June 17, 2014; (4) Zarate C, Charney DS, Manji HK, Mathew SJ, Krystal JH, Department of Veterans Affairs. Methods for Treating Suicidal Ideation, Patent Application 14/197.767 filed on March 5, 2014, by Yale University Office of Cooperative Research; (5) Arias A, Petrakis I, Krystal JH. Composition and methods to treat addiction. Provisional Use Patent Application 61/973/961 filed on April 2, 2014, by Yale University Office of Cooperative Research; (6) Chekroud A, Gueorguieva R, Krystal JH. Treatment Selection for Major Depressive Disorder, filed on June 3, 2016, USPTO docket Y0087.70116US00. Provisional patent submission by Yale University; (7) Gihyun Y, Petrakis I, Krystal JH. Compounds, Compositions and Methods for Treating or Preventing Depression and Other Diseases. US Provisional Patent Application 62/444552, filed on January 10, 2017, by Yale University Office of Cooperative Research OCR 7088 US01; and (8) Abdallah C, Krystal JH, Duman R, Sanacora G. Combination Therapy for Treating or Preventing Depression or Other Mood Diseases. US Provisional Patent Application 62/719935 filed on August 20, 2018, by Yale University Office of Cooperative Research OCR 7451 US01. Dr Krystal reported receiving provision of drug from Cerevel and Novartis; stock options from Biohaven Pharmaceuticals, RBNC, Sage, Epivario, Terran, Atai, and Spring Care; patent royalties from Janssen Pharmaceuticals; and personal fees from Biogen, Neurocrine, Takeda, Jazz, Aptinyx, Bionomics, Compass, Concert, Epiodyne, Sunovion, Taisho, BioXcel, Eisai, Psychogenics, Greenwich Biosciences, and Boehringer Ingelheim for advising on clinical trials. In addition, Dr Krystal reported having patent No. 8,778,979 with royalties paid from Biohaven for Use of Glutamate Modulating Agents in the Treatment of Mental Disorders, patent 9,592,207 with royalties paid from Janssen Intranasal for Administration of Ketamine to Treat Depression, and patent 15,379,013 with royalties paid from Janssen Methods for Treating Suicidal Ideation outside the submitted work. Dr Norman reported receiving grants from the Department of Defense, the US Department of Veterans Affairs, and Patient-Centered Outcomes Research Institute and personal fees from Elsevier Press and UptoDate outside the submitted work. No other disclosures were reported.

Funding/Support: The National Health and Resilience in Veterans Study was supported by the US Department of Veterans Affairs National Center for Posttraumatic Stress Disorder.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank the veterans who participated in this study.

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