Prospective Association of Unmet Mental Health Treatment Needs With Suicidal Behavior Among Combat-Deployed Soldiers
Abstract: Military personnel frequently report discontinuing or not pursuing psychiatric treatment despite perceiving a need for services. This study aimed to examine how unmet need for treatment or support among U.S. Army soldiers relates to future suicidal ideation (SI) or suicide attempt (SA). Mental health treatment need and help seeking in the past 12 months were evaluated for soldiers (N=4,645) who subsequently deployed to Afghanistan. Weighted logistic regression models were used to examine the prospective association of predeployment treatment needs with SI and SA during and after deployment, with adjustment for potential confounders. Compared with soldiers without predeployment treatment needs, those who reported not seeking help despite needing it had increased risk for SI during deployment (adjusted OR [AOR]=1.73), past-30-day SI at 2–3 months postdeployment (AOR=2.08), past-30-day SI at 8–9 months postdeployment (AOR=2.01), and SA through 8–9 months postdeployment (AOR=3.65). Soldiers who sought help and stopped treatment without improvement had elevated SI risk at 2–3 months postdeployment (AOR=2.35). Those who sought help and stopped after improving did not have increased SI risk during or 2–3 months after deployment but had elevated risks for SI (AOR=1.71) and SA (AOR=3.43) by 8–9 months postdeployment. Risks for all suicidality outcomes were also elevated among soldiers who reported receiving ongoing treatment before deployment. Unmet or ongoing needs for mental health treatment or support before deployment are associated with increased risk for suicidal behavior during and after deployment. Detecting and addressing treatment needs among soldiers before deployment may help prevent suicidality during deployment and reintegration periods.
Abstract: Background: Exposure to potentially morally injurious events (PMIEs) during military service can lead to moral injury (MI) outcomes and posttraumatic stress symptoms (PTSS). This longitudinal study examined the relationships between PMIE exposure, MI outcomes, and PTSS among Israeli combat veterans, and the potential protective role of dispositional forgiveness in these associations. Method: Participants were 169 Israeli combat veterans who participated in a six-year longitudinal study with four measurement points (T1: 12 months before enlistment, T2: Six months following enlistment- pre-deployment, T3: 18 months following enlistment- post-deployment, and T4: 28 months following discharge). Participants’ characteristics were assessed via semi-structured interviews (T1) and validated self-report measures (T2-T4) between 2019-2024. Results: Approximately 36% of participants reported exposure to PMIEs during service, with 13% exceeding the clinical threshold for probable PTSD at T4. PMIE-Betrayal at T3 was positively associated with MI outcomes of shame and trust violation at T4. The indirect effect of PMIEs on PTSS through MI outcome-Shame depended on forgiveness levels. Among veterans with low forgiveness, higher exposure to PMIE-Betrayal was associated with increased MI shame, which was linked to more severe PTSS. Conversely, for those with high forgiveness, exposure to PMIE-Self and Other was associated with decreased MI shame and subsequently reduced PTSS. Conclusion: Dispositional forgiveness moderates the relationship between PMIE exposure and MI outcomes, particularly shame, which mediates the development of PTSS. These findings highlight forgiveness as a potential target for intervention in treating moral injury and preventing PTSS among combat veterans.