Loneliness a Major Risk Factor for Suicidal Thoughts

Pauline Anderson

October 06, 2017

Loneliness is an important risk factor for suicidal ideation among older US veterans, new research suggests.

On the other hand, having strong social supports may guard against suicidal thinking in this population.

"We found that loneliness, as well as disability, were two of the strongest risk factors for the development of suicidal ideation," lead author Robert H. Pietrzak, PhD, MPH, associate professor of psychiatry, Yale University School of Medicine, New Haven, Conneticut, and director, Translational Psychiatric Epidemiology Laboratory, National Center for Posttraumatic Stress Disorder (PTSD), US Department of Veterans Affairs, told Medscape Medical News.

The study was published in the October issue of World Psychiatry.</

Vietnam Veterans

The researchers analyzed data on 2093 veterans from the National Health and Resilience in Veterans Study, a nationally representative, prospective cohort study of US military veterans. Most had served during the Vietnam War, which ended in 1975.

The mean age of participants was 62 years, and the cohort was predominantly male and white. Most had not been exposed to combat.

Participants completed a baseline survey in the fall of 2011 and at least one additional survey over a 4-year follow-up period.

In the anonymous surveys, participants were asked how often in the past 2 weeks they had had thoughts that they might be better off dead or had had thoughts of hurting themselves. Possible scored responses included the following:

  • Not at all (coded 0)

  • Several days (coded 1)

  • More than half the days (coded 2)

  • Nearly every day (coded 3)

Suicidal ideation was endorsed if answers were "1" or higher.

None of the participants reported suicidal ideation in the baseline survey. During the follow-up period, 7.5% developed suicidal ideation.

The researchers examined potential risk factors for suicidal thoughts and possible protective factors. One possible risk factor was loneliness, which was assessed using the Loneliness Scale.

For loneliness and each of the other variables, the researchers computed the relative variance explained (RVE), which ranks by percentage the contribution of each risk factor to predicting the development of suicidal ideation.

The investigators found that greater scores on the measure of loneliness were the strongest risk factor for the development of suicidal ideation (RVE, 16.5%).

Increased risk for suicidal ideation was also associated with disability in activities of daily living, such as needing help with housework and with taking medication properly (RVE, 14.8%), greater severity of PTSD symptoms (RVE, 7.9%), alcohol use problems (RVE, 5.7%), and older age (RVE, 2.0%).

Importantly, several factors appeared to protect against suicidal thoughts. These included greater social support (RVE, 20.3%) and psychological resilience, which Dr Pietrzak described as "perceived ability to manage adversity" (RVE, 8.0%).

He stressed that social supports ― including emotional and informational supports ― are "critical" to military veterans. "Research on veteran mental health has repeatedly underscored the importance of social support in facilitating successful reintegration into civilian life and in promoting psychological resilience."


Another protective factor was curiosity, which included such actions as frequently looking for new opportunities to grow as a person (RVE, 9.3%).

"That probably suggests that there are things of interest to veterans that they still want to do," said Dr Pietrzak. "It's having a natural curiosity about people and the world, it's something to live for."

Strategies for coping with stress can be either protective or a risk factor. Examples include soliciting advice on stress management or alcohol use, said Dr Pietrzak.

In this study, being exposed to combat was not an independent predictor of suicidal ideation.

Reaching out to veterans who are not connected to the Veterans Affairs (VA) system is important, said Dr Pietrzak. Only about 1 of 5 US military veterans report that the VA is their primary source of healthcare.

Suicidal ideation is linked to suicide attempts and to completed suicides. Although this study did not assess suicides per se (it was not possible to include death statistics, given the anonymous nature of the survey), research shows that 65% of veterans who commit suicide are 50 years of age or older, said Dr Pietrzak.

Studies show that vets are more than twice as likely to kill themselves as their civilian counterparts. About 20 veterans die by suicide every day.

Dr Pietrzak noted that at-risk vets might benefit from cognitive-behavioral therapy, tele-mental health care, and VA-based programs, such as Vet-to-Vet, which uses a peer-support approach.

He stressed the importance of "personalizing" such interventions to address the "unique needs of individual veterans."

In addition to asking veterans about PTSD and depression, clinicians might ask about their social support network "and do periodic updates to see how that changes over time," said Dr Pietrzak.

Clinicians also might ask about how the vet is managing stress, and they can track loneliness by administering the three-item measure of loneliness at regular checkups, he added.

In addition, it is important conduct a multimodal assessment that targets a broad range of possible suicide risk factors as well as protective factors, he said.

Many of the problems facing older vets are related to aging, including physical and cognitive decline. "The focus should be on promoting resilience and the ability to manage these challenges on a day-to-day basis," said Dr Pietrzak.

"Results of our study suggest that preventing suicidal thinking may not only be about fixing what is wrong but also building what is strong."

Help Is Available

Commenting on the findings for Medscape Medical News, Elspeth Cameron Ritchie, MD, a retired military psychiatrist who treats many veterans, some from the Vietnam War era, said the study findings "generally confirm what we already know" and are "very consistent with what I see in my daily practice."

She added, "it's always good to have data to support what you think you know."

Dr Ritchie said she was somewhat surprised that the authors did not mention problems with pain or sleep, which many veterans suffer.

The study used some terms that she was not familiar with, including "denial-based" and "acceptance-based" coping. Also, she said the role of "curiosity" was "new to me," adding that "it makes sense" as a protective factor in suicidal ideation.

Vietnam War veterans are now entering their 70s; many are dealing with retirement and possibly the loss of a spouse, as well as emergent problems related to aging, said Dr Ritchie.

In some, their PTSD, including flashbacks and nightmares, has been triggered by the 10-episode PBS television series The Vietnam War. The war will likely get even more attention with the 50th anniversary next year of the Tet Offensive, one of the largest military campaigns of the war. That offensive was launched by the North Vietnamese military and the Viet Cong against South Vietnamese and US forces.

In addition to trying to broaden social supports for vets and asking what they're doing in their retirement, clinicians can try interventions involving diet and exercise, said Dr Ritchie.

"There are a lot of supports out there for vets, if they're willing to try them. Often, it's just getting them to reach out."

The study was funded by the National Center for PTSD, US Department of Veterans Affairs. Dr Pietrzak works for the VA. Dr Ritchie, who recently took a position with the VA, noted that her comments were not made on behalf of the VA.

World Psychiatry. 2017; 3:326-327. Full text

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