PTSD

Contents lists available at ScienceDirect

Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Research paper

PTSD symptoms and suicide risk in veterans: Serial indirect effects via depression and anger

Jessica M. McKinneya, Jameson K. Hirscha, ⁎ , Peter C. Brittonb

a Department of Psychology, East Tennessee State University, United States b Center of Excellence, Canandaigua Veterans Administration Medical Center, United States

A R T I C L E I N F O

Keywords: Veterans Suicide Depression Anger Hostility

A B S T R A C T

Background: Suicide rates are higher in veterans compared to the general population, perhaps due to trauma exposure. Previous literature highlights depressive symptoms and anger as contributors to suicide risk. PTSD symptoms may indirectly affect suicide risk by increasing the severity of such cognitive-emotional factors. Method: A sample of community dwelling veterans (N=545) completed online surveys, including the PTSD Checklist-Military Version, Suicidal Behaviors Questionnaire-Revised, Multidimensional Health Profile- Psychosocial Functioning, and Differential Emotions Scale –IV. Bivariate and serial mediation analyses were conducted to test for direct and indirect effects of PTSD symptoms on suicide risk. Results: In bivariate analyses, PTSD symptoms, depression, anger, and internal hostility were positively related to suicide risk. In serial mediation analyses, there was a significant total effect of PTSD symptoms on suicide risk in both models. PTSD symptoms were also indirectly related to suicidal behavior via depression and internal hostility, and via internal hostility alone. Anger was not a significant mediator. Limitation: Our cross-sectional sample was predominantly White and male; prospective studies with diverse veterans are needed. Discussion: Our findings may have implications for veteran suicide prevention. The effects of PTSD and depression on anger, particularly internal hostility, are related to suicide risk, suggesting a potential mechanism of action for the PTSD-suicide linkage. A multi-faceted therapeutic approach, targeting depression and internal hostility, via cognitive-behavioral techniques such as behavioral activation and cognitive restructuring, may reduce suicide risk in veterans who have experienced trauma.

Suicide is the 10th leading cause of death in the U.S., with over 40,000 suicides reported in 2014 (Drapeau and McIntosh, 2015). Of these suicides, it is estimated that approximately 22% are comprised of veterans (Kemp and Bossarte, 2012). This disproportionate rate of suicide in the veteran population may be due to various risk factors, including psychopathology, such as symptoms of posttraumatic stress disorder (PTSD) (e.g., feelings of detachment and hypervigilance; Conner et al., 2014) and depression, and cognitive-emotional factors (Nock et al., 2013), including anger (Gonzalez et al., 2015). The independent contributions of these risk factors have been examined in both active military personnel and veteran samples, particularly the association between PTSD and suicide risk, given the increased prevalence of PTSD in this population (Parikh et al., 2015; Wisco et al., 2014).

Both a diagnosis of PTSD, as well as sub-clinical symptoms, are associated with poor physical and mental health in community and veteran samples, including suicide risk (Asnaani et al., 2014;

Cukrowicz et al., 2011; Gill et al., 2014; Jakupcak et al., 2011; Pietrzak et al., 2011; Wisco et al., 2014), although there are some mixed findings (Zivin et al., 2007). For instance, PTSD may be a more salient predictor of suicide attempt than depression which is itself, more predictive of ideation (May and Klonsky, 2016); in the current study, we examine suicide risk, or proneness, which involves self-report of both past and anticipated future suicidal activity, including ideation and attempts. Despite differences in assessing suicidal behavior, there is a long-documented history of veterans with PTSD reporting suicidal ideation and dying by suicide more frequently than non-PTSD veteran counterparts (Bullman and Kang, 1994; Jakupcak et al., 2009).

Although a definitive theoretical and empirical link between PTSD and suicide has yet to be established (Panagioti et al., 2009), current models focus on several areas of vulnerability, including comorbidity with other psychiatric symptoms, such as depression; types of combat exposure (Maguen et al., 2012); type and number of traumas experi- enced (LeBouthillier et al., 2015); use of suicidal behavior as a

http://dx.doi.org/10.1016/j.jad.2017.03.008 Received 4 October 2016; Received in revised form 22 January 2017; Accepted 5 March 2017

⁎ Correspondence to: Department of Psychology, East Tennessee State University, P.O. Box 70649, Johnson City, TN 37614, United States. E-mail address: [email protected] (J.K. Hirsch).

Journal of Affective Disorders 214 (2017) 100–107

Available online 07 March 2017 0165-0327/ © 2017 Elsevier B.V. All rights reserved.

MARK

maladaptive means of coping with distress (Blake et al., 1992; Fairbank et al., 1991; Panagioti et al., 2012); and, the influence of internalized cognitive-emotional factors including shame (Gaudet et al., 2016) and guilt (Hendin and Haas, 1991). Yet, despite evidence of independent associations, little work has been done to elucidate potential mechan- isms of action for the PTSD-suicide linkage. For instance, it may be that the experience of symptoms of PTSD is disruptively-associated with multiple aspects of cognitive-affective functioning in a way that contributes to vulnerability for suicide risk.

One explanatory factor in the PTSD-suicide linkage may be disrup- tion to mood, including the experience of depressive symptoms. Depression, which may manifest as feelings of worthlessness and hopelessness, general low mood, and changes in physical activity, is linked to poor physical (i.e., general health, physical role limitations) and mental health functioning (i.e., decreased mood, alcohol use; Asnaani et al., 2014), as well as suicidal ideation and death by suicide in veterans (LeardMann et al., 2013; Ramsawh et al., 2014). PTSD and depression are intertwined, as both may result from trauma (Franklin and Zimmerman, 2001) and, indeed, may share some overlapping symptoms, including rumination, dysphoria, sleep difficulties (Elhai et al., 2015; Lemaire and Graham, 2011; Roley et al., 2015), and exacerbation of suicide risk in both community and veteran samples (Handley et al., 2012; Morina et al., 2013; Ramsawh et al., 2014).

Yet, theory and empirical evidence suggest that temporal ordering may exist, with depressive symptoms more likely to be a consequence of PTSD than to precede trauma and the onset of PTSD (Breslau, 2002; Breslau et al., 1997). Depression, as well as other disorders, often serves as a mediator of the relation between PTSD and suicide risk, for instance in a sample of veterans receiving VA healthcare services (Conner et al., 2014). Such downstream effects may persist, as trauma and depression are associated with additional impairments to cogni- tive-emotional functioning that may contribute to suicide risk (Raab et al., 2013).

As an example, in both PTSD and depression, feelings of frustration and anger are common, perhaps as a result of the perceived loss of autonomy and control over one’s circumstances that is common in times of trauma and distress (Genuchi and Valdez, 2015; Gonzalez et al., 2015; Reyes and Hicklin, 2005; Sharma and Sharma, 2008). Indeed, anger is one of the most common issues reported by returning service members (Izard et al., 1993; Renshaw and Kiddie, 2012; Thomas et al., 2010), and is conceptualized as having two components: 1) internal hostility, which is comprised of suppressed anger, and feelings of anger, disgust, and contempt directed towards one’s self); and, 2) externalized anger, or feelings of annoyance, contempt, hostility and aggression, and the desire to express these feelings toward others.

Anger and aggression often emerge after the experience of a trauma (Orth and Wieland, 2006), and are viewed as secondary emotions to depressive and anxiety disorders, including PTSD (Orth et al., 2008; Renshaw and Kiddie, 2012; Sharma and Sharma, 2008). Accordingly, anger is a frequently-reported experience by persons diagnosed with major depressive disorder (Fava et al., 2010, 1997) and PTSD (Jakupcak and Tull, 2005; Novaco and Chemtob, 2002). For example, when in a depressed mood, individuals tend to express greater anger towards other individuals (Finman and Berkowitz, 1989) and, in a sample of combat veterans, depression was a mediator of the associa- tion between PTSD and both state and trait anger (Raab et al., 2013).

With regard to suicide, anger and aggression have been widely studied as precipitants, and are related to suicidal behavior in the general population (Goldney et al., 2009; Hawkins et al., 2014; Jandl et al., 2010; Jang et al., 2014) and in military samples (Novaco et al., 2012). Both state, or reactive anger, and trait anger are associated with suicide, perhaps via the emotional disruption and impulsivity that are characteristic of anger (Ammerman et al., 2015; Daniel et al., 2009). As well, the experience of anger may trigger both the behavioral activation system (BAS), which although typically linked to pleasurable affect, is also related to impulsivity and approach-aggression situations, and the

behavioral inhibition system (BIS), which is related to avoidance and negative affect (Harmon-Jones, 2003; Smits and Kuppens, 2005).

Although PTSD, depression, and anger have been examined as independent predictors of suicide risk, a comprehensive model includ- ing all of these factors has yet to be examined. In the current study, we conducted bivariate and serial mediation analyses to examine such a comprehensive model, in a community sample of veterans. At the bivariate level, we hypothesized that PTSD symptoms, depressive symptoms, anger (i.e., externalized anger), internal hostility (i.e., internalized anger), and suicide risk would be positively related. At the multivariate level, we hypothesized that depression and anger/ internal hostility would sequentially mediate the association between PTSD and suicide risk, such that greater levels of PTSD symptoms would be related to more depressive symptoms and, serially, to greater anger/internal hostility and suicide risk.

1. Methods

1.1. Participants

Participants (N=545) in this IRB-approved study were recruited via online invitations distributed to veterans-related social media groups (e.g., military-related Facebook pages) and national organizations (e.g., Veterans of Foreign Wars [VFW] chapters). Participants completed online surveys that were administered through [www.surveymonkey. com]. The sample was primarily male (n=382; 70.1%), White (n=469; 86.1%), Army (n=209; 38.3%), served throughout multiple eras (n=240; 44.0%), received some care through the Veterans Health Affairs (n =279; 51.2%) and had a mean age of 49.9 (SD=16.78) (see Table 1). Participants provided informed consent at the beginning of the survey and were entered into a drawing for a chance to win an Amazon gift card.

Table 1 Characteristics of participants.

Percentage of participants (%) n

Ethnicity Caucasian 86.1% 469 African American 1.5% 8 American Indian/Alaska Native .9% 5 Asian .2% 1 Multiracial 7.0% 38 Other 1.8% 10 No response 2.5% 14

Branch of Service Army 38.3% 209 Navy 16.8% 92 Air Force 16.1% 88 Marine Corps 7.5% 41 National Guard 2.6% 14 Army Reserves 1.6% 9 Coast Guard .9% 5 Multiple Branches 15.9% 85 No response .3% 2

Era of Service September 2001 or later 28.1% 153 August 1990 to August 2001 7.3% 40 May 1975 to July 1990 4.8% 26 August 1964 to April 1975 14.8% 81 February 1955 to July 1964 .2% 1 July 1950 to January 1955 .4% 2 December 1941 to December 1946 .4% 2 Multiple eras 44.0% 240

VHA Usage Yes 51.2% 279 No 48.8% 266

J.M. McKinney et al. Journal of Affective Disorders 214 (2017) 100–107

101

1.2. Measures

Demographic characteristics including age, sex, race and ethnicity, branch of service, era of service, and use of VHA medical services were assessed, in addition to the variables of interest. Differences in suicide rates across branches of the military (Eaton et al., 2006), dates of service (Fanning and Pietrzak, 2013; Pietrzak et al., 2011; Wisco et al., 2014), and with varying usage of VHA care (Hoffmire et al., 2015), provide a rationale for covariance of these variables.

Posttraumatic stress disorder symptoms were assessed using the PTSD Checklist-Military Version (PCL-M) for DSM-IV (Weathers et al., 1991), which has 17 items measuring the following types of symptoms: intrusive (e.g., “Repeated, disturbing dreams of a stressful military experience?”), avoidance (e.g., “Avoiding thinking about or talking about a stressful military experience or avoid having feelings related to it?”), numbing (e.g., “Loss of interest in things that you used to enjoy?”), and hyperarousal (e.g., “Feeling jumpy or easily startled?”) symptoms. Each item is rated on a Likert scale from 1 (“not at all”) to 5 (“extremely”) to indicate the degree to which the symptom has bothered the respondent over the past month. PTSD symptom severity scores are determined by summing the respondent’s answers to all 17 items, with higher scores indicating higher severity of symptoms. The PCL-M has excellent reliability in military samples (α=.97; Yarvis et al., 2012). In the current sample, internal consistency was excellent (Cronbach’s α=.97).

Suicide risk was assessed utilizing the Suicidal Behaviors Questionnaire-Revised (SBQ-R). A total of four items measures both suicidal thoughts and behaviors (Osman et al., 2001), including suicidal ideation and attempts (“Have you ever thought about or attempted to kill yourself?”), suicidal ideation within the past year (“How often have you thought about killing yourself in the past year?”), communication of intent (“Have you ever told someone that you were going to commit suicide, or that you might do it?”), and the likelihood of attempting suicide in the future (“How likely is it that you will attempt suicide someday?”). Each item is rated on a Likert scale, with higher total scores indicating greater suicidal behavior. Previous studies using veteran samples have found adequate (α=.76; Currier et al., 2015) to good (α=.84; Rudd et al., 2011) internal consistency. In the current sample, internal consistency was good (Cronbach’s α=.81).

Depressive symptoms were assessed using the Multidimensional Health Profile-Psychosocial Functioning screening tool (MHP-P) (Ruehlman et al., 1998). The MHP-P is comprised of a total of 58 items that cover the areas of life stress, coping skills, social resources, and mental health. The depression subscale of the mental health scale includes three items (e.g., “How much has your mood been generally happy, upbeat, or positive?”) rated on a Likert scale from 1 (“not at all”) to 5 (“very”) to indicate how the respondent has felt over the past two weeks. Higher scores indicate increased levels of depressive symptoms. In a previous sample utilizing trauma-exposed individuals, internal consistency was good (Cronbach’s α=.85; Williams et al., 2011). In the current sample, internal consistency was good (Cronbach’s α=.86).

Symptoms of anger were assessed using the Differential Emotions Scale-IV (DES-IV) (Izard, 1979). The DES-IV-B is composed of 36 items that assess discrete trait emotions including the following two variables: anger, which represents external anger and internal hostility, conceptualized as anger directed towards the self (i.e., internal anger). Each subscale is comprised of three items, asking respondents to answer how often they feel anger in their daily life (e.g., “Feel like screaming at somebody or banging on something”) and hostility inward (e.g., “Feel you can’t stand yourself”). Items are scored on a Likert scale from 1 (“rarely or never”) to 5 (“very often”), with higher scores indicating greater levels of anger and hostility inward. Previous studies indicate adequate (α=.75, internal hostility) and good (α=.85, anger) internal consistency (Izard et al., 1993). In the current sample, internal consistency was good (Cronbach’s α=.89) for anger and excellent (Cronbach’s α=.91) for internal hostility.

1.3. Statistical analyses

1.3.1. Bivariate analyses Pearson’s product-moment correlations were used to examine

linear associations between, and independence of, PTSD symptoms, anger, internal hostility, depressive symptoms, and suicide risk; no associations exceeded the recommended cut-off for multicollinearity (r > .80) (Katz, 2006).

1.3.2. Serial mediation analyses We conducted a serial mediation model (Hayes, 2013) with

depression (1st order mediator) and anger (2nd order) as mediators in Model 1, and depression (1st order) and internal hostility (2nd order) as mediators in Model 2 (Figs. 1 and 2). In a serial mediation model, mediators are assumed to have a direct effect on each other (Hayes, 2013), and the independent variable (PTSD symptoms) influences the mediators in a serial fashion and, subsequently, the dependent variable (suicide risk).

Serial mediation models provide the results found in simple mediation models, including a total effect (i.e., c: relation between independent and dependent variables without controlling for media- tors), direct effect (i.e.,c′: relation between independent and dependent variables after controlling for mediating variables), and a total indirect effect (i.e., ab: role of all mediating variables in the relation between independent and dependent variables). In addition, a serial mediation

Fig. 1. Illustration of an indirect effects model for serial mediation utilizing depressive symptoms and anger. Note. MV=mediator variable. a1=direct effect of PTSD symptoms on depressive symptoms; a2=direct effect of PTSD symptoms on anger; a3=direct effect of depressive symptoms on anger; b1=direct effect of depressive symptoms on suicide risk; b2=direct effect of anger on suicide risks; c=total effect of PTSD symptoms on suicide risk, without accounting for depressive symptoms and anger; c′=direct effect of PTSD symptoms on suicide risk when accounting for depressive symptoms and anger. For specific total and indirect effect results, refer to Table 4. Adapted from Preacher and Hayes (2012). *p≤.001.

Fig. 2. Illustration of an indirect effects model for serial mediation utilizing depressive symptoms and internal hostility. Note. MV=mediator variable. a1=direct effect of PTSD symptoms on depressive symptoms; a2=direct effect of PTSD symptoms on internal hostility; a3=direct effect of depressive symptoms on internal hostility; b1=direct effect of depressive symptoms on suicide risk; b2=direct effect of internal hostility on suicide risk; c=total effect of PTSD symptoms on suicide risk, without accounting for depressive symptoms and internal hostility; c′=direct effect of PTSD symptoms on suicide risk when accounting for depressive symptoms and internal hostility. For specific total and indirect effect results, refer to Table 4. *p≤.01, **p≤.001.

J.M. McKinney et al. Journal of Affective Disorders 214 (2017) 100–107

102

model with two mediators (i.e., depression and anger/internal hosti- lity) can have three specific indirect effects, which provide information regarding the role of a specific mediator in the relation between the independent and dependent variables: 1) through depression alone (a1b1), 2) through depression and anger/internal hostility in serial fashion (a1a3b2), and 3) through anger/internal hostility alone (a2b2).

Mediation models assess indirect effects without the necessity for the relation between the independent and dependent variable to be significant. Furthermore, Hayes’ (2013) mediation analyses employ bootstrapping, a non-parametric resampling technique that involves random and repeated sub-sampling of data without need to satisfy the assumption of normally distributed data. Bootstrapping also yields a 95% confidence interval; indirect effects are significant when the 95% confidence interval does not contain zero. For this model, we utilized 10,000 bootstrapped samples.

2. Results

Our bivariate hypothesis was supported, as all study variables were significantly associated in the predicted directions (see Table 2). With regard to our dependent variable, PTSD symptoms (r=.45, p < .001), depressive symptoms (r=.48, p < .001), anger (r=.38, p < .001), and internal hostility (r=.45, p < .001) were positively related to suicide risk. Depressive symptoms (r=.77, p < .001), anger (r=.70, p < .001), and internal hostility (r=.71, p < .001) were positively associated with PTSD symptoms. Anger (r=.64, p < .001) and internal hostility (r=.75, p < .001) were also positively associated with depressive symptoms and with each other (r=.74, p < .001).

In serial mediation analyses (Model 1; Table 3; Fig. 1), there was a significant total effect of PTSD on suicide risk (c=.062, CI=.048 to .076). The direct effect of PTSD symptoms on suicide risk was reduced and fell out of significance when depression and anger were added as mediators (c′=.019, CI=−.002 to .040), indicating significant mediation. The total indirect effect of PTSD symptoms on suicide risk was also significant (ab=.044, SE=.009, CI=.026 to .062). As well, a significant specific indirect effect was found for PTSD symptoms through depressive symptoms alone (a1b1=.037, SE=.008, CI=.021 to .053). Greater levels of PTSD symptoms were associated with higher levels of depressive symptoms which were, in turn, associated with greater suicide risk. Proposed pathways via anger, and via depression and anger in serial fashion, were not supported.

In our second serial mediation model (Model 2; Table 4; Fig. 2), there was a significant total effect of PTSD on suicide risk (c=.062, CI=.048 to .076). The direct effect of PTSD symptoms on suicide risk was reduced and fell out of significance when depression and internal hostility were added as mediators (c′=.016, CI=−.004 to .036), indicating significant mediation. The total indirect effect of PTSD symptoms on suicide risk was significant (ab=.046, SE=.009, CI=.029 to .064).

Significant specific indirect effects were found for all paths of the PTSD- suicide risk relationship. First, there was a significant indirect pathway for PTSD symptoms through depressive symptoms alone (a1b1=.029, SE=.009, CI=.012 to .045). Greater levels of PTSD symptoms were associated with more depressive symptoms and, in turn, to greater suicide risk. Second, there was a significant indirect pathway for PTSD symptoms through depressive symptoms and internal hostility in serial fashion (a1a3b2=.010, SE=.004, CI=.003 to .018); PTSD symptoms were sequen- tially associated with greater levels of depressive symptoms and increased levels of internal hostility and, in turn, increased suicide risk. Finally, there was a significant indirect pathway for PTSD symptoms through internal hostility alone (a1b2=.008, SE=.003, CI=.003 to .015). Greater levels of PTSD symptoms were associated with more internal hostility and, in turn, to greater suicide risk.

3. Discussion

In our sample of community veterans, we found, in support of hypotheses, that PTSD symptoms were associated with suicide risk

Table 2 Means, standard deviations, and correlations among variables of interest (N=545).

Variable M SD PTSD symptoms

Depressive symptoms

Anger Internal hostility

1. PTSD symptoms

44.72 19.82 – – – –

2. Depressive symptoms

8.47 3.53 .773 – – –

3. Anger 8.86 3.31 .700 .639 – – 4. Internal

hostility 7.60 3.55 .707 .746 .739 –

5. Suicide risk 8.06 2.69 .451 .475 .380 .448

Note. PTSD symptoms=PTSD Checklist-Military Version (PCL-M) for DSM-IV; depres- sive symptoms=Multidimensional Health Profile- Psychosocial Functioning (MHP-P); anger and internal hostility = Differential Emotions Scale-IV; and, suicide risk=Suicidal Behaviors Questionnaire - Revised (SBQ-R). All values are p≤.001

Table 3 Specific indirect effects between PTSD symptoms and suicide risk for serial mediation utilizing depressive symptoms and anger (N=545).

BCa 95% CI

Effect b Lower Upper

ab .044 .026 .062 a1b1 .037 .021 .053 a1a3b2 .002 −.001 .006 a2b2 .005 −.004 .013

Suicide Risk Total Effect Model R2 = .200*

Note. a, b, c, and c′ represent unstandardized regression coefficients: a1=direct effect of PTSD symptoms on depressive symptoms; a2=direct effect of PTSD symptoms on anger; a3=direct effect of depressive symptoms on anger; b1 = direct effect of depressive symptoms on suicide risk; b2=direct effect of anger on suicide risk; c=total effect of PTSD symptoms on suicide risk, without accounting for depressive symptoms and anger; c′=direct effect of PTSD symptoms on suicide risk when accounting for depressive symptoms and anger; ab=Total Indirect Effect; a1b1=specific indirect effect through depressive symptoms; a1a3b1=specific indirect effect through depressive symptoms and anger; a2b2=specific indirect effect through anger. CI=bias corrected and accelerated 95% confidence interval; 10,000 bootstrap samples; covariates included age, sex, ethnicity, branch of service, era of service, and VHA usage. * p≤.001.

Table 4 Specific indirect effects between PTSD symptoms and suicide risk for serial mediation utilizing depressive symptoms and internal hostility (N=545).

BCa 95% CI

Effect b Lower Upper

ab .046 .029 .064 a1b1 .029 .012 .045 a1a3b2 .010 .003 .018 a2b2 .008 .003 .015

Suicide Risk Total Effect Model R2=.201*

Note. a, b, c, and c′ represent unstandardized regression coefficients: a1=direct effect of PTSD symptoms on depressive symptoms; a2=direct effect of PTSD symptoms on internal hostility; a3=direct effect of depressive symptoms on internal hostility; b1=direct effect of depressive symptoms on suicide risk; b2 = direct effect of internal hostility on suicide risk; c=total effect of PTSD symptoms on suicide risk, without accounting for depressive symptoms and internal hostility; c′=direct effect of PTSD symptoms on suicide risk when accounting for depressive symptoms and internal hostility; ab=Total Indirect Effect; a1b1=specific indirect effect through depressive symptoms; a1a3b1=specific indirect effect through depressive symptoms and internal hostility; a2b2=specific indirect effect through internal hostility. CI=bias corrected and accelerated 95% confidence interval; 10,000 bootstrap samples; covariates included age, sex, ethnicity, branch of service, era of service, and VHA usage.* p≤.001.

J.M. McKinney et al. Journal of Affective Disorders 214 (2017) 100–107

103

through the following mechanisms: (i) through total effect of all variables (ii) indirectly via higher levels of depressive symptoms in both models; (iii) indirectly via higher levels of depressive symptoms and, sequentially, greater levels of internal hostility; and, (iv) indirectly via increased internal hostility. In other words, we found that PTSD, itself, was related to suicide risk accounting for all mediators, but also indirectly via depression, and indirectly via internal hostility. As well, PTSD was related, serially, to greater depressive symptoms and, in turn, to more internal hostility and greater suicide risk.

In general, that PTSD, depression, anger (with external only related at the bivariate level) and suicide risk are all related, and that the former risk factors contribute to the latter outcome, are consistent with the extant literature (Ramsawh et al., 2014). Our novel findings expand this previous work by highlighting potential underlying pathways whereby symptoms of PTSD are related to suicide risk, particularly the effect of PTSD on mood and emotion regulation abilities (Gonzalez et al., 2015).

Consistently, across bivariate and multivariate analyses, and across indirect and serial models, internal hostility was related to suicide risk and, further, was a significant mediator linking PTSD and depression to suicide risk. There is both theoretical and empirical support indicating that PTSD symptoms may affect an individual’s ability to psychologi- cally distance themselves from the negative events in their lives, including their trauma; such lack of separation may result in an over-identification with negative experiences, whereby they become integrated into self-identity and chronically and deleteriously impact mood (Janssen et al., 2015). Specifically, trauma related rumination, particularly about the self and world, in combat PTSD is associated with increased levels of negative affect and decreased ability to control anger expression (Germain et al., 2016). Further, once depressed, psychological distancing from positive experiences occurs, resulting in an inability to benefit from achievements and attainment of goals. This lack of rewards, paired with identification with, and internalization of, the negative aspects of one’s life, may result in a sense of self- frustration and self-anger that increases vulnerability to suicide risk. Previous research confirms this, as inner-directed anger (i.e., internal hostility) is associated with increased suicide risk across samples, including civilians and veterans with PTSD (Olatunji et al., 2010), psychiatric patients (Claes et al., 2010; Giegling et al., 2009); sexual assault survivors (Miller and Resick, 2007), and adolescents (Lehnert et al., 1994; Nixon et al., 2002).

Given that external anger is a commonly described symptom of depression and suicide risk factor (Genuchi, 2015; Genuchi and Valdez, 2015), it is surprising that it was not a significant contributor to suicide risk in the context of PTSD, as it has been in previous research (Daniel et al., 2009; Zlotnick et al., 1997). However, there is a precedent for such a pattern of effects. For instance, previous research suggests that internalized, but not externalized, anger/hostility is associated with depressive symptoms (Cautin et al., 2001). As well, some forms of PTSD (e.g., internalized PTSD), may result in greater depressive symptoms and self-directed anger (i.e., internal hostility; Castillo et al., 2014; Miller et al., 2004) and, thus, suicide risk.

Although related to suicide risk in our bivariate analyses, it may simply be that external anger is more likely to be associated with acts of aggression toward others, whereas internal hostility more often man- ifests as harm to the self. Additionally, externalized anger is sometimes conceptualized as “venting,” providing a cathartic release of negative emotions and decreasing risk of engagement in maladaptive coping, including suicidal behavior (i.e., suicide attempts; Lohr et al., 2007).

Finally, in the context of precipitating depressive symptoms, there may be an increased tendency to engage in internalization of anger (i.e., internal hostility), rather than externalization. For instance, although irritability and anger can certainly manifest from depression, depressed persons tend to be more self-critical, often viewing themselves as worthless and helpless, and as being in a hopeless situation. This self- perception of low efficacy and inability to resolve stressors and attain goals, with accompanying frustration and self-directed anger

(Abdolmanafi et al., 2011; Abi-habib and Luyten, 2013), may be more likely to lead to suicide risk, than externalized anger.

3.1. Limitations

Our findings should be viewed in the context of minor limitations. First, our cross-sectional design precludes exploration of causal relationships, and bi-directionality is a possibility. For instance, individuals with greater trait anger are at an increased risk for developing PTSD symptoms (Heinrichs et al., 2005; Meffert et al., 2008) and, similarly, depressive symptoms and anger have a cyclical relationship (Busch, 2009), indicating the need for prospective, long- itudinal research to determine the true ordering of these risk factors.

Our use of a measure of trait anger, rather than state anger, may also be a limitation, as it may seem counter-intuitive that a disposi- tional characteristic could be altered by experiences or psychopathol- ogy (Chemtob et al., 1994; Lommen et al., 2014). However, previous research indicates that personality traits do, indeed, change over time (Roberts and Mroczek, 2008) and can be influenced by trauma (Orth et al., 2008).

Our sample is also predominantly male and White, which might typically limit the generalizability of our findings; however, most U.S. veterans are male and White, suggesting that our findings are applic- able to the larger population of interest (U.S. Census Bureau, 2012). As with any self-selection recruitment process, social desirability may contribute to respondent bias. For instance, veterans who agreed to participate and, thus, to help other veterans, may experience less self- stigma against mental illness and treatment seeking, which is often prevalent in the military population (Rosen et al., 2011). As well, veterans recruited from social media, national organizations and VFW posts, may have more extensive support systems available, thereby reducing their risk for psychopathology and suicide. Although a veteran sample, individuals may not have taken the survey if they are still associated with the military or employed other government positions. Military personnel have reported fear of losing their careers via disclosure of any mental health issues, potentially influencing their participation in surveys over mental health concerns (Acosta et al., 2014).

Finally, although correlation findings did not exceed the cut-off for multicollinearity, anger and internal hostility were highly correlated, nearing the .80 recommended cut-off. This would potentially suggest that these subscales do not, in fact, measure different aspects of anger. However, internal hostility was the only factor to work in the serial mediation models, suggesting that despite their high correlation, anger and internal hostility measure different subtle aspects of anger.

3.2. Implications

These findings are particularly salient in the context of media portrayal of PTSD and society’s focus on how to treat veterans with PTSD. Society tends to highlight the external symptoms of PTSD in the media, including anger, violence, and flashbacks. However, these findings suggest that the internal, rather than the external, symptoms of PTSD should be the main focus as these symptoms are more worrisome when related to potential suicide risk.

Our findings may have important implications for suicide preven- tion efforts in community dwelling veterans. Since depressive symp- toms and internal hostility served as significant mediators in the PTSD symptoms-suicide linkage, they may also be useful intervention targets. To begin, healthcare providers should consider screening for depres- sion and signs of both external and internal anger/hostility, in veterans presenting with PTSD symptoms, as a potential means of inferring suicide risk (Department of Veterans Affairs, 2002). Interventions designed to target depressive symptoms often result in decreased suicide risk (Fisher et al., 2015; Pietrzak et al., 2010) and, as well, cognitive-behavioral treatments are effective at reducing levels of

J.M. McKinney et al. Journal of Affective Disorders 214 (2017) 100–107

104

anger, including in veterans with PTSD (Chemtob et al., 1997). Techniques such as behavioral activation and cognitive restructuring, when used in conjunction with exposure-based therapies, may allow for simultaneous targeting of PTSD, depressive symptoms, and anger (Cahill et al., 2003; Strachan et al., 2012). Cognitive processing therapy, one of the predominant forms of treatment used for PTSD, has also been shown to target depressive symptoms and anger as well, lending itself as a useful tool to potentially target these symptoms and in turn, reduce suicide risk (Galovski et al., 2014). Stress inoculation training prior to combat exposure may also be a valuable approach in the context of trauma. Therapeutically bolstering a patient’s perceived ability to regulate future negative emotions, and to resolve future stressors, may proactively reduce the likelihood of the development of depression (Gonzalez et al., 2015), as well as consequent negative effects on emotion regulation (i.e., anger) and suicide risk.

4. Conclusions

In a sample of community veterans, we found that the relation between PTSD symptoms and suicide risk is influenced by the sequential associations between depression and anger. The experience of trauma may set in motion a cascade of events that includes disruptions to the ability to regulate cognitive (e.g., depression) and emotional (e.g., anger) functioning and which, consequently, contri- butes to vulnerability to suicidal behavior. Although future research on the interrelations between these risk factors is needed to substantiate our findings, healthcare providers working with veterans may want to consider a multi-faceted approach to treatment, which simultaneously addresses symptoms of PTSD and depression, but also focuses on the role of anger, particularly toward the self, as a critical point of suicide intervention with veterans.

Conflicts of interest

None.

Acknowledgements

None.

References

Abdolmanafi, A., Besharat, M.A., Farahani, H., Khodaii, M.R., 2011. The moderating role of locus of control on the relationship between anger and depression in patients with major depression disorder. Procedia-Soc. Behav. Sci. 30, 297–301. http:// dx.doi.org/10.1016/j.sbspro.2011.10.059.

Abi-Habib, R., Luyten, P., 2013. The role of dependency and self-criticism in the relationship between anger and depression. Personal. Individ. Differ. 55 (8), 921–925. http://dx.doi.org/10.1016/j.paid.2013.07.466.

Acosta, J.D., Becker, A., Cerully, J.L., Fisher, M.P., Martin, L.T., Vardavas, R., Slaughter, M.E., Schell, T.L., 2014. Mental health Stigma in the Military. RAND Corporation, Santa Monica.

Ammerman, B.A., Kleiman, E.M., Uyeji, L.L., Knorr, A.C., McCloskey, M.S., 2015. Suicidal and violent behavior: the role of anger, emotion dysregulation, and impulsivity. Personal. Individ. Differ. 79, 57–62. http://dx.doi.org/10.1016/ j.paid.2015.01.044.

Asnaani, A., Reddy, M.K., Shea, M.T., 2014. The impact of PSTD symptoms on physical and mental health functioning in returning veterans. J. Anxiety Disord. 28 (3), 310–317. http://dx.doi.org/10.1016/j.janxdis.2014.01.005.

Blake, D.D., Cook, J.D., Keane, T.M., 1992. Post-traumatic stress disorder and coping in veterans who are seeking medical treatment. J. Clin. Psychol. 48 (6), 695–704. http://dx.doi.org/10.1002/1097-4679(199211)48:6 < 695::AID-JCLP2270480602 > 3.0.CO;2-P.

Breslau, N., 2002. Epidemiologic studies of trauma, posttraumatic stress disorder, and other psychiatric disorders. Can. J. Psychiatry/Rev. Can. Psychiatr. 47 (10), 923–929.

Breslau, N., Davis, G.C., Peterson, E.L., Schultz, L., 1997. Psychiatric sequelae of posttraumatic stress disorder in women. Arch. Gen. Psychiatry 54 (1), 81–87. http:// dx.doi.org/10.1001/archpsyc.1997.01830130087016.

Bullman, T.A., Kang, H.K., 1994. Posttraumatic stress disorder and the risk of traumatic

deaths among Vietnam veterans. In: Fullerton, C.S., Ursano, R.J., Fullerton, C.S., Ursano, R.J. (Eds.), Posttraumatic Stress Disorder: Acute and Long-Term Responses to Trauma and Disaster. American Psychiatric Association, Arlington, VA, US, 175–189.

Busch, F.N., 2009. Anger and depression. Adv. Psychiatr. Treat. J. Contin. Prof. Dev. 15, 271–278. http://dx.doi.org/10.1192/apt.bp.107.004937.

Cahill, S.P., Rauch, S.A., Hembree, E.A., Foa, E.B., 2003. Effect of cognitive-behavioral treatments for PTSD on anger. J. Cogn. Psychother. 17 (2), 113–131. http:// dx.doi.org/10.1891/jcop.17.2.113.57434.

Castillo, D.T., Joseph, J.S., Tharp, A.T., C'de Baca, J., Torres-Sena, L.M., Qualls, C., Miller, M.W., 2014. Externalizing and internalizing subtypes of posttraumatic psychopathology and anger expression. J. Trauma. Stress 27 (1), 108–111. http:// dx.doi.org/10.1002/jts.21886.

Cautin, R.L., Overholser, J.C., Goetz, P., 2001. Assessment of mode of anger expression in adolescent psychiatric inpatients. Adolescence 36 (141), 163–170.

Chemtob, C.M., Hamada, R.S., Roitblat, H.L., Muraoka, M.Y., 1994. Anger, impulsivity, and anger control in combat-related posttraumatic stress disorder. J. Consult. Clin. Psychol. 62 (4), 827–832. http://dx.doi.org/10.1037/0022-006X.62.4.827.

Chemtob, C.M., Novaco, R.W., Hamada, R.S., Gross, D.M., 1997. Cognitive-behavioral treatment for severe anger in posttraumatic stress disorder. J. Consult. Clin. Psychol. 65 (1), 184–189. http://dx.doi.org/10.1037/0022-006X.65.1.184.

Claes, L., Muehlenkamp, J., Vandereycken, W., Hamelinck, L., Martens, H., Claes, S., 2010. Comparison of non-suicidal self-injurious behavior and suicide attempts in patients admitted to a psychiatric crisis unit. Personal. Individ. Differ. 48 (1), 83–87. http://dx.doi.org/10.1016/j.paid.2009.09.001.

Conner, K.R., Bossarte, R.M., He, H., Arora, J., Lu, N., Tu, X.M., Katz, I.R., 2014. Posttraumatic stress disorder and suicide in 5.9 million individuals receiving care in the veterans health administration health system. J. Affect. Disord. 166, 1–5. http:// dx.doi.org/10.1016/j.jad.2014.04.067.

Cukrowicz, K.C., Schlegel, E.F., Smith, P.N., Jacobs, M.P., Van Orden, K.A., Paukert, A.L., Pettit, J.W., Joiner, T.E., 2011. Suicide ideation among college students evidencing subclinical depression. J. Am. Coll. Health 59 (7), 575–581. http:// dx.doi.org/10.1080/07448481.2010.483710.

Currier, J.M., Holland, J.M., Drescher, K., Foy, D., 2015. Initial psychometric evaluation of the Moral Injury Questionnaire - Military version. Clin. Psychol. Psychother. 22 (1), 54–63. http://dx.doi.org/10.1002/cpp.1866.

Daniel, S.S., Goldston, D.B., Erkanli, A., Franklin, J.C., Mayfield, A.M., 2009. Trait anger, anger expression, and suicide attempts among adolescents and young adults: a prospective study. J. Clin. Child Adolesc. Psychol. 38 (5), 661–671. http:// dx.doi.org/10.1080/15374410903103494.

Department of Veterans Affairs, 2002. Posttraumatic stress disorder: Implications for primary care. Retrieved from: ⟨http://www.publichealth.va.gov/docs/vhi/ posttraumatic.pdf⟩.

Drapeau, C.W., McIntosh, J.L., 2015. U.S.A. suicide 2014: Official Final Data. American Association of Suicidology, Washington, DC, Retrieved from ⟨http://www. suicidology.org⟩.

Eaton, K.M., Messer, S.C., Wilson, A.G., Hoge, C.W., 2006. Strengthening the validity of population-based suicide rate comparisons: an illustration using U.S. military and civilian data. Suicide Life-Threat. Behav. 36 (2), 182–191. http://dx.doi.org/ 10.1521/suli.2006.36.2.182.

Elhai, J.D., Contractor, A.A., Tamburrino, M., Fine, T.H., Cohen, G., Shirley, E., Chan, P.K., Liberzon, I., Calabrese, J.R., Galea, S., 2015. Structural relations between DSM- 5 PTSD and major depression symptoms in military soldiers. J. Affect. Disord. 175, 373–378. http://dx.doi.org/10.1016/j.jad.2015.01.034.

Fairbank, J.A., Hansen, D.J., Fitterling, J.M., 1991. Patterns of appraisal and coping across different stressor conditions among former prisoners of war with and without posttraumatic stress disorder. J. Consult. Clin. Psychol. 59 (2), 274–281. http:// dx.doi.org/10.1037/0022-006X.59.2.274.

Fanning, J.R., Pietrzak, R.H., 2013. Suicidality among older male veterans in the United States: results from the National Health and Resilience in Veterans Study. J. Psychiatr. Res. 47 (11), 1766–1775. http://dx.doi.org/10.1016/ j.jpsychires.2013.07.015.

Fava, M., Hwang, I., Rush, A.J., Sampson, N., Walters, E.E., Kessler, R.C., 2010. The importance of irritability as a symptom of major depressive disorder: results from the National Comorbidity Survey replication. Mol. Psychiatry 15, 856–867.

Fava, M., Uebelacker, L.A., Alpert, J.E., Nierenberg, A.A., Pava, J.A., Rosenbaum, J.F., 1997. Major depressive subtypes and treatment response. Biol. Psychiatry 42, 568–576.

Finman, R., Berkowitz, L., 1989. Some factors influencing the effect of depressed mood on anger and overt hostility toward another. J. Res. Personal. 23 (1), 70–84. http:// dx.doi.org/10.1016/0092-6566(89)90034-2.

Fisher, L.B., Overholser, J.C., Ridley, J., Braden, A., Rosoff, C., 2015. From the outside looking in: sense of belonging, depression, and suicide risk. Psychiatry Interpers. Biol. Process. 78 (1), 29–41.

Franklin, C.L., Zimmerman, M., 2001. Posttraumatic stress disorder and major depressive disorder: Investigating the role of overlapping symptoms in diagnostic comorbidity. J. Nerv. Ment. Dis. 189 (8), 548–551. http://dx.doi.org/10.1097/ 00005053-200108000-00008.

Galovski, T.E., Elwood, L.S., Blain, L.M., Resick, P.A., 2014. Changes in anger in relationship to responsivity to PTSD treatment. Psychol. Trauma Theory Res. Pract. Policy 6 (1), 56–64. http://dx.doi.org/10.1037/a0031364.

Gaudet, C.M., Sowers, K.M., Nugent, W.R., Boriskin, J.A., 2016. A review of PTSD and shame in military veterans. J. Hum. Behav. Soc. Environ. 26 (1), 56–68. http://

J.M. McKinney et al. Journal of Affective Disorders 214 (2017) 100–107

105

dx.doi.org/10.1080/10911359.2015.1059168. Genuchi, M., 2015. Anger and hostility as primary externalizing features of depression in

college men. Int. J. Men's Health 14 (2), 113–128. Genuchi, M.C., Valdez, J.N., 2015. The role of anger as a component of a masculine

variation of depression. Psychol. Men Masc. 16 (2), 149–159. http://dx.doi.org/ 10.1037/a0036155.

Germain, C.L., Kangas, M., Taylor, A., Forbes, D., 2016. The role of trauma‐related cognitive processes in the relationship between combat‐PTSD symptom severity and anger expression and control. Aust. J. Psychol. 68 (2), 73–81. http://dx.doi.org/ 10.1111/ajpy.12097.

Giegling, I., Olgiati, P., Hartmann, A.M., Calati, R., Möller, H., Rujescu, D., Serretti, A., 2009. Personality and attempted suicide. Analysis of anger, aggression and impulsivity. J. Psychiatr. Res. 43 (16), 1262–1271. http://dx.doi.org/10.1016/ j.jpsychires.2009.04.013.

Gill, J., Lee, H., Barr, T., Baxter, T., Heinzelmann, M., Rak, H., Mysliwiec, V., 2014. Lower health related quality of life in U.S. military personnel is associated with service-related disorders and inflammation. Psychiatry Res. 216 (1), 116–122. http://dx.doi.org/10.1016/j.psychres.2014.01.046.

Goldney, R., Winefield, A., Saebel, J., Winefield, H., Tiggerman, M., 2009. Anger, suicidal ideation, and attempted suicide: a prospective study. Compr. Psychiatry 38 (5), 264–268. http://dx.doi.org/10.1016/S0010-440X(97)90058-4.

Gonzalez, O.I., Novaco, R.W., Reger, M.A., Gahm, G.A., 2015. Anger intensification with combat-related PTSD and depression comorbidity. Psychol. Trauma Theory Res. Pract. Policy 8 (1), 9–16. http://dx.doi.org/10.1037/tra0000042.

Handley, T.E., Inder, K.J., Kay-Lambkin, F.J., Stain, H.J., Fitzgerald, M., Lewin, T.J., Atia, J.R., Kelly, B.J., 2012. Contributors to suicidality in rural communities: beyond the effects of depression. BioMed. Cent. Psychiatry 12 (8), 1–10. http://dx.doi.org/ 10.1186/1471-244X-12-105.

Harmon-Jones, E., 2003. Anger and the behavioral approach system. Personal. Individ. Differ. 35, 995–1005. http://dx.doi.org/10.1016/S0191-8869(02)00313-6.

Hawkins, K.A., Hames, J.L., Ribeiro, J.D., Silva, C., Joiner, T.E., Cougle, J.R., 2014. An examination of the relationship between anger and suicide risk through the lens of the interpersonal theory of suicide. J. Psychiatr. Res. 50, 59–65. http://dx.doi.org/ 10.1016/j.jpsychires.2013.12.005.

Hayes, A.F., 2013. An Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-Based Approach. Guilford Press, New York.

Heinrichs, M., Wagner, D., Schoch, W., Soravia, L.M., Hellhammer, D.H., Ehlert, U., 2005. Predicting posttraumatic stress symptoms from pretraumatic risk factors: a 2- year prospective follow-up study in firefighters. Am. J. Psychiatry 162 (12), 2276–2286. http://dx.doi.org/10.1176/appi.ajp.162.12.2276.

Hendin, H., Haas, A.P., 1991. Suicide and guilt as manifestations of PTSD in Vietnam combat veterans. Am. J. Psychiatry 148 (5), 586–591.

Hoffmire, C.A., Kemp, J.E., Bossarte, R.M., 2015. Changes in suicide mortality for veterans and nonveterans by gender and history of VHA service use, 2000–2010. Psychiatr. Serv. 66 (9), 959–965. http://dx.doi.org/10.1176/appi.ps.201400031.

Izard, C.E., 1979. Differential Emotions Scale. ETS m1979. Izard, C.E., Libero, D.Z., Putnam, P., Haynes, O.M., 1993. Stability of emotion

experiences and their relations to traits of personality. J. Personal. Soc. Psychol. 64 (5), 847–860. http://dx.doi.org/10.1037/0022-3514.64.5.847.

Jakupcak, M., Cook, J., Imel, Z., Fontana, A., Rosenheck, R., McFall, M., 2009. Posttraumatic stress disorder as a risk factor for suicidal ideation in Iraq and Afghanistan war veterans. J. Trauma. Stress 22 (4), 303–306. http://dx.doi.org/ 10.1002/jts.20423.

Jakupcak, M., Hoerster, K.D., Varra, A., Vannoy, S., Felker, B., Hunt, S., 2011. Hopelessness and suicidal ideation in Iraq and Afghanistan war veterans reporting subthreshold and threshold posttraumatic stress disorder. J. Nerv. Ment. Dis. 199 (4), 272–275. http://dx.doi.org/10.1097/NMD.0b013e3182124604.

Jakupcak, M., Tull, M.T., 2005. Effects of trauma exposure on anger, aggression, and violence in a nonclinical sample of men. Violence Vict. 20 (5), 589–598. http:// dx.doi.org/10.1891/vivi.2005.20.5.589.

Jandl, M., Steyer, J., Kaschka, W.P., 2010. Suicide risk markers in major depressive disorder: a study of electrodermal activity and event-related potentials. J. Affect. Disord. 123 (1–3), 138–149. http://dx.doi.org/10.1016/j.jad.2009.09.011.

Jang, J., Park, J., Oh, K., Lee, K., Kim, M.S., Yoon, M., Ko, S.H., Cho, H.C., Chung, Y., 2014. Predictors of suicidal ideation in a community sample: roles of anger, self- esteem, and depression. Psychiatry Res. 216 (1), 74–81. http://dx.doi.org/10.1016/ j.psychres.2013.12.054.

Janssen, S.J., Hearne, T.L., Takarangi, M.T., 2015. The relation between self-reported PTSD and depression symptoms and the psychological distance of positive and negative events. J. Behav. Ther. Exp. Psychiatry 48, 177–184. http://dx.doi.org/ 10.1016/j.jbtep.2015.04.002.

Katz, M.H., 2006. Multivariable Analysis: A Practical Guide for Clinicians. Cambridge University Press, New York, New York.

Kemp, J., Bossarte, R., 2012. Suicide data report, 2012. Retrieved from: ⟨http://www.va. gov/opa/docs/suicide-data-report-2012-final.pdf⟩.

May, A.M., Klonsky, E.D., 2016. What distinguishes suicide attempters from suicide ideators? A meta‐analysis of potential factors. Clin. Psychol. Sci. Pract. 23, 5–20. http://dx.doi.org/10.1111/cpsp.12136.

LeardMann, C.A., Powell, T.M., Smith, T.C., Bell, M.R., Smith, B., Boyko, E.J., Hooper, T.I., Gackstetter, G.D., Ghamsary, M., Hoge, C.W., 2013. Risk factors associated with suicide in current and former US military personnel. J. Am. Med. Assoc. 310 (5), 496–506. http://dx.doi.org/10.1001/jama.2013.65164.

LeBouthillier, D.M., McMillan, K.A., Thibodeau, M.A., Asmundson, G.G., 2015. Types and number of traumas associated with suicidal ideation and suicide attempts in PTSD: findings from a U.S. nationally representative sample. J. Trauma. Stress 28 (3), 183–190. http://dx.doi.org/10.1002/jts.22010.

Lehnert, K.L., Overholser, J.C., Spirito, A., 1994. Internalized and externalized anger in adolescent suicide attempters. J. Adolesc. Res. 9 (1), 105–119. http://dx.doi.org/ 10.1177/074355489491008.

Lemaire, C.M., Graham, D.P., 2011. Factors associated with suicidal ideation in OEF/OIF veterans. J. Affect. Disord. 130 (1–2), 231–238. http://dx.doi.org/10.1016/ j.jad.2010.10.021.

Lohr, J.M., Olatunji, B.O., Baumeister, R.F., Bushman, B.J., 2007. The psychology of anger venting and empirically supported alternatives that do no harm. The Scientific Review of Mental Health Practice: Objective Investigations of Controversial and Unorthodox Claims in Clinical Psychology, Psychiatry, and Social Work, 5 (1), pp. 53–64.

Lommen, M.J., Engelhard, I.M., van de Schoot, R., van den Hout, M.A., 2014. Anger: cause or consequence of posttraumatic stress? A prospective study of Dutch soldiers. J. Trauma. Stress 27 (2), 200–207. http://dx.doi.org/10.1002/jts.21904.

Maguen, S., Metzler, T.J., Bosch, J., Marmar, C.R., Knight, S.J., Neylan, T.C., 2012. Killing in combat may be independently associated with suicidal ideation. Depress. Anxiety 29 (11), 918–923. http://dx.doi.org/10.1002/da.21954.

Meffert, S.M., Metzler, T.J., Henn-Haase, C., McCaslin, S., Inslicht, S., Chemtob, C., Neylan, T., Marmar, C.R., 2008. A prospective study of trait anger and PTSD symptoms in police. J. Trauma. Stress 21 (4), 410–416. http://dx.doi.org/10.1002/ jts.20350.

Miller, M.W., Kaloupek, D.G., Dillon, A.L., Keane, T.M., 2004. Externalizing and internalizing subtypes of combat-related PTSD: a replication and extension using the PSY-5 Scales. J. Abnorm. Psychol. 113 (4), 636–645. http://dx.doi.org/10.1037/ 0021-843X.113.4.636.

Miller, M.W., Resick, P.A., 2007. Internalizing and externalizing subtypes in female sexual assault survivors: implications for understanding of complex PTSD. Behav. Ther. 38 (1), 58–71. http://dx.doi.org/10.1016/j.beth.2006.04.003.

Morina, N., Ajdukovic, D., Bogic, M., Franciskovic, T., Kucukalic, A., Lecic-Tosevski, D., Morina, L., Popovski, M., Priebe, S., 2013. Co-occurrence of major depressive episode and posttraumatic stress disorder among survivors of war: how is it different from either condition alone? J. Clin. Psychiatry 74 (3), e212–e218. http:// dx.doi.org/10.4088/JCP.12m07844.

Nixon, M.K., Cloutier, P.F., Aggarwal, S., 2002. Affect regulation and addictive aspects of repetitive self-injury in hospitalized adolescents. J. Am. Acad. Child Adolesc. Psychiatry 41 (11), 1333–1341. http://dx.doi.org/10.1097/00004583-200211000- 00015.

Nock, M.K., Deming, C.A., Fullerton, C.S., Gilman, S.E., Goldenberg, M., Kessler, R.C., McCarroll, J.E., McLaughlin, K.A., Peterson, C., Schoenbaum, M., Stanley, B., Ursano, R.J., 2013. Suicide among soldiers: a review of psychosocial risk and protective factors. Psychiatry Interpers. Biol. Process. 76 (2), 97–125. http:// dx.doi.org/10.1521/psyc.2013.76.2.97.

Novaco, R.W., Chemtob, C.M., 2002. Anger and combat-related posttraumatic stress disorder. J. Trauma. Stress 15 (2), 123–132.

Novaco, R.W., Swanson, R.D., Gonzalez, O.I., Gahm, G.A., Reger, M.D., 2012. Anger and postcombat mental health: validation of a brief anger measure with U.S. soldiers postdeployed from Iraq and Afghanistan. Psychol. Assess. 24 (3), 661–675. http:// dx.doi.org/10.1037/a0026636.

Olatunji, B.O., Ciesielski, B.G., Tolin, D.F., 2010. Fear and loathing: a meta-analytic review of the specificity of anger in PTSD. Behav. Ther. 41 (1), 93–105. http:// dx.doi.org/10.1016/j.beth.2009.01.004.

Orth, U., Cahill, S.P., Foa, E.B., Maercker, A., 2008. Anger and posttraumatic stress disorder symptoms in crime victims: a longitudinal analysis. J. Consult. Clin. Psychol. 76 (2), 208–218. http://dx.doi.org/10.1037/0022-006X.76.2.208.

Orth, U., Wieland, E., 2006. Anger, hostility, and posttraumatic stress disorder in trauma-exposed adults: a meta-analysis. J. Couns. Clin. Psychol. 74 (4), 698–706. http://dx.doi.org/10.1037/0022-006X.74.4.698.

Osman, A., Bagge, C.L., Gutierrez, P.M., Konick, L.C., Kopper, B.A., Barrios, F.X., 2001. The Suicidal Behaviors Questionnaire–Revised (SBQ-R): validation with clinical and nonclinical samples. Assessment 8 (4), 443–454. http://dx.doi.org/10.1177/ 107319110100800409.

Panagioti, M., Gooding, P., Tarrier, N., 2009. Post-traumatic stress disorder and suicidal behavior: a narrative review. Clin. Psychol. Rev. 29 (6), 471–482. http://dx.doi.org/ 10.1016/j.cpr.2009.05.001.

Panagioti, M., Gooding, P., Taylor, P., Tarrier, N., 2012. Negative self-appraisals and suicidal behavior among trauma victims experiencing PTSD symptoms: the mediating role of defeat and entrapment. Depress. Anxiety 29 (3), 187–194. http:// dx.doi.org/10.1002/da.21917.

Parikh, R.B., Canaan, Y., Oms, J.D., 2015. Addressing PTSD and suicide in US veterans. J. Clin. Psychiatry 76 (8), e1037. http://dx.doi.org/10.4088/JCP.15lr09830.

Pietrzak, R.H., Goldstein, M.B., Malley, J.C., Rivers, A.J., Johnson, D.C., Southwick, S.M., 2010. Risk and protective factors associated with suicidal ideation in veterans of operations enduring freedom and Iraqi freedom. J. Affect. Disord. 123 (1–3), 102–107. http://dx.doi.org/10.1016/j.jad.2009.08.001.

Pietrzak, R.H., Russo, A.R., Ling, Q., Southwick, S.M., 2011. Suicidal ideation in treatment-seeking veterans of operations enduring freedom and Iraqi freedom: the role of coping strategies, resilience, and social support. J. Psychiatr. Res. 45 (6), 720–726. http://dx.doi.org/10.1016/j.jpsychires.2010.11.015.

Raab, P.A., Mackintosh, M., Gros, D.F., Morland, L.A., 2013. Influence of depression on state and trait anger in veterans with posttraumatic stress disorder. Cogn. Ther. Res. 37 (4), 673–679. http://dx.doi.org/10.1007/s10608-012-9506-z.

Ramsawh, H.J., Fullerton, C.S., Mash, H.H., Ng, T.H., Kessler, R.C., Stein, M.B., Ursano, R.J., 2014. Risk for suicidal behaviors associated with PTSD, depression, and their comorbidity in the U.S. Army. J. Affect. Disord. 161, 116–122. http://dx.doi.org/ 10.1016/j.jad.2014.03.016.

Renshaw, K.D., Kiddie, N.S., 2012. Internal anger and external expressions of aggression

J.M. McKinney et al. Journal of Affective Disorders 214 (2017) 100–107

106

in OEF/OIF veterans. Mil. Psychol. 24 (3), 221–235. http://dx.doi.org/10.1080/ 08995605.2012.678197.

Reyes, V.A., Hicklin, T.A., 2005. Anger in the combat zone. Mil. Med. 170 (6), 483–487. Roberts, B.W., Mroczek, D., 2008. Personality trait change in adulthood. Curr. Dir.

Psychol. Sci. 17 (1), 31–35. http://dx.doi.org/10.1111/j.1467-8721.2008.00543.x. Roley, M.E., Claycomb, M.A., Contractor, A.A., Dranger, P., Armour, C., Elhai, J.D.,

2015. The relationship between rumination, PTSD, and depression symptoms. J. Affect. Disord. 180, 116–121. http://dx.doi.org/10.1016/j.jad.2015.04.006.

Rosen, C.S., Greenbaum, M.A., Fitt, J.E., Laffaye, C., Norris, V.A., Kimerling, R., 2011. Stigma, help-seeking attitudes, and use of psychotherapy in veterans with diagnoses of posttraumatic stress disorder. J. Nerv. Ment. Dis. 199 (11), 879–885. http:// dx.doi.org/10.1097/NMD.0b013e3182349ea5.

Rudd, M.D., Goulding, J., Bryan, C.J., 2011. Student veterans: a national survey exploring psychological symptoms and suicide risk. Prof. Psychol. Res. Pract. 42 (5), 354–360. http://dx.doi.org/10.1037/a0025164.

Ruehlman, L.S., Lanyon, R.I., Karoly, P., 1998. Multidimensional Health Profile Professional Manual. Psychological Assessment Resources, Inc, Odessa.

Sharma, S., Sharma, M., 2008. Stress-induced psychological vital signs in military domain: assessment and intervention issues. Psychol. Stud. 53 (1), 7–19.

Smits, D.M., Kuppens, P., 2005. The relations between anger, coping with anger, and aggression, and the BIS/BAS system. Personal. Individ. Differ. 39 (4), 783–793. http://dx.doi.org/10.1016/j.paid.2005.02.023.

Strachan, M., Gros, D.F., Ruggiero, K.J., Lejuez, C.W., Acierno, R., 2012. An integrated approach to delivering exposure-based treatment for symptoms of PTSD and depression in OIF/OEF veterans: preliminary findings. Behav. Ther. 43 (3), 560–569. http://dx.doi.org/10.1016/j.beth.2011.03.003.

Thomas, J.L., Wilk, J.E., Riviere, L.A., McGurk, D., Castro, C.A., Hoge, C.W., 2010.

Prevalence of mental health problems and functional impairment among active component and National Guard soldiers 3 and 12 months following combat in Iraq. Arch. Gen. Psychiatry 67 (6), 614–623. http://dx.doi.org/10.1001/ archgenpsychiatry.2010.54.

U.S. Census Bureau, 2012. A snapshot of our nation’s veterans. Retrieved from: ⟨http:// www.census.gov/library/infographics/veterans.html⟩.

Weathers, F., Huska, J., Keane, T., 1991. The PTSD Checklist Military Version (PCL-M). National Center for PTSD, Boston, MA.

Williams, J.L., McDevitt-Murphy, M.E., Fields, J.A., Weathers, F.W., Flood, A.M., 2011. A comparison of multidimensional health profiles across three trauma-exposed diagnostic groups. J. Psychopathol. Behav. Assess. 33 (4), 531–539. http:// dx.doi.org/10.1007/s10862-011-9251-8.

Wisco, B.E., Marx, B.P., Wolf, E.J., Miller, M.W., Southwick, S.M., Pietrzak, R.H., 2014. Posttraumatic stress disorder in the US veteran population: results from the National Health and Resilience in Veterans Study. J. Clin. Psychiatry 75 (12), 1338–1346. http://dx.doi.org/10.4088/JCP.14m09328.

Yarvis, J.S., Yoon, E., Amenuke, M., Simien-Turner, S., Landers, G.D., 2012. Assessment of PTSD in older veterans: the posttraumatic stress disorder checklist: Military Version (PCL-M). Adv. Soc. Work 13 (1), 185–202.

Zivin, K., Kim, H.M., McCarthy, J.F., Austin, K.L., Hoggatt, K.J., Walters, H., Valenstein, M., 2007. Suicide mortality among individuals receiving treatment for depression in the Veterans Affairs health system: associations with patient and treatment setting characteristics. Am. J. Public Health 97 (12), 2193–2198. http://dx.doi.org/ 10.2105/AJPH.2007.115477.

Zlotnick, C., Donaldson, D., Spirito, A., Pearlstein, T., 1997. Affect regulation and suicide attempts in adolescent inpatients. J. Am. Acad. Child Adolesc. Psychiatry 36 (6), 793–798. http://dx.doi.org/10.1097/00004583-199706000-00016.

J.M. McKinney et al. Journal of Affective Disorders 214 (2017) 100–107

107