Journal of Affective Disorders 148 (2013) 37–41

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Journal of Affective Disorders

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Research report

Guilt is more strongly associated with suicidal ideation amongmilitary personnel with direct combat exposure

Craig J. Bryan a,n, Bobbie Ray-Sannerud a, Chad E. Morrow b, Neysa Etienne c

a National Center for Veterans Studies, 260 S. Central Campus Dr., Room 205, Salt Lake City, UT 84112, United Statesb Hurlburt Field, FL 32544, United Statesc Maxwell Air Force Base, 50 S Lemay Plaza Montgomery, AL 36112, United States

a r t i c l e i n f o

Article history:

Received 18 October 2012

Received in revised form

7 November 2012

Accepted 20 November 2012Available online 8 December 2012

Keywords:

Suicide

Military

Suicidal ideation

Guilt

Combat

27/$ - see front matter & 2013 Elsevier B.V. A

x.doi.org/10.1016/j.jad.2012.11.044

esponding author.

ail address: craig.bryan@utah.edu (C.J. Bryan)

a b s t r a c t

Background: Suicide rates in the U.S. military have been rising rapidly in the past decade. Research

suggests guilt is a significant predictor of suicidal ideation among military personnel, and may be

especially pronounced among those who have been exposure to combat-related traumas. The current

study explored the interactive effect of direct combat exposure and guilt on suicidal ideation in a

clinical sample of military personnel.

Methods: Ninety-seven active duty U.S. Air Force personnel receiving outpatient mental health

treatment at two military clinics completed self-report symptom measures of guilt, depression,

hopelessness, perceived burdensomeness, posttraumatic stress disorder, and suicidal ideation.

Results: Generalized multiple regression analyses indicated a significant interaction of guilt and direct

combat exposure (B¼ .124, SE¼ .053, p¼ .020), suggesting a stronger relationship of guilt with suicidal

ideation among participants who had direct combat exposure as compared to those who had not. The

interactions of direct combat exposure with depression (B¼ .004, SE¼ .040, p¼ .926), PTSD symptoms

(B¼ .016, SE¼ .018, p¼ .382), perceived burdensomeness (B¼ .159, SE¼ .152, p¼ .300) and hopelessness

(B¼ .069, SE¼ .036, p¼ .057) were nonsignificant.

Conclusions: Although guilt is associated with more severe suicidal ideation in general among military

personnel, it is especially pronounced among those who have had direct combat exposure.

& 2013 Elsevier B.V. All rights reserved.

1. Introduction

The suicide rate in the United States Armed Forces has doubledsince the initiation of military operations in Afghanistan and Iraq,recently surpassing the age- and gender-adjusted suicide rate forthe U.S. general population despite historical trends for decreasedrisk for suicide (Department of Defense [DOD], 2011). Within theU.S. Air Force, a dramatic increase in suicides has occurred inrecent years, with 2010 marking the highest suicide rate in 17years (Department of Defense, 2011). Given these temporaltrends, questions have been raised about the possible role ofdeployment and combat exposure on increased suicide rates inthe military as a whole. Data to date indicate that only one-quarter of active duty Air Force personnel who die by suicide haveever deployed to a combat zone, however, and less than 7% havedirectly experienced combat (Department of Defense, 2011),suggesting that direct combat exposure might not be a significantcontributor to suicidal behaviors suicides among Air Force personnel.

ll rights reserved.

.

Military data from other branches of the military also indicate thathistory of deployment and direct combat exposure are not over-represented among military suicides (Department of Defense, 2011).Among military veterans, studies have similarly failed to support anassociation between direct combat exposure with suicide attempts,although significant associations with increased rates and severity ofsuicidal ideation have been noted, especially among military veter-ans with elevated levels of trauma symptoms (Maguen et al., 2012;Rudd, in press; Sareen et al., 2007).

Evidence for a relationship between direct combat exposureand suicide risk has also been indirectly inferred from studiesdemonstrating that significantly higher rates of death by suicide(Boscarino, 2006; Drescher et al., 2003; Farberow et al., 1990),suicide attempts (Freeman et al., 2000; Kramer et al., 1994; Nadet al., 2008), and suicidal ideation (Butterfield et al., 2005) areobserved among combat veterans with posttraumatic stressdisorder (PTSD) relative to combat veterans without PTSD. Inlight of these findings, Bryan and colleagues (in press) haverecently suggested that guilt might be an important contributorto suicide risk among military personnel. Guilt is typically con-ceptualized as a controllable psychological state that is linked to aspecific action or behavior, and often entails a sense of regret or

C.J. Bryan et al. / Journal of Affective Disorders 148 (2013) 37–4138

remorse, or ‘‘feeling bad about what I did’’ (Kim et al., 2011;Tangney and Dearing, 2002). Guilt is a common experience oftrauma victims, including combat veterans, and is believed to be acore affective feature of combat-related PTSD (Litz et al., 2009).The central role of guilt in PTSD is further supported by clinicaltrials demonstrating that guilt decreases for trauma victims whoreceive trauma-focused therapies for PTSD (i.e., prolonged expo-sure and cognitive processing therapy), but does not decrease fortrauma victims who do not receive these therapies (Resick et al.,2002).

Guilt has also been proposed to be a central cognitive-affectivestate for many suicidal individuals (e.g., Orbach, 1997), includingmilitary and veteran samples. For instance, combat-related guiltwas the most significant predictor of suicidal ideation and suicideattempts among Vietnam combat veterans (Hendin and Haas,1991), and was significantly correlated with suicidal ideation in aclinical sample of Iraq and Afghanistan combat veterans withcombat-related PTSD (McLean et al., 2012). In a more generalclinical sample of military personnel, guilt was significantlyassociated with severity of suicidal ideation among militarypersonnel beyond the effects of other robust risk factors such ashopelessness, past suicide attempts, and depression (Bryan et al.,in press). Unfortunately, these studies did not consider how therelationship of guilt with suicidal ideation might differ accordingto history of direct combat exposure.

Given that guilt might be especially salient among thosemilitary personnel and veterans who have been exposed tocombat-related traumas, the primary aim of the current studywas to determine if guilt was differentially associated withsuicidal ideation according to history of direct combat exposurein a clinical sample of active duty Air Force personnel. Wespecifically hypothesized that military personnel who had directcombat exposure would report a stronger relationship of guilt andsuicidal ideation as compared to military personnel who had notbeen in direct combat.

2. Method

2.1. Participants

Participants included 97 active duty Air Force personnel (58.8%male, 39.2% female, 2.1% unknown) ranging in age from 21 to 54years (M¼34.13, SD¼8.69) who were currently receiving out-patient mental health treatment at two military clinics in the Southand West U.S. Consistent with this age range, rank distribution wasjunior enlisted (E1–E4, 23.7%), noncommissioned officer (E5–E6,42.2%), senior noncommissioned officer (E7–E9, 14.4%), and officer(O1–O6, 19.6%). Racial distribution was 68.0% Caucasian, 19.6%African American, 2.1% Asian, 1.0% Native American, 1.0% NativeHawaiian/Pacific Islander, and 4.1% ‘‘other.’’ Eight participants(8.2%) endorsed Hispanic or Latino ethnicity.

Reflective of a general outpatient mental health clinic patientpopulation, participants were diagnosed with a range of DSM-IVdiagnoses (M¼1.19, SD¼ .64, range: 0 to 4) by a licensed psy-chiatrist, psychologist, or social worker: 27.8% posttraumaticstress disorder, 22.7% major depressive disorder, 19.6% adjust-ment disorder, 9.3% generalized anxiety disorder, 6.2% depressionnot otherwise specified, 6.2% anxiety not otherwise specified, 4.1%dysthymic disorder, 4.1% panic disorder, 3.1% bipolar II disorder,3.1% alcohol dependence, and several additional Axis I conditionsoccurring in less than 1.0% of participants. Eleven participantswere additionally diagnosed with an Axis II personality disorder:5.2% borderline personality disorder, 2.1% personality disordernot otherwise specified, and 1.0% each of schizotypal, antisocial,histrionic, and dependent personality disorders.

2.2. Procedures

Participants were recruited from two outpatient militarymental health clinics, one located in the South U.S. and thesecond located in the West U.S. All current patients and newpatients were invited to participate by clinic staff following theirregularly-scheduled mental health appointments or intakeappointments, without exclusion. The only inclusion criterionwas to be currently accessing outpatient mental health treat-ment; there were no exclusion criteria. Patients voluntarilyprovided informed consent for the study and then completed ananonymous survey packet in the waiting room immediatelyfollowing invitation and agreement to participate. Completedpackets were returned to collection boxes located at the check-in desks of each clinic. The current study was reviewed andapproved as exempt research by the Wright–Patterson Air ForceBase Institutional Review Board.

2.3. Measures

2.3.1. Beck scale for suicidal ideation (BSSI)

Severity of current suicidal ideation was assessed with theBeck scale for suicidal ideation (BSSI; Beck et al., 1988), which is a19-item self-report measure of the individual’s beliefs and atti-tudes about suicide such as frequency and duration of ideation,specificity of planning, and preparations for death. Responses aresummed to a total score ranging from 0 to 38, with higher scoresindicating more severe suicidal ideation. The BSSI has very goodinternal consistency and convergent validity, and has been foundto predict future suicide attempts and death by suicide (Beck andSteer, 1991). Internal consistency for the BSSI in the currentsample was .89.

2.3.2. Self-injurious thoughts and behaviors interview (SITBI)

Past suicide attempts were assessed using the self-injuriousthoughts and behaviors interview (SITBI; Nock et al., 2007), whichis a structured interview that assesses the presence, frequency,and characteristics of self-injurious thoughts and behaviors overthe individual’s lifespan. The interview has good interrater relia-bility (k¼ .99), test-retest reliability over six months (k¼ .70), anddemonstrates strong convergent validity with other measures ofsuicidal ideation (k¼ .54; Nock et al., 2007).

2.3.3. Future dispositions inventory (FDI)

The negative focus subscale of the FDI (Osman et al., 2010) wasused to assess intensity of hopelessness and pessimism. Thenegative focus subscale consists of 8 items (e.g., ‘‘I worry thatthings will never go well for me no matter what I do,’’ I doubtwhether things will ever get better for me in life,’’ ‘‘I fear that I willrun into more difficulties in the years ahead’’) that respondents rateon a 5-point Likert scale ranging from 1 (‘‘not at all true’’) to 5(‘‘extremely true’’). The scale is reliable (4 .83), correlates stronglyin the expected directions with measures of hopelessness, adaptivecoping, and psychological symptoms, and can differentiate betweensuicidal and nonsuicidal groups (Osman et al., 2010).

2.3.4. Patient health questionnaire-9 (PHQ-9)

The PHQ-9 (Kroenke et al., 2001) was used to assess depres-sion symptom severity. The PHQ-9 directs respondents to indicatethe frequency of experiencing the nine symptoms of majordepressive disorder during the past two weeks, with total scoresranging from 0 to 36. The PHQ-9 is widely used in clinical andresearch settings, and has demonstrated good internal consis-tency and sensitivity and specificity for major depressive disorder

Table 1Means, standard deviations, and intercorrelations of all variables (n¼97).

1. 2. 3. 4. 5. 6. 7. 8. 9.

Gender –

Age .10 –

Suicide attempt .03 � .18 –

PTSD .16 .17 .35** –

Hopelessness .07 � .19 .31** .46** –

Depression .22* .11 .30** .74** .57** –

Burdensomeness .06 .03 .37** .48** .58** .53** –

Combat exposure � .03 .30**� .03 .17 � .18 .08 .03 –

Suicidal ideation .06 .01 .51** .34** .33** .27** .56** .12 –

M – 34.13 – 43.12 10.26 10.66 1.28 – 2.58

SD – 8.69 – 19.41 7.63 7.17 1.66 – 4.36

n po .05.nn po .01.

C.J. Bryan et al. / Journal of Affective Disorders 148 (2013) 37–41 39

(Kroenke et al.). Internal consistency for the PHQ-9 in the currentsample was.92.

2.3.5. Posttraumatic stress disorder checklist (PCL)

The PTSD checklist (PCL; Weathers et al., 1993) was used toassess PTSD symptom severity. The PCL directs respondents toconsider the most stressful experience in their lives and toindicate the severity with which each symptom of PTSD has beenexperienced within the past 30 days. The scale has demonstratedexcellent reliability, validity, and diagnostic utility (Blanchardet al., 1996; Weathers et al., 1993). Internal consistency for thePCL in the current sample was .97.

2.3.6. Interpersonal needs questionnaire (INQ)

The perceived burdensomeness subscale of the interpersonalneeds questionnaire (INQ; Van Orden et al., 2012) was used toassess the extent of respondents’ belief that others would bebetter off without them. The scale contains six statements (e.g.,‘‘The people in my life would be better off if I were gone’’, ‘‘I thinkI make things worse for the people in my life’’) that are rated on ascale ranging from 1 (‘‘not at all true for me’’) to 7 (‘‘very true forme’’). The scale has been found to be reliable across diverseclinical and nonclinical samples, correlates with measures of self-liking and perceived self-competence, and has been found tosignificantly predict suicidal ideation and suicide attemptsbeyond the effects of other risk factors, thereby establishing itas a particularly robust predictor of suicide risk. Internal consis-tency for the current sample was .92.

2.3.7. Personal feelings questionnaire-2 (PFQ2)

The PFQ2 (Harder et al., 1993) was used to measure guilt. ThePFQ2 directs respondents to indicate how frequently they experi-ence six different emotional or cognitive states (e.g., mild guilt,worry about hurting or injuring someone, regret, remorse) on ascale ranging from 0 (‘‘never’’) to 4 (‘‘continuously or almostcontinuously’’). The guilt subscale has good internal consistency(4 .72) and test–retest stability (4 .85) and correlates stronglywith other measures of guilt, shame, self-derogation, and socialanxiety (Harder et al., 1993; Harder and Zalma, 1990). Internalconsistency for the PFQ2 guilt scale in the current sample was .85.

2.4. Data analysis

Generalized linear modeling with robust maximum likelihoodwas utilized to test the associations of direct combat exposure andguilt with severity of suicidal ideation. The following variables wereentered as predictors: gender, age, history of suicide attempts,PTSD symptoms, depression symptoms, hopelessness, perceived

burdensomeness, direct combat exposure, and guilt. In terms ofpower, the current study was sufficiently powered (.80) to detect amoderately small effect (f2¼ .08) for a two-tailed test of significancewith a p-value o .05.

3. Results

Fifty-nine (61.5%) participants had deployed to Iraq and/orAfghanistan, of which approximately half (n¼25; 25.8% of sam-ple) reported having direct combat exposure. Almost half ofparticipants (n¼54; 44.3% of sample) reported some level ofsuicidal ideation or desire within the past week, with total BSSIscores ranging from 0 to 20. Nine (9.3%) reported making a suicideattempt in the past. Means, standard deviations, and intercorrela-tions of all variables are displayed in Table 1. As would beexpected in a clinical setting psychological symptoms wereelevated and intercorrelated with each other. Suicidal ideationwas positive correlated with previous suicide attempts, PTSDsymptoms, hopelessness, depression, and perceived burdensome-ness. Direct combat exposure was positively correlated with age,indicating that older military personnel were more likely to havebeen in combat.

3.1. Is the association of guilt and suicidal ideation stronger among

military personnel with direct combat exposure?

Generalized regression analyses were conducted in two steps.In the first step, all predictors were entered simultaneously, theresults of which are summarized in Table 2. Guilt was signifi-cantly associated with more severe suicidal ideation (B¼ .130,SE¼ .044, p¼ .003) above and beyond the effects of all covariates,but direct combat exposure was not (B¼ .046, SE¼ .303, p¼ .880).In the second step, the interaction of guilt with direct combatexposure was added to the model, resulting in a significantinteraction (B¼ .124, SE¼ .053, p¼ .020). The form of the interac-tion is plotted in Fig. 1, and indicates that for military personnelwith no direct combat exposure, guilt was not significantlyassociated with suicidal ideation (t¼ .529, p¼ .598), but formilitary personnel with direct combat exposure, suicidal ideationbecame more severe as guilt increased (t¼3.144, p¼ .002).

To determine if a similar pattern existed for other clinical riskfactors, we repeated the regression analyses several times, ‘‘repla-cing’’ the interaction of combat exposure and guilt with thefollowing variables: depression, PTSD symptoms, and hopeless-ness. The interactions of depression with direct combat exposure(B¼ .004, SE¼ .040, p¼ .926), PTSD symptoms with direct combatexposure (B¼ .016, SE¼ .018, p¼ .382), and perceived burden-someness with direct combat exposure (B¼ .158, SE¼ .152,

Table 2Generalized regression coefficients predicting severity of suicidal ideation.

Step 1 Step 2

B SE p B SE p

Gender .172 .301 .569 .307 .312 .326

Age .039 .017 .023 .041 .018 .021

Suicide attempt 1.156 .395 .003 1.346 .407 .001

PTSD .011 .011 .318 .015 .012 .204

Hopelessness .007 .029 .807 .003 .030 .912

Depression � .096 .034 .005 � .103 .035 .004

Burdensomeness .206 .107 .055 .174 .108 .107

Combat .046 .303 .880 �1.282 .649 .048

Guilt .130 .044 .003 .098 .048 .041

Combat� guilt – – – .124 .053 .020

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

Low guilt High guilt

Dep

ende

nt V

aria

ble

Combat

No combat

Fig. 1. Interaction of guilt and combat exposure on severity of suicidal ideation

among 97 Air Force personnel receiving outpatient mental health treatment.

C.J. Bryan et al. / Journal of Affective Disorders 148 (2013) 37–4140

p¼ .300) were not significant, but the interaction of hopelessnesswith direct combat exposure (B¼ .069, SE¼ .036, p¼ .057) showeda strong trend towards significance, with hopelessness showing asomewhat stronger association with increased suicidal ideationamong military personnel who had been in direct combat.

4. Discussion

Consistent with expectations, results of the current studyindicated that guilt is differentially associated with suicidalideation among those military personnel according to history ofdirect combat exposure. Specifically, although guilt was signifi-cantly associated with more severe suicidal ideation in general, itwas especially pronounced among those military personnel whohad direct combat exposure. In comparison, depression, PTSDsymptomatology, and perceived burdensomeness did not show adifferential relationship with suicidal ideation according to directcombat exposure, suggesting that guilt might be a relativelystronger risk factor for increased suicidal ideation among militarypersonnel who have been in direct combat. This aligns withprevious findings that guilt is an especially strong predictor ofsuicidal ideation among veterans who have been involved indirect combat (Hendin and Haas, 1991; McLean et al., 2012), andmight provide an explanation for the increased rates of suicidalideation and intent observed in several studies among veteransinvolved in direct combat (Maguen et al., 2012; Rudd, in press;Sareen et al., 2007). From a clinical perspective, these resultssuggest that assessing guilt might be especially important whenconducting suicide risk assessments with veterans who have beeninvolved in direct combat. Similarly, treatments that have beenshown to reduce trauma-related guilt such as prolonged exposure

or cognitive processing therapy (Resick et al., 2002) could poten-tially reduce suicide risk and prevent suicidal behavior in militarypersonnel and veterans who have been involved in direct combat.Clinical trials are needed to explicitly test this possibility.

In the current study, the interaction of hopelessness and directcombat exposure demonstrated a nonsignificant trend towardssignificance, with hopelessness showing a stronger relationshipwith suicidal ideation among veterans who have been involved indirect combat than among military personnel without directcombat exposure. It is possible that hopelessness, too, might bemore strongly associated with suicidal ideation among veteranswho have been involved in direct combat although with a muchsmaller effect than guilt. As noted above, because our study wasonly sufficiently powered to detect moderately small effect sizes(f24 .08), it seems likely that the current sample was too small,implicating the need to conduct additional studies with largersample sizes to explore this possibility.

In addition to the limitation of small sample size, conclusionsmight not generalize to personnel in other Branches of themilitary with more frequent and higher intensity exposure tocombat. Along these same lines, our study did not assess forexposure to different dimensions of combat (e.g., going on patrols,killing, witnessing injury), which could be differentially related tosuicide risk. Future studies with larger samples from both clinicaland nonclinical settings are necessary to determine the general-izability of our findings. The current study is additionally limitedby self-report methodology, which can be vulnerable to responsebias, although the fact that data were collected via anonymoussurveys from military personnel who had already self-identifiedfor mental health treatment likely reduces the impact of stigmaon response patterns. Nonetheless, follow-up studies using struc-tured diagnostic interviews (especially for PTSD) would contri-bute considerably to our understanding of guilt, direct combatexposure, and suicidal ideation. Despite these limitations, resultsof the current study suggest that some risk factors for suicidalideation might be ‘‘augmented’’ by direct exposure to combat,highlighting the importance of recognizing different subgroups ofmilitary personnel and veterans that might warrant differenttypes of clinical interventions or prevention programs.

Role of funding sourceThis study received no financial support. The views expressed in this article

are those of the authors and do not necessarily represent the official position or

policy of the U.S. Government, the Department of Defense, or the U.S. Army.

Conflict of interestNone of the authors have any actual or potential conflicts of interest.

AcknowledgementThe authors would like to acknowledge the contributions and assistance of

TSgt (Ret) AnnaBelle Bryan on this project.

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