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Objective: Suicide is a leading cause of death in the United States. This has prompted the U.S. surgeon general to issue a report describing actionable items to reduce suicide rates, including a recommendation to increase the use of the caring letters intervention. This intervention involves mailing brief, nondemanding messages of care. As part of the Department of Veterans Affairs' (VA's) efforts to reduce suicide rates among veterans, a caring letters project was developed for veterans who contact the Veterans Crisis Line (VCL). This article describes the results of qualitative interviews conducted to better understand the experiences of veterans who received caring letters., Methods: Beginning in 2020, all identifiable veterans who used Veterans Health Administration services and contacted the VCL received nine letters over 1 year, along with a list of mental health resources. Semistructured interviews (N=23) were conducted, and content analysis was used to identify veterans' perspectives and suggestions for improving the intervention., Results: Sixteen men and seven women participated (mean age=53 years). Feedback varied, with most participants reporting that receiving caring letters had a positive impact and others noting aspects that could be improved to enhance the intervention's caring intent. Some also reported that the letters helped them engage with community resources and made them more likely to seek VA care., Conclusions: The caring letters intervention, received after contact with the VCL, was well received by participants. They described feeling appreciated, cared for, encouraged, and connected. The results of this study will inform future evaluation examining veteran outcomes., Competing Interests: Dr. Landes is a consultant for RAND and UTHealth Houston. Dr. Abraham is a consultant for Roche and Strategic Science and Technologies. Dr. Garrido has received grant funding from Arnold Ventures and the Commonwealth Foundation. The other authors report no financial relationships with commercial interests.

The U.S. Veterans Health Administration developed a suicide prediction statistical model and implemented a novel clinical program, Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET). This high-value suicide prevention program aims to efficiently identify patients at risk and connect them with care. Starting in April 2017, national REACH VET metric data were collected from electronic health records to evaluate required task completion. By October 2020, 98% of veterans identified (N=6,579) were contacted by providers and had their care evaluated. In the nation's largest health care system, it was feasible to implement a clinical program based on a suicide prediction model.

Importance: Although interest is high in addressing suicide mortality after the transition from military to civilian life, little is known about the risk factors associated with this transition. To support the ongoing suicide surveillance work of the US Department of Veterans Affairs (VA) Office of Mental Health and Suicide Prevention, examining these factors is important for targeting suicide prevention efforts., Objective: To examine the prevalence, patterns, and associated characteristics of suicide mortality among US service members after separation from military active status., Design, Setting, and Participants: This retrospective population-based cohort study obtained demographic and military service data from the VA/Department of Defense Identity Repository. Individuals who served on active duty in the US Army, Navy, Air Force, Marine Corps, or Coast Guard after September 11, 2001, and who separated from active status between January 1, 2010, and December 31, 2017, were included in the cohort. Data analyses were conducted from September 9, 2019, to April 1, 2020., Main Outcomes and Measures: Suicide mortality within 6 years after separation from military service., Results: A total of 1 868 970 service members (1 572 523 men [84.1%]; mean [SD] age at separation, 30.9 [9.9] years) separated from the military during the study period. Through the end of the study period (December 31, 2017), 3030 suicides (2860 men and 170 women) were identified as having occurred within 6 years of separation from the military. Statistically significant differences in suicide risk were found by demographic and military service characteristics. Suicide rates after separation were time dependent, generally peaking 6 to 12 months after separation and declining only modestly over the study period. Male service members had a statistically significantly higher hazard of suicide than their female counterparts (hazard ratio [HR], 3.13; 95% CI, 2.68-3.69). Younger individuals (aged 17-19 years; HR, 4.46 [95% CI, 3.71-5.36]) had suicide hazard rates that were approximately 4.5 times higher than those who transitioned at an older age (≥40 years). Service branch remained a risk factor for suicide even 6 years after separation; those who separated from the Marine Corps (HR, 1.55; 95% CI, 1.36-1.78) and the Army (HR, 1.48; 95% CI, 1.31-1.67) had a higher hazard than those who transitioned from the Air Force. The hazard for those who separated from the active component was higher than for those who separated from the reserve component (HR, 1.29; 95% CI, 1.18-1.42). Service members with a shorter length of service had a higher hazard (HR, 1.26; 95% CI, 1.11-1.42) than those with a longer service history., Conclusions and Relevance: Results of this study show that not all service members who recently transitioned from military life had the same risk of suicide. The data suggest that awareness of military service and demographic characteristics can help identify those most at risk for suicide to target prevention efforts.

Concerns exist regarding the perceived risks of conducting suicide-focused research among an acutely distressed population. Background: The current study assessed changes in participant distress before and after participation in a suicide-focused research study conducted on a psychiatric inpatient unit. Aims: Participants included 37 veterans who were receiving treatment on a psychiatric inpatient unit and completed a survey-based research study focused on suicide-related behaviors and experiences. Method: Participants included 37 veterans who were receiving treatment on a psychiatric inpatient unit and completed a survey-based research study focused on suicide-related behaviors and experiences. Results: Participants reported no significant changes in self-reported distress. The majority of participants reported unchanged or decreased distress. Reviews of electronic medical records revealed no behavioral dysregulation and minimal use of as-needed medications or changes in mood following participation. Limitations: Findings add to research conducted across a variety of settings (i.e., outpatient, online, laboratory), indicating that participating in suicide-focused research is not significantly associated with increased distress or suicide risk.Conclusion: Findings add to research conducted across a variety of settings (i.e., outpatient, online, laboratory), indicating that participating in suicide-focused research is not significantly associated with increased distress or suicide risk.

The Caring Contacts suicide prevention intervention has been promoted by the Joint Commission, given its effectiveness, high reach, and cost effectiveness. Despite its increased application, no study has examined whether patient characteristics influence perceptions of the intervention, which may inform implementation efforts and ultimately impact effectiveness. One hundred fifty-four veterans were recruited from a Veterans Affairs psychiatric inpatient unit. Participants completed a survey to provide feedback on preferences, including the message correspondent, format (e.g., postcard, email), the importance of handwriting (vs. typed), visual presentation, and schedule for mailings. Results demonstrated that Caring Contacts preferences did not differ by most variables, including military rank, combat deployment history, or most personal technology use characteristics. Some demographic differences were identified, especially by age. More older veterans preferred messages to be sent in a physical letter compared to younger veterans, but if messages were sent via postal mail, younger veterans had a stronger preference for messages to be handwritten and sent using real stamps and colorful envelopes. Overall, findings suggest that few Caring Contacts adaptations are needed based on patient characteristics. Programs targeting older cohorts should consider postal mail formats for Caring Contacts.

Objective: The Caring Contacts intervention has been implemented with a variety of methodologies. The purpose of this study was to examine high-risk inpatient preferences for the Caring Contacts intervention., Method: Veteran psychiatric inpatients (N = 154) completed an anonymous patient preferences survey to obtain feedback on Caring Contact methods such as message wording, preferred correspondent, frequency of contact, duration of the intervention, imagery, and mailing modality., Results: Eighty-five percent of veterans Agreed or Strongly Agreed that they would like to receive Caring Contacts from at least one of the correspondent options, with inpatient or outpatient mental health counselor, or primary care physician most preferred. Example messages based on prior studies were overwhelmingly rated as caring and helpful; 84% believed that Caring Contacts could help suicidal individuals. Letters or postcards sent through postal mail were preferred over e-mail or text messages. Participants most commonly thought Caring Contacts should be sent monthly for a period of a year., Conclusions: The results of this study suggest that most high-risk veterans would perceive Caring Contacts as helpful and caring. The results provide several practical, helpful tips for programs seeking to establish a Caring Contacts program., (© 2018 The American Association of Suicidology.)

This paper presents data from the United States Department of Defense Suicide Event Report System for years 2012-2015 to detail descriptive, longitudinal rate data and risk factor profiles associated with military suicide. The annual findings were aggregated from all U.S. military suicide deaths and suicide attempts. Data elements included the most common method of suicide (firearms), most common behavioral health diagnoses (substance abuse/dependence), common life stressors (failed intimate-partner relationships), and an individual's history of operational deployment. Age- and sex-adjusted rates for the Services were compared with rates for the U.S. adult population. Results showed that the current reporting period (2015) is similar to patterns that have been observed over the preceding years and to patterns reported in the overall U.S. adult population. Suicide rates remain elevated but stable for both the Active and Reserve Components of the Military Services compared to historical levels observed prior to 2003. Finally, we discuss common errors and misinterpretations that can occur when analyzing surveillance data., (Published by Oxford University Press on behalf of Association of Military Surgeons of the United States 2019.)

Deployment to a combat zone is a fundamental mission for most military forces, but prior research suggests that there is a complex and nuanced association between deployment and related risk factors for suicide. Deployment and combat experiences vary greatly among military personnel and can affect a variety of protective and risk factors for suicide. This article offers a critical examination of the association among modern U.S. military deployments, suicide attempts, and death while considering the context of a prominent theory of suicide. Although previous work has demonstrated that deployment is not associated with suicide overall in this population, there is growing evidence that risk may be elevated shortly after deployment, and for some subgroups. Specific aspects of combat exposure, including the experience of killing or witnessing death in combat, may be important contributing factors. An analysis of the literature illustrates that deployment-related risk factors for suicide are complex. The limitations of the literature are discussed, and future directions are suggested.

Purpose: To compare rates of external causes of mortality among individuals who served in the military (before and after separation from the military) to the U.S., Methods: This retrospective cohort study examined all 3.9 million service members who served from 2002 to 2007. External cause mortality data from 2002 to 2009 were used to calculate standardized mortality ratios. Negative binomial regression compared differences in the mortality rates for pre- and post-separation., Results: Accident and suicide mortality rates were highest among cohort members under 30 years of age, and most of the accident and suicide rates for these younger individuals exceeded expectation given the U.S. population mortality rates. Military suicide rates began below the expected U.S. rate in 2002 but exceeded the U.S. rate by 2009. Accident, homicide, and undetermined mortality rates remained below the U.S. rates throughout the study period. Mortality rates for all external causes were significantly higher among separated individuals compared with those who did not separate. Mortality rates for individuals after separation from service decreased over time but remained higher than the rates for those who had not separated from service., Conclusions: Higher rates of death for all external causes of mortality after separation suggest prevention opportunities. Future research should examine how preseparation characteristics and experiences may predict postseparation adverse outcomes to inform transition programs., (Published by Elsevier Inc.)

US Army suicide rates increased significantly in the last decade and have remained high. To inform future research hypotheses, Army suicide surveillance data (2012-2014) were compared to similar Army data for suicides from 1975 to 1982. Preliminary data suggest that suicide rates increased across most demographic groups, but may have decreased among divorced soldiers. Mental health utilization increased over time. Legal problems and physical health problems were identified in a higher percentage of cases in the recent data relative to the 1975-1982 era. Potential implications for suicide prevention are discussed., (Published 2016. This article is a US Government work and is in the public domain in the USA.)

The association between suicide and combat injuries sustained during the wars in Iraq and Afghanistan was examined. A retrospective population-based cohort design was conducted using official military records to identify combat injuries (October 7, 2001, to December 31, 2007). Those who were injured during combat had higher crude suicide rates than those who deployed and were not injured (incidence rate ratio [IRR] = 1.50; confidence interval [CI] = 1.06, 2.12), or never deployed (IRR = 1.46; CI = 1.04, 2.06). After adjusting for demographics, these findings were no longer statistically significant. Although our data did not support an elevated suicide risk among wounded service members, additional research is needed to examine the impact of injury severity., (Published 2016. This article is a U.S. Government work and is in the public domain in the USA.)

Military suicide has escalated in recent years, however almost no research has used military surveillance data to examine suicide risk factors. The aims of the current study were to compare suicide risk factors among US Soldiers who died by suicide, attempted suicide, and controls using a prospective case-control design. Controls were 247 Soldiers completing standard post-deployment assessment procedures. Cases were 276 suicide decedents (n=85) or suicide attempters (n=191), drawn from the Department of Defense Suicide Event Report. Compared to controls, suicide attempters and decedents had greater odds of failed intimate relationships, legal problems, and substance abuse problems in the past 90 days. Suicide attempters and decedents also had greater odds of a history of a mood disorder and prior suicide attempt compared to controls. Suicide decedents had greater odds of exposure to legal problems in the past 90 days and lower odds of ever having an anxiety disorder, compared to suicide attempters. Vigilance toward early detection of modifiable suicide risk factors such as relationship dissolution, mood disorders, substance abuse, and legal problems may help reduce suicide risk among US Soldiers., (Published by Elsevier Ireland Ltd.)

Importance: A pressing question in military suicide prevention research is whether deployment in support of Operation Enduring Freedom or Operation Iraqi Freedom relates to suicide risk. Prior smaller studies report differing results and often have not included suicides that occurred after separation from military service., Objective: To examine the association between deployment and suicide among all 3.9 million US military personnel who served during Operation Enduring Freedom or Operation Iraqi Freedom, including suicides that occurred after separation., Design, Setting, and Participants: This retrospective cohort design used administrative data to identify dates of deployment for all service members (October 7, 2001, to December 31, 2007) and suicide data (October 7, 2001, to December 31, 2009) to estimate rates of suicide-specific mortality. Hazard ratios were estimated from time-dependent Cox proportional hazards regression models to compare deployed service members with those who did not deploy., Main Outcomes and Measures: Suicide mortality from the Department of Defense Medical Mortality Registry and the National Death Index., Results: Deployment was not associated with the rate of suicide (hazard ratio, 0.96; 99% CI, 0.87-1.05). There was an increased rate of suicide associated with separation from military service (hazard ratio, 1.63; 99% CI, 1.50-1.77), regardless of whether service members had deployed or not. Rates of suicide were also elevated for service members who separated with less than 4 years of military service or who did not separate with an honorable discharge., Conclusions and Relevance: Findings do not support an association between deployment and suicide mortality in this cohort. Early military separation (<4 years) and discharge that is not honorable were suicide risk factors.

Purpose: We conducted a retrospective cohort mortality study to determine the postservice suicide risk of recent wartime veterans comparing them with the US general population as well as comparing deployed veterans to nondeployed veterans., Methods: Veterans were identified from the Defense Manpower Data Center records, and deployment to Iraq or Afghanistan war zone was determined from the Contingency Tracking System. Vital status of 317,581 deployed and 964,493 nondeployed veterans was followed from the time of discharge to December 31, 2009. Underlying causes of death were obtained from the National Death Index Plus., Results: Based on 9353 deaths (deployed, 1650; nondeployed, 7703), of which 1868 were suicide deaths (351; 1517), both veteran cohorts had 24% to 25% lower mortality risk from all causes combined but had 41% to 61% higher risk of suicide relative to the US general population. However, the suicide risk was not associated with a history of deployment to the war zone. After controlling for age, sex, race, marital status, branch of service, and rank, deployed veterans showed a lower risk of suicide compared with nondeployed veterans (hazard ratio, 0.84; 95% confidence interval, 0.75-0.95). Multiple deployments were not associated with the excess suicide risk among deployed veterans (hazard ratio, 1.00; 95% confidence interval, 0.79-1.28)., Conclusions: Veterans exhibit significantly higher suicide risk compared with the US general population. However, deployment to the Iraq or Afghanistan war, by itself, was not associated with the excess suicide risk., (Published by Elsevier Inc.)

To help understand suicide among soldiers, we compared suicide events between active duty U.S. Army versus civilian decedents to identify differences and inform military prevention efforts. We linked 141 Army suicide records from 2005 to 2010 to National Violent Death Reporting System (NVDRS) data. We described the decedents' military background and compared their precipitators of death captured in NVDRS to those of demographically matched civilian suicide decedents. Both groups commonly had mental health and intimate partner precipitating circumstances, but soldier decedents less commonly disclosed suicide intent., (© Published 2014. This article is a U.S. Government work and is in the public domain in the USA. Suicide and Life-Threatening Behavior published by Wiley Periodicals, Inc. on behalf of American Association of Suicidology.)

Identification of risk and protective factors for suicide is a priority for the United States military, especially in light of the recent steady increase in military suicide rates. The Department of Defense Suicide Event Report contains comprehensive data on suicides for active duty military personnel, but no analogous control data is available to permit identification of factors that differentially determine suicide risk. This proof-of-concept study was conducted to determine the feasibility of collecting such control data. The study employed a prospective case-control design in which control cases were randomly selected from a large Army installation at a rate of four control participants for every qualifying Army suicide. Although 111 Army suicides were confirmed during the study period, just 27 control soldiers completed the study. Despite the small control sample, preliminary analyses comparing suicide cases to controls identified several factors more frequently reported for suicide cases, including recent failed intimate relationships, outpatient mental health history, mood disorder diagnosis, substance abuse history, and prior self-injury. No deployment-related risk factors were found. These data are consistent with existing literature and form a foundation for larger control studies. Methodological lessons learned regarding study design and recruitment are discussed to inform future studies., (Reprint & Copyright © 2014 Association of Military Surgeons of the U.S.)

The Department of Defense Suicide Event Report Program collects extensive information on suicides and suicide attempts from the U.S. Air Force, Army, Marine Corps, and Navy. Data are compiled on demographics, suicide event details, behavioral health treatment history, military history, and information about other potential risk factors such as psychosocial stressors that were present at the time of the event. The ultimate goal of this standardized suicide surveillance program is to assist suicide prevention in the U.S. military. Descriptive data are presented on 816 suicides and 1,514 suicide attempts reported through the program between 2008 and 2010., (© 2013 This article is a U.S. Government work and is in the public domain in the USA.)

Suicides are increasing among active duty US Army soldiers. To help focus prevention strategies, we characterized 56 US Army suicides that occurred from 2005 to 2007 in 17 US states using 2 large-scale surveillance systems. We found that intimate partner problems and military-related stress, particularly job stress, were common among decedents. Many decedents were also identified as having suicidal ideation, a sad or depressed mood, or a recent crisis before death. Focusing efforts to prevent these forms of stress might reduce suicides among soldiers.

Suicide is a leading cause of deaths of U.S. service members. Medical care providers may play a role in suicide prevention. We summarized the outpatient experiences of service members prior to suicide or self-inflicted injury and compared them with service members without suicidal behavior. During 2001-2010, 45 percent of individuals who completed suicide and 75 percent of those who injured themselves had outpatient encounters within 30 days prior to suicide/self-harm. Primary care was the most frequently visited clinical service prior to suicide/self-harm. As compared to their counterparts, service members with suicidal behavior had especially excessive outpatient visit rates within, but not prior to, 60 days of their deaths/injuries. The finding suggests that there may be one or more "triggering" events that lead to care-seeking. These results may help identify individuals that should be screened for suicide risk.

Suicide risk based on occupational cohorts within the U.S. military was investigated. Rates of suicide based on military occupational categories were computed for the Department of Defense (DoD) active component population between 2001 and 2010. The combined infantry, gun crews, and seamanship specialist group was at increased risk of suicide compared to the overall military population even when adjusted for gender, age, and deployment history. The results provide useful information that can help inform the DoD's suicide prevention mission. Data limitations and recommended areas for future research are discussed. (Contains 2 tables.)

The U.S. Department of Veterans Affairs (VA) and Department of Defense clinical practice guideline on the treatment of veterans at risk for suicide recommends considering caring contacts interventions after a psychiatric hospitalization for suicidal ideation or suicide attempt. This quality improvement project examined the implementation of the recommendation at a large VA health care system. The project enrolled 29% of hospitalized veterans (N=135 of 462). Enrollment barriers included lack of staff availability and veteran ineligibility due to homelessness or housing instability. Opportunities to improve the reach of the intervention in future quality improvement processes are discussed, especially because acceptability of the intervention was high among veterans. [ABSTRACT FROM AUTHOR]

Background: The Veterans Health Administration (VHA) implemented REACH VET, which analyzes health records to identify veterans at statistically elevated risk for suicide and other adverse outcomes compared to other veterans in VHA. This project evaluated REACH VET program implementation at a large VA health care system by examining program fidelity and treatment engagement, receipt of suicide prevention interventions, and suicide‐related behaviors in the 6 months following identification. Methods: Over a 12‐month period, 218 unique cases were identified by REACH VET within a local VA system. Data were extracted from the VA's electronic medical records. Results: Protocol adherence for required clinical and administrative steps was 94% and above. After identification, 88% received outpatient mental health treatment, 21% had a psychiatric hospitalization, and 83% engaged in Safety Planning around the time of identification or in the following six months. Twenty‐six percent of cases were identified by another existing method for identifying high‐risk veterans. Five percent had a medically documented suicide attempt, and none were known to die by suicide in the following 6 months. Conclusions: Local evaluation suggested high protocol fidelity and high engagement in mental health and suicide prevention services following identification among veterans who remained at elevated risk in the 6 months that followed. [ABSTRACT FROM AUTHOR]

To improve the identification and intervention of suicide risk, the Veterans Health Administration implemented the use of electronic patient record flags (PRF) to indicate when a veteran is identified as high risk for suicide and to increase the clinical contacts made with the veteran. The current study utilized an intersectional approach to assess potential disparities in the likelihood of receiving a PRF and the likelihood of receiving post‐PRF follow‐up care among veterans with substance use disorders (SUDs). Among 458,092 veterans who received a SUD diagnosis in 2012, Black veterans were less likely to receive a PRF, although Black‐disabled veterans and Black‐female veterans were more likely to receive a PRF. Homelessness was related to greater likelihood of receiving a PRF and post‐PRF care. Hispanic/Latinx veterans who experienced homelessness were more likely to receive post‐PRF care, while disabled veterans who experienced homelessness were less likely. Hispanic/Latinx, female veterans, and Black‐disabled veterans were significantly less likely to receive post‐PRF care. Overall, few marginalized or intersecting identities were associated with decreased PRF or decreased follow‐up care. There are opportunities for specific strategies that promote engagement in VA follow‐up services for veterans identifying as Hispanic/Latinx women, disabled Black veterans, and disabled homeless veterans. [ABSTRACT FROM AUTHOR]

Objective: Veterans die by suicide at a higher rate than the U.S. population, and veterans more frequently use a firearm as the suicide method. Consequently, firearm accessibility and storage represent important prevention considerations. This project aimed to explore the implementation of suicide prevention efforts among veterans who went on to die by suicide, with and without the use of a firearm, and to identify factors that differentiated veteran suicide decedents to help inform suicide prevention efforts.Methods: Data from the Veteran Health Administration Behavior Health Autopsy Program was analyzed for 97 veteran suicide decedents.Results: Results demonstrated that veterans who used a firearm for suicide were less likely to have engaged in suicide prevention efforts overall and were less likely to have received lethal means safety counseling / safety planning. Veterans who died by firearm had lower levels of notable risk factors (e.g., prior suicide attempt, no-shows for appointments), however were more likely to have a documented unsecured firearm in their home.Conclusion: These findings support the benefit of broadening the reach of suicide prevention efforts, especially for high-risk veterans with access to firearms. [ABSTRACT FROM AUTHOR]

Research suggests the prevalence of suicide ideation and suicide attempts in the transgender veteran community may be upwards of 20 times higher than nontransgender veterans, who are known to be at increased risk than the general US population. This study aimed to understand the potential influence of external and internal minority stress experienced during and after military service on past-year and recent suicide ideation in a sample of 201 transgender veterans. Nonparametric bootstrapping analyses indicated past-year transgender-specific discrimination and rejection (external minority stress) indirectly predicted frequency of both past-year and past 2-week suicide ideation through past-year shame related to gender identity (internal minority stress). This result was significant when controlling for symptoms of depression and demographics. Similar patterns emerged when examining relationships among military external and internal minority stress on suicide outcomes. These results suggest that attempts to reduce both the experience and impact of minority stressors related to gender identity during and after military service may be an important avenue for suicide prevention. [ABSTRACT FROM AUTHOR]

Recent advances in statistical methods and computing power have improved the ability to predict risks associated with mental illness with more efficiency and accuracy. However, integrating statistical prediction into a clinical setting poses new challenges that need creative solutions. A case example explores the challenges and innovations that emerged at a Department of Veterans Affairs hospital while implementing REACH VET (Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment), a suicide prevention program that is based on a predictive model that identifies veterans at statistical risk for suicide. [ABSTRACT FROM AUTHOR]

For example, a clinician recently informed the implementation team about a veteran who expressed his appreciation for the outreach as he was experiencing suicidal ideation in the context of financial stress and worsening medical conditions. The feasibility and acceptability of the REACH VET PM-based program are in part related to the manner in which it is being implemented: to maximize benefits and minimize harms. Toward this end, during the initial rollout, the REACH VET implementation team provided training regarding program requirements. [Extracted from the article]

Abstract: This study examined combat and mental health as risk factors of suicidal ideation among 2854 U.S. soldiers returning from deployment in support of Operation Iraqi Freedom. Data were collected as part of a postdeployment screening program at a large Army medical facility. Overall, 2.8% of soldiers reported suicidal ideation. Postdeployment depression symptoms were associated with suicidal thoughts, while postdeployment PTSD symptoms were associated with current desire for self harm. Postdeployment depression and PTSD symptoms mediated the association between killing in combat and suicidal thinking, while postdeployment PTSD symptoms mediated the association between killing in combat and desire for self harm. These results provide preliminary evidence that suicidal thinking and the desire for self-harm are associated with different mental health predictors, and that the impact of killing on suicidal ideation may be important to consider in the evaluation and care of our newly returning veterans. [Copyright &y& Elsevier]