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Suicide bereavement and postvention literature often espouses risk for subsequent suicidal behavior among those previously exposed to a suicide death. Most often risk is discussed in relation to kin; however, many more individuals are exposed to suicide, and the impact of this exposure is important to understand in relation to targeting postvention. This review examined the research literature (1990-2014) to determine the evidence base for risk among those exposed to suicide. The findings demonstrate that risk of suicidal behaviors among those exposed to the suicide is significantly higher than those unexposed. These results are discussed within the context of current research in the field of postvention, and suggestions for future research are suggested. [ABSTRACT FROM AUTHOR]

Suicide is an important public health concern requiring ongoing research to understand risk factors for suicide ideation. A dual-frame, random digit dial survey was utilized to identify demographic and suicide-related factors associated with suicide ideation in a statewide sample of 1,736 adults. The PH-Q 9 Depression scale suicide ideation question was used to assess current suicide ideation in both the full sample and suicide exposed sub-sample. Being non-married and having previous suicide exposure were separately associated with higher risks of suicide ideation in the full sample. Being male, having increased suicide exposures, and having increased perceptions of closeness to the decedent increased risks, while older age decreased risks for the suicide exposed. Implications for future screening and research are discussed. [ABSTRACT FROM AUTHOR]

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Suicide attempt survivors' interpretations of reactions to attempts are understudied, yet could inform prevention efforts concerning subsequent attempts. Interviews with 40 attempt survivors about family and friend reactions were analyzed using interpretive phenomenological techniques. Three distinct patterns emerged as follows: (a) Stigmatizing statements and emphasis on reactor's feelings were interpreted as signs that attempt survivors were a burden to others, (b) avoidant reactions and excessive monitoring were interpreted as cues that suicidal behavior must remain hidden to not be a burden, and (c) asking questions and projecting strength were interpreted as signs that attempt survivors belonged and were not a burden. These findings highlight the importance of working with family and friends to encourage reactions that reduce the risk of future attempts. [ABSTRACT FROM AUTHOR]

This study examined the impact of personality, coping, and perceived closeness on help-seeking attitudes in suicide bereaved adults. Participants (n = 418; mean age = 49.50; 90% women, 89.7% Caucasian) completed measures of personality (neuroticism, extraversion, openness, conscientiousness, and agreeableness), coping, and attitudes toward seeking mental health services. Regression analyses revealed neuroticism as the strongest predictor of help-seeking attitudes. Relatively neurotic adult women bereaved by suicide may be at-risk for developing unhealthy coping styles, low stigma indifference, and more negative help-seeking attitudes. [ABSTRACT FROM PUBLISHER]

In light of prevailing confusion over the meaning of the term "suicide survivor," we propose a more exact terminology for designating different levels of impact on those left behind by suicide, ranging on a continuum from those exposed to suicide through those who are affected by it and finally to those who are bereaved by suicide in the short- or long-term, as a function of their loss of a close emotional attachment through this tragic form of loss. We briefly note the possible utility of this terminological specificity in promoting more clearly targeted research and intervention efforts, and call for closer investigation of various categories of "survivorship" in future studies. [ABSTRACT FROM AUTHOR]

Three hundred and eighteen parent-bereaved children aged 5-17 recruited from the community and their surviving parents were interviewed at 1, 6, 13, and 25 months post-parental death about their participation in funeral related rituals and subsequent adjustment following the death. Nearly all the children attended their parent's visitation, funeral, and burial. Children from families who did not have such rituals fare less well over time. Children who reported internalizing or externalizing behavior at rituals were more likely to experience some increased problems in the first two years post-death. Children who were withdrawn or quiet during the rituals had fewer subsequent problems than children who acted out during these rituals. Visitation attendance was associated with better outcome one and two years later. The symbolism of rituals (e.g., playing a favorite song) often brings comfort to child survivors. Cremation does not appear to have any negative effect on children's outcome.

Three studies resulted in the Willingness to Intervene Against Suicide Questionnaire. College students (ns = 172, 253, and 367) completed an online questionnaire based on theory of planned behavior constructs regarding suicide intervention. Exploratory factor analysis produced 10 factors: intervening will affect the suicidal person and the participant; important others recommend seeking help, suggesting the suicidal person see a counselor, and talking to the suicidal person; interpersonal and intervention self-efficacy; and intention to seek outside help, encourage to seek outside help, and recognize a need for action. The Willingness to Intervene Against Suicide Questionnaire assesses college students’ willingness to intervene when someone is suicidal. [ABSTRACT FROM PUBLISHER]

The field of suicide postvention remains relatively immature in terms of the current knowledge base. This manuscript examines the existing knowledge regarding suicide bereavement and describes the limitations of the suicide bereavement knowledge base using a critical review of the literature specifically relating to suicide bereavement published in the previous 10 years. Six limitations are identified in the literature: concern about samples used in research, sampling only people who have been help-seeking, women being overrepresented in studies, additional design issues including limitations by research ethics boards, definitional problems in who is suicide bereaved, and determining the size of the population bereaved by suicides. This is followed by a discussion of the need to define the suicide bereaved population, as well as understand the effect of suicide bereavement. The paper closes with suggestions for future directions that are required in the field of suicide bereavement in order to best understand and help those people left behind in the wake of suicide deaths. [ABSTRACT FROM AUTHOR]

Objective: To determine experiences about suicide and those affected by it and to determine students' attitudes, perceptions, and behavioral intentions about suicide prevention resources. Participants: 117 students (62% female, 63% undergraduate). Methods: 1000 randomly-selected students were emailed a request to complete an online survey. Results: The experience of knowing someone who has attempted or died by suicide is common for college students - 65% reported they knew someone who attempted or died by suicide. About 21.5% endorsed being 'suicide survivors,' 'personally affected' by a suicide. Undergraduate students were more likely than graduate students to see suicide as preventable. Most respondents are aware people who are suicidal show warning signs. Conclusions: Students on a college campus are likely to be exposed to suicides and suicide attempts. Supports for people exposed to suicidal behavior, targeted messaging to specific groups of students and gatekeeper training with students overall is needed on campuses. [ABSTRACT FROM AUTHOR]

Myth-busting, in which a so-called myth is presented and dispelled by facts, is used in suicide prevention gatekeeper trainings such as QPR. Evidence from other areas of public health shows this technique leads to memory for myths and not facts. An internet survey was used to determine if the "myths" and "facts" presented in QPR are endorsed as such by the suicidology community and to determine if demographics influenced statement identification. Overall, statements did reflect the opinions of the suicidology community and any type of training increased correct identification. Future research should focus on whether myth-busting is an appropriate strategy for suicidology. [ABSTRACT FROM AUTHOR]

To update and expand Rubey and McIntosh's (1996) survivors of suicide support groups report, SPAN USA completed a survey of U.S. support group leaders (n = 100; 24% completion). There are now more survivor groups (from 280 to 417), and the majority of groups now have a survivor leader (78% vs. 25%). Groups continue to be small (88% < 10 members per session) and meet on a monthly basis (55%). Sharing continues to be a universal experience in groups, which tend to be open-ended (85%). Current groups are newer, and more operate without a sponsor. Further research is needed to examine group member perspectives and effectiveness of groups. [ABSTRACT FROM AUTHOR]

Support groups for suicide survivors (those individuals bereaved following a suicide) are widely used, but little research evidence is available to determine their efficacy. This paper outlines the pressing public health need to conduct research and determine effective ways to identify and meet the needs of suicide survivors, particularly through survivor support groups. After describing the various approaches to survivor support groups, we explain the need for further research, despite the inherent challenges. Finally, we pose several questions for researchers to consider as they work with survivors to develop a research agenda that sheds more light on the experiences of survivors and the help provided by survivor support groups. [ABSTRACT FROM AUTHOR]

Archival data from suicide survivors presenting for treatment from 1999-2005 at the Baton Rouge Crisis Intervention Center (BRCIC) were used to examine differences in those who received an active model of postvention (APM; n = 150) compared to those who received a traditional passive postvention (PP, n = 206). APM presented sooner for treatment (48 days) than PP (97 days). APM survivors were more likely to have been the survivor of a violent suicide. APM were more likely than PP to attend survivor support group meetings and APM attended more groups. To better understand the efficacy of APM in helping survivors, a prospective evaluation is needed. [ABSTRACT FROM AUTHOR]

In this pilot study we report on proximate outcomes of a 1-hour community gatekeeper training in-service for 76 nonclinical employees in a university hospital workplace setting. Pre-post analyses resulted in positive changes in participants' knowledge about suicide and attitudes (self-efficacy) about intervening with suicidal individuals. A subset of participants engaged in role play practice of gatekeeper skills following training and rated the experience positively. Fifty-five observations were rated using an observational measure developed for this study and approximately half of these demonstrated satisfactory skills post training. Participants in this workplace gatekeeper training reported sharing new knowledge and skills with family, friends, and coworkers. [ABSTRACT FROM AUTHOR]

Analyzes the role of ritual in parent-bereaved children. Impact of cremation on grieving rituals; Influence of attendance at funeral rituals on bereaved children; Association between child participation in visitation, funeral and burial and the development of psychiatric symptomatology.

Introduction: This study sought to investigate general perceptions of suicide‐related hospital‐based care that Transgender/Gender Diverse (TGD) adults have experienced as well as correlates of their perceived usefulness of this care. Methods: Data were collected via a cross‐sectional online survey of N = 3718 self‐identified TGD individuals. Single‐item self‐report measures of all constructs of interest were used. Results: A total of n = 1056 participants indicated hospitalization for either a past suicide attempt (SA) or suicidal ideation (SI). Irrespective of being hospitalized for SI or SA, perceived usefulness of hospital‐based care was low with 50% or more of participants rating their care as some degree of unhelpful. Older age, general trust in mental healthcare providers, and voluntary admission were related to higher perceived helpfulness of care for both SI and SA admissions. Higher pride in TGD identity was positively related to perceived helpfulness of care but only for admissions related to SAs. Conclusion: Improving perceived usefulness of hospital‐based care may be important for improving subsequent suicide‐related help‐seeking. Increasing training and provision of care that improves trust with mental healthcare providers and potentially reduces need for involuntary admission may help improve hospital‐based, suicide‐related care in TGD adults. [ABSTRACT FROM AUTHOR]

Background: Although suicide bereavement is associated with suicide and self-harm, evidence regarding mechanisms is lacking. We investigated whether depression and substance use (alcohol and/or other drugs) explain the association between partner suicide bereavement and suicide. Methods: Linkage of nationwide, longitudinal data from Denmark for the period 1980–2016 facilitated a comparison of 22 668 individuals exposed to bereavement by a partner's suicide with 913 402 individuals bereaved by a partner's death due to other causes. Using causal mediation models, we estimated the degree to which depression and substance use (considered separately) mediated the association between suicide bereavement and suicide. Results: Suicide-bereaved partners were found to have a higher risk of suicide (HRadj = 1.59, 95% CI 1.36–1.86) and of depression (ORadj 1.16, 95% CI 1.09–1.25) when compared to other-bereaved partners, but a lower risk of substance use (ORadj 0.83; 95% CI 0.78–0.88). An increased risk of suicide was found among any bereaved individuals with a depression diagnosis recorded post-bereavement (ORadj 3.92, 95% CI 3.55–4.34). Mediation analysis revealed that depression mediated 2% (1.68%; 95% CI 0.23%–3.14%; p = 0.024) of the association between suicide bereavement and suicide in partners when using bereaved controls. Conclusions: Depression is a partial mediator of the association between suicide bereavement and suicide. Efforts to prevent and optimize the treatment of depression in suicide-bereaved people could reduce their suicide risk. Our findings might be conservative because we did not include cases of depression diagnosed in primary care. Further work is needed to understand this and other mediators. [ABSTRACT FROM AUTHOR]

Background: Most research investigating the effect of suicide on loss survivors has been limited to first‐degree family members. Few studies examine the impact of suicide on others outside the immediate family and the influence of relationship type and closeness on mental health. Methods: This study used data from a sample obtained through random digit dialing (n = 805) to assess exposure to suicide loss, relationship types, perceived closeness, and mental health symptoms (prolonged grief, depression, anxiety, and posttraumatic stress disorder). Results: Familial status, friend status, and higher perceived closeness were associated with prolonged grief, depression, and posttraumatic stress disorder, with the strongest adjusted associations observed for posttraumatic stress disorder and prolonged grief. In general, the magnitude of adjusted standardized associations for closeness and mental health symptoms was stronger than those observed for familial status and mental health symptoms and friend status and mental health symptoms. Conclusion: Closeness, familial status, and friend status are associated with mental health symptoms experienced after suicide loss, but the magnitude of associations was strongest for closeness. Future studies should examine perceived closeness in addition to other factors related to relationship type and dynamics to assess the complexities of suicide bereavement reactions. [ABSTRACT FROM AUTHOR]

Survivors' adaptation to a suicide loss is likely influenced by their attitudes toward suicide and their respective sociocultural contexts. Our study aimed to compare suicide attitudes and their association with depressive symptoms and sense of community safety in Japanese and American suicide loss survivors. A total of 193 Japanese survivors and 232 American survivors completed online surveys. The results show that Japanese survivors tended not to consider suicide as an illness or to recognize that others understood their experience but were more likely than American survivors to consider suicide as justifiable. Regression analyses indicated that taking suicide as a right was associated with depressive symptoms. Further, their sense of being understood by others was positively correlated with perceived community safety in both samples, but justifying suicide and considering it to be an illness was positively related to perceived community safety only among Japanese survivors. [ABSTRACT FROM AUTHOR]

Background: Transgender and gender diverse (TGD) individuals, especially veterans, experience elevated rates of non-suicidal self-injury (NSSI) and suicide related behaviors compared to gender majority individuals. Research has yet to compare TGD veterans to non-veterans or look at correlates of NSSI and related behaviors to suicide related outcomes. This study examines prevalence and suicide related correlates of NSSI among TGD veterans and TGD non-veterans.Method: Data analyzed in the were part of the Trans Lifeline Mental Health Survey. Both TGD veterans (N = 313) and non-veterans (N = 3,972) completed an online, cross-sectional survey that included self-report measures of NSSI, suicidal ideation (SI), and suicidal attempt (SA) along with lifetime hospitalization and avoidance of care due to NSSI.Results: Results of this paper indicate that prevalence of NSSI, SI, and SA are elevated in both the TGD veterans and non-veteran subpopulations. Further, veterans compared to non-veterans have a lower prevalence of NSSI but higher prevalence of hospitalization when self-harm is inflicted, reflecting more healthcare utilization or increased severity of NSSI episodes. Additionally, veterans were less likely to avoid care due to NSSI. Further, veteran status seemed to be a protective factor against demographic differences that increased rates of NSSI history in non-veteran TGD individuals.Limitations: The limitations of this study include its cross-sectional study design, one question assessing SA, and few TGD male veterans.Conclusion: NSSI is an important risk factor in future suicide related outcome such as SI and SA. Further, differences in healthcare utilization among TGD veterans and non-veterans are apparent. [ABSTRACT FROM AUTHOR]

The article presents a study that investigates the extent to which bereavement results in the development of psychiatric symptoms in 1,420 young people in 11 counties of North Carolina. Among the study's participants, 172 had lost a parent while 815 experienced the loss of a non-parent relative. The results showed that children who lost a parent or another family member are more likely than non-bereaved children to experience symptoms of depression and separation anxiety around the time of the death and the year immediately following it.

Objective: To provide the first estimates of the risk of suicide after bereavement by the suicide of any first‐degree relative and the proportion of suicides in Denmark attributable to suicide bereavement. Methods: We conducted a nationwide nested case–control study defining cases as all Danish‐born individuals who died by suicide in Denmark between 01 January 1980 and 31 December 2016 (n = 32,248), age‐matched to four living controls. Using three exposure categories (bereavement by the suicide of a relative [parent, offspring, sibling, and spouse/cohabitee]; non‐suicide bereavement; no bereavement) and conditional logistic regression adjusted for pre‐specified covariates we estimated the odds of exposure to suicide bereavement in cases versus controls. We tested whether associations differed for men and women, estimated the population attributable fraction (PAF) of suicides in our population at risk that could be attributed to a first‐degree relative's suicide loss, and estimated the attributable fraction among the exposed (AFe). Results: Suicide bereavement was associated with an increased odds of suicide when compared with no bereavement (ORadj2 = 2.90, 95% CI: 2.46–3.40) or non‐suicide bereavement (ORadj2 = 1.48, 95% CI: 1.25–1.74). There was no evidence to support any interaction with sex. PAF (0.69%; 95% CI: 0.62%–0.77%) and AFe (60.12%; 95% CI: 53.19%–66.03%) estimates suggested that in Denmark 0.69% of suicides, and 60% of suicides among suicide‐bereaved relatives, could be prevented if it was possible to address all factors increasing suicide risk in suicide‐bereaved relatives. Conclusion: Suicide bereavement in relatives and partners contributes to at least one in 145 suicides in Denmark. [ABSTRACT FROM AUTHOR]

Existing literature has found a link between disclosure of a stigmatized identity and improved mental health; however, research on the impact of suicide disclosure to family members is scarce. Suicide attempt survivors (n = 74) in the United States were examined to assess whether family reaction moderates or mediates the relationship between suicide disclosure and subsequent depression symptoms. Family reaction did not moderate but did mediate the relationship between disclosure and depression symptoms while controlling for time since most recent attempt. Higher rates of disclosure predicted more positive family reactions, which in turn predicted less severe depression symptoms. Findings indicate that family members can play an essential role in the recovery process after an attempt occurs, which has important implications for both researchers and clinicians who seek to decrease stigma for attempt survivors while simultaneously decreasing the likelihood of future attempts. [ABSTRACT FROM AUTHOR]

Alarming numbers of military veterans end their lives each day which has a profound effect on the military population. This study examines a sample ( N = 434) of suicide-exposed (i.e., personally knowing someone who has died by suicide) veterans to determine whether the proportion of individuals who report high impact from suicide exposure and those who have clinically-significant posttraumatic stress disorder symptoms is related to marital status. Using Hill's ( Social Casework 49: 139-150, 1958) ABC-X model for conceptualizing the relationships between variables, mean scores for posttraumatic stress disorder were significantly different between groups, and the odds of a married veteran reporting high-impact suicide exposure were 2.19 times lower than the odds of a single veteran reporting high-impact. Likewise, the odds of a veteran with high-impact suicide exposure having clinically-significant posttraumatic stress disorder symptoms were 10.04 times higher than veterans with low-impact suicide exposure. Findings indicate that veterans who are married are less likely to be highly-affected by another individual's suicide. Thus, marriage is a protective factor for suicide-exposed veterans. [ABSTRACT FROM AUTHOR]

Seeking to provide more systematic information on treatment-seeking and those not seeking help after a suicide, we investigated demographic, experiential and grief problems related correlates among recently suicide bereaved adults, conducting an on-line survey of a sample of U.S. 1,132 adults who lost a loved one to suicide during the last six years. Focusing upon first-degree relative loss survivors ( n = 222) we hypothesized those not seeking help would be more likely to report conventional religiosity, greater social support and more use of alternative treatment modalities. Instead, we found those not seeking help were almost twice as likely to not attend religious services, compared to help seekers. Social support enhanced the bereaved individuals' pursuit of treatments and those who did not obtain help appeared reluctant to getting non-traditional treatment support. Help seekers were more likely to experience post-traumatic growth and less likely to see suicide loss survivorship as stigmatizing., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The Stigma of Suicide Scale (SOSS) is a measure of public attitudes toward suicide decedents, which makes it unique from other scales that measure more general attitudes toward suicide. The aim of this study was to further replicate and extend the reliability and factor structure of the SOSS (both long- and short form) in a sample of individuals directly impacted by suicide. This study also sought to identify factors that impact suicide attitudes unique to this sample. The sample included 312 participants who had personal experience with suicide. Results provided support for the oblique three-factor structure of the SOSS (stigma, isolation/depression, and glorification/normalization), with a superior model fit for the 16-item short form version. Correlates of suicide attitudes among individuals exposed to suicide included perceived relationship closeness to a suicide decedent, experience with both loss and attempt, and the sex of the suicide decedent., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The purpose of this study was to test the reliability and validity of the Willingness to Intervene against Suicide Enhanced (WISE) questionnaire. The WISE is a revised version of the Willingness to Intervene against Suicide (WIS) questionnaire, which was based on the theory of planned behavior, and it has consistently predicted the intention to intervene with a suicidal individual. Evaluation of the WIS showed that it was internally consistent with adequate goodness-of-fit indices for three of the four scales. The subjective norms scale did not meet the goodness-of-fit indices standard cutoff criteria. Due to this, the WIS questionnaire has been revised into the WISE. However, the dimensionality of these factors needed to be tested. College students ( n  = 824) completed an online survey to test the WISE. The data were analyzed using confirmatory factor analysis, reliability analysis, and multiple regression. The WISE was internally consistent, and the scales met acceptable criteria for goodness-of-fit indices. The WISE explained a range of variance in participants' intention to intervene from 12 to 40%.

Importance: Suicide rates in the US increased by 35.6% from 2001 to 2021. Given that most individuals die on their first attempt, earlier detection and intervention are crucial. Understanding modifiable risk factors is key to effective prevention strategies., Objective: To identify distinct suicide profiles or classes, associated signs of suicidal intent, and patterns of modifiable risks for targeted prevention efforts., Design, Setting, and Participants: This cross-sectional study used data from the 2003-2020 National Violent Death Reporting System Restricted Access Database for 306 800 suicide decedents. Statistical analysis was performed from July 2022 to June 2023., Exposures: Suicide decedent profiles were determined using latent class analyses of available data on suicide circumstances, toxicology, and methods., Main Outcomes and Measures: Disclosure of recent intent, suicide note presence, and known psychotropic usage., Results: Among 306 800 suicide decedents (mean [SD] age, 46.3 [18.4] years; 239 627 males [78.1%] and 67 108 females [21.9%]), 5 profiles or classes were identified. The largest class, class 4 (97 175 [31.7%]), predominantly faced physical health challenges, followed by polysubstance problems in class 5 (58 803 [19.2%]), and crisis, alcohol-related, and intimate partner problems in class 3 (55 367 [18.0%]), mental health problems (class 2, 53 928 [17.6%]), and comorbid mental health and substance use disorders (class 1, 41 527 [13.5%]). Class 4 had the lowest rates of disclosing suicidal intent (13 952 [14.4%]) and leaving a suicide note (24 351 [25.1%]). Adjusting for covariates, compared with class 1, class 4 had the highest odds of not disclosing suicide intent (odds ratio [OR], 2.58; 95% CI, 2.51-2.66) and not leaving a suicide note (OR, 1.45; 95% CI, 1.41-1.49). Class 4 also had the lowest rates of all known psychiatric illnesses and psychotropic medications among all suicide profiles. Class 4 had more older adults (23 794 were aged 55-70 years [24.5%]; 20 100 aged ≥71 years [20.7%]), veterans (22 220 [22.9%]), widows (8633 [8.9%]), individuals with less than high school education (15 690 [16.1%]), and rural residents (23 966 [24.7%])., Conclusions and Relevance: This study identified 5 distinct suicide profiles, highlighting a need for tailored prevention strategies. Improving the detection and treatment of coexisting mental health conditions, substance and alcohol use disorders, and physical illnesses is paramount. The implementation of means restriction strategies plays a vital role in reducing suicide risks across most of the profiles, reinforcing the need for a multifaceted approach to suicide prevention.

Previous research has documented many behavioral problems associated with being a female victim of sexual assault, but little attention has been devoted to whether this experience might be related to premature mortalities. We investigated this utilizing the National Longitudinal Study of Adolescent to Adult Health survey, collected from over 10,000 adolescent females in 1995, whose premature deaths ( n  = 65) were noted in 2007 in National Death Index records. Significant associations were found between females with a substance misuse history and their premature deaths, but not with being a sexual assault victim. The subset of respondents ( n  = 208) evincing both these characteristics showed significantly higher risks of dying prematurely, as did those females with early histories of drug misuse alone. Yet, adolescent females with histories of drug misuse who also attempted suicide ( n  = 214) did not show similar elevated risks of dying prematurely compared to others without these experiences. This exploratory evidence points to an affinity between both being a female sexual assault victim and having an early history of misusing drugs, putting such people at heightened risks for dying prematurely, suggesting the potential benefits of counseling and supportive services for those so affected.

Although exposure to the suicide death of a military colleague has been shown quantitatively to increase suicide risk factors among veterans, there are very few studies where veterans have been asked about this experience. This article presents a qualitative analysis of 38 interviews with U.S. veterans with exposure to the suicide death of a military colleague in past war operations. Participants described the impact of exposure in relation to the military context and official response to the death, which had long-term ramifications. Our findings suggest suicide prevention and postvention responses for veterans should be informed by the lived experience of veterans, including those for whom this experience occurred significantly in the past, as the impacts of different military policies and practices in response to suicide deaths over time are relevant to the impact of exposure to death of a military colleague in the short and long term.

Background: The toll associated with suicide goes well beyond the individual who died. This study focuses on a risk factor for veteran suicide that has received little previous empirical attention-exposure to the suicide death of another person., Objective: The study's primary objective is to describe the mental health outcomes associated with suicide exposure among veterans who served on active duty after September 2001 ("post-9/11"). The secondary objective is to elucidate why some veterans develop persistent problems following suicide exposure, whereas others do not., Methods: This is an explanatory, sequential, mixed methods study of a nationally representative sample of post-9/11 veterans enrolled in Department of Veterans Affairs (VA) health care. Our sampling strategy was designed for adequate representation of female and American Indian and Alaska Native veterans to allow for examination of associations between suicide exposure and outcomes within these groups. Primary outcomes comprise mental health problems associated with trauma and loss (posttraumatic stress disorder and prolonged grief disorder) and suicide precursors (suicidal ideation, attempts, and planning). Data collection will be implemented in 3 waves. During wave 1, we will field a brief survey to a national probability sample to assess exposure history (suicide, other sudden death, or neither) and exposure characteristics (eg, closeness with the decedent) among 11,400 respondents. In wave 2, we will include 39.47% (4500/11,400) of the wave-1 respondents, stratified by exposure history (suicide, other sudden death, or neither), to assess health outcomes and other variables of interest. During wave 3, we will conduct interviews with a purposive subsample of 32 respondents exposed to suicide who differ in mental health outcomes. We will supplement the survey and interview data with VA administrative data identifying diagnoses, reported suicide attempts, and health care use., Results: The study began on July 1, 2022, and will end on June 30, 2026. This is the only national, population-based study of suicide exposure in veterans and the first one designed to study differences based on sex and race. Comparing those exposed to suicide with those exposed to sudden death for reasons other than suicide (eg, combat) and those unexposed to any sudden death may allow for the identification of the common and unique contribution of suicide exposure to outcomes and help seeking., Conclusions: Integrating survey, qualitative, and VA administrative data to address significant knowledge gaps regarding the effects of suicide exposure in a national sample will lay the foundation for interventions to address the needs of individuals affected by a suicide death, including female and American Indian and Alaska Native veterans., International Registered Report Identifier (irrid): DERR1-10.2196/51324., (©Nina A Sayer, David B Nelson, Jaimie L Gradus, Rebecca K Sripada, Maureen Murdoch, Alan R Teo, Robert J Orazem, Julie Cerel. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 26.09.2023.)