Case 66: Prominent Assessment Instruments in Suicide and PTSD Research on U.S. Veterans

Prominent Assessment Instruments

in Suicide and PTSD Research on U.S. Veterans

        Over the past 2 decades, clinicians have expressed extensive research interest in the study of 2 prominent afflictions (Suicide/Suicide Potential; PTSD) affecting veterans in the USA (Bisson et al., 2019; Bohnert et al., 2017; Bush 2012, 2014; Jackson, 2017; Kessler et al., 2017; Shura et al., 2019; Wilson & Keane, 2004; Wisco et al., 2014). From a clinical perspective, both these mental health conditions tend to have high co-occurring rates (DeBeer et al., 2014; Horwitz et al., 2019; Pompili et al., 2013; Watkins et al., 2017). The prospect for efficacious treatment for these conditions resides in the accurate diagnosis and assessment of veterans presenting with various forms of psychopathology and mental health symptoms that may confer either the potential for Suicide (or suicidal ideation) and/or Posttraumatic stress (see Stanley et al., 2019). Thus, the challenges for both mental health providers and VA patients are not only great but indeed potentially life-threatening. In fact, according to VA and government statistics, veterans account for about 20% of all suicides in the USA, over twice the rate of the general population. Moreover, due to the ubiquitous media coverage of ‘veteran suicides’ over the past decade, veterans could be increasingly prone to the effects of ‘suicide contagion’ which can increase the probability of one’s personal risk for suicide (see Wolford-Clevenger et al., 2019).

        To date, there is an extensive body of extant literature on the topic of Suicide and PTSD. Moreover, research with a focus on the screening and evaluation of these clinical conditions has been advancing at an exponential pace, culminating in copious books and book chapters addressing the specific issue of assessment and testing of veterans (Bongar et al., 2017; Kearney et al., 2017; Kleespies & AhnAllen, 2017). Moreover, several studies have addressed mental health assessment ‘practices’ with regard to Suicide (potential) and PTSD (see Elhai et al., 2005; Pease et al., 2017). Indeed, this emerging literature prompts an interesting question --Which tests/assessment protocols are most relied upon by researchers when they formulate investigatory research designs for studies screening veterans for these clinical conditions?

        Unfortunately, the answer to this important issue is rather confounded. In terms of government guidelines, the Joint Commission’s National Patient Goal (NPSG 15) directs suicide risk assessment for patients who present with emotional or behavioral complaints, and all VA facilities are mandated to comply with NPSG 15 (see Doran et al., 2016). However, according to Green et al. (2017, p. 209), there has been little consensus at VA facilities regarding specific assessment protocols for suicide risk screenings (although the VA has recently addressed this issue to some degree); moreover, these screenings do not usually assess for ‘self-harm’ (e.g., physical fighting, self-cutting). In addition, research has shown that military members inconsistently confirm or under-report critical data-points such as suicide-attempt history (Hom et al., 2019).

        To address this critical issue regarding assessment, the current analysis of the recent mental health literature identified the major tests/ measures/ assessment instruments evident in research studies on the subject areas of Suicide potential and PTSD with a focus on veterans. A Boolean online search of the  database  PsycINFO,  using  keywords (veterans + suicide; veterans + PTSD) for years 2013-2019, produced 323 and 1,098 articles for each condition, respectively. The PsycINFO display offers a scroll-down menu option for tests and measures cited in the search results (in terms of frequency of mentions);  for  comparison  purposes,  I replicated the search command for all populations under study (so as to gauge any differences between studies overall versus those limited to veteran populations). Table 1 presents the listing, in rank order, of the top tests/assessment protocols for both these analyses.

Table 1. Predominant Measures Used by Researchers in the Study of Suicide/PTSD in Veterans

        Table 1 illustrates the most prominent assessment measures for Suicide potential and/or PTSD used by researchers in the study of veteran populations. These results indicate that several measures are relied upon frequently by these researchers on investigations for both these clinical conditions, i.e., the PTSD Checklist-Military Version, the Beck Depression Inventory, the Mini International Neuropsychiatric Interview,

the Patient Health Questionnaire-9, and the Alcohol Use Disorders Identification Test.

Several of these instruments have been found to be among the most popular evaluation techniques reported by practitioner samples (Piotrowski, 2018; Stolberg & Bongar, 2009; Wright et al., 2017). A recent survey of assessment practices by VA psychologists reported that the PTSD Checklist is used by 30% of the sample (Russo, 2018).

        Interestingly, these most relied upon tests/measures in research seem to contrast to some degree the most popular tests used specifically by PTSD/trauma clinicians in practice. Although the current findings confirm practitioners’ survey data reported by Elhai et al. (2005) with regard to reliance on the PTSD Checklist, Clinician-Administered PTSD Scale and Structured Clinical Interview for DSM, the Elhai et al. sample favored use of several instruments not found popular in the current analysis of researchers (i.e., Trauma Symptom Inventory, Posttraumatic Stress Diagnostic Scale, the MMPI-2-Keane PTSD Scale, the Impact of Event Scale, the SCL-90 Revised-PTSD Scale). The reason for this discrepancy is not readily apparent, other than that investigators may find some assessment instruments more amenable to research.

        Although not listed in the current analysis, the Primary Care-PTSD Screen is currently a standard screening tool used in VA facilities (Calhoun et al., 2010). Noteworthy, the development of novel PTSD measures seems to be an active area of research endeavor (e.g., Del Vecchio et al., 2011), as well as perennial modifications to practice guidelines for the treatment of PTSD conditions (see Courtois & Brown, 2019).

        With regard to the issue of suicide, it is somewhat difficult to interpret the current listing of assessment methods used by researchers, as there is a dearth of prior test-usage studies in this clinical area. However, several of the measures used in suicide studies (listed in Table 1) are also used frequently in PTSD research. Apparently, the Columbia Suicide Severity Rating Scale has reportedly been adapted as a tool for the assessment of suicide risk in some VA facilities (Green et al., 2017). In addition, researchers are also focusing on the impact of combat exposure on suicide potential in veterans; the Combat Experiences Scale and the Combat Exposure Scale are most noteworthy in this regard (Corona et al., 2019; Kopacz et al., 2016). At the same time, researchers continue to publish a myriad of assessment approaches in the study of suicidology (Forkmann et al., 2018), including suicide ideation measures specific to veteran populations (Hom et al., 2019). Current psychological assessment protocol at VA facilities mandate the use of the modified PC-PTSD, which includes an item on ‘self-harm’. Undoubtedly, the clinical utility of such a brief screener prompts concerns regarding ‘false negatives’ and the need for a more comprehensive evaluation of suicidal ideation for veterans in need of mental health treatment (Simons et al., 2019).

        In conclusion, it appears that researchers, studying veteran samples, tend to rely on both traditional (e.g., Beck scales; see Piotrowski & Lubin, 1990) and domain-specific measures in the study of Suicide and PTSD. It must be noted that more rigorous research on suicide risk assessment is urgently needed, particularly since the current state of the research science in this domain (i.e., risk factors) offers limited diagnostic assistance to practitioners (see Sommers-Flanagan & Shaw, 2017). Moreover, co-morbidity factors in suicidal ideation are a much under-researched area of study (see Cheref et al., 2019; Riblet, 2019). Further, the contemporary ‘social networking’ milieu may provide an additional data-source in the assessment of suicide potential for researchers and treatment personnel to consider (Cero & Witte, 2019). Finally, future research efforts should focus on the PTSD-Suicide link, where extant research on efficacious intervention and treatment for posttraumatic states could make a significant contribution in addressing and reducing suicide rates of military veterans.

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