Hazardous drinking and clinical correlates among suicidal patients receiving psychiatric inpatient care at military medical settings

Addictive Behaviors 102 (2020) 106178

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Hazardous drinking and clinical correlates among suicidal patients receiving psychiatric inpatient care at military medical settings

T

Jeremy W. Luka, Jessica M. LaCroixa, Matthew F. Thompsona, Charles Darmoura, Kanchana U. Pereraa, David Goldstonb, Alyssa Soumoffc, Jennifer Weaverd, ⁎ Marjan Ghahramanlou-Hollowaya, a

Uniformed Services University of the Health Sciences, Department of Medical and Clinical Psychology, 4301 Jones Bridge Road, Bethesda, MD 20814, USA Duke University School of Medicine, Box 3527 Med Ctr, Durham, NC 27710, USA c Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889, USA d Fort Belvoir Community Hospital, 9300 DeWitt Loop, Fort Belvoir, VA 22060, USA b

HIGHLIGHTS

were collected from a unique sample of military psychiatric inpatients. • Data this clinical sample, 28.9% of participants reported hazardous drinking. • InHazardous was associated with a diagnosis of Substance Use Disorder. • Hazardous drinking was associated with a history of actual, but not interrupted or aborted, suicide attempt(s). • Link betweendrinking hazardous drinking and single attempt history remained after controlling for covariates. • ARTICLE INFO

ABSTRACT

Keywords: Alcohol Psychiatric inpatient Military Suicide attempt Suicide ideation

Background: To describe prevalence and identify clinical correlates of hazardous drinking among suicidal inpatients at military medical settings. Method: Data were drawn from the baseline assessment of a multisite randomized controlled trial of PostAdmission Cognitive Therapy (PACT). Participants were military Service members or adult beneficiaries (N = 218) who were admitted to inpatient care following a suicide-related crisis. Hazardous alcohol use in the past year was assessed using the Alcohol Use Disorder Identification Test (AUDIT). Results: The average AUDIT score was 6.78 (SD = 7.87), with 28.9% reporting hazardous drinking (scored ≥8 on the AUDIT). Hazardous drinkers were more likely than nonhazardous drinkers to meet diagnosis of Substance Use Disorder (SUD; Odds Ratio [OR] = 5.96, 95% confidence intervals [CI] = 2.13, 16.71). Hazardous drinking was neither associated with measures of suicide ideation nor aborted or interrupted suicide attempt. However, hazardous drinkers had greater risk of having both single (RRR [Relative Risk Ratio] = 2.55, 95% CI = 1.18, 5.50) and multiple actual suicide attempts (RRR = 2.38, 95% CI = 1.06, 5.32) than nonhazardous drinkers. The association between hazardous drinking and single (but not multiple) actual suicide attempt remained significant after controlling for gender, depressive symptoms, hopelessness, Post-Traumatic Stress Disorder, and SUD (adjusted RRR = 2.48, 95% CI = 1.09, 5.65). Conclusions: A history of actual suicide attempt is associated with hazardous alcohol use among suicidal psychiatric inpatients. Assessment of drinking and drug use may inform case conceptualization and treatment of suicide-related behaviors in psychiatric inpatient settings.

⁎ Corresponding author at: Department of Medical and Clinical Psychology and Psychiatry, Uniformed Services University of the Health Sciences (USUHS), 4301 Jones Bridge Road, Room 3046, Bethesda, MD 20814-4799, United States. E-mail addresses: [email protected] (J.W. Luk), [email protected] (J.M. LaCroix), [email protected] (M.F. Thompson), [email protected] (C. Darmour), [email protected] (K.U. Perera), [email protected] (D. Goldston), [email protected] (A. Soumoff), [email protected] (J. Weaver), [email protected] (M. Ghahramanlou-Holloway).

https://doi.org/10.1016/j.addbeh.2019.106178 Received 12 July 2019; Received in revised form 19 September 2019; Accepted 11 October 2019 Available online 23 October 2019 0306-4603/ Published by Elsevier Ltd.

Addictive Behaviors 102 (2020) 106178

J.W. Luk, et al.

1. Introduction

1.3. Hazardous drinking and suicide behaviors

Epidemiologic evidence suggests that mental disorders and suicidality commonly co-occur with excessive drinking among United States (US) military Service members and Veterans (Meadows et al., 2018). Among new soldiers in the US Army, lifetime prevalence of PostTraumatic Stress Disorder (PTSD), Generalized Anxiety Disorder (GAD), Major Depressive Disorder (MDD), and suicide ideation were higher among soldiers who misused alcohol than those who did not (Stein et al., 2017). Additionally, US Veterans with lifetime alcohol use disorder were more likely to report lifetime and current mood and anxiety disorders, drug use disorder, current suicide ideation, and lifetime suicide attempt (Fuehrlein et al., 2016). These findings point to the importance of assessing alcohol misuse as a risk indicator for other clinical characteristics as it may inform case conceptualization (e.g., alcohol misuse as a maladaptive coping strategy for mental health issues or suicidality). Accordingly, the present study examined the prevalence and clinical correlates of hazardous drinking among suicidal inpatients at military medical settings.

The lifetime risk of suicide is elevated among individuals with alcoholism (Murphy & Wetzel, 1990). In a large-scale cohort study, individuals who had an alcohol-related emergency hospital admission were at much higher risk for subsequent suicide death (Hazard Ratio = 26.8; Bowden et al., 2018). Acute alcohol use is also associated with higher odds of suicide attempt (Odds Ratio [OR] = 6.97; Borges et al., 2017). Among individuals presenting to a hospital after a suicide attempt, one-third reported consuming alcohol prior to the attempt, although the majority reported that they did not drink alcohol to specifically facilitate the attempt (Bagge, Conner, Reed, Dawkins, & Murray, 2015). In exploring the link between alcohol misuse and suicide attempt, it may be useful to differentiate between types of attempts. Actual suicide attempts refer to self-directed injurious behaviors with the intent to die. Distinguished from actual attempts, aborted and interrupted attempts refer to self-directed injurious behaviors that are stopped by oneself or interrupted by external circumstances, respectively (Posner et al., 2011). A history of aborted/interrupted attempt is important to study as individuals with such history share important suicide risk characteristics with those who have a history of actual suicide attempt (Burke, Hamilton, Ammerman, Stange, & Alloy, 2016). However, individuals with a history of only aborted attempts may represent a less clinically severe group than individuals with a history of actual attempt (Rogers, Hom, Dougherty, Gallyer, & Joiner, 2018). Considering the link between hazardous alcohol use and history of different types of suicide attempts can inform prevention efforts, as the prevention of hazardous alcohol use in high-risk populations, such as among drinkers with suicide ideation and/or attempt histories, has the potential to mitigate risk of future suicide attempt (Conner, Bagge, Goldston, & Ilgen, 2014). Within the US military, suicide has been a leading cause of death for the past decade and has recently surpassed combat and transportation accidents to become the leading cause of death among active duty Service members (Armed Forces Health Surveillance Center, 2014). Alcohol misuse has been associated with suicide ideation in a nonclinical military sample (Stein et al., 2017), and drinking to avoid rejection, or to “fit in,” has been linked to seriously considering and/or attempting suicide in the US Army (Mash et al., 2016). Among US military personnel, depression and alcohol-related problems were associated with increased risk of death by suicide (LeardMann et al., 2013). Given these studies, it is reasonable to expect elevated hazardous drinking in a clinical sample of suicidal individuals; however, its potential associations with specific dimensions of ideation intensity and types of suicide attempts have not been adequately studied in a psychiatric inpatient setting.

1.1. Prevalence of hazardous drinking in the US military Excessive drinking is prevalent among US young adults and can lead to alcohol-related injuries, overdose, and hospitalization (Hingson, Zha, & Smyth, 2017; White & Hingson, 2013). According to the Department of Defense Health Related Behaviors Survey (HRBS), prevalence of heavy drinking and binge drinking among US active duty military Service members increased from 1998 to 2008 (Bray, Brown, & Williams, 2013). In 2008, 33.1% of active duty military Service members met criteria for hazardous drinking, as indicated by a score of 8 or more on the Alcohol Use Disorders Identification Test (AUDIT; Bray et al., 2009; Mattiko, Olmsted, Brown, & Bray, 2011). In 2015, 30.0% of Service members reported binge drinking, which was higher than the prevalence of 24.7% among civilian US adults, and 35.3% met criteria indicative of hazardous drinking based on the AUDIT for Consumption (Meadows et al., 2018). The persistently elevated drinking rates are concerning, as excessive drinking among US active duty military Service members may lead to negative consequences such as job performance problems, alcohol-impaired driving, and criminal justice problems (Stahre, Brewer, Fonseca, & Naimi, 2009), and may compromise psychological fitness and operational readiness (Jonas et al., 2010). 1.2. Hazardous drinking and mental disorders in military and Veteran samples Drinking to cope has been proposed as a key motivation underlying psychological distress and hazardous drinking among current and former military Service members (Mohr, McCabe, Haverly, Hammer, & Carlson, 2018). For instance, US Veterans who screened positive for PTSD or depression were two times more likely to report alcohol misuse than those who screened negative for these conditions (Jakupcak et al., 2010). A comparative analysis of military and civilian students revealed that coping motives are positively associated with alcohol-related problems among military members but not civilian students (Whiteman & Barry, 2011), possibly due to heightened stress exposure among military students. The use of drugs and alcohol to cope with symptoms of PTSD or depression has been associated with higher self-reported peak blood alcohol concentration and greater likelihood of binge drinking (Cucciare, Darrow, & Weingardt, 2011). Among US military Veterans, drinking to cope motives mediated the associations between PTSD symptoms with hazardous drinking (McDevitt-Murphy, Luciano, Tripp, & Eddinger, 2017) and alcohol-related problems (Miller, Pedersen, & Marshall, 2017). Despite these studies, less is known about the prevalence and correlates of hazardous drinking among suicidal military personnel.

1.4. The current study The goals of this study were to (1) describe the prevalence of hazardous drinking in a sample of military personnel and adult beneficiaries psychiatrically hospitalized following a suicide-related crisis, (2) test the associations between hazardous drinking and four mental disorders previously examined in epidemiologic studies (PTSD, GAD, MDD, and Substance Use Disorder [SUD]; Fuehrlein et al., 2016; Stein et al., 2017), and (3) examine the associations between hazardous drinking and lifetime measures of suicide ideation (i.e., frequency, duration, and controllability) and attempt (i.e., aborted, interrupted, and actual attempts). We hypothesized that hazardous drinkers would have higher odds of meeting criteria for mental disorders and report greater frequency and duration but lower controllability of suicide ideation than nonhazardous drinkers/nondrinkers. Given that hazardous drinking may reduce self-control or put one self in riskier environments, we expected a history of actual (but not aborted or interrupted) suicide attempt would be associated with hazardous drinking. 2

J.W. Luk, et al.

Addictive Behaviors 102 (2020) 106178

2. Methods

Table 1 Demographic characteristics and AUDIT scores in the PACT sample (N = 218).

2.1. Participants Data came from the baseline assessment of a multisite randomized controlled trial assessing the efficacy of Post-Admission Cognitive Therapy (PACT; Ghahramanlou-Holloway, Cox, & Greene, 2012). Data utilized in this study were different from those presented in pilot trials of PACT (Ghahramanlou-Holloway et al., 2018; LaCroix et al., 2018). Participants (N = 218, mean age = 30.0, SD = 9.6) were military Service members (n = 192) and adult beneficiaries1 (n = 26) who had a recent suicide-related crisis which warranted psychiatric inpatient hospitalization. As shown in Table 1, the sample was 37.6% female, 40.8% racial/ethnic minorities, 36.2% had an associate degree or higher, and 41.7% were married. Most military Service members were enlisted (81.8%) and each of the five military branches were represented.

Age, Mean (SD), Years Gender Male Female Race/Ethnicity Non-Hispanic White African American Hispanic Asian/Pacific Islanders Mixed Race Other Education High school diploma Some college, no degree Associate degree or higher Marital Status Never married Married Separated/Divorced Pay Grade/Ranka E1-E4 E5-E9 W1-W5 O1-O6 Cadet/Midshipman Military Brancha Army Air Force Navy Marine Corps Coast Guard AUDITb Score, Mean (SD) 0–7 (Abstinence/Low-risk) 8–15 (Hazardous Drinking) 16–19 (Harmful Drinking) 20–40 (Possible Dependence)

2.2. Measures 2.2.1. Hazardous drinking The AUDIT is a 10-item instrument developed by the World Health Organization as a screening tool to identify individuals with hazardous/ harmful alcohol consumption (Saunders, Aasland, Babor, De la Fuente, & Grant, 1993). Items assess three domains of alcohol use in the past year: drinking quantity and frequency (3 items), dependence symptoms (3 items), and harmful alcohol use (4 items). Each item response ranges from 0 to 4, yielding a maximum possible score of 40. An AUDIT score of 8 or more is indicative of hazardous/harmful alcohol use (Babor, Higgins-Biddle, Saunders, & Monteiro, 2001). The AUDIT has been used in military samples to identify hazardous drinking (scores between 8 and 15), harmful drinking (scores between 16 and 19), and possible alcohol dependence (scores between 20 and 40; Mattiko et al., 2011). In the current study, the clinician-administered version was used.

Frequency

Percent

30.0

(9.6)

136 82

62.4% 37.6%

129 32 28 15 10 4

59.2% 14.7% 12.8% 6.9% 4.6% 1.8%

50 89 79

22.9% 40.8% 36.2%

87 91 40

39.9% 41.7% 18.4%

83 74 4 23 8

43.2% 38.5% 2.1% 12.0% 4.2%

82 22 51 34 3 6.78 155 30 12 21

42.7% 11.5% 26.6% 17.7% 1.6% (7.87) 71.1% 13.8% 5.5% 9.6%

Military Pay Grade/Rank and Branch are presented for military personnel only (n = 192). b Alcohol Use Disorders Identification Test. a

2.2.2. Mental disorders The Mini International Neuropsychiatric Interview (MINI) is a brief, clinician-administered structured interview assessing psychiatric disorders (Sheehan et al., 1998). The MINI has good inter-rater and testretest reliability (Lecrubier et al., 1997), and was validated through comparisons with the Structured Clinical Interview for DSM-III-R Patients (SCID-P) and the Composite International Diagnostic Interview (CIDI) (Sheehan et al., 1997). For the purpose of this study, we utilized PTSD, GAD, and current MDD for analyses. We created the SUD variable by combining the non-alcohol substance abuse (n = 5) and nonalcohol substance dependence diagnoses (n = 13) into a binary variable (1 = either diagnosis versus 0 = neither).

suicide ideation) of ideation, as well as deterrents and reasons for ideation or attempt. In the current study, we focused on frequency, duration, and controllability of ideation, because there is no prior literature or theoretical rationale to link hazardous drinking to deterrents or reasons for suicide. The frequency and duration items are rated on a 5-point scale, whereas the controllability item ranges from 0 = “does not attempt to control thoughts” to 1 = “easily able to control thoughts” to 5 “unable to control thoughts.” Due to skewed and non-normal distributions, we dichotomized the ideation items by contrasting the highest possible response (i.e., “many times each day” for frequency; “more than 8 h/ persistent or continuous” for duration; and “unable to control thoughts” for low controllability) versus all other responses. For the controllability item, we analyzed the data in two ways: first coding “does not attempt to control thoughts” as a valid zero and then recoding it as missing due to the ambiguity of this response option. The C-SSRS also assesses lifetime prevalence of actual, interrupted, and aborted suicide attempts. For the current analysis, history of aborted, interrupted, and actual suicide attempt was categorized into three groups capturing zero, single (one time), and multiple (two or more times) suicide attempts.

2.2.3. Suicide ideation and attempt The Columbia-Suicide Severity Rating Scale (C-SSRS; Posner et al., 2011) is a clinician-administered interview assessing the intensity of suicide ideation and prevalence of lifetime suicide behavior. Suicide ideation intensity can be assessed using five items measuring frequency, duration, and controllability (reflecting ease or difficulty in controlling 1 Sensitivity analyses were conducted to evaluate the appropriateness of including adult beneficiaries as part of the analytic sample. Although military Service members were less likely to be females than adult beneficiaries (76.9% vs. 32.3%, OR = 0.14, 95% CI = 0.05–0.37, p < 0.001), military Service members and adult beneficiaries did not differ in terms of age (p = 0.169), racial/ethnic minority status (p = 0.130), education (p = 0.162), and marital status (p = 0.455). Moreover, all the significant findings found in the analytic sample were fully replicated in the restricted sample of 192 military Service members only. This supports the inclusion of adult beneficiaries as a reasonable choice which simultaneously maximizes sample size and generalizability of findings.

2.2.4. Covariates Depressive symptoms and hopelessness are theoretically linked to increased risk of suicide-related behaviors and were included as study covariates (Beck & Steer, 1989; Ribeiro et al., 2012). These constructs were measured using the Beck Depression Inventory-II (BDI-II; Beck, 3

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Table 2 Prevalence of mental disorders based on the MINI International Neuropsychiatric Interview by hazardous drinking status (AUDIT score ≥ 8). Mental Disorders

PTSD GAD MDD SUD

AUDIT ≥ 8 (n = 63)

AUDIT < 8 (n = 155)

n

%

n

%

26 38 58 12

41.3% 60.3% 92.1% 19.4%

51 90 144 6

33.1% 58.1% 92.9% 3.9%

Odds Ratios

95% CI

1.42 1.10 0.89 5.96

(0.78, 2.59) (0.60, 1.99) (0.29, 2.66) (2.13, 16.71)

Note. For PTSD, one participant with AUDIT < 8 had missing data. For SUD, one participant with AUDIT ≥ 8 had missing data. Percentages were calculated based on valid frequencies. Logistic regressions were conducted to obtain the odds ratios of meeting criteria for mental disorders among those who reported hazardous drinking compared to those who did not report hazardous drinking. Statistically significant results (p < 0.05) are highlighted in bold. AUDIT = Alcohol Use Disorders Identification Test. PTSD = Post-Traumatic Stress Disorder. MDD = Major Depressive Disorder. GAD = Generalized Anxiety Disorder. SUD = Substance Use Disorder. CI = Confidence Intervals. Table 3 Hazardous drinking and the frequency, duration and controllability of lifetime suicide ideation. C-SSRS Suicide Ideation

Frequency – many times each day Duration – more than 8 h/day Controllability – unable to control Controllability – unable to controla

AUDIT ≥ 8 (n = 63)

AUDIT < 8 (n = 155)

n

%

n

%

23/62 15/62 20/62 20/50

37.1% 24.2% 32.3% 40.0%

56/155 25/154 49/155 49/125

36.1% 16.2% 31.6% 39.2%

Odds Ratios

95% CI

1.04 1.65 1.03 1.03

(0.57, (0.80, (0.55, (0.53,

1.92) 3.39) 1.94) 2.02)

Note. C-SSRS = Columbia-Suicide Severity Rating Scale. One participant with AUDIT ≥ 8 had missing data on all three items. An additional participant with AUDIT < 8 had missing data on the duration item. Valid percentages are presented. a Response option “0 = does not attempt to control thoughts” (n = 42) was coded as missing. The odds ratios were very similar regardless of the coding of this ambiguous response option.

Steer, & Brown, 1996) and the Beck Hopelessness Scale (BHS; Beck, Weissman, Lester, & Trexler, 1974).

drinkers did not reported greater odds of experiencing more frequent, more durable, and more uncontrollable lifetime suicide ideation than nonhazardous drinkers.2 As shown in Table 4, hazardous drinkers had higher risk of reporting a lifetime history of both single and multiple actual suicide attempts than nonhazardous drinkers (single attempt: 46.0% vs. 34.8%; Relative Risk Ratios [RRR] = 2.55, 95% CI = 1.18, 5.50; multiple attempts: 34.9% vs. 28.4%; RRR = 2.38, 95% CI = 1.06, 5.32). The association between hazardous drinking and single actual suicide attempt remained significant after controlling for female gender, depressive symptoms, hopelessness, PTSD, and SUD (adjusted RRR = 2.48, 95% CI = 1.09, 5.65). In the adjusted model, SUD showed a nonsignificant trend in its association with multiple attempt history (RRR = 4.40, p = 0.076), which likely contributed to the attenuated association between hazardous drinking and history of multiple actual suicide attempts.

2.3. Statistical analyses Data analyses were conducted in STATA 14.2. First, we obtained descriptive statistics on the AUDIT to evaluate prevalence and severity of hazardous drinking in this sample. Second, we used logistic regressions to examine the associations between hazardous drinking and mental disorders. Third, we used logistic regression analyses to examine associations between hazardous drinking and lifetime suicide ideation frequency, duration, and controllability. Fourth, we used multinomial logistic regressions to examine associations between hazardous drinking and a lifetime history of aborted, interrupted, and actual suicide attempt(s). To rule out competing suicide risk factors as alternative explanations for any observed associations, we further estimated the adjusted relative risk ratios of suicide attempts after controlling for female gender, depressive symptoms, hopelessness, PTSD, and SUD. 3. Results

2 Although not part of the planned analyses, the Scale for Suicide Ideation (SSI; Beck, Kovacs, & Weissman, 1979) was administrated to the PACT study participants and could be used as an additional measure of suicide ideation (n = 217). To further explore possible associations between hazardous drinking and suicide ideation, two post hoc tests were conducted. An independent samples t-test showed no significant difference in SSI score at the most severe time point between hazardous drinkers (M = 26.28, SD = 8.17) and nonhazardous drinkers (M = 27.33, SD = 5.64), t = −1.09, p = 0.277. Due to skewed distribution, SSI score at current time point (i.e., during the clinical interview at inpatient hospitalization) was dichotomized (1 = “any current suicide ideation” vs. 0 = “no current suicide ideation”) for analysis using a logistic regression (with nonhazardous drinking set as the referent group). Hazardous drinking was not associated with increased odds of any current SSI (52.4% vs. 63.6%; OR = 0.63, 95% CI = 0.35, 1.14). In summary, supplementary analyses using the SSI corroborated with our planned analyses using the C-SSRS, indicating the lack of an association between hazardous drinking and suicide ideation in the current sample.

The average AUDIT score in this sample was 6.78 (SD = 7.87), with a range from 0 to 35 (see Table 1). Overall, 28.9% of participants had a score of 8 or more on the AUDIT: 13.8% scored between 8 and 15 (hazardous drinking), 5.5% scored between 16 and 19 (harmful drinking), and 9.6% scored above 20 (possible alcohol dependence). Table 2 shows the proportion of participants meeting criteria for mental disorders. Hazardous drinkers were more likely than nonhazardous drinkers to meet diagnostic criteria for SUD (19.4% vs. 3.9%; OR [Odds Ratio] = 5.96, 95% confidence intervals [CI] = 2.13, 16.71), but were no more likely than nonhazardous drinkers to meet criteria for PTSD, GAD, or current MDD. Results from logistic and multinomial logistic regressions on the associations between hazardous drinking and suicide ideation and attempt are presented in Tables 3 and 4. As shown in Table 3, hazardous 4

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Table 4 Hazardous drinking and lifetime history of suicide attempts. C-SSRS Attempt History

Aborted suicide attempt 0 time 1 time 2 or more times Interrupted suicide attempt 0 time 1 time 2 or more times Actual suicide attempt 0 time 1 time 2 or more times

AUDIT ≥ 8 (n = 63)

AUDIT < 8 (n = 155)

RRR

95% CI

ARRR

95% CI

n

%

N

%

37 18 8

58.7% 28.6% 12.7%

84 44 27

54.2% 28.4% 17.4%

– 0.93 0.67

– (0.47, 1.82) (0.28, 1.62)

– – –

– – –

42 17 4

66.7% 27.0% 6.4%

120 25 10

77.4% 16.1% 6.5%

– 1.94 1.14

– (0.96, 3.95) (0.34, 3.84)

– – –

– – –

12 29 22

19.1% 46.0% 34.9%

57 54 44

36.8% 34.8% 28.4%

– 2.55 2.38

– (1.18, 5.50) (1.06, 5.32)

– 2.48 1.99

– (1.09, 5.65) (0.83, 4.78)

Note. C-SSRS = Columbia-Suicide Severity Rating Scale. RRR = Relative Risk Ratios. ARRR = Adjusted Relative Risk Ratios. Covariates included female gender, depressive symptoms (BDI-II), hopelessness (BHS), PTSD, and SUD. Statistically significant results (p < 0.05) are highlighted in bold.

positive for current MDD. The lack of variability in internalizing symptoms may partially explain the absence of associations between hazardous drinking with GAD and current MDD.3 Consistent with research on externalizing behaviors (Grant et al., 2015; Krueger et al., 2002), SUD was positively associated with hazardous drinking and emerged as the only significant mental health correlate identified in the current study. This finding suggests that screening for substance use problems may be warranted among military inpatients who scored in the range of hazardous or harmful drinking on the AUDIT. Hazardous drinking was neither associated with dimensions of suicide ideation nor aborted or interrupted suicide attempts, but was associated with a lifetime history of actual suicide attempt(s). These findings are consistent with prior research showing that impairment from substance use is linked to suicide plan and attempt but not ideation (Conner et al., 2007). Moreover, depression may be more strongly associated with suicide ideation than plan or attempt, whereas externalizing problems that are indicative of poor impulse control are predictive of suicide planning and attempt (Nock, Hwang, Sampson, & Kessler, 2010). Lack of associations with aborted and interrupted attempts warrants future research, including the possibility that individuals not under the influence of alcohol could better manage their urges to act on suicide thoughts, or that they tend to be in safer environments where family/peer interventions are more likely to occur. Hazardous drinking was uniquely associated with a lifetime history of single actual suicide attempt. In line with the Fluid Vulnerability Theory, hazardous drinking may serve as both a dynamic and stable suicide risk which facilitates potentially harmful behavior (Rudd, 2006). It has been posited that, for those experiencing suicide ideation, alcohol may serve to reduce inhibitions, lessen fears, or anesthetize pain associated with suicide behaviors (Pompili et al., 2010). Thus, as our results indicate, hazardous drinking may be less related to suicide ideation in military inpatient samples, but may rather facilitate the transition from ideation to attempt. Although it is impossible to determine the temporal sequence of actual suicide attempt and hazardous drinking in the current study, the possibility that hazardous drinkers might engage in more “impulsive” decision-making leading to a suicide attempt should be further examined in future research with military

4. Discussion In a high-risk psychiatric inpatient sample of military personnel and adult beneficiaries, 28.9% of participants reported hazardous drinking in the past year. This percent estimate was within the range of positive AUDIT screenings found in other military samples such as 23.9% in the SERVe Project (Mohr et al., 2018) and 33.1% in the 2008 HRBS (Bray et al., 2009; Mattiko et al., 2011). As the assessment of hazardous alcohol use in the current study was not anonymous and was administered by clinicians in person, underreporting of alcohol misuse could have biased this estimate. Moreover, individuals who struggle with alcohol misuse are known to underutilize treatment (Saunders, Zygowicz, & D'Angelo, 2006), which could have contributed to nonparticipation in the current randomized controlled trial. Even with these caveats, about one in ten (9.6%) participants in the PACT study had an AUDIT score of 20–40, indicative of potential alcohol dependence that warrants referral to a specialist for diagnostic evaluation and treatment (Babor et al., 2001). Because alcohol-related negative consequences tend to be more severe among individuals who score at the highest level of the AUDIT (Mattiko et al., 2011), assessment of whether alcohol use serves as a maintaining factor in mental health problems and suicide-related behaviors may be important for this subgroup of individuals with the highest AUDIT scores. Common comorbid mental disorders including PTSD, MDD, and GAD were not associated with hazardous drinking in the current sample of military suicidal inpatients. Prior research suggested that military Service members may drink to cope with PTSD and depression (Miller et al., 2017; Mohr et al., 2018) and that PTSD symptoms tend to improve after an integrated brief alcohol intervention (Luciano et al., 2018). As the overall prevalence of PTSD is higher in the current sample than in the general population (Blanco et al., 2013), our findings suggest that a positive screen for PTSD among military suicidal inpatients may be common but less indicative of co-occurring alcohol misuse. The lack of association between PTSD and hazardous drinking in the current sample may be due to the smaller sample size and the assessment of PTSD as a diagnosis rather than symptoms. For instance, a recent study showed that the association between alcohol misuse and PTSD is more driven by intrusion and numbing symptoms as opposed to avoidance and hyperarousal symptoms (Langdon et al., 2016). While beyond the scope of the present study, additional research is needed to conduct a more nuanced examination of various PTSD symptoms and hazardous drinking among military suicidal inpatients. In contrast to epidemiologic findings (Fuehrlein et al., 2016; Stein et al., 2017), MDD and GAD were both unrelated to hazardous drinking in the current sample. Given that participants in this study had all experienced a suicide-related crisis, the majority of them were screened

3 In the PACT sample, the prevalence of current MDD is generally high (> 92%). Although examining current MDD remained our primary focus, post hoc analysis was conducted to examine if hazardous drinking would be associated with recurrent MDD (n = 214). A logistic regression indicated that hazardous drinking was not associated with increased odds of MDD, recurrent (46.7% vs. 48.7% among nonhazardous drinkers; OR = 0.92, 95% CI = 0.51, 1.68), supporting our conclusion that hazardous drinking was not associated with MDD in military psychiatric inpatient settings.

5

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and Veteran populations (Murphy & Garavan, 2011; Rimkeviciene & De Leo, 2015). To optimally inform prevention and intervention efforts, longitudinal research should examine whether impulsive decisionmaking represents a shared etiological pathway leading to both hazardous drinking and suicide attempt, or if hazardous drinking impairs decision-making which then elevates risk of suicide attempt. This study has several limitations. First, causality cannot be determined given the cross-sectional data analyses. Specifically, as lifetime measures of suicide ideation and attempt were used, it is unclear how hazardous drinking might be associated with suicide-related behaviors at more specific time points. Second, drinking motives were not assessed as part of the study protocol and so we could not explore whether certain drinking motives (e.g., drinking to cope or self-medicate) may elevate suicide risk among hazardous drinkers. Third, because not all study participants were military Service members, we did not include military-specific variables such as combat history as part of the analysis. Lastly, there is potential for underreporting of both alcohol- and suicide-related behaviors among Service members due to perceived stigma and fear of serious repercussions (Gibbons, Migliore, Convoy, Greiner, & DeLeon, 2014). The current study shows that hazardous drinking is found among 28.9% of military suicidal inpatients and is associated with substance use problems and a lifetime history of a single, and potentially multiple, actual suicide attempt(s). One important implication, therefore, is to encourage screening and evaluation of alcohol and substance use problems in the management and treatment of suicide-related behaviors. Additional work is also needed to improve our understanding of the association between hazardous drinking and suicide risk during different periods of time. Within the military context, alcohol misuse is prevalent among military Service members during basic training and pre-deployment (Derefinko et al., 2016; Harbertson, Hale, Watkins, Michael, & Scott, 2016), and missed opportunities for alcohol misuse prevention have been identified during the post-deployment period (Adams et al., 2019; Larson, Mohr, Adams, Wooten, & Williams, 2014). Accordingly, it may be important to adapt or develop brief psychosocial interventions that address alcohol and suicide risk tailored to the specific stage of military service. Finally, as the effect of drinking on suicide risk may be proximal in time (Conner et al., 2014), research methodologies such as ecological momentary assessment may be utilized in future studies to capture the moment-to-moment fluctuations in impulsivity, drinking motives, and suicide ideation, and to test changes in these variables as possible pathways leading to hazardous alcohol use and suicide attempt.

oversight for baseline and follow-up data collection; additionally, Jessica LaCroix contributed to the data analytic plan and edited this manuscript and David Goldston contributed to parent study design and safety procedures. Matthew Thompson and Charles Darmour assisted with literature review and the drafting of the introduction and discussion. Kanchana Perera served a key role in the preparation of RCT assessment packet, database development, monitoring of data collection, data management, and preparation. Alyssa Soumoff and Jennifer Weaver contributed to the design the parent study and served as hospital site principal investigators. Marjan Ghahramanlou-Holloway served as the principal investigator for the parent RCT study, obtained funding for the project, gained all regulatory approvals, implemented the study procedures, provided oversight for data collection, edited the manuscript, and supervised all aspects of the study. All authors have approved the final manuscript. Conflict of interest No conflicts declared. Acknowledgements The authors would like to thank Laura Novak for her administrative assistance in formatting and submitting this manuscript. References Adams, R. S., Dietrich, E. J., Gray, J. C., Milliken, C. S., Moresco, N., & Larson, M. J. (2019). Post-deployment screening in the military health system: An opportunity to intervene for possible alcohol use disorder. Health Affairs, 38(8), 1298–1306. Armed Forces Health Surveillance Center (2014). Surveillance snapshot: Manner and cause of death, active component, US Armed Forces, 1998–2013. MSMR, 21(10), 21. Babor, T. F., Higgins-Biddle, J., Saunders, J., & Monteiro, M. (2001). The alcohol use disorders identification test (AUDIT): Guidelines for use in primary care. World Health Organization, Department of Mental Health and Substance Abuse. Bagge, C. L., Conner, K. R., Reed, L., Dawkins, M., & Murray, K. (2015). Alcohol use to facilitate a suicide attempt: An event-based examination. Journal of Studies on Alcohol and Drugs, 76(3), 474–481. Beck, A. T., & Steer, R. A. (1989). Clinical predictors of eventual suicide: A 5-to 10-year prospective study of suicide attempters. Journal of Affective Disorders, 17(3), 203–209. Beck, A. T., Kovacs, M., & Weissman, A. (1979). Assessment of suicidal intention: The Scale for Suicide Ideation. Journal of Consulting and Clinical Psychology, 47(2), 343–352. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck depression inventory-II. San Antonio, 78(2), 490–498. Beck, A. T., Weissman, A., Lester, D., & Trexler, L. (1974). The measurement of pessimism: The hopelessness scale. Journal of Consulting and Clinical Psychology, 42(6), 861–865. Blanco, C., Xu, Y., Brady, K., Pérez-Fuentes, G., Okuda, M., & Wang, S. (2013). Comorbidity of posttraumatic stress disorder with alcohol dependence among US adults: Results from National Epidemiological Survey on Alcohol and Related Conditions. Drug and Alcohol Dependence, 132(3), 630–638. Borges, G., Bagge, C., Cherpitel, C. J., Conner, K., Orozco, R., & Rossow, I. (2017). A metaanalysis of acute use of alcohol and the risk of suicide attempt. Psychological Medicine, 47(5), 949–957. Bowden, B., John, A., Trefan, L., Morgan, J., Farewell, D., & Fone, D. (2018). Risk of suicide following an alcohol-related emergency hospital admission: An electronic cohort study of 2.8 million people. PLoS One, 13(4) e0194772. Bray, R. M., Brown, J. M., & Williams, J. (2013). Trends in binge and heavy drinking, alcohol-related problems, and combat exposure in the US military. Substance Use & Misuse, 48(10), 799–810. Bray, R. M., Pemberton, M. R., Hourani, L. L., Witt, M., Olmsted, K. L., Brown, J. M., ... Scheffler, S. (2009). Department of Defense survey of health related behaviors among active duty military personnel. Research Triangle Park, NC: Research Triangle Institute. Burke, T. A., Hamilton, J. L., Ammerman, B. A., Stange, J. P., & Alloy, L. B. (2016). Suicide risk characteristics among aborted, interrupted, and actual suicide attempters. Psychiatry Research, 242, 357–364. Conner, K. R., Bagge, C. L., Goldston, D. B., & Ilgen, M. A. (2014). Alcohol and suicidal behavior: What is known and what can be done. American Journal of Preventive Medicine, 47(3), S204–S208. Conner, K. R., Hesselbrock, V. M., Meldrum, S. C., Schuckit, M. A., Bucholz, K. K., Gamble, S. A., ... Kramer, J. (2007). Transitions to, and correlates of, suicidal ideation, plans, and unplanned and planned suicide attempts among 3,729 men and women with alcohol dependence. Journal of Studies on Alcohol and Drugs, 68(5), 654–662. Cucciare, M. A., Darrow, M., & Weingardt, K. R. (2011). Characterizing binge drinking among US military Veterans receiving a brief alcohol intervention. Addictive

Disclosures Role of Funding Source This work was supported by the United States Department of Defense, United States Army Medical Research and Materiel Command, Military Operational Medicine Research Program [grant number W81XWH-11-2-0106]. The funding sponsor had no role in the study design, collection, analysis, or interpretation of data, writing the manuscript, or the decision to submit the paper for publication. The views expressed in this article are those of the authors and do not reflect the official policy of the Uniformed Services University of the Health Sciences, Department of Army/Navy/Air Force, Department of Defense, or U.S. Government. Contributors Jeremy Luk conceptualized the aims and hypotheses for this manuscript, formulated the data analytic plan, ran the statistical analyses, and wrote the first draft of the manuscript. Jessica LaCroix and David Goldston served as co-principal investigators for the randomized controlled trial (RCT; parent study) and in this capacity provided 6

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