Combat injury, pain, and suicidal ideation in U.S. army service members and veterans

Pain is associated with suicidal thoughts and behaviors among U.S. service members and veterans. Risk for suicidal ideation (SI) may vary based on the origins of pain, with combat injury being a particularly fear-inducing and relevant source of pain for service members. Established SI-related factors, such as perceived burdensomeness and acquired capability may also be important to these associations. We examined the associations of (1) combat injury, post-deployment pain, and SI prospectively in U.S. Army service members assessed before and at three timepoints after a combat deployment; and in a separate sample (2) ongoing combat-injury-related pain and SI cross-sectionally at long-term follow-up approximately 6 years post-enlistment. We also included pain-related (pain intensity, interference, and catastrophizing) and SI-related (perceived burdensomeness, acquired capability) factors in both sets of analyses. In the longitudinal sample (n=4645), combat injury was not prospectively associated with past-30-day SI at 3 or 9 months post-deployment. However, pain interference (OR=1.60, 95%CI:1.13–2.27) and pain catastrophizing (OR=1.57, 95%CI:1.04–2.38) at 3 months post-deployment were prospectively associated with SI at 9 months post-deployment. In the cross-sectional sample (n=6333), pain interference (OR=2.21, 95%CI:1.63–3.01), but not combat-injury-related pain, was associated with past-30-day SI. Furthermore, the relations between pain interference and SI were maintained in both samples even after adjustment for perceived burdensomeness and acquired capability, central components of the Interpersonal Theory of Suicide. Results indicate that SI is more strongly associated with pain-related factors—such as the perception of pain's impact on functioning—than to the occurrence of combat injury, per se. Perspective: The functional and psychological consequences of pain, rather than the cause of pain, are associated with increased risk of suicidal ideation among U.S. soldiers. Treatment and prevention of suicidal ideation in this population may benefit from a focus on effective pain management.