Death Studies, 39: 24–29, 2015 Copyright # Taylor & Francis Group, LLC ISSN: 0748-1187 print=1091-7683 online DOI: 10.1080/07481187.2013.871604

Life Meaning Is Associated With Suicidal Ideation Among Depressed Veterans Abby Braden Department of Pediatrics, University of California, San Diego, California, USA

James Overholser Department of Psychology, Case Western Reserve University, Cleveland, Ohio, USA

Lauren Fisher Massachusetts General Hospital, Boston, Massachusetts, USA

Josephine Ridley Cleveland Wade Park VA Medical Center, Cleveland, Ohio, USA

Suicide is a major public health concern among U.S. veterans. Even when asked directly, veterans who die by suicide have been found to deny suicidal thoughts. Psychological assessment needs to go beyond the current risk factors and evaluate underlying factors that may increase suicide risk. In the present study, diagnostic interviews and self-report questionnaires were used to measure life meaning and suicidal ideation in a sample of 110 depressed veterans. Life meaning was significantly associated with suicidal ideation, even after accounting for depression and suicide history. Life meaning may be an important, previously ignored indicator of suicide risk.

Suicide among U.S. veterans (defined as any individual who has served in any of the U.S. military branches during peacetime or war) is a major public health concern. In the United States, veterans are at higher risk for suicide than nonveterans (Kaplan, Huguet, McFarland, & Newsom, 2007). Veterans comprised 22.2% of completed suicides in the United States from 1999 to 2010, which included approximately 8,030 veterans per year who die by suicide (Department of Veterans Affairs, 2012). The Veterans Healthcare Administration (VHA) System is the largest single healthcare system in the United States, and, within the veteran community, veterans being treated in the VHA are at highest risk for suicide (Blow et al., 2012). Since 2007, the VHA has made a concerted effort to improve veteran suicide Received 28 June 2013; accepted 26 November 2013. Address correspondence to Abby Braden, Center for Healthy Eating and Activity Research, University of California, San Diego, Suite C-203, San Diego, CA 92037. E-mail: [email protected]

prevention by investigating patient characteristics associated with suicide risk (Department of Veterans Affairs, Office of Inspector General, 2007). However, prevalence rates of veteran suicides in the United States remain high (Department of Veterans Affairs, 2012). A continued focus on identifying suicide risk factors among veterans is needed to guide suicide prevention and intervention strategies. Among veterans being treated in the VHA, those with a psychiatric diagnosis are at highest risk for completing suicide (Ilgen et al., 2010). Mental health conditions are relatively common in this population, with 25.6% of veterans obtaining a psychiatric diagnosis (Ilgen et al., 2010). Depressive disorders and substance abuse disorders are the most frequent psychiatric diagnoses, affecting 14.5% and 10.0% of veterans, respectively (Ilgen et al., 2010). Depressed veterans who are treated in veterans affairs (VA) hospitals are particularly vulnerable as suicide rates in this subgroup are estimated to be 7 to 8 times higher than the normal population (Zivin et al., 2007).

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Additional suicide risk factors among veterans include posttraumatic stress disorder (PTSD), alcohol abuse, a prior suicide attempt, a history of inpatient hospitalization, and subjectively poor mental and physical health (Lish et al., 1996; Pietrzak et al., 2010). In response to the VHA’s initiative to target prevention efforts among high-risk groups, all veterans are screened for depression and PTSD, and those who screen positive are automatically asked to complete a suicide risk assessment (Department of Veterans Affairs, Office of Inspector General, 2007). In the VA hospitals, a suicide risk assessment partially involves direct questions by a provider about the presence of suicidal ideation, suicide plans, and protective factors. Despite the recent focus on suicide assessment and prevention in the VHA, unidentified at-risk veterans remain, resulting in cases of undetected, high-risk veterans who eventually complete suicide. Current methods of suicide risk assessment in the VHA are not satisfactory. Veterans who ultimately complete suicide are not consistently identified as high risk by VA providers, even when these veterans contacted providers in the months prior to death. Several recent investigations have examined veterans’ healthcare utilization in the months prior to suicide. Findings indicate that almost all veterans enrolled in VA hospitals who died by suicide saw a provider within the year before death, and approximately half contacted a provider in the month prior to death (Britton et al., 2012). Furthermore, although documented suicidal ideation was the strongest predictor of completed suicide 1 week after contact, suicidal ideation was only documented in 18% of suicides that occurred 1 week after care (Britton et al., 2012). Further problematic, direct assessment of suicidal thoughts and feelings does not always capture veterans at highest risk. For example, among veterans who completed suicide and had been assessed for suicidal ideation at their final visit before death, 78% denied the presence of suicidal ideation (Denneson et al., 2010). Assessment of suicidal ideation alone fails to recognize all veterans with high suicide risk. Routine methods of suicide risk assessment lack the sensitivity needed to accurately identify veterans at risk of eventual suicide. A recent qualitative study examined the experience of 34 veterans who had recently screened positive for suicidal ideation (Ganzini et al., 2013). Veterans admitted to minimizing or denying suicidal thoughts to providers (Ganzini et al., 2013). Reasons for failing to report active suicidal thoughts included feelings of shame, a belief that suicidal thoughts should be kept private, concern about the consequences of revealing suicidal thoughts (e.g., hospitalization), and a negative perception of the automated, computer reminder process associated with suicide risk assessments (Ganzini et al., 2013). Suicide prevention among U.S. veterans who are receiving care in VA hospitals

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may be improved by developing novel methods of suicide assessment. Life meaning may be an important suicide risk factor that could be used to identify high risk veterans who experience but deny suicidal ideation. Victor Frankl (1959) believed that all humans are motivated to discover meaning in their lives. Following the work of Frankl, subsequent investigations further supported life meaning as an important construct. In a large community sample, life meaning was related to well-being, social support, good physical health, and absence of physical disability (Skrabski, Kopp, Rozsa, Rethelyi, & Rahe, 2005). On the contrary, lower levels of life meaning have been associated with depression and hopelessness (Mascaro & Rosen, 2006). Two prior studies have evaluated life meaning in general samples of U.S. veterans. Among 174 veterans, lower life meaning was related to self-reported depressive symptoms, PTSD severity, and guilt (Owens, Steger, Whitesell, & Herrera, 2009). Among 1,168 different veterans, a loss of life meaning was associated with seeking assistance from clergy or from VA mental health professionals (Fontana & Rosenheck, 2005). Although life meaning is an important psychological factor, there are no prior studies focusing on the role of life meaning among veterans being treated in VA hospitals. Battista and Almond (1973) defined life meaning as ‘‘an individual’s belief that he is fulfilling a life framework or life-goal that provides him [sic] with a highly valued understanding of his life’’ (Battista & Almond, 1973, p. 410). Life meaning includes (a) a framework of viewing life within a perspective or context, and the development of life goals based on this outlook, and (b) a sense of fulfillment, indicating that one has fulfilled or is in the process of fulfilling life goals (Battista & Almond, 1973). Life meaning may be a useful construct to evaluate in depressed veterans who frequently undergo routine suicide risk assessments within the VHA. If life meaning is closely related to suicidal ideation among depressed veterans, then an absence of life meaning could serve as a suicide risk factor in this high risk group. Studies using nonveteran samples have suggested a link between life meaning and past suicidal ideation (Lester & Badro, 1992), current suicidal ideation (Lester & Badro, 1992), and history of suicide attempts (Mehlum, 1998). A recent study replicated these findings among 273 active duty military personnel, showing a significant relationship between a lack of life meaning and emotional distress and suicidal ideation (Bryan et al., 2013). However, the association between life meaning and suicidal ideation has not been examined among depressed veterans being treated in VA hospitals, a subgroup at high risk for suicide. The relationship between depression, life meaning, and suicidal ideation among depressed veterans could

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be explained by the meaning-making model. The meaningmaking model has provided a framework for understanding psychological adjustment following stressful or traumatic life events (Park, 2010). According to this theory, making sense of difficult life experiences can lead to life meaning (Park, 2010), and, conversely, an inability to make sense of these experiences can result in depression and increased psychological distress (Park, 2010). Veterans who have been suffering from depression for several years could be struggling with the process of meaning-making, preventing them from developing a comprehensive framework of their life (i.e., life meaning; Owens et al., 2009). Furthermore, among chronically depressed veterans, a prolonged negative mood and related psychosocial difficulties could preclude the development of life meaning, contributing to the onset of suicidal ideation. Clarification of the association between life meaning and suicidal ideation in depressed veterans could inform treatment development and suicide prevention strategies.

METHOD Participants A total of 132 individuals provided informed consent for study participation; 14 were dropped because of incomplete data, five were subsequently deemed ineligible, two did not return the questionnaire packet, and one was dropped because he was suicidal at the time of the assessment and thus had to be escorted to the psychiatric emergency room. Thus, 110 participants provided complete data. Most (100; 90.9%) were men, and ages ranged from 22 to 83 (M ¼ 52.31, SD ¼ 10.34). Over half of the sample was African American (n ¼ 71; 64.5%) and about one third was Caucasian (n ¼ 36; 32.7%). Few participants were employed (n ¼ 15; 13.6%). Eligibility requirements included a primary diagnosis of a mood disorder (i.e., major depressive disorder, dysthymic disorder, and adjustment disorder with depressed mood). Exclusion criteria included an age younger than 18; or a diagnosis of bipolar disorder, schizophrenia, dementia, mental retardation, or an organic brain disorder. There were 81 mental health outpatients and 29 partial hospitalization patients. As would be expected, outpatients were significantly more likely to be employed than partial hospitalization patients, but these two groups were not significantly different in age, gender, ethnicity, marital status, self-reported physical health, comorbid PTSD diagnosis, history of suicide attempts, and prior inpatient hospitalizations. The study was approved by the Institutional Review Boards of Case Western Reserve University and the Louis Stokes Cleveland VA Medical Center.

At assessment, all participants met criteria for a depressive disorder. Diagnoses included recurrent major depressive disorder (84.5%), dysthymia (10.9%), single episode major depressive disorder (3.6%), and adjustment disorder with depressed mood (0.9%). Most (n ¼ 80; 72%) participants reported a depressed mood persisting for 1 year or longer. Almost half (n ¼ 51; 46.4%) of the participants had a prior psychiatric hospitalization, and one third (n ¼ 37; 33.6%) reported a past suicide attempt. In addition, some participants met criteria for a comorbid psychiatric disorder, including PTSD (n ¼ 23; 20.91%), substance abuse=dependence (n ¼ 20; 18.18%), generalized anxiety disorder (n ¼ 9; 8.18%), and alcohol abuse=dependence (n ¼ 8; 7.27%). Measures The Structured Clinical Interview for DSM-IV (SCID v2.0; First, Spitzer, Gibbon, & Williams, 1995) is a semistructured clinical interview designed to assess Axis I diagnoses based on DSM-IV criteria (American Psychiatric Association, 2000). The SCID asks about frequency, chronicity, and severity of symptoms. Good interrater reliability (a ¼ .80) and adequate test-rest reliability (a ¼ .61) have been established for the diagnosis of a major depressive disorder among psychiatric inpatients (Zanarini & Frankenburg, 2001). The SCID was significantly correlated with a self-report measure of depression in psychiatric outpatients (Zimmerman, Sheeran, & Young, 2004). Suicide history was assessed with an interview that included many yes–no questions such as ‘‘Have you ever attempted suicide?’’ and ‘‘Have you been previously hospitalized for a psychiatric reason?’’ Physical health status was measured in the packet of self-report questionnaires with a single question that asked, ‘‘In general would you say your physical health is . . . ’’ Response options ranged from poor, moderately poor, average, moderately good, to very good. The Beck Depression Inventory (BDI-2; Beck, Steer, & Brown, 1996) is a 21-item self-report measure commonly used to evaluate cognitive, behavioral, and affective symptoms of depression in the previous 2 weeks. Items are scored from 0 to 3. Total scores can range from 0 to 63 with higher scores indicating more severe depression. The BDI-2 was internally consistent in an outpatient sample of people with mixed psychiatric disorders (a ¼ .93; Beck et al., 1996). In a sample of college students, the BDI-2 was significantly, positively correlated with self-report measures of depression and anxiety (Storch, Roberti, & Roth, 2004). In the present study, Cronbach’s alpha showed very good internal consistency (a ¼ .91) for the BDI. The Beck Scale for Suicide Ideation (BSSI; Beck & Steer, 1991) is 21 items used to evaluate the presence

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and severity of suicidal thoughts. The first 19 items assess the severity of suicidal plans and attitudes; final two examine the number of previous suicide attempts and the level of intent to die associated with the most recent attempt. Individuals who endorse Items 4 or 5 are considered suicide ideators (Beck & Steer, 1991). The BSSI was highly internally consistent (a ¼ .95) when completed by psychiatric inpatients (Steer, Kumar, & Beck, 1993). BSSI scores highly correlate with clinician ratings of suicidal ideation for psychiatric outpatients (Beck, Steer, & Ranieri, 1988). Internal consistency using Cronbach’s alpha indicated very high internal consistency (a ¼ .96) in the current sample. The Framework Subscale of the Life Regard Index (LRI; Debats, 1998) is a 14-item measure adapted from Battista and Almond’s (1973) original meaning scale. The LRI Framework Subscale measures the degree to which an individual envisions life within a meaningful perspective and has developed life goals from this outlook. For the present study, the Fulfillment Subscale was not administered in the measurement of life meaning, because of potential overlap between subjective feelings of life meaning and additional study variables including depression. Debats (1998) revised the original LRI (Battista & Almond, 1973) to include a 3-point Likert scale ranging from 0 (do not agree) to 2 (agree) instead of a 5-point scale and reordered the items to alternate between positively and negatively worded items. Total scores range from 0 to 42 and higher scores indicate greater life meaning. Factor analysis of the original LRI revealed two subscales, Framework and Fulfillment (Van Ranst & Marcoen, 1997). The Framework Subscale was internally consistent when completed by college students (a ¼ .81 to .87; Mascaro & Rosen, 2006), and Cronbach’s alpha was high in the present sample (a ¼ .86). Procedure Participants were recruited from two mental health clinics at the local VA medical center: the partial hospitalization program and the outpatient mental health clinic. All assessment appointments were completed at the VA medical center in reserved office space. After completing informed consent procedures, a clinical psychology graduate student administered the diagnostic interview and the suicide history form. Next, study participants were asked to complete a questionnaire packet consisting of the BDI-II, the BSSI, the LRI, and the physical health item. Participants were compensated $10 for their time.

RESULTS No group differences were observed on BDI, BSSI, and LRI. Thus, the outpatients and partial hospitalization

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TABLE 1 Linear Regression Model Examining the Relationship Between Life Meaning and Suicidal Ideation, After Controlling for Suicide Risk Factors Variable

B

b

Covariates Past suicide attempt 3.40 0.21 History of an inpatient hospitalization 0.34 0.02 Physical health status 1.45 0.09 Beck Depression Inventory 0.18 0.29 Life meaning Framework Subscale of the Life Regard Index 0.35 0.29

p

0.02 0.80 0.29 0.01 0.00

inpatients were combined into one sample. Means, standard deviations, and intercorrelations were calculated to examine the relationships between the BDI, BSSI, and LRI. Mean scores on the BDI and LRI were 27.53 (SD ¼ 12.12) and 11.77 (SD ¼ 5.39), respectively. BSSI scores indicated that 30.9% of the sample included suicidal individuals. Intercorrelations were all significant, with correlation coefficients ranging from .47 to .57. More severe suicidal ideation was significantly related to poor physical health, r ¼ .24, p < .05, a past suicide attempt, r ¼ .24, p < .05, and history of an inpatient psychiatric hospitalization, r ¼ .20, p < .05. Suicidal ideation was unrelated to age, gender, ethnicity, marital status, employment status, or PTSD diagnosis. A hierarchical multiple regression assessed the association between life meaning and suicidal ideation after controlling for the influence of depressive symptoms, physical health, suicide attempt history, and history of an inpatient hospitalization (Table 1). After controlling for significant covariates, life meaning accounted for an additional 5.5% (DR2 ¼ .055) of the variance in the model, which was significant, F change (1, 102) ¼ 8.76, p < .01. The final model explained 35.7% of the variance in suicidal ideation, which was significant, F(5, 102) ¼ 11.32, p < .01. In the final model, three factors were significantly related to suicidal ideation: depression severity, suicide attempt history, and life meaning (Table 1).

DISCUSSION The current study found that less life meaning was significantly related to more severe suicidal ideation in these high-risk veterans. Furthermore, the relationship between life meaning and suicidal ideation remained significant after accounting for other important suicide risk factors (depressive symptoms, poor physical health, prior inpatient psychiatric hospitalization, and past suicide attempt). The three best indicators of suicidal ideation were depression severity, history of a suicide attempt, and life meaning.

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Life meaning may be a significant but previously ignored risk factor underlying suicidal tendencies in depressed veterans. The association between life meaning and suicidal ideation replicated previous investigations that found a link between life meaning and suicidal behaviors (Harlow et al., 1986; Lester & Badro, 1992; Mehlum, 1998). However, this was the first study that examined life meaning and suicidal ideation among a treatment-seeking sample of veterans. Depressive symptoms and past suicidal behaviors are frequently assessed in VA hospitals as risk factors for suicidal ideation (Corson, Gerrity, & Dobscha, 2004). However, assessment of these factors alone is not sensitive enough to identify veterans who are at risk for eventual suicide completion. Some veterans with suicidal thoughts and plans deny them to providers (Denneson et al., 2010), contributing to the high rates of veteran suicides in the United States. Consequently, identifying additional risk factors for suicidal ideation among veterans is necessary. Evaluation of life meaning may complement traditional methods of suicide risk assessment. Veterans may feel more comfortable and respond more honestly to questions about life meaning, in contrast to direct questions about suicidal ideation. Life meaning may be a particularly reliable indicator of suicidal ideation among veterans with chronic psychological or medical conditions, as opposed to other groups of veterans. The current study included a relatively distressed sample. On average, veterans were moderately depressed (BDI, M ¼ 27.53) and almost one third of the sample was experiencing current thoughts of suicide. Furthermore, life meaning appeared to be significantly lower in the current sample of veterans, as compared to previous samples representing the general population, students, and distressed students (Debats et al., 1993). Veterans struggling with years of prolonged depression may lose a sense of life meaning over time, contributing to the development of suicidal ideation. According to the meaning-making model (Park, 2010), chronically depressed veterans may have difficulty with the meaning-making process, and thus start to consider suicide. Note that the present study was not an intervention, and the present findings are limited to a cross-sectional assessment. Further, present veterans were chronically depressed, so these results may not apply to all veterans. Depressed, suicidal veterans may benefit from interventions targeting life meaning. Interventions enhancing life meaning and the meaning-making process have been developed for other groups including depressed therapy patients (Seligman, Rashid, & Parks, 2006), cancer patients (Greenstein & Breitbart, 2000), older adults with dementia (Mackinlay & Trevitt, 2010), and bereaved parents (Neimeyer, 2000). A randomized clinical trial showed that meaning centered group therapy

for advanced cancer patients resulted in greater life meaning and spiritual well-being, as compared to supportive therapy (Breitbart et al., 2010). Even general psychotherapy patients experience enhanced meaning during treatment, as sudden gains in therapy were related to improvements in meaning (Adler, Harmeling, & Walder-Biesanz, 2013). Depressed veterans may also benefit from interventions that target life meaning.

REFERENCES Adler, J. M., Harmeling, L. H., & Walder-Biesanz, I. (2013). Narrative meaning making is associated with sudden gains in psychotherapy clients’ mental health under routine clinical conditions. Journal of Clinical and Consulting Psychology, 81(5), 1–7. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Battista, J., & Almond, R. (1973). The development of meaning in life. Psychiatry, 36, 409–427. Beck, A. T., & Steer, R. A. (1991). Manual for the Beck Scale for Suicide Ideation. San Antonio, TX: Psychological Corporation. Beck, A. T., Steer, R. A., & Brown, G. (1996). Manual for the Beck Depression Inventory-II. San Antonio, TX: Psychological Corp. Beck, A. T., Steer, R. A., & Ranieri, W. F. (1988). Scale for Suicide Ideation: Psychometric properties of a self-report version. Journal of Clinical Psychology, 44, 499–505. Blow, F. C., Bohnert, A. S. B., Ilgen, M. A., Ignacio, R. J. F., Valenstein, M. M., & Knox, K. L. (2012). Suicide mortality among patients treated by the Veterans Health Administration from 2000–2007. American Journal of Public Health, 102, 98–104. Breitbart, W., Rosenfeld, B., Gibson, C., Pessin, H., Poppito, S., Nelson, C., . . . Olden, M. (2010). Meaning-centered group psychotherapy for patients with advanced cancer: a randomized controlled trial. Psycho-oncology, 19, 21–28. Britton, P. C., Ilgen, M. A., Valenstein, M., Knox, K., Claassen, C. A., & Conner, K. R. (2012). Differences between veteran suicides with and without psychiatric symptoms. American Journal of Public Health, 102(Suppl 1), S125–S130. Bryan, C. J., Elder, W. B., McNaughton-Cassill, M. C., Osman, A. C., Hernandez, A. M., & Allison, S. D. (2013). Meaning in life, emotional distress, suicidal ideation, and life functioning in an active duty military sample. Journal of Positive Psychology, 8, 444–452. Corson, K., Gerrity, M. S., & Dobscha, S. K. (2004). Screening for depression and suicidality in a VA primary care setting: 2 items are better than 1 item. The American Journal of Managed Care, 10, 839–845. Debats, D. (1998). Measurement of personal meaning: The psychometric properties of the life regard index. In P. T. P. Wong & P. S. Fry (Eds.), The human quest for meaning: A handbook of psychological research and clinical applications (pp. 395–436). Mahwah, NJ: Lawrence Erlbaum. Denneson, L. N., Basham, C., Dickinson, K. C., Crutchfield, M. C., Millet, L., Shen, X., & Dobscha, S. K. (2010). Suicide risk assessment and content of VA health care contacts before suicide completion by Veterans in Oregon. Psychiatric Services, 61, 1192–1197. Department of Veterans Affairs. (2012). Suicide data report, 2012. Retrieved from www.va.gov/opa/docs/Suicide-Data-Report-2012final.pdf Department of Veterans Affairs, Office of Inspector General. (2007). Healthcare inspection: Implementing VHA’s mental health strategic plan initiatives for suicide prevention. Retrieved from http:// www.va.gov/oig/54/reports/VAOIG-06-03706-126.pdf

LIFE MEANING First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1995). Structured clinical interview for DSM-IV Axis I disorders (SCID, Version 2). New York, NY: American Psychiatric Press, Inc. Fontana, A., & Rosenheck, R. (2005). The role of loss of meaning in the pursuit of treatment for posttraumatic stress disorder. Journal of Traumatic Stress, 18, 133–136. Frankl, V. (1959). Man’s search for meaning. Boston, MA: Beacon Press. Ganzini, L., Denneson, L. M., Press, N., Bair, M. J., Helmer, D. A., Poat, J., & Dobscha, S. K. (2013). Trust is the basis for effective suicide risk screening and assessment in veterans. Journal of General Internal Medicine, 28, 1215–1221. Greenstein, M., & Breitbart, W. (2000). Cancer and the experience of meaning: A group psychotherapy program for people with cancer. American Journal of Psychotherapy, 54, 486–500. Ilgen, M. A., Bohnert, A. S. B., Ignacio, R. V., McCarthy, J. F., Valenstein, M. M., Kim, M., & Blow, F. C. (2010). Psychiatric diagnoses and risk of suicide in veterans. Archives of General Psychiatry, 67, 1152–1158. Kaplan, M. S., Huguet, N., McFarland, B. H., & Newsom, J. T. (2007). Suicide among male veterans: A prospective population-based study. Journal of Epidemiology and Community Health, 61, 619–624. Lester, D., & Badro, S. (1992). Depression, suicidal preoccupation and purpose in life in a subclinical population. Personality and Individual Differences, 13, 75–76. Lish, J. B., Zimmerman, M., Farber, N. J., Lush, D. T., Kuzma, M. A., & Plescia, G. (1996). Suicide screening in a primary care setting at a veterans affairs medical center. Psychosomatics, 37, 413–424. Mackinlay, E., & Trevitt, C. (2010). Living in aged care: Using spiritual reminiscence to enhance meaning in life for those with dementia. International Journal of Mental Health Nursing, 19, 394–401. Mascaro, N., & Rosen, D. H. (2006). The role of existential meaning as a buffer against stress. Journal of Humanistic Psychology, 46, 168–190. Mehlum, L. (1998). Suicidal ideation and sense of coherence in male conscripts. Acta Psychiatrica Scandanavia, 98, 487–492. Neimeyer, R. A. (2000). Searching for the meaning of meaning: Grief therapy and the process of reconstruction. Death Studies, 24, 541–558.

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Owens, G. P., Steger, M. F., Whitesell, A. A., & Herrera, C. J. (2009). Posttraumatic stress disorder, guilt, depression, and meaning in life among military veterans. Journal of Traumatic Stress, 22, 654–657. Park, C. L. (2010). Making sense of the meaning literature: An integrative review of meaning making and its effects on adjustment to stressful life events. Psychological Bulletin, 136, 257–301. Pietrzak, R. H., Goldstein, M. B., Malley, J. C., Rivers, A. J., Johnson, D. C., & Southwick, S. M. (2010). Risk and protective factors associated with suicidal ideation in veterans of operations enduring freedom and Iraqi freedom. Journal of Affective Disorders, 123, 102–107. Seligman, M. E. P., Rashid, T., & Parks, A. C. (2006). Positive psychotherapy. American Psychologist, 61, 774–778. Skrabski, A., Kopp, M., Rozsa, S., Rethelyi, J., & Rahe, R. (2005). Life meaning: An important correlate of health in the Hungarian population. International Journal of Behavioral Medicine, 12(2), 78–85. Steer, R., Kumar, G., & Beck, A. (1993). Self-reported suicidal ideation in adolescent psychiatric inpatients. Journal of Consulting and Clinical Psychology, 61, 1096–1099. Storch, E. A., Roberti, J. W., & Roth, D. A. (2004). Factor structure, concurrent validity, and internal consistency of the Beck Depression Inventory—Second Edition in a sample of college students. Depression and Anxiety, 19, 187–189. Van Ranst, N., & Marcoen, A. (1997). Meaning in life of young and elderly adults: An examination of the factorial validity and invariance of the life regard index. Personality & Individual Differences, 22, 877–884. Zanarini, M., & Frankenburg, F. (2001). Attainment and maintenance of reliability of axis I and II disorders over the course of a longitudinal study. Comprehensive Psychiatry, 42, 369–374. Zimmerman, M., Sheeran, T., & Young, D. (2004). The diagnostic inventory for depression: A self-report scale to diagnose DSM-IV major depressive disorder. Journal of Clinical Psychology, 60, 87–110. Zivin, K., Kim, M., McCarthy, J. F., Austin, K. L., Hoggatt, K. J., Walters, H., & Valenstein, M. (2007). Suicide mortality among individuals receiving treatment for depression in the veterans affairs health system: Associations with patient and treatment setting characteristics. American Journal of Public Health, 97, 2193–2198.

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Life meaning is associated with suicidal ideation among depressed veterans.

Suicide is a major public health concern among U.S. veterans. Even when asked directly, veterans who die by suicide have been found to deny suicidal t...
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