Posted on November 7, 2021 by Amanda Cerreto

This article originally appeared in UTSA Today by Shea Connor.

Sandra Morissette NOVEMBER 8, 2021 — Roughly 5,000 students at UTSA are active-duty military members, veterans, reserves/guard, ROTC or service-connected family members. With a significant number of military-affiliated Roadrunners on campus, and San Antonio being home to one of the largest concentrations of Air Force and Army bases in the nation, the university considers research into issues affecting active-duty personnel and veterans of paramount importance.

Sandra Morissette , professor of clinical psychology and chair of the Department of Psychology, has been one of the nation's leading researchers in the field of military and veteran mental health. Since joining the university in 2015, Morissette has contributed to dozens of studies on military health psychology, with a particular emphasis on PTSD, addictive behaviors, and functional recovery and post-warzone adjustment in veterans. In recent years, her work has increasingly focused on veteran suicide.

With Veterans Day coming up this week, UTSA Today connected with Morissette to discuss her research involving veteran suicide, broad efforts to address the substantial veteran suicide rate and how the Roadrunner community can help "reduce the stigma" around veteran mental health.

"I think the best thing one can do to combat stigma is to get to know people and their experiences with mental health struggles."

Predicting suicide attempts has long been a challenge for psychologists, but you recently collaborated with researchers at several universities and the U.S. Department of Veterans Affairs (VA) on a suicide attempt risk checklist to help clinicians identify individuals who may be at a higher risk of suicide. Can you tell us more about the development of the checklist?

Predicting when someone will attempt suicide is one of the most high-stakes jobs of a health care provider, but notoriously challenging to do. Unfortunately, data suggest that clinicians' ability to predict suicide attempts is not consistently more accurate than structured assessments, and some of the most widely used assessments predict no better than chance. This is deeply concerning for all people at risk for suicide, but particularly in the context of the latest VA data indicating that 17 veterans die by suicide every day.

Our collaborative research group was inspired to come together in order to address these challenges among veterans. We shared our data across three studies totaling over 35,000 participants to develop and validate the Durham Risk Score (DRS). The DRS was a strong predictor of future attempts, with 82% of prospective suicide attempts occurring among those who had DRS scores in the top 15%. These preliminary findings suggest that the DRS could enhance clinicians' ability to predict future suicide attempts, and correspondingly, guide them to put a safety plan in place when a veteran scores in a particular range—even if they aren't acutely suicidal.

Predicting who will attempt suicide in the future is one piece of the puzzle, and we are continuing this research to optimize scoring and testing across more independent samples and clinical settings. More research is also needed to get better at predicting those who are in acute risk, as many suicides are impulsive in nature.

Two months ago, the VA annual report showed a fairly significant decrease in veteran suicides . The rate remains much higher compared to non-veteran populations, but this is still a step in the right direction. What efforts have significantly contributed to this decrease?

Suicide rates have dropped some over the last decade, but are still very worrisome, with 17 veterans dying by suicide each day. Identifying what led to the decrease is a hard question to answer because VA has used multiple strategies at the same time. The list is actually pretty long, but I think it's important for people to know the extent to which VA has tried to reduce suicide rates in veterans.

For example, VA medical centers have hired suicide prevention coordinators, and there is now routine screening in primary care and high-risk flag monitoring of medical records. They have developed critical community partnerships and are part of the #BeThereCampaign national alliance for suicide prevention. They expanded crisis line services ( 1-800-273-TALK ), and provided Operation SAVE training to healthcare providers, as well as lethal means safety training and a safe gun storage challenge. They further increased access to services through executive orders to expand eligibility for mental health care for those who were discharged as “other than honorable.” Really, they have done a lot, and these collective efforts have likely contributed to decreased rates over time.

However, although improved, it hasn't been enough and the numbers are still too high. The bigger question is then: What do we need to be doing that we are not already doing, and how can we develop innovative approaches to further reduce death by suicide? How can we help these veterans to lead meaningful lives so they want to live?

You published a paper about cannabis use disorder as a predictor of suicide attempts in veterans, which is a very interesting topic. What were the major takeaways from that study?

This was another study aimed at trying to gain a better understanding of risk factors for suicide attempts in veterans. Cannabis use is a hot topic and rapidly being legalized across many states, so we were naturally interested in this area. Cannabis use disorder (CUD) is on the rise in veterans. Some veterans, for example, report that they use cannabis to self-medicate symptoms of post-traumatic stress disorder (PTSD), pain, or to sleep.

Setting politics aside, we wanted to learn more about how CUD might affect the risk for suicide in veterans over and above other known risk factors. What we found was that even after we accounted for numerous other risk factors—traumatic life events, traumatic brain injury, PTSD, depression, alcohol use disorder, and non-cannabis drug use disorder—CUD was a unique, significant predictor of suicidal self-injury. These findings provide an initial signal that CUD could increase suicide risk in unintended ways, noting that more research is clearly needed to replicate these findings.

You've extensively researched veterans with PTSD, but you also recently contributed to research about firefighters experiencing PTSD and depression symptoms . You've stressed before that both populations are highly resilient and that the majority of veterans and first responders don't experience PTSD, but they are generally exposed to more trauma than the average person. When it comes to matters of mental health, what similarities exist amongst the two populations and what are some key differences?

Thank you for acknowledging resilience, which is incredibly important. Indeed, most veterans and first responders will not develop PTSD, but they are at higher risk than the general population by virtue of their higher trauma exposure. Both veterans and first responders are considered to have hazardous occupations, and one of the things they share in common is a willingness to run towards —not away from —dangerous situations.

But there are also critical differences when studying these populations, and I think it is fundamentally important to study both to better understand reactions to trauma. For veterans, for example, many times their trauma occurred a long time ago—such as during training or deployment—and thus, we are better positioned to conduct research to understand the long-term impact following that trauma. By contrast, although we cannot exactly predict when and how potentially traumatic events will occur among first responders, we can anticipate that, by virtue of their jobs, they will occur. Thus, studying first responders helps us to understand and study responses to potentially traumatic events prospectively over time.

You might have noticed that I shifted to using the term potentially traumatic events, and that's because for many, these events won't be traumatic at all, rather just part of their job. For a minority, they will experience these life-threatening events as traumatic and develop PTSD. It is important for us to better understand who will be resilient and who is at risk so that effective preventative interventions can be developed.

Read about UTSA's call campaign to reach out to 1,600 student veterans during the pandemic.
Learn more about UTSA's recognition as a Best for Vets university by Military Times.
Find out how poems written by UTSA's military liaison are raising awareness of military sexual trauma.

Because of their aforementioned resiliency, veterans and first responders are often less likely to seek help if they do encounter mental health struggles. You've frequently discussed the importance of “reducing the stigma” that surrounds the mental state. How can individuals here at UTSA do their part to reduce that stigma?

We are still trying to better understand why and when people, including veterans and first responders, seek mental health care. Both self-stigma and public stigma can certainly be an influence, but there could also be other barriers, such as time or travel constraints, work/family/school obligations, finances, or not knowing about resources or how to get connected. This isn't unique to veterans or first responders.

I think the best thing one can do to combat stigma is to get to know people and their experiences with mental health struggles, whether as veterans, first responders, students, etc. First, you'll find out that more people are struggling with mental health challenges than you might think, and it can help with self-stigma to know that you are not alone. Second, when you talk firsthand with people, you get to know them and the struggles we have in common as human beings. This can help you re-think stigmatized beliefs one might have and the common ground we share. Third, and perhaps most importantly, when someone is struggling with mental health problems or having suicidal thoughts, find out how to get them connected and help them by doing the work to get connected—if they so choose—or seek a supportive person to help you if it is yourself. Getting connected to services when struggling with mental health problems can feel daunting, so this can help reduce at least one potential barrier to care.

UTSA has outstanding counseling services . Or, if you are worried about someone at UTSA being a risk to themselves or others and do not know what to do, you could reach out to UTSA's Behavioral Intervention Team .

— Amanda Cerreto