Intimate Partner Violence, Suicide, and Their Overlapping Risk in Women Veterans: A Review of the Literature

Abstract

Introduction

Suicidal thoughts and behaviors (STB) and intimate partner violence (IPV) are both serious and prevalent problems in the Veteran population that often occur in tandem, particularly among women Veterans. Women Veterans, the fastest growing segment of the Veteran population, may have unique overlapping risks that are worth exploring. Although the intersection of IPV and STB is well documented in the civilian population, it has not been thoroughly explored in women Veterans.

Materials and Methods

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework, we conducted a systematic review of the STB and IPV literature specifically related to women Veterans. We only included articles that sampled women Veterans, rather than active duty/reservist/National Guard women; due to the small volume of STB research using samples of only women Veterans, we included studies that used mixed-gender samples. We extracted risk factors for STB and/or IPV involvement from 56 selected articles and placed them into tables for comparison to determine commonalities.

Results

Common risk factors fell into three categories: socio-demographic risk factors (young age, unemployment, and sexual minority status) were significant across both bodies of literature; mental health risk factors (general psychopathology, post-traumatic stress disorder (PTSD), depression, sleep disturbance, and substance use/abuse) also had significant overlap; and military service-related risk factors (military sexual trauma (MST) and deployment factors) were also relevant across both bodies of literature. Mental health risk factors, particularly PTSD, were the most common.

Conclusion

Frequently, the risk factors for IPV and STB are shared and it is important to consider how research, screening and intervention efforts for these serious problems might be integrated. Our exploration of the literature may be used as a basis for future research with women Veterans on the intersection of STB and IPV. Further, Veterans Health Administration clinicians should be aware of these intersecting risk factors to enhance care and improve screening for both issues in women Veteran clients.

women, Veterans, intimate partner violence, suicide, intersection

INTRODUCTION

The link between suicidal thoughts and behaviors (STB) and intimate partner violence (IPV) in the civilian population has been well established for over two decades.^1,2 STB, broadly defined, refers to suicidal ideation, suicide attempts, and death by suicide; IPV, as defined by the Centers for Disease Control, encompasses “physical violence, sexual violence, stalking and psychological aggression (including coercive acts) by a current or former intimate partner.”³ The mental health consequences associated with IPV victimization, particularly depression and post-traumatic stress disorder (PTSD), are deeply connected to STB.^1,2 Veterans, a former member of the armed forces,⁴ may have even greater intersecting risk for STB and IPV due to their military service. Further, women Veterans, who comprise one of the fastest growing subpopulations of Veterans, may have distinctive intersecting risks worth exploring. Within the Veteran population, STB and IPV are both considered major public health concerns, but they are typically examined and discussed as separate issues rather than as connected to one another.

In recent years, concurrent with Operations Iraqi Freedom (OIF), Enduring Freedom (OEF), and New Dawn (OND), there has been a marked increase in STB among Veterans, with an average of 20 Veterans dying by suicide every day.⁵ Veterans are at greater risk for suicide than the general population, and women Veterans are estimated to have particularly elevated suicide rates compared to their female civilian counterparts.^5,6 In a 2014 report, among Veterans using Veteran Health Administration, males have a suicide rate of 41.8 per 100,000 compared to females, who have a rate of 17.3. However, the rate for women has increased since 2001 when it was 14.4 compared to its current 17.3.⁷

One study found that OEF/OIF women Veterans were more likely to have reported suicide attempts (OR = 1.3, 95%CI 1.0–1.6) and less likely to have reported ideation (OR = 0.8, 95%CI 0.7–0.9) than male Veterans, suggesting an elevated risk of suicide even within their Veteran cohort.⁸ Efforts to target the Veteran suicide epidemic have led to the establishment of VA sponsored resources such as the Veteran and Military Crisis Line, a 24/7 hotline; the placement of suicide prevention coordinators in each VA medical center to coordinate care for suicidal Veterans; and emphasis on suicide research support and funding through various mechanisms including the Center of Excellence for Suicide Prevention and the Rocky Mountain Mental Illness Research Education and Clinical Center for Veteran Suicide Prevention.

Similarly, there has been a recent surge in attention to IPV among Veterans. Despite efforts to curb IPV rates in this population, studies estimate between 18% and 54% of women Veterans report some level of IPV⁹; those identified from VA health care registries report the highest prevalence.^10,11 The VA’s effort to reduce these rates have included the creation of a VA-chartered IPV Task Force in 2012, and the establishment of needed infrastructure to promote IPV assistance at national, regional and local levels, including employing domestic violence coordinators.

Although research on suicide and IPV among women Veterans is growing, examinations of the intersection of STB and IPV in this population are scant. Indeed, only one study, from 2005, is known to have reported on the intersection between suicide and IPV in women Veterans.¹⁰ Given the growing interest in targeting these issues in women Veterans, the present systematic review was conducted to identify common risk factors, and to highlight the need for targeted research on intersecting IPV and suicide risk among women Veterans.

METHODS

The authors used the PRISMA framework to conduct a systematic review of the literature regarding STB and IPV in women Veterans.¹² Queries were limited to articles published between 2006 and 2016. The following research databases were utilized in this literature search: SAGE Journals, PubMed, ProQuest, and JSTOR. Search terms included: “female Veterans,” “women Veterans,” “female-to-male,” “male-to-female,” “female-perpetrated,” “intimate partner violence,” “domestic violence,” “victims,” “victimization,” “perpetrators,” “perpetration,” “bidirectional IPV,” “common couple violence,” “suicide,” “suicidality,” “suicidal ideation,” “suicide attempt,” and “suicide risk.” The terms were entered into the databases in varying Boolean combinations and each combination was entered into all databases. Additional records were identified for inclusion via the reference sections of relevant records returned in the initial search. After removing duplicates from the query results, we selected records of suspected relevance by title and screened abstracts. Finally, articles with relevant abstracts were reviewed in their entirety to determine whether they met inclusion criteria for the review (Fig. 1).

FIGURE 1.

PRISMA flow diagram.¹¹

Several inclusion criteria were applied for this literature review. First, only articles that specifically sampled women Veterans, rather than active duty/reservist/National Guard women, were included. This study was conducted in partnership with the Canandaigua VA Center of Excellence for Suicide Prevention and an interdisciplinary team comprised of psychologists, attorneys, and health services researchers. We determined the scope with the goal of creating a curriculum to be created, disseminated and tested at a later time. Ultimately, due to the small volume of STB research using samples of only women Veterans, we included studies that used mixed-gender samples. We specifically sought articles that examined risk factors for suicide and IPV outcomes (Table I).

TABLE I.

Female Veteran Risk Factor Representation in Literature

Risk Factor	Suicide	IPV
Young age8,13–17	X	X
Unemployment15,16,18,19	X	X
Sexual minority status16,20,21	X	X
General psychopathology8,18,22–35	X	X
Traumatic brain injury8,36,37	X	X
PTSD8,18,20,23,24,28,33,34,37–50	X	X
Depression18,22,23,33,34,37,40–42,44,51–53	X	X
Substance/alcohol problem8,17–19,24,25,28,33,34,40,52,54–57	X	X
Military sexual trauma16,19,22,47,58–61	X	X
Deployment factors22,62,63	X	X
Sleep disturbance33,64	X	X
Comorbid PTSD/depression8,23,29,30	X
Low social support29,32,40	X
Schizophrenia8,18,24	X
Prior suicide attempt/hospitalization8,18,23	X
Anxiety disorder8,18,27,33	X	X
Past physical/sexual abuse49,61		X
Avoidance cluster – PTSD23,38	X
Marital status18,42	X
Bipolar disorder8,22,24,25,33	X	X
Psychotic disorder18,23–25	X
Current physical/sexual abuse46,60	Xa	X
Middle age6,18,31	X
Chronic pain8,31,58	X	X
Army service61		X
Negative alteration in cognition and mood cluster – PTSD38	X
Depersonalization38	X
Polytrauma clinical triad (PTSD, TBI, and Chronic Pain)8	X
Anger/difficulty controlling violent behavior18,48	X	X
Comorbid PTSD/substance abuse8,35	X	X
Veteran officer8	X
Homelessness19		Xa
Low SES58		X
Longer length of military service58		X
Lower education61		X
Combat experiences62	X
Moral injury62	X
Problem-solving difficulty51	X
Financial issues16,60	Xa	X
Perceived burdensomeness43	Xa
Thwarted belongingness43	Xa
Acquired capability43	Xa
Rehospitalization for substance use disorder54		X
Childhood victimization19,61		X

^aQualitative interview study.

The authors (P.I. and C.C.) then created two separate risk factor charts showing the IPV and suicide risk factors derived from each article pulled from the literature. The charts show the representation of each risk factor in the bodies of literature in a quantifiable way by including counts of how many articles measured and analyzed each risk factor. We subsequently combined the risk factors from each chart in a Venn diagram to examine any overlap between the IPV and suicide bodies of literature. This Venn diagram allowed us to not only examine risk factor overlap beyond what is presently discussed in the literature, but also to visually represent gaps for future research consideration (Fig. 2).

FIGURE 2.

Suicide and IPV risk factors for female veterans.

RESULTS

Our Boolean searches yielded a total of 3,029 records; 75 additional records were identified through reference sections, a supplemental volume of the American Journal of Public Health focused on Veteran suicide, and a general Google Scholar search. After removing duplicates, 962 articles remained. From this list, 629 records were selected for abstract screening and subsequently 106 articles were selected for full-text screening. Finally, 56 articles were selected for inclusion in the present review. Table I below shows whether each risk factor is associated with STB, IPV or both and cites the specific articles that show these associations. Overlapping risk factors fell into three categories: (1) socio-demographic; (2) mental health; and (3) military service-related.

Socio-demographic Risk Factors

Eleven articles discussed socio-demographic risk factors for suicide or IPV that had distinct overlap. Young age, unemployment, and sexual minority status were significant across both bodies of literature.

Young Age

Young age is identified as a demographic risk factor for female Veteran STB five times in the literature. analyses of National Violent Death Reporting System records for female Veterans and their non-Veteran counterparts found higher standardized mortality ratios (SMRs) in younger Veterans than older Veterans, with SMRs of 3.1 (95%CI 2.31–3.96) and 1.8 (95%CI 1.37–2.29), respectively,¹³ and the highest suicide rates among female Veterans aged 18–34 years compared to all age groups.¹⁴ Finally, when a mixed-gender sample of OEF/OIF Veteran VHA users (14% female) was stratified by age, 18–25 year olds were significantly more likely than 41–55 year olds and those who were 56 and over to report suicidal ideation and/or attempt.⁸ Two articles found young age was associated with IPV among women Veterans. A 2009 study of a mixed-gender sample of Vietnam Veterans (26% female) found that younger age was related to IPV perpetration among both male and female Veterans.¹⁵ “Younger age” in this study appears to refer to age relative to the rest of the sample, rather than a specific age range. A study of past-year IPV victimization in female VHA users revealed higher rates of IPV in women under 30 than the general population of women Veterans (26% versus a range of 5–23% among older women).¹⁷

Unemployment

Only one study noted an association between unemployment and STB, and three noted an association between unemployment and IPV. In a review of data from a mixed-gender sample of VHA users (3% female), those reporting suicidal ideation were more likely to be unemployed than those not reporting suicidal ideation (66.9% and 62.6% respectively).¹⁸ Findings in a separate sample of female VHA users support this suggestion, as past-year IPV victimization was associated with economic hardship such as unemployment.¹⁶ Finally, a study of aggression in male and female Vietnam Veterans found unemployment was correlated with aggression in women Veterans.¹⁵

Sexual Minority Status

A small number of studies identified sexual minority status (i.e., lesbian, bisexual) as a risk factor for both STB and IPV victimization. In a sample of 422 military and Veteran students, sexual minority students were more likely than sexual majority students to report suicidal ideation, suicidal plans, suicide attempts, and non-suicidal self-injury. The authors suggested that this risk may be moderated by disproportionate trauma exposure in this subpopulation.²⁰ Further, female Veteran/personnel sexual minority students in this study reported greater rates of physical and sexual assault, though the authors did not clarify whether this included IPV. However, Kimerling et al found that sexual minority women VHA users experienced higher rates of past-year IPV than sexual majority women.¹⁶ Additionally, another study found that sexual, physical, and stalking IPV were reported over two times more for sexual minority women than for sexual majority women, and that sexual minority women were also more likely to experience multiple forms of violence.²¹

Mental Health Risk Factors

Forty-four articles examined risk factors that involved mental health concerns. Several mental health risk factors overlapped among the suicide and IPV literature, including general psychopathology, PTSD, depression, sleep disturbance, and substance use/abuse.

General Psychopathology

General psychopathology, which refers to the presence of any or multiple mental health problems/diagnoses, is related to women Veterans’ risk of STB and IPV. Numerous studies noted statistically significant associations between varying kinds of disorders and STB, such as psychotic disorders, anxiety disorders, personality disorders, and bipolar disorder.^8,18,22–25 For example, in a sample of Veteran suicide decedents with and without psychiatric symptoms (3% female), those reporting psychiatric symptoms prior to death were more likely to have suicidal ideation, have a suicide plan, and receive a suicide assessment, and were more likely to die by suicide within 60 days of their last VHA visit, than those without. Gender was controlled for in these analyses, with females with psychiatric symptoms at greater risk of STB.²⁶ Further, VHA users receiving care for substance use who reported difficulty controlling their violent behavior were classified as being at higher suicide risk than those without substance use treatment despite having no prior history of suicidal ideation.¹⁸ This sample of VHA users was almost 96% male, so more research is needed on how this might apply to female veterans.¹⁵ Other studies found that comorbid conditions, such as the polytrauma clinical triad (PTSD, traumatic brain injury (TBI), and chronic pain, or other combinations),⁸ comorbid anxiety disorders,²⁷ or PTSD comorbid with mental disorders such as major depressive disorder (MDD), substance use disorder (SUD), and alcohol use disorder were associated with increased STB.^8,23,28–30

Pain was not identified as an individual and separate risk factor for STB in studies of women Veterans identified in the sampling frame. However, two studies of the link between comorbid mental health disorders and STB controlled for pain as an additional comorbid condition and found significant relationships, suggesting that pain may be of interest as a separate risk factor.^8,31 Lastly, a 2012 study examining data from a mixed-gender sample (9.9% female) found that poor mental health, fair/poor health status, and rare availability of social/emotional support contributed to the relationship between sexual minority status and increased suicidal ideation among Veterans.³²

Psychopathology is also significantly associated with IPV victimization among women Veterans. Several studies reported that women Veterans experiencing IPV victimization were at increased odds of reporting separate mental health concerns such as bipolar disorder, anxiety, depression, PTSD or reporting multiple mental health concerns.^33,34 Additionally, women Veterans with comorbid PTSD and SUD report greater levels of both physical and psychological IPV victimization.³⁵ IPV victimization also may lead to chronic pain in women Veterans.³⁴ The literature on female Veteran IPV perpetration does not identify general psychopathology as a risk factor, suggesting an area for further research to determine if the relationship does or does not exist.

Traumatic Brain Injury

Three studies discuss TBI as a correlate of suicide in women Veterans. A survival analysis of a mixed-gender (10.23% female) sample of Veterans receiving care found that those with a history of TBI were 1.55 times more likely to die by suicide (95% CI, 1.39–2.82) than those without.³⁶ Others suggest that TBI is an indirect and cumulative correlate via mental health issues; in a qualitative interview study, 13 Veterans (1 woman) with histories of clinically significant suicidal ideation and TBI reported that the mental health sequelae of TBI, such as cognitive impairment and emotional and psychiatric distress, contributed to their STB.⁶⁵ Additionally, Finley and colleagues reported that TBI is associated with increased STB risk when comorbid with chronic pain and PTSD.⁸

One study also showed that IPV-related TBI was associated with worse mental health. In a sample of women Veteran VHA users, those with a history of IPV-related TBI reported significantly greater depression and PTSD symptoms than those who experienced IPV without TBI. Additionally, women with IPV-related TBI experienced greater overall IPV victimization than those without TBI.³⁷

PTSD

Many authors cited PTSD as a correlate of STB^{8,18,23,24,28,38–42}; a recent study of gender differences in Veteran suicide, found that ever being diagnosed with depression, anxiety, or PTSD had the strongest association with suicidal ideation and attempts among both men and women, compared to other covariates.⁴² Another study that compared women Veterans’ deployment experiences in OIF and OEF to the components of Joiner’s interpersonal psychological theory of suicide found that PTSD facilitated their sense of not belonging because of their status as a female in a male dominated profession and also feeling isolate as members of the military in a civilian world.⁴³ Further, other authors found specific PTSD symptom clusters were associated with STB. For example, among a small sample of Veterans diagnosed with PTSD (22.1% female), “negative alterations in cognition and mood” and “arousal and reactivity” PTSD symptom clusters were associated with both suicidal ideation and suicide attempts.³⁸ Additional studied found associations between the PTSD “avoidance” cluster and both suicidal ideation and suicide attempts.^23,38 Finally, in a sample of predominately women Veterans, 89% of 128, diagnosed with military sexual trauma (MST)-related PTSD, the PTSD “hyperarousal” symptom cluster was associated with suicidal ideation.⁴⁴

PTSD is one of the most commonly cited risk factors in the IPV literature, with 11 articles addressing it, and is distinguished as a risk factor for both IPV perpetration and victimization among women Veterans.^{21,33,34,37,45–48} Controlling for MST, women Veterans who reported IPV in the past year had increased odds of depression (OR = 3.0, 95%CI 1.46–6.26) and PTSD (OR = 2.4, 95%CI 1.08–5.08) when compared to women Veterans who did not report IPV in the past year.³⁴ Another study found similar results; women Veterans who reported experiences of intimate partner stalking were four times more likely to report probable PTSD than those who did not.⁴⁹ When specifying between the different forms of IPV, similar findings are found between PTSD and sexual IPV but not between PTSD and psychological or physical IPV.³³ Some of the literature delves deeper into the relationship between IPV involvement and PTSD. One study found that IPV-related PTSD strengthened the relationship between IPV victimization and chronic pain in women Veterans.⁵⁸ Beyond links between PTSD and IPV victimization, the severity of PTSD symptoms is associated with both partners’ reports of Veterans’ psychological abuse perpetration, and IPV perpetration reported by both women Veterans and their partners.^45,50 More specifically, PTSD anger symptoms were associated with aggression and violence toward family members, especially among female Veterans in a mixed-gender (16% female) sample of Veterans.⁴⁸

Depression

Eight articles identified an association between depression and STB and five identified an association between depression and IPV. Depression was found to be directly associated with STB,^18,41,51 as well as a moderator of deployment experiences and suicidal ideation.²² Further, depression had the strongest association with suicidal ideation when compared to psychotic disorders and PTSD,²³ a finding corroborated by additional research among both men and women Veterans.⁴² Additionally, depression was associated with suicidal ideation among a sample of 272 OEF/OIF Veterans (OR = 5.97, 95%CI = 1.86–19.13), and depressive symptoms increased the influence of post-traumatic symptoms on suicidal ideation among Veterans diagnosed with MST-related PTSD.^40,44

Depression is also associated with both IPV victimization and perpetration.^52,53 A survey of women Veteran VA patients revealed a three times greater likelihood of reporting depression in those women who reported sexual IPV victimization, while another study reported a 3.21 times greater risk of depression among women reporting any IPV involvement.^33,34 Additionally, as with PTSD, women Veterans who sustained an IPV-related TBI were more likely to report depression.³⁷

Sleep Disturbance

One article from each body of literature found sleep disturbance was associated with both STB and IPV. A study of 381 Veteran suicide decedents who had accessed VA health care in the last year found that those with documented sleep disturbance died sooner after that visit than those without.⁶⁴ A separate study of 249 female VHA users reported that those women reporting sexual IPV victimization were three times more likely to report sleep disruption.³³

Substance/Alcohol Problems

A total of seven articles discussed substance/alcohol problems as related to STB among women Veterans. Most studies noting substance and/or alcohol problems used mixed-gender, rather than all female, samples of Veterans.^{8,17,18,25,28,40} Several studies showed that female Veterans with substance use disorders (SUDs) were at higher risk of future suicide (HR = 6.6, 95%CI 4.72–9.29) compared to female Veterans without SUDs,²⁴ and that, similar to PTSD, SUDs are a risk factor for STB among depressed Veterans even after adjusting for PTSD and age.¹⁷ This relationship between SUDs and STB was also found when patients with SUD were comorbid with a variety of other conditions including pain, PTSD, and other mental health risk factors.⁸

Eight articles found that SUDs, mainly alcohol abuse, were associated with IPV victimization. For example, a study of CDC data on Veteran and non-Veteran women found a statistically significant association between IPV victimization and alcohol abuse (AOR 1.8, 95%CI 1.5–2.1).⁵² Another study supports this finding, reporting that psychological IPV victimization was associated with alcohol misuse in women Veterans.⁵⁴ During focus groups, homeless women Veterans reported that trauma during military service (including MST) was associated with their substance abuse.¹⁹ Indeed, physical abuse in particular seemed to be associated with alcohol misuse.⁵⁴ A recent study reported three times the odds (95%CI 1.05–8.93) of alcohol dependence in women Veterans who experienced IPV in the past year,³⁴ and another showed increased odds of problem drinking among women Veterans reporting sexual IPV (OR = 3.8, 95%CI 1.04–14.26).³³

One article found that alcohol misuse was associated with IPV perpetration. In a sample of Veterans and non-Veterans, those who indicated having a drinking problem were more likely to have perpetrated IPV than those without, regardless of Veteran status.⁵⁶ Additionally, in a study of opposite-sex couples (12% where female partner was a Veteran), substance abuse was directly associated with Veterans’ reports of IPV perpetration and also appeared to moderate the relationship between PTSD and perpetration.⁵⁷ Lastly, Veterans with comorbid SUDs and PTSD reported more psychological and physical IPV involvement than those with only one of the disorders (PTSD or SUD).³⁵

Military Service-Related Risk Factors

Eleven articles were specifically focused on military service-related risk factors relevant to women Veterans – these included MST and deployment factors.

Military Sexual Trauma

Four articles found associations between MST and STB among women Veterans. With life-time prevalence predictions as high as 40% among women Veterans,⁶⁶ MST may, in fact, be a particularly salient risk factor for STB. Sexual harassment during deployment was associated with increased suicidal ideation in women Veterans in a mixed-gender sample of OEF/OIF Veterans.²² In a series of qualitative interviews with workers at the Veteran and Military Crisis Line, participants expressed that MST and its psychological sequelae were common reasons women Veterans called the crisis line.⁶⁰ Participants also cited violent relationships as a common reason for women calling, suggesting STB resulting from IPV.

Women Veterans who reported MST also reported subsequent IPV victimization.^19,47,58 This belief is supported by two studies sampling female VHA users, which reported greater than two times the prevalence of past year IPV victimization in those reporting histories of MST.^16,61 A small study of female Veterans found 49% reported MST, and of those reporting MST, 15% said the MST was IPV-related.⁴⁷ There is, however, no evidence in the literature to suggest a connection between MST and IPV perpetration among women Veterans.

Deployment Factors

The literature also illustrated the relationship between female Veteran deployment experiences and increased risk for STB and IPV. In addition to findings that sexual harassment during deployment was associated with increased suicidal ideation in female Veterans, one study also reported that the mental health outcomes of adverse deployment experiences (e.g., combat exposure), such as PTSD, alcohol use disorder, and depression, were associated with suicidal ideation in both female and male Veterans.²² Additionally, in a sample of Veterans with alcohol problems, having fired their weapon at the enemy or killed/believed to have killed the enemy during deployment was independently associated with suicidal ideation.⁶² In another study, female Veterans with deployment histories reported greater than two times the odds of psychological IPV victimization compared to those without deployment histories.⁶³ The authors suggested that this association may be moderated by relationship stress related to deployment.

Homelessness

Homelessness was a unique risk-factor spanning several categories of risk factors: unemployment, substance abuse, and MST. A mixed-gender sample of homeless Veterans (50% female) found that IPV victimization (defined as current sexual or physical abuse) was significantly associated with increased suicidal ideation and suicide attempts among homeless women Veterans.⁶⁷ IPV focus groups with homeless female Veterans suggested their experiences with IPV victimization led to unemployment, which subsequently led to homelessness.¹⁹ In a mixed-gender sample of homeless Veterans, abuse, and sexual abuse in particular, was a predictor of re-hospitalization for substance abuse among women.⁵⁵ In a sample of homeless VHA-connected Veterans (7% female), women Veterans were not only more likely to experience MST, but the experience was associated with a higher likelihood of both mental health problems and suicide attempts and death.⁵⁹ More specifically, MST was associated with SUD and depression, both of which increase suicide risk, and was also associated with an increase in suicidal ideation among women Veterans.⁵⁹ Further, Homeless female Veterans reported the belief that experiencing MST during their service contributed to their victimization in later abusive relationships.¹⁹ The mention of homelessness across the literature makes homeless female Veterans particularly vulnerable to IPV and suicide risks.

DISCUSSION

This systematic review of the bodies of literature about women Veterans’ experiences with STB and IPV identified multiple common risk factors and offers a glimpse at the relationship between IPV and STB in women Veterans. Our findings suggest that common risk factors fall into three categories: socio-demographic risk factors, mental health risk factors, and military service-related risk factors. Of these categories, mental health risk factors were most prevalent in the literature. Such findings may provide good guidance for future research directions and clinical best practices.

In many clinical practices and interventions, these issues of socio-demographic, mental health and military risk factors remain in separate silos. Even among non-Veteran populations, the notion of including social determinants of health in screening, assessment, referrals and follow-ups is becoming increasingly recognized. In a recent article by Garg and colleagues (2016) discussing these issues in the general population, they note “Social determinants – the circumstances in which people live and work – powerfully affect health. In fact, social and environmental factors are estimated to have twice the impact of quality health care on the overall health of an individual.” Perhaps this is even more true for female Veterans who face increased risk for IPV, suicidal ideations and physical and mental health consequences of their service.

In the current socio and political climate, many people who have experienced victimization are stepping forward. In the climate of #MeToo, we may see more women stepping forward to disclose their abuse experiences in their past military service. To date, the VA has employed both suicide prevention experts and intimate partner violence counselors. However, the time may be right for offices to come together and break down the siloes that we see between suicide and IPV research and care. So often, as this paper suggests, the risk factors are shared. While no studies to date have been able to categorically state a causal direction as opposed to statistical associations, we know these two public health issues are connected. It is important to address both, but remember to screen for both STB and IPV, even if one issue becomes visible first. While some settings require screening, such as those health and mental health settings that are hospital affiliated, many providers operating in independent locations do not. Even those that screen for mental health and IPV may not be screening for past or current military experience. By offering integrated screening and interventions, we would better understand why a patient referred to mental health care cannot get there (e.g., a perpetrator prevents or inhibits care), and help a patient work through those barriers. A first important step is to understand these intersections via what the existing literature can tell us, to inform the direction of future studies.

This review has several important limitations, including the distinct lack of suicide literature focusing on, or oversampling for, women Veterans. A majority of the suicide literature included here used mixed-gender samples in which women Veterans constituted anywhere between 3% and 51% of the total sample size. Further, those articles that performed gender-stratified analysis still had small female sample sizes compared to the male samples, around 10–20%. Only five of these articles performed gender-stratified analysis, making it difficult to determine the extent to which the results of articles using non-stratified analysis apply to the women Veteran population. Although these sample sizes are representative of gender distribution in the Veteran population as a whole, they reduce analytical power. Finally, a vast majority of the literature included in this review consisted of cross-sectional studies. This therefore limits causal links between, and determining directionality of, the risk factors and IPV and/or suicide. However, even with these limitations, there are several next steps that may be considered to help ameliorate the mental health and IPV burdens of female Veterans.

It is important for providers, both within and outside the Veteran Health Administration, to know that certain lived experiences, including military service and IPV, may impact mental health symptoms, as well as intervention opportunities. One such way to address these co-occurring issues may be a medical legal partnership, which co-locates IPV experts, attorneys, case workers, psychologists and other helping professionals together under one roof to reduce the patient burden of not only physically getting to myriad care locations, but assists with not having to bear the burden of coordinating her care providers. Such innovations offered with a trauma-informed approach may be a next step for creation and implementation to meet the unique needs of female Veterans suffering from mental health burden and IPV currently or in their past. Screening for, and viewing, the IPV as a significant contributor to STB is an important first step; addressing safety concerns in addition is critical to helping our female Veteran patients heal.

Previous Presentations

International Family Violence Conference, University of New Hampshire Family Research Laboratory, Portsmouth NH, July 12, 2016

Funding

Center of Excellence for Suicide Prevention, Hendershot funding, University of Rochester Medical Center Departments of Psychiatry and Obstetrics and Gynecology. The contents do not represent the views of the US Department of Veterans Affairs or the United States Government.