Post-9/11 veterans often face visible challenges like finding gainful employment or recovering from physical injuries, but some of their struggles are invisible. Veterans may carry a sense of isolation and the painful belief that their presence is a burden to those around them. When these thoughts persist over time, they could contribute to an increased risk of suicide, according to a new study by researchers at the Clearinghouse for Military Family Readiness at Penn State (Clearinghouse).
The research, available online now and slated for publication in the August issue of the Journal of Affective Disorders, sheds light on how these emotional struggles - what researchers call "thwarted belongingness" and "perceived burdensomeness" - contribute to suicide risk in this population.
"Compared to civilians, military veterans are at significantly higher risk for suicide," said Keith Aronson, director of the Clearinghouse, research professor in the Department of Biobehavioral Health and lead author of the study. "Our study looked at what role perceptions of interpersonal difficulties play in that risk, and what we can learn from it."
An analysis of national Veteran Affairs data, published in the Journal of the American Medical Association, is alarming, Aronson said. From 2001 to 2020, suicide rates among veterans rose sharply and included a 95% increase among young adults, a 58% increase for those nearing retirement and a 21% increase for veterans 75 years and older. Compared to civilians, veterans were 42% more likely to report having suicidal thoughts, 97% more likely to report suicide planning and nearly three times more likely than their civilian peers to attempt suicide.
The current study is grounded in the interpersonal theory of suicide, which posits that suicide risk increases when individuals experience two powerful cognitive-emotional constructs: thwarted belongingness and perceived burdensomeness. Thwarted belongingness refers to feeling lonely and isolated from others. Perceived burdensomeness involves the belief that one's existence is a hardship to loved ones and often includes feelings of self-hatred or a sense that others would be better off without them.
"These are more than just thoughts and feelings, they're measurable risk factors," said Ryan Chesnut, assistant research professor at the Clearinghouse and co-author on the paper. "Veterans sometimes describe being emotionally withdrawn, distrustful of others or hypervigilant, while others have struggles with trauma, injuries or finances. These experiences are potential indicators of thwarted belongingness and perceived burdensomeness."
While prior studies generally provide only a snapshot in time, this research followed thousands of post-9/11 veterans over six and a half years and used data from the Veterans Metrics Initiative (TVMI) and its extension, the Veterans Engaging in Transition Studies. This allowed researchers to explore trait-like patterns, which are stable over time, and state-like experiences, which shift with life circumstances.
The results revealed that trait-like passive suicidal ideation - recurring thoughts such as "I'd be better off dead" - was the strongest and most consistent predictor of suicidal thoughts and intentions to act on these thoughts.
"These thoughts about being better off dead are especially concerning when they show up early in the transition," said study author Daniel F. Perkins, principal scientist at the Clearinghouse, an applied research center at the Social Science Research Institute and professor of family and youth resiliency and policy in the College of Agricultural Sciences. "They're often stable over time and are associated with an elevated long-term risk."
The study also found that trait-like perceived burdensomeness predicted the intention to act on suicidal thoughts, develop a plan or take actions that could contribute to suicide but not to thoughts of suicide. In contrast, trait-like thwarted belongingness, while a central part of the interpersonal theory, was not a significant predictor of suicidal thoughts or intent over time. The relationship between state-like variables, those that change over time, was complex but consistent. For example, thwarted belongingness measured at one point in time was strongly related to thwarted belongingness measured at later points. Similar patterns were observed for perceived burdensomeness and suicidal ideation. State-like perceived burdensomeness was found to predict thoughts of suicide during the mid-to-late stages of the transition process, especially between years four and six after leaving the military.
The researchers also pointed out that suicide risk is not always captured adequately by self-report questionnaires alone. Real-life experiences like being excluded from social events, losing a job or dealing with a chronic illness may not be fully reflected in standard assessments. The study's longitudinal approach, which tracks individuals over time, offers a clearer view of how internal states and external life circumstances interact to elevate risk.
According to the researchers, the findings suggest a need for health care providers and professionals who work with veterans to ask the right questions, early and often. Tools like the Columbia Suicide Severity Rating Scale and the Interpersonal Needs Questionnaire are widely available, quick to complete and free to use. They offer an initial avenue to begin conversations about suicide risk. These tools can help identify veterans who are struggling before they reach a crisis point.
"It's important to recognize that a veteran's thoughts and feelings of loneliness or being a burden may reflect real challenges, or they may be shaped by distorted perceptions," Aronson explained. "Regardless of their accuracy, these feelings are powerful and meaningful. They deserve our attention because they can increase suicide risk, but with the right support, they can also be addressed and alleviated."
If you are a veteran or service member in crisis or you're concerned about one, help is available. Call the Veterans Crisis Line by dialing 988 and then pressing 1, text 838255 or chat online at VeteransCrisisLine.net. Support is free, confidential and available 24/7.
This work was supported by the Henry M. Jackson Foundation for the Advancement of Military Medicine, The Pew Charitable Trusts, The Heinz Endowments, May & Stanley Smith Charitable Trust, The Arthur M. Blank Family Foundation and Wounded Warrior Project. It also leveraged funding from the U.S. Department of Agriculture's National Institute of Food and Agriculture and Hatch Appropriations.
