title: A national cohort study of the association between the polytrauma clinical triad and suicide-related behavior among US Veterans who served in Iraq and Afghanistan.
abstract: OBJECTIVE
  We examined the association of posttraumatic stress disorder (PTSD), traumatic brain injury, and chronic pain-the polytrauma clinical triad (PCT)-independently and with other conditions, with suicide-related behavior (SRB) risk among Operation Enduring Freedom (OEF; Afghanistan) and Operation Iraqi Freedom (OIF) veterans.
  
  
  METHODS
  We used Department of Veterans Affairs (VA) administrative data to identify OEF and OIF veterans receiving VA care in fiscal years 2009-2011; we used International Classification of Diseases, Ninth Revision, Clinical Modification codes to characterize 211652 cohort members. Descriptive statistics were followed by multinomial logistic regression analyses predicting SRB.
  
  
  RESULTS
  Co-occurrence of PCT conditions was associated with significant increase in suicide ideation risk (odds ratio [OR] = 1.9; 95% confidence interval [CI]=1.5, 2.4) or attempt and ideation (OR=2.6; 95% CI=1.5, 4.6), but did not exceed increased risk with PTSD alone (ideation: OR=2.3; 95% CI=2.0, 2.6; attempt: OR=2.0; 95% CI=1.4, 2.9; ideation and attempt: OR=1.8; 95% CI=1.2, 2.8). Ideation risk was significantly elevated when PTSD was comorbid with depression (OR=4.2; 95% CI=3.6, 4.8) or substance abuse (OR=4.7; 95% CI = 3.9, 5.6).
  
  
  CONCLUSIONS
  Although PCT was a moderate SRB predictor, interactions among PCT conditions, particularly PTSD, and depression or substance abuse had larger risk increases.
authors.affiliation: Erin P. Finley, Mary Bollinger, Polly H. Noël, Jacqueline A. Pugh, Albana Dassori, and Mary Jo V. Pugh are with South Texas Veterans Health Care System, San Antonio. Raymond Palmer is with Department of Epidemiology and Biostatistics, University of Texas Health Science Center, San Antonio. Megan E. Amuan is with Center for Health Quality, Outcomes and Economic Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA. Laurel A. Copeland is with Center for Applied Health Research, jointly sponsored by Central Texas Veterans, Health Care System and Scott and White Healthcare System, Temple, TX. Craig Bryan is with National Center for Veterans Studies and Department of Psychology, The University of Utah, Salt Lake City, UT.
authors.forename: Erin P
authors.initials: EP
authors.lastname: Finley
authors.forename: Mary
authors.initials: M
authors.lastname: Bollinger
authors.forename: Polly H
authors.initials: PH
authors.lastname: Noël
authors.forename: Megan E
authors.initials: ME
authors.lastname: Amuan
authors.forename: Laurel A
authors.initials: LA
authors.lastname: Copeland
authors.forename: Jacqueline A
authors.initials: JA
authors.lastname: Pugh
authors.forename: Albana
authors.initials: A
authors.lastname: Dassori
authors.forename: Raymond
authors.initials: R
authors.lastname: Palmer
authors.forename: Craig
authors.initials: C
authors.lastname: Bryan
authors.forename: Mary Jo V
authors.initials: MJ
authors.lastname: Pugh
mesh_terms: D000293:Adolescent; D000328:Adult; D055826:Afghan Campaign 2001-; D001930:Brain Injuries / Q000150:complications* / Q000453:epidemiology / Q000523:psychology; D059350:Chronic Pain / Q000150:complications* / Q000453:epidemiology / Q000523:psychology; D015897:Comorbidity; D003863:Depression / Q000150:complications / Q000453:epidemiology; D005260:Female; D006801:Humans; D054542:Iraq War, 2003-2011; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D013313:Stress Disorders, Post-Traumatic / Q000150:complications* / Q000453:epidemiology / Q000523:psychology; D019966:Substance-Related Disorders / Q000150:complications / Q000453:epidemiology; D059020:Suicidal Ideation; D013405:Suicide / Q000523:psychology / Q000706:statistics & numerical data*; D013406:Suicide, Attempted / Q000523:psychology / Q000706:statistics & numerical data; D014481:United States / Q000453:epidemiology; D014728:Veterans / Q000523:psychology / Q000706:statistics & numerical data*; D055815:Young Adult