U.S. combat veterans' responses to suicide and combat deaths: A mixed-methods study.

RATIONALE

Limited research has examined how combat veterans experience deaths of comrades to combat or suicide. We sought to investigate the process and identify factors that predict the level of grief among post-9/11 U.S. veterans.

METHODS

Using a mixed-methods study design during 2016-2017, U.S. combat veterans of the Iraq and Afghanistan conflicts who lost comrades to both combat and suicide (N = 28) participated in semi-structured interviews, and veterans who lost a comrade in combat or to suicide (N = 178) completed online surveys that assessed grief, combat exposure, unit cohesion, anger, posttraumatic stress symptoms (PTSS), and past diagnoses of PTSD and depression.

RESULTS

Text analyses of interview transcripts revealed seven themes: 1) Suicide death is unexpected and can make acceptance of loss harder; 2) Combat death is expected and can ease acceptance of loss; 3) Combat death is heroic and can make acceptance of loss easier; 4) Brotherhood forged in combat intensifies the emotional response; 5) Guilt over the inability to prevent a comrade's death makes acceptance harder; 6) Attribution of blame for a death creates anger; and 7) Detachment from the civilian world may make it more difficult to cope with comrades' deaths. Regression analyses of survey data indicated: 1) suicide loss predicted non-acceptance of the loss; 2) mode of death moderated the association between unit cohesion and grief; 3) combat exposure, anger, closeness to the deceased, and having a past diagnosis of depression predicted the level of grief; and 4) combat exposure is a similarly strong predictor of grief and PTSS. Results highlight how veterans' grief further delineates war's toll.

CONCLUSION

The mixed-methods design tells a rich story about a previously unexplored consequence of war. These findings have important public health implications because outcomes impact not only veterans but also their families and communities.