Disaggregating Data Regarding Suicidal Ideation and Suicide Attempts among Post-9/11 Asian American and Pacific Islander Veterans

Abstract

The suicide rate among Asian American and Pacific Islander veterans has increased; however, data aggregation for these groups, combined with underinclusion in research, limits understanding regarding risk. We conducted a secondary analysis of Comparative Health Assessment Interview Research Study 2018 data to compare suicidal ideation (SI) and suicide attempt (SA) prevalence among 668 post-9/11 veterans who identified as Asian American, Pacific Islander, or both and described SI and SA prevalence among specific subgroups. Veterans who identified as both Asian American and Pacific Islander were more likely to report experiencing SI (lifetime and during their military service), compared to those who identified solely as Asian American or Pacific Islander (military SI only). Statistically significant differences were not detected for SI preceding or following military service or for lifetime SA. Weighted estimates for lifetime SI and SA were 24.2% and 6.5%, respectively, and prevalence varied widely among specific Asian American and Pacific Islander groups. However, small cell sizes and wide confidence intervals were limitations. Increased clinical attention to screen for and mitigate suicide risk among veterans who identify as both Asian American and Pacific Islander may be warranted. To ensure that suicide prevention strategies optimally address their needs and experiences, research is needed to elucidate suicide drivers in this population. Considering the heterogeneity in SI and SA prevalence among different Asian American and Pacific Islander groups, continued research with larger subsamples that disaggregates analyses by race and ethnicity is essential to deliver prevention and health promotion strategies targeted to the highest-risk groups.

Keywords

suicidal ideation suicide attempts Asian American Pacific Islander veteran

Asian American and Pacific Islander individuals have served in the U.S. military for two centuries (Department of Veterans Affairs, Center for Minority Veterans, 2013) and constituted 2.0% of the U.S. veteran population (nearly 386,000 individuals¹) in Fiscal Year 2020 (National Center for Veterans Analysis and Statistics, 2020). In 2019, 4.6% of the Department of Defense force reported their race as Asian American and 1.0% as Pacific Islander (Department of Defense, Office of the Deputy Assistant Secretary of Defense for Military Community and Family Policy, 2019). Thus, the proportions of Asian American and Pacific Islander veterans are expected to increase over time (i.e., to 2.6% and 0.4%, respectively, by Fiscal Year 2050; National Center for Veterans Analysis and Statistics, 2020).

Nonetheless, research focused on Asian American and Pacific Islander veterans, including those who served recently, remains limited. In a review conducted by Tsai and Kong (2012), the authors noted the paucity of research on Asian American and Pacific Islander veterans, including the complete absence of studies on Asian American and Pacific Islander veterans who served post-9/11. This gap is notable, considering that post-9/11 veterans are more likely to have a history of deployment and service in a combat zone and to have experienced a distressing trauma, relative to pre-9/11 veterans (Parker et al., 2019). Many post-9/11 veterans have also experienced hazardous exposures and mental and physical health conditions (Waszak & Holmes, 2017). In a recent survey of post-9/11 veterans, rates of mental health screens suggested probable diagnoses ranging from 51% (depression) to 73% (anxiety disorders) among those who screened positive for a mental health disorder (Aronson et al., 2020). Furthermore, 77% of post-9/11 veterans reported having a medical condition that was ongoing. Post-9/11 veterans also report more difficulties adjusting to civilian life, compared to pre-9/11 veterans (Parker et al., 2019). Of note, the transition period from military separation back to civilian life has been referred to as the “deadly gap,” reflecting a period of increased suicide risk due to heightened risk factors concurrent with potentially limited mental health care use (Sokol et al., 2021). Furthermore, one study found that for some post-9/11 veterans (i.e., females), their risk for suicide mortality remained heightened for 7 years following separation (Bullman et al., 2015). For these reasons, a particular emphasis on better understanding the needs of post-9/11 veterans, both with regard to mental and physical health as well as suicide risk and prevention, specifically, has emerged.

Unfortunately, a dearth of research exists on suicide among Asian American and Pacific Islander veterans, including those who served post-9/11 (Tsai & Kong, 2012). To our knowledge, the main source of information regarding suicide among Asian American and Pacific Islander veterans is the annual suicide prevention report published by the Department of Veterans Affairs, Office of Mental Health and Suicide Prevention (2021). This report revealed a sizable increase (157%) in the unadjusted suicide rate among Asian American and Pacific Islander veterans: from 11.0 to 28.3 per 100,000 from 2001 to 2019 (Department of Veterans Affairs, Office of Mental Health and Suicide Prevention, 2021). The large magnitude of this increase appears to be unique to Asian American and Pacific Islander veterans, compared to veterans of other races, for whom the percent increase varied from 5% (American Indian and Alaskan Native) to 45% (White) (Department of Veterans Affairs, Office of Mental Health and Suicide Prevention, 2021). Of note, from 2014 to 2019, the age-adjusted suicide rate among Asian American and Pacific Islander individuals within the general U.S. population also increased (though by a smaller magnitude, 16%), with marked increases from 2013 to 2019 for 15- to 24-year-old males and females (by 40% and 42%, respectively; Ramchand et al., 2021). These findings suggest that suicide is a growing problem among individuals who identify as Asian American or Pacific Islander, with particularly concerning trends among veteran cohorts (Department of Veterans Affairs, Office of Mental Health and Suicide Prevention, 2021).

However, information regarding the prevalence of suicidal ideation and suicide attempts in Asian American and Pacific Islander veteran populations remains sparse. This is problematic, as suicidal ideation and suicide attempts are important upstream precursors to suicide, and identification can facilitate targeted intervention and prevention (Franklin et al., 2017; Jobes & Joiner, 2019; Kleiman, 2020). Yet methodological limitations, such as missing data regarding race (McCarthy et al., 2017) and relatively small numbers of Asian American and Pacific Islander veterans in prior studies (Tsai & Kong, 2012), have precluded in-depth understanding of the prevalence of suicidal thoughts and behaviors in these populations. Determining the prevalence of suicidal ideation and attempts among Asian American and Pacific Islander veterans could help with ascertaining the extent of these health concerns within these populations and identifying those in need of increased clinical attention—an integral aspect of prevention. Such efforts would benefit from disaggregating findings by race and/or ethnicity.

Prior research on mental health concerns, including suicide, has largely examined Asian American and Pacific Islanders together as a single group, despite substantial heterogeneity with respect to geography, cultures, and beliefs (Budiman & Ruiz, 2021; Holland & Palaniappan, 2012; Srinivasan & Guillermo, 2000). Asian American and Pacific Islander populations comprise approximately 50 ethnic groups, with over 100 languages spoken (National Alliance on Mental Illness, n.d.). Thus, grouping all Asian American and Pacific Islander individuals together likely masks important between-group differences. It also precludes understanding health disparities within and between these populations (Holland & Palaniappan, 2012; Islam et al., 2010). The lack of disaggregated data for Asian American and Pacific Islander populations has been described as a substantial impediment to developing policies to comprehensively address mental health within these populations (Fang, 2018). As such, there have been calls to disaggregate data for Asian American and Pacific Islander individuals to provide more granular findings to determine how to target resources, offer culturally responsive services, and improve health care quality (Fang, 2018; Holland & Palaniappan, 2012).

Both research and theory underscore the utility of a disaggregated approach to understanding suicide risk and strengthening suicide prevention. Prior research has found differences in rates of suicidal ideation and suicide among various groups of Asian Americans, such as higher rates among those who identified as Korean or Japanese and lower rates among those who identified as Indian (Kuroki, 2018; Wong et al., 2014). Indeed, differences would be expected based on the cultural model of suicide (J. P. Chu et al., 2010), which posits that culture influences the specific stressors that lead to suicide (e.g., minority stress, social discord). The cultural meaning of stressors and suicide (e.g., cultural sanctions regarding the acceptability of suicide), along with individual pain thresholds, influence suicidal thoughts and behaviors, and the expression of suicidal thoughts and behaviors (e.g., language, method) is influenced by culture (i.e., idioms of distress).

Among Asian American and Pacific Islander individuals within the United States, stressors can include racism, acculturative stress, family obligations, and pressure to meet expectations regarding high academic achievement (i.e., the “model minority myth” [Hwang & Ting, 2008; Lee et al., 2009; Miller et al., 2011]). Interpersonal factors more commonly precipitate suicide attempts among young U.S. adults who are Asian, relative to those who identify as Black (Rosario-Williams et al., 2022). Additionally, the circumstances preceding suicide death differ between Asian American and Pacific Islander, relative to White individuals within the United States; among Asian American and Pacific Islander individuals, recent mental health problems, mental health treatment, disclosure of suicidal ideation, and intimate partner problems were reported to be less common, whereas school problems were twice as prevalent (Wong et al., 2017). Regarding the expression of suicidal thoughts among those who are Asian American or Pacific Islander, concerns exist regarding underreporting of suicidal ideation and “hidden” suicidal ideation (J. Chu et al., 2018); in one study with a community sample, 60% of Asian American and Pacific Islander adults who were experiencing suicidal desire reported that they had hidden their desire to kill themselves from other people. Further underscoring the concerning nature of this finding, “hidden” suicidal ideation was associated with increased severity of both suicidal distress and cultural suicide risk (J. Chu et al., 2018). Suicide methods also differ, with hanging used more frequently and firearms and poisoning less frequently among Asian American and Pacific Islanders, compared to White Americans, who died by suicide (Wong et al., 2018). However, it is unknown if these findings regarding suicide precipitants, expression, and methods apply to Asian American and Pacific Islander veterans.

Moreover, varied experiences during military service and reintegration across different Asian American and Pacific Islander veteran groups may differentially exacerbate suicide risk (Tsai & Kong, 2012). Asian American and Pacific Islander service members and veterans have described experiencing microaggressions, normalization of racial discrimination, and insufficient recourse regarding such experiences when reported (President’s Advisory Commission on Asian Americans and Pacific Islanders, 2017). Such experiences may vary in prevalence and be particularly detrimental for specific Asian American and Pacific Islander groups (Loo, 1994).

Further, a significant portion of Asian American and Pacific Islander individuals identify as both Asian American and Pacific Islander (Jones et al., 2021). As such, it is also important to examine if the prevalence of suicidal ideation and attempts differs for individuals who identify as both Asian American and Pacific Islander. Notably, although the population of multiracial individuals within the United States is growing, multiracial individuals have historically been excluded in racial discourse (Bratter & Gorman, 2011). This is problematic, as multiracial individuals have experienced different patterns of mental health utilization (e.g., among those who attempted suicide, lower use of outpatient mental health services, compared to non-Hispanic White individuals; Sheehan et al., 2018) and potential suicide risk factors (e.g., rumination, depression; Cheref et al., 2015). Moreover, among college students, those who were multiracial had increased odds of experiencing suicidal ideation, suicide plans, and non-suicidal self-injury, along with mental and behavioral health concerns (e.g., depression, anxiety), relative to monoracial individuals (Oh et al., 2023). Research is warranted to understand if veterans who identify as both Asian American and Pacific Islander experience a heightened prevalence of suicidal ideation and attempts.

To address these areas of need, we conducted a secondary analysis of data collected from a population-based sample of post-9/11 Asian American and Pacific Islander veterans who participated in the Comparative Health Assessment Interview (CHAI) Research Study (Hoffmire et al., 2021). Our first aim was to compare the prevalence of suicidal ideation (lifetime, pre-military, during military service, and post-military) and suicide attempts (lifetime) between veterans who identified as Asian American, Pacific Islander, or both. Our second aim was to explore the prevalence of suicidal ideation among specific groups of Asian American (e.g., Filipino, Korean, Chinese, Japanese, Asian Indian, Vietnamese) and Pacific Islander (e.g., Native Hawaiian, Guamanian) veterans.

Method

Procedures

The sample for this secondary analysis was derived from the CHAI Research Study (Hoffmire et al., 2021). CHAI is a cross-sectional observational study that was conducted in 2018 to examine associations between military experiences and health and well-being among Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) veterans who served on active-duty military service after September 11, 2001 (i.e., post-9/11 veterans). Inclusion criteria comprised post-9/11 service (i.e., between October 1, 2001 and May 31, 2015), separation from military service by June 30, 2015, and a postal address within the 50 states or District of Columbia (though two participants provided updated addresses in U.S. territories). Exclusion criteria included no access to telephone or internet, being physically unable to complete the survey, and being incarcerated at the time of study invitation.

The U.S. Veterans Eligibility Trends and Statistics dataset, which is the most comprehensive dataset available on all living U.S. veterans, was used to construct the sampling frame (Hauser, 2019; National Center for Veterans Analysis and Statistics, 2020). Gender, deployment status, military branch, service component, and first activation in relation to 9/11 were used as sampling stratification variables. Additional details regarding the sampling frame are available (Hoffmire et al., 2021). Of 67,500 eligible veterans, 38,633 were invited to participate (i.e., received one invitation mailing, two reminder mailings, and follow-up telephone calls). Overall, 15,170 veterans responded (response rate of 40%). For this secondary analysis, we included any veteran participants who identified as Asian American and/or Pacific Islander on the survey. Thus, our analytic sample for this manuscript included 668 veterans (573 Asian American, 59 Pacific Islander, and 36 participants who identified as both Asian American and Pacific Islander).

The Department of Veterans Affairs (VA) Central Institutional Review Board provided regulatory oversight and approval for the CHAI Research Study (Protocol 17-29). All participants provided informed consent to participate, either verbally (for those who participated by telephone) or online (by checking a box to indicate consent). The core CHAI survey was self-administered online and through computer-assisted telephone interviewing. Monetary incentives included $1 upon invitation and $50 upon survey completion.

Measures

Measures analyzed for the present aims are described next. Underlying research materials can be accessed by emailing the senior author.

Suicidal Ideation and Attempts

Constructs of interest included lifetime suicidal ideation (“Have you ever actually had any thoughts of killing yourself?”) and suicide attempts, assessed with a modified version of the Columbia-Suicide Severity Rating Scale (Posner et al., 2011). In addition to the assessment of lifetime suicidal ideation and attempts, the presence or absence of suicidal ideation and suicide attempts relative to military service was queried. Specifically, participants who endorsed experiencing lifetime suicidal ideation or attempts were asked if such experiences had occurred preceding, during, and/or following their military service. The Columbia-Suicide Severity Rating Scale has demonstrated predictive validity with veteran samples (Matarazzo et al., 2019), and analyses with these added questions regarding the timing of suicidal ideation and attempts have been published previously (Hoffmire et al., 2021).

Race

Race was assessed with the question, “What is your race?” with instructions to select all responses that applied. This question was administered in a prior study of veterans (Blosnich et al., 2022) and updated to reflect Census Bureau categories. For our analyses, we categorized participants as Asian American if they selected Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or “Other Asian (e.g., Hmong, Laotian, Thai, Pakistani, Cambodian, and so on).” We categorized participants as Pacific Islander if they selected Native Hawaiian, Guamanian or Chamorro, Samoan, or “Other Pacific Islander (e.g., Fijian, Tongan, and so on).” Respondents who indicated their race as White, Black, African American, American Indian or Alaska Native, and/or some other race, in the absence of endorsing any of the Asian American or Pacific Islander response options, were excluded from the analytic sample. Asian American and/or Pacific Islander racial subgroups were constructed in two ways: (a) mutually exclusive, such that participants could fall into only one category, with those reporting multiple races categorized as such; and (b) non-mutually exclusive categories for which participants were included in each Asian American and/or Pacific Islander group they identified with.

Additional Variables

Additional constructs pertinent to the present analyses (i.e., for descriptive purposes or as potential covariates) included age, gender identity, ethnicity, sexual orientation, marital status, education, employment, time at risk (described below), current residence in a metropolitan statistical area, region, primary branch of service, service in the Reserve or National Guard, deployment history, combat exposure in OEF/OIF/OND, and military sexual trauma history. These were assessed via self-report, with a few exceptions. Missing gender identity or non-conforming gender identity were filled with the frame sex variable (n = 5). Time at risk was calculated based on military service and age. Years at risk pre-military was calculated as age at military entry minus nine due to the low risk of suicidal ideation and suicide attempts before 10 years of age. Time at risk during military service was calculated as age at separation minus age at entry. Time at risk after military service was calculated as age at the time of survey minus age at separation.

Analysis Plan

Descriptive analyses (e.g., unweighted frequencies, weighted percentages with 95% confidence intervals [CIs]) were conducted, along with comparisons of these estimates based on Asian American and Pacific Islander self-identification. Regarding the outcomes of interest, all participants were asked about lifetime suicidal ideation; however, suicidal ideation could not be determined for eight participants who declined to respond to this question or answered “I don’t know.” As noted previously, suicidal ideation prior to, during, and after military service was queried only when lifetime suicidal ideation was endorsed. Similarly, individuals who reported experiencing suicidal ideation were asked about lifetime suicide attempts. In contrast, individuals who did not endorse experiencing lifetime suicidal ideation were coded as having had no lifetime suicide attempts. In the rare instances where suicidal ideation and/or suicide attempts could not be determined, observations were set to missing (n = 8).

Demographic and military characteristics are presented as weighted proportions (or weighted means) and compared across groups using second-order Rao–Scott chi-square tests (domain analysis for means). Deployment in support of OEF/OIF/OND was only asked of those endorsing deployment, and combat in support of OEF/OIF/OND was only asked of those endorsing deployment in support of these efforts. All other missing data were due to responses of “I don’t know” or declining to respond. Poisson regression with robust error variance (Talbot et al., 2023) was employed to compare lifetime and period (relative to military service) prevalence of suicidal ideation and suicide attempts. Lifetime models controlled for age and gender, whereas the period models controlled for gender and years at risk. Results are presented as prevalence ratios (PRs) with 95% CIs.

All analyses, including percentages, were weighted to account for the study’s probability sampling design and stratification, non-response bias adjustment, and population calibration (see Hoffmire et al., 2021 for additional weighting details).

Results

Sample Characteristics

Table 1 reports demographic and military service characteristics for the analytic sample of Asian American and Pacific Islander veterans (weighted to reflect the post-9/11 Asian American and Pacific Islander veteran population), along with the subsamples who identified as Asian American, Pacific Islander, or both. Table 1 also includes comparisons between veterans who identified as Asian American, Pacific Islander, or both. Veterans who identified as both Asian American and Pacific Islander were, on average, older than those who identified solely as Asian American or Pacific Islander. No other demographic or military service characteristics significantly differed across groups.

Table 1

Demographic and Military Characteristics

Characteristic	Full sample (N = 668)		AA only (n = 573)		PI only (n = 59)		Both (n = 36)		p
Characteristic	Mean	SE	Mean	SE	Mean	SE	Mean	SE	p
Age	37.30	0.43	37.35	0.43	34.80	1.63	42.17	1.86	^a
	n	Weighted %	n	Weighted %	n	Weighted %	n	Weighted %	p
Gender									.16
Female	249	16.69	207	15.62	27	22.88	15	25.57
Male	419	83.31	366	84.38	32	77.12	21	74.43
Ethnicity (n = 665)									.47
Hispanic, Latino or Spanish Origin	56	8.27	46	7.71	5	13.39	5	8.42
Not Hispanic, Latino or Spanish Origin	609	91.73	524	92.29	54	86.61	31	91.58
Sexual orientation (n = 663)									.39
Straight	624	96.05	540	96.64	53	94.40	31	87.10
Lesbian/gay	15	1.79	11	1.59	3	3.02	1	3.21
Bisexual	17	1.28	13	1.01	1	0.76	3	8.30
Other	7	0.88	5	0.76	1	1.83	1	1.40
Marital status (n = 667)									.61
Never married	129	25.25	110	24.31	11	33.73	8	26.01
Married/domestic partnership	420	58.24	363	58.72	37	55.66	20	53.70
Separated/divorced	113	16.20	95	16.66	10	10.15	8	20.29
Widowed	5	0.31	4	0.30	1	0.46	0	0.00
Education									.30
< High school/high school/GED	36	8.37	28	7.53	4	13.36	4	15.29
Some college credit, no degree	158	24.27	135	24.27	15	22.19	8	29.22
Associate’s or bachelor’s degree	315	45.71	270	44.99	31	55.68	14	38.26
Graduate degree	159	21.64	140	23.22	9	8.77	10	17.23
Paid employment (n = 666)									.20
Working	526	79.88	455	80.72	41	69.45	30	86.49
Not working, actively looking	65	11.38	52	10.41	11	22.81	2	5.25
Not working, not looking	75	8.74	65	8.87	7	7.74	3	8.26
Current residence^b (n = 658)									.70
MSA	601	90.78	522	90.86	50	92.05	29	86.12
Non-MSA	57	9.22	44	9.14	7	7.95	6	13.88
Region^c (n = 658)									.49
Northeast	47	9.67	44	10.34	1	4.14	2	7.26
Midwest	62	9.25	55	9.67	2	5.49	5	8.49
South	243	34.39	207	33.85	28	42.82	8	27.50
West	302	46.24	256	45.63	26	47.54	20	56.75
Other	4	0.45	4	0.52	0	0.00	0	0.00
Primary branch of service (n = 665)									.51
Army	314	50.53	263	49.38	36	62.49	15	47.55
Marine Corps	54	11.24	47	11.27	4	10.84	3	11.45
Navy	147	20.22	133	21.58	7	11.35	7	11.30
Air Force	149	17.87	127	17.77	12	15.33	10	26.09
Coast Guard	1	0.14	0	0.00	0	0.00	1	3.60
Ever Reserve/National Guard service									.89
Yes	355	50.46	304	50.72	28	47.39	23	51.95
No	313	49.54	269	49.28	31	52.61	13	48.05
Deployment—Ever									.52
Yes	456	66.99	391	67.15	39	61.69	26	76.03
No	212	33.01	182	32.85	20	38.31	10	23.97
Deployment—OEF/OIF/OND^d (n =451)									.22
Yes	353	79.90	304	80.44	26	68.54	23	90.65
No	98	20.10	84	19.56	12	31.46	2	9.35
OEF/OIF/OND combat^e (n = 353)									.24
Yes	259	77.64	223	78.76	22	79.23	14	55.43
No	94	22.36	81	21.24	4	20.77	9	44.57
Military sexual harassment (n = 630)									.63
Yes	133	13.28	106	12.83	17	16.46	10	16.14
No	497	86.72	436	87.17	39	83.54	22	83.86
Military sexual assault (n = 643)									.40
Yes	37	2.99	29	2.78	4	3.08	4	7.73
No	606	97.01	524	97.22	54	96.92	28	92.27
Military sexual trauma^f (n = 631)									.65
Yes	134	13.39	107	12.96	17	16.46	10	16.14
No	497	86.61	436	87.04	39	83.54	22	83.86

Note. Percentages were calculated based on the available sample size for each variable. Sample size for each variable was based on N = 668, unless noted otherwise. Percentages were weighted using the main study population weight. p-values correspond to Rao–Scott chi-square values. AA = Asian American; MSA = Metropolitan Statistical Area; OEF = Operation Enduring Freedom; OIF = Operation Iraqi Freedom; OND = Operation New Dawn; PI = Pacific Islander; SE, standard error.

AA vs. PI: p = .12; AA vs. both: p = .01; PI vs. both: p = .002.

MSAs contains at least one county with a city population ≥50,000 or a Census Bureau-defined urbanized area with a total population ≥100,000.

Northeast: CT, ME, MA, NH, NJ, NY, PA, RI, VT; Midwest: IL, IN, IA, KS, MI, MN, MO, NE, ND, OH, SD, WI; South: AL, AR, DE, DC, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX, VA, WV; West: AK, AZ, CA, CO, HI, ID, MT, NV, NM, OR, UT, WA, WY.

Percentages were calculated from the subsample who reported ever deploying.

Percentages were calculated from the subsample who reported having OEF/OIF/OND deployment(s).

Operationalized as reporting a history of military sexual harassment and/or military sexual assault.

As reflected in Table 1, the mean age within the overall sample was 37.30 (standard error = 0.43). The majority of veterans identified as male (83.31%), non-Hispanic (91.73%), and heterosexual (96.05%). Over half (58.24%) were currently married or in a domestic partnership. Most indicated that they were working (79.88%) and resided in a metropolitan statistical area (90.78%). Education was highly variable, with associate or bachelor’s degrees as the most common degrees (45.71%). The West (46.24%) and South (34.39%) were the most common regions of residence. Approximately half of the veterans reported their primary branch of service as the Army (50.53%), and approximately half had (ever) served in the Reserve or National Guard (50.46%). The majority had deployed (66.99%); of those, 79.90% had deployed for OEF/OIF/OND. Among those deployed in support of OEF/OIF/OND, 77.64% were exposed to combat. A portion of veterans reported experiencing military sexual trauma (13.39%), including military sexual assault (2.99%).

Lifetime and Period Prevalence of Suicidal Ideation and Suicide Attempts

Suicidal Ideation

The prevalence of suicidal ideation by group (i.e., among veterans who identified as Asian American, Pacific Islander, or both) is reported in Table 2. Within the overall sample of Asian American and Pacific Islander veterans, 24.2% (95% CI: 20.4, 28.0) reported experiencing suicidal ideation in their lifetime. When descriptively examining when this had occurred in relation to military service, suicidal ideation was most prevalent in the overall sample following military service (19.4%; 95% CI: 15.7, 23.1), was less common during military service (13.7%; 95% CI: 10.5, 16.9), and had the lowest prevalence prior to military service (9.3%; 95% CI: 6.8, 11.8).

Table 2

Period Prevalence of Active Suicidal Ideation and Suicide Attempt by Group

Variable	Asian American only (n = 566)			Pacific Islander only (n = 58)			Both (n = 36)
	%	95% CI		%	95% CI		%	95% CI
	%	LL	UL	%	LL	UL	%	LL	UL
Suicidal ideation
Lifetime	23.4	19.5	27.3	21.0	7.9	34.0	48.9	30.2	67.6
Pre-military	8.7	6.2	11.2	13.7	1.9	25.5	13.0	0	26.5
During military	12.7	9.3	16.1	15.8	3.9	27.7	29.6	11.9	47.2
Post-military	19.2	15.3	23.1	15.6	4.5	26.6	33.6	14.5	52.7
Suicide attempt
Lifetime	5.7	3.4	7.9	10.2	0.69	19.8	16.5	0.99	32.0
Pre-military	2.4	1.1	3.8	4.4	0	10.8	9.8	0	24.2
During military	2.4	0.99	3.7	7.1	0	14.6	15.0	0	30.4
Post-military	3.3	1.6	5.0	4.6	0	11.1	4.7	0	11.6

Note. All percentages presented were weighted using the main population weight and were not adjusted for duration of time at risk. CI = confidence interval; LL = lower limit; UL = upper limit.

Suicide Attempt

The prevalence of suicide attempt by group is reported in Table 2. Within the overall sample, 6.5% (95% CI: 4.4, 8.6) of participants reported a lifetime suicide attempt. The prevalence of suicide attempts was relatively similar across time periods, including prior to (2.9%; 95% CI: 1.5, 4.4), during (3.3%; 95% CI: 1.8, 4.8), and following (3.5%; 95% CI: 1.9, 5.2) military service.

Comparing Suicidal Ideation and Suicide Attempt Prevalence across Groups

Results of the adjusted models are included in Table 3. Adjusting for age and gender, those who identified as both Asian American and Pacific Islander were significantly more likely to report experiencing lifetime suicidal ideation, compared to those who identified solely as Asian American (PR = 2.26; 95% CI [1.47, 3.48]; p = .0002) or Pacific Islander (PR = 2.64; [1.11, 6.24]; p = .03). Adjusting for gender and years at risk, those who identified as both Asian American and Pacific Islander were also significantly more likely to report experiencing suicidal ideation during their military service, compared to those who identified solely as Asian American (PR = 2.36; [1.21, 4.60]; p = .01). In contrast, no significant differences were detected in the prevalence of suicidal ideation prior to or following military service nor with regard to lifetime suicide attempts.

Table 3

PRs for Adjusted Models

Variable	PI only vs. AA only			Both vs. AA only			Both vs. PI only
	PR	95% CI		PR	95% CI		PR	95% CI
	PR	LL	UL	PR	LL	UL	PR	LL	UL
Suicidal ideation
Lifetime	0.85	0.38	1.91	2.26**	1.47	3.48	2.64*	1.11	6.24
Pre-military^a,b	1.63	0.48	5.56	1.52	0.26	8.78	0.93	0.13	6.93
During military^b	1.29	0.45	3.66	2.36*	1.21	4.60	1.83	0.60	5.61
Post-military	0.68	0.26	1.80	1.78	0.90	3.50	2.60	0.84	8.06
Suicide attempt^b,c
Lifetime	0.98	0.93	1.03	0.94	0.86	1.03	0.96	0.87	1.07

Note. Lifetime models were adjusted for age and gender. AA = Asian American; CI = confidence interval; PI = Pacific Islander; PR = prevalence ratio; LL = lower limit; UL = upper limit.

Pre-military years at risk was calculated as age at entry minus nine given that suicidal ideation or suicide attempt prior to 10 years of age is uncommon.

Adjusted for years at risk and gender.

For suicide attempt, only the lifetime adjusted model could be run due to small cell sizes.

p < .05. **p < .001.

Exploring Prevalence of Lifetime Suicidal Ideation and Attempts Among Specific Groups

Mutually Exclusive

Finally, we explored the prevalence of lifetime suicidal ideation and suicide attempts among specific groups of Asian American and Pacific Islander veterans (Table 4). A large number (n = 307, 46% of the sample) identified as more than one race, including 36 participants who identified as both Asian American and Pacific Islander; among those identifying solely as Asian American, 20 identified with two or more Asian groups, and 221 identified with at least one race other than Asian American. Among those identifying solely as Pacific Islander, 26 identified with at least one race other than Pacific Islander. Among the group identifying as both Asian American and Pacific Islander, 21 identified with at least one race other than Asian American and Pacific Islander.

Table 4

Lifetime Prevalence of Suicidal Ideation and Suicide Attempt by Mutually Exclusive Subgroups

Subgroup	Total	Suicidal ideation				Suicide attempt
	N	n	%	95% CI		n	%	95% CI
	N	n	%	LL	UL	n	%	LL	UL
Other Pacific Islander	12	12	1.2	0	4.0	12	0	0	0
Native Hawaiian	4	4	3.3	0	47.4	4	3.3	0	47.4
Asian Indian	22	20	10.1	0	21.8	21	1.5	0	4.4
Filipino	129	128	13.9	7.6	20.3	128	4.8	0.8	8.8
Chinese	32	32	15.7	0	31.7	32	6.9	0	20.2
Korean	54	54	23.9	9.9	37.9	54	7.1	0	14.7
Samoan	5	5	24.2	0	70.9	5	24.2	0	70.9
Japanese	23	23	26.9	2.0	51.9	23	1.5	0	4.7
Other Asian	45	44	28.6	11.5	45.7	43	5.7	0	12.8
Vietnamese	27	27	27.9	8.3	47.6	27	9.8	0	22.6
Guamanian/Chamorro	8	8	38.7	0	79.7	8	17.2	0	49.0
Multiple races	307	303	30.3	23.6	37.1	303	7.3	3.8	10.7

Note. The n’s listed refer to the subsample sizes for the respective analyses. Subgroups listed in this table are mutually exclusive, such that any given participant could only be classified into a single subgroup. Individuals who identified as multiple racial subgroups where at least one race was Asian American and/or Pacific Islander were thus classified in the “multiple races” category. Not all 307 participants reporting multiple races reported multiple Asian American and/or Pacific Islander races. CI = confidence interval; LL = lower limit; UL = upper limit.

Suicidal Ideation

The prevalence of lifetime suicidal ideation appeared to be highest among those who identified as Guamanian or Chamorro (38.7%), followed by multiple races (30.3%), Other Asian (28.6%), Vietnamese (27.9%), Japanese (26.9%), Samoan (24.2%), Korean (23.9%), Chinese (15.7%), Filipino (13.9%), Asian Indian (10.1%), Native Hawaiian (3.3%), and Other Pacific Islander (1.2%). However, these estimates tended to be based on small cell sizes, and thus precision was limited, as evidenced by wide CIs (Table 4).

Suicide Attempts

Prevalence of lifetime suicide attempts appeared to be highest among those who identified as Samoan (24.2%), followed by Guamanian or Chamorro (17.2%), Vietnamese (9.8%), multiple races (7.3%), Korean (7.1%), Chinese (6.9%), Filipino (4.8%), Other Asian (5.7%), Native Hawaiian (3.3%), Japanese (1.5%), and Asian Indian (1.5%). These estimates were also based on very small cell sizes and had wide CIs.

Not Mutually Exclusive

Suicidal Ideation

Finally, we also examined the disaggregated prevalence of lifetime suicidal ideation and suicide attempts, in a manner that was not mutually exclusive (i.e., participants could be included in multiple groups; Table 5). In doing so, the prevalence of lifetime suicidal ideation appeared to be highest among those who identified as Guamanian or Chamorro (43.9%), followed by Samoan (43.3%), Other Asian (33.6%), Korean (33.3%), Vietnamese (32.8%), Native Hawaiian (31.1%), Other Pacific Islander (26.8%), Chinese (26.7%), Japanese (25.5%), Asian Indian (20.4%), and Filipino (19.3%). However, most of these estimates were based on small cell sizes, which limited precision, as evidenced by wide CIs.

Table 5

Lifetime Prevalence of Suicidal Ideation and Suicide Attempt by Subgroups (Not Mutually Exclusive)

Subgroup	Total	Suicidal ideation				Suicide attempt
	N	n	%	95% CI		n	%	95% CI
	N	n	%	LL	UL	n	%	LL	UL
Filipino	225	224	19.3	13.3	25.3	224	4.8	1.7	7.9
Asian Indian	52	49	20.4	7.3	33.5	50	6.5	0	14.9
Japanese	83	83	25.5	13.4	37.6	83	7.9	0.7	15.1
Chinese	88	87	26.7	14.4	39.0	87	4.2	0	9.4
Other Pacific Islander	39	38	26.8	10.4	43.1	38	9.6	0.3	18.9
Native Hawaiian	42	42	31.1	14.8	47.4	42	9.7	0	20.5
Vietnamese	42	42	32.8	15.7	49.8	42	7.1	0	16.3
Korean	96	96	33.3	23.1	43.6	96	9.3	3.0	15.5
Other Asian	88	86	33.6	20.8	46.4	85	7.7	0.2	15.3
Samoan	15	15	43.3	13.7	72.9	15	32.3	2.9	61.7
Guamanian/Chamorro	16	16	43.9	13.0	74.8	16	30.7	2.3	59.1

Note. The n’s listed refer to the subsample sizes for the respective analyses. Groups listed above are not mutually exclusive. Specifically, 361 participants reported one Asian American and/or Pacific Islander race and 307 reported multiple races which included at least one race that was Asian American and/or Pacific Islander (i.e., 226 participants reported two races, 53 reported three races, 22 reported four races, and 6 reported five or more races). Participants reporting more than one race are included in all Asian American and/or Pacific Islander groups listed above with which they identified. CI = confidence interval; LL = lower limit; UL = upper limit.

Suicide Attempts

Additionally, prevalence of lifetime suicide attempts appeared to be highest among those who identified as Samoan (32.3%) or Guamanian or Chamorro (30.7%), followed by Native Hawaiian (9.7%), Other Pacific Islander (9.6%), Korean (9.3%), Japanese (7.9%), Other Asian (7.7%), Vietnamese (7.1%), Asian Indian (6.5%), Filipino (4.8%), and Chinese (4.2%). These estimates were also based on very small cell sizes and had wide CIs.

Discussion

To our knowledge, this is the first study to report on the prevalence of suicidal ideation and suicide attempts among Asian American and Pacific Islander veterans. Our findings suggest a lifetime prevalence of 24.2% for suicidal ideation and 6.5% for suicide attempts among Asian American and Pacific Islander veterans who served post-9/11, with particularly high rates of suicidal ideation following military service (19.4%). Nonetheless, our results also highlight substantial variation in the prevalence of suicidal ideation among Asian American and Pacific Islander veterans. Specifically, lifetime suicidal ideation prevalence was higher among veterans who identified as both Asian American and Pacific Islander (48.9%), compared to veterans who identified solely as Asian American (23.4%) or Pacific Islander (21.0%). Prevalence of suicidal ideation during military service was also higher among veterans who identified as both Asian American and Pacific Islander (29.6%), relative to those who identified solely as Asian American (12.7%).

These differences may relate to diverse experiences, such as distinct military experiences among veterans who identify as both Asian American and Pacific Islander. Prior research has highlighted the challenges that multiracial individuals can experience (Finney et al., 2020; Sheehan et al., 2018), which can include increased odds of experiencing suicidal ideation and attempts (Oh et al., 2023). Various theories have also been developed to explain multiracial identity development (Bergkamp et al., 2020), which have varied in their approaches (Rockquemore et al., 2009). More recent theories have taken an ecological approach that focuses on social factors as an important aspect of the broader context of identity development (Rockquemore et al., 2009), emphasizing interactions between the individual and their broader socio-political context (Bergkamp et al., 2020). Additionally, the cultural model of suicide (J. P. Chu et al., 2010) underscores the need to examine culturally specific stressors that lead to suicide. Incorporating both the cultural model of suicide and recent theories of multiracial identity development into future research may illuminate future research directions pertinent to understanding suicide risk among Asian American and Pacific Islander veterans. For example, an important next step for future research is understanding the specific experiences and contexts of veterans who identify as Asian American and Pacific Islander—preceding, during, and following their military service. Examining factors, such as prejudice and discrimination that Asian American and Pacific Islander veterans may experience during and following their military service, and determining if these are associated with suicidal ideation and attempts is warranted. Understanding the specific stressors leading to suicide among veterans who identify as both Asian American and Pacific Islander, the cultural meaning of stressors and suicide, and how suicidal thoughts and behaviors are expressed is also essential.

Although there were neither significant differences between Asian American and Pacific Islander veterans in the prevalence of suicidal ideation prior to or following military service nor regarding lifetime suicide attempts, some of these variables (e.g., pre-military suicidal ideation, lifetime suicide attempts) had small cell sizes for subgroup comparisons. Sample sizes of veterans identifying as Pacific Islander and as both Pacific Islander and Asian American were also small. Thus, additional research is warranted to determine if differences exist in the prevalence of suicidal ideation and suicide attempts at different life periods.

To provide an initial signal regarding specific groups of Asian American and Pacific Islander veterans who may be at increased risk for suicidal ideation and attempts, we computed the weighted prevalence of lifetime suicidal ideation and suicide attempts among specific groups. Such findings should be interpreted with caution, considering small sample sizes, overlapping CIs, and lack of formal between-group comparisons. Nonetheless, our exploratory results suggest substantial variation may exist in the prevalence of both lifetime suicidal ideation (which ranged from 19.3% among Filipino veterans to 43.9% in Guamanian or Chamorro veterans; non-mutually exclusive groupings) and suicide attempts (which ranged from 4.2% in Chinese veterans to 32.3% in Samoan veterans; non-mutually exclusive groupings). These initial findings further underscore the utility of disaggregating data regarding race and ethnicity when examining the prevalence of suicidal ideation and suicide attempts, as there likely are specific groups of Asian American and Pacific Islander veterans whose risks for suicidal ideation and attempts are particularly elevated. This would generally mirror findings with the non-veteran population, in which specific groups of Asian adults are at elevated risk for suicidal ideation and suicide (Kuroki, 2018; Wong et al., 2014).

Implications for Suicide Prevention and Health Promotion

Our findings suggest that post-9/11 veterans who identify as both Asian American and Pacific Islander may be at particularly elevated risk for experiencing suicidal ideation. Suicide prevention initiatives, including assessing and mitigating suicide risk among post-9/11 veterans who are both Asian American and Pacific Islander, therefore remain critical. Ensuring that such efforts are culturally sensitive and effective for this patient population is essential. For example, efforts are needed to evaluate whether suicide risk screening and evaluation procedures within healthcare settings (i.e., Department of Veterans Affairs Suicide Risk Identification Strategy [Risk ID]) result in appropriate identification of Asian American and/or Pacific Islander veterans at risk for suicide, as well as services aimed at decreasing risk (Bahraini et al., 2022). This holds especially true given prior research noting rates of non-disclosure of suicidal desire among Asian American and Pacific Islander veterans (J. Chu et al., 2018), suggesting the potential import of identifying culturally-sensitive methods of assessing and classifying risk for these veterans.

Furthermore, given the substantial variation in suicidal ideation and attempt prevalence across different groups of Asian American and/or Pacific Islander veterans, our results also highlight the utility of a more nuanced assessment regarding race and ethnicity among those who have served in the military, with a specific focus on individuals from multiracial backgrounds. Ascertaining more specific information regarding race, as well as idiographic drivers of risk in these groups of veterans, within clinical settings may help with better identification of those at elevated risk for suicide.

In addition to improving suicide prevention for Asian American and Pacific Islander veterans, additional research is needed to understand how we can strengthen health promotion for these veterans. For example, understanding how we can optimally enhance well-being may be particularly helpful given that post-9/11 veterans demonstrate strengths across a number of positive health behaviors (Vogt et al., 2022) and that better vocational, financial, and social well-being are associated with lower levels of suicidal ideation during the transition from military service back to civilian life (Hoffmire et al., 2023). As such, ensuring that health and social services are both effective and appropriately tailored for Asian American and Pacific Islander veterans may be paramount for mitigating rising suicide rates in this population. Nonetheless, such assertions remain speculative and require further research.

Limitations

As previously noted, although our overall sample size of Asian American and Pacific Islander veterans was relatively large (n = 668), sample sizes of specific cohorts were smaller, including for Pacific Islander veterans, veterans who identified as both Asian American and Pacific Islander, and specific groups within these (e.g., Native Hawaiian, Samoan, Guamanian/Chamorro). Although percentages were weighted, small sample sizes limited precision (resulting in large CIs for some analyses) and likely reduced our ability to detect significant between-group differences. Relatedly, the lack of a priori sampling of veterans from U.S. territories, such as Guam and the Northern Mariana Islands, precludes generalizability to veterans residing in those regions, despite noted concerns regarding suicide among Asian American and Pacific Islander veterans in these regions (Monteith et al., 2023). Generalizability is also limited to post-9/11 veterans; consequently, research is needed to characterize the prevalence of suicidal ideation and suicide attempts among Asian American and Pacific Islander veterans who served prior to the recent conflicts, as their experiences may differ in important ways. Additionally, we did not examine if there were differences in the prevalence of suicidal ideation and attempts among Asian American and Pacific Islander veterans, compared to veterans who were not Asian American and/or Pacific Islander; this is an important avenue for future research. Finally, our assessment of suicidal ideation and attempts was based on brief self-report items, rather than an in-depth clinician assessment, and the assessment of these outcomes relative to military service was a modification to the validated Columbia-Suicide Severity Rating Scale (Posner et al., 2011), which could introduce recall bias. As military service is a distinct time period in one’s life that likely serves as a clear time anchor for experiences of suicidal ideation and attempts, recall bias related to this modification is expected to be minimal.

Future Research

In addition to the aforementioned future research directions, additional avenues for subsequent research are apparent. First, understanding more about the experiences of veterans who identify as both Asian American and Pacific Islander, particularly during their military service, may help with understanding the elevated prevalence of suicidal ideation among these veterans. Additionally, there is a need for an intersectional lens in this line of research (Wong et al., 2018). Understanding how factors such as gender identity, region, sexual orientation, and age intersect with race and ethnicity, along with experiences of identity-based discrimination, is essential. There is also a need to identify drivers of suicidal self-directed violence among different groups of Asian American and Pacific Islander veterans, to elucidate how these vary within and between cultures, and to determine how to tailor suicide prevention initiatives to be culturally responsive to the needs, experiences, and preferences of Asian American and Pacific Islander veterans. Considering the presence of “hidden” suicidal ideation among Asian American and Pacific Islander adults (J. Chu et al., 2018), future research should examine if willingness to disclose suicidal ideation and behaviors differs by race and ethnicity. In addition, efforts are needed to increase understanding regarding methods of suicide attempts among these veteran populations and whether recommended suicide prevention strategies (e.g., firearm lethal means safety) hold the same promise for Asian American and Pacific Islander veterans as they do for other veteran cohorts. Lastly, we emphasize the need for studies on suicide mortality among Asian American and Pacific Islander veterans to understand whether differences observed in the present study extend to suicide death, as such findings would have important implications.

Conclusions

In sum, our findings highlight the value of undertaking a nuanced examination of suicidal ideation and suicide attempts among Asian American and Pacific Islander veterans. By examining prevalence across time periods (i.e., in relation to military service), the present study provides new information for understanding periods of risk among Asian American and Pacific Islander veterans and how risk may differ among specific groups. Furthermore, by disaggregating data to explore which groups of Asian American and Pacific Islander veterans have the highest prevalence of suicidal ideation and suicide attempts, findings can be used to begin to inform priority targets of future suicide prevention efforts for groups identified as experiencing the highest risk. Small sample sizes within studies (Shimkhada et al., 2021), even among many large national surveys (Islam et al., 2010), present an ongoing barrier to disaggregating data and determining culturally responsive actions. As this was particularly notable for Pacific Islander veterans in the current sample, further research on this population is essential. Despite these challenges, continued endeavors to understand the nuances of which veteran groups are at the greatest risk for suicidal ideation and attempts are essential to understand the scope of this problem and how it can be addressed in a culturally responsive manner.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This material was supported by the U.S. Department of Veterans Affairs (VA), including the VA Health Outcomes Military Exposures Epidemiology Program, the VA Office of Mental Health and Suicide Prevention, and the VA Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention. The views expressed are those of the authors and do not necessarily represent the views or policy of the VA or the United States Government. The authors would like to thank the Veterans who participated in this study, as well as Carlee Kreisel for her initial contributions. Authors Monteith, Holliday, Miller, Bahraini, and Hoffmire have received funding from the U.S. Department of Veterans Affairs, Office of Mental Health and Suicide Prevention to conduct work focused on suicide risk and prevention among Asian American and Pacific Islander Veterans. The authors also report grant funding from the Department of Veterans Affairs (Monteith, Hoffmire, Holliday, Brenner, Miller, Forster, Bahraini), Department of Defense (Monteith, Forster, Holliday, Brenner, Hoffmire), National Institutes of Health (Brenner, Hoffmire), American Psychological Association (Monteith), and State of Colorado (Brenner). Dr. Brenner also reports editorial renumeration from Wolters Kluwer, and royalties from the American Psychological Association and Oxford University Press, and consults with sports leagues via her university affiliation.

ORCID iD

Lindsey L. Monteith

Notes

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