Among recently returned veterans, a new study says those who are married or living with a partner are at higher suicide risk than soldiers who are single, and older married female veterans are at the greatest risk.

While one might assume soldiers returning from deployment would find comfort and support reuniting with a spouse or loved one, the transition to a domestic environment can cause stress, according to the analysis by researchers at the University of Connecticut and U.S. Department of Veterans Affairs.

For some veterans, the transition back to a domestic home environment—and all of the pressures, roles, and responsibilities that come with it—only adds to their internal struggles.

“It certainly makes sense when you think about it,” says Crystal Park, UConn psychology professor and one of the study’s co-authors. “There are added pressures that come with maintaining a relationship and meeting household needs. People may have expectations when they’re away and when they return it’s not what they imagined, the romance may not be there. It’s just the daily grind and that can drive up stress levels and increase feelings of despair.”

The findings are based on the responses of 772 recently returned veterans who participated in the Survey of Experiences of Returning Veterans (SERV), a longitudinal study overseen by the U.S. Department of Veterans Affairs. Given the recent influx of women into the armed services, the survey sought to gauge the experiences of female veterans, in particular. As a result of a targeted recruiting campaign, women represented more than 40 percent of those surveyed, which is more than double the actual representation in the military.

In the survey, the average age of veterans was 35, and they had served in Iran, Afghanistan, and surrounding areas as part of Operations Enduring Freedom, Iraqi Freedom, and New Dawn. Most of them—62 percent—served in the Army. Seventy-five percent reported exposure to combat.

More than 20 percent of those surveyed reported thoughts of suicide, with 6 percent reporting a past attempt and current thoughts of suicide. Significantly, the study confirmed prior reports of female veterans, in general, being at increased risk of suicide relative to men.

Younger veterans in their 20s, both male and female, reported much less suicide ideation than older vets in their 40s and 50s who completed the survey. Park suspects the finding may be due to the fact that many older veterans of recent conflicts were members of the National Guard or military reserves who were called into service.

“A lot of the people who went over there weren’t active duty military,” says Park. “They were people who signed up for something but probably never anticipated they would be going to Afghanistan to fight the Taliban. They had jobs. They had kids. They had a life that was much different than someone who chooses to enlist in the military.”

The survey also looked at the role veterans’ religious feelings and spirituality might play in increasing or decreasing suicide risk.

Researchers found that veterans who had negative attitudes about religion and spirituality—meaning they felt God was punishing them or that God had abandoned them—were at significantly higher risk for suicide, even after accounting for depression and other variables.

Interestingly, the researchers found that positive feelings about religion and spirituality—feelings that God is a partner in your life and someone you can turn to for guidance, support and strength—did not significantly reduce veterans’ suicide risk.

Most importantly, Park says, the study clearly showed that spiritual struggle among veterans is a separate and independent risk factor for suicide and not just a reflection of people’s depression.

“This suggests that people are experiencing some profound spiritual struggle over and above any depression they might have,” says Park. “What people experience, what they do, and what they witness can have profound negative effects on them when they come back.”

The findings emphasize the importance of religion and spirituality in veteran suicide prevention efforts, the researchers say, and underscore the need for counseling and supports that are both gender specific and tailored to the needs of veterans during their initial reintegration into civilian life.

Addressing suicidal behavior among veterans is a major public health concern. It is estimated that 20 veterans die daily by suicide and 18 percent of all suicide deaths in the United States are attributed to current or former military personnel.

But Park says the issue is far greater than those statistics reflect.

“There are a lot more veterans out there thinking about suicide and who are in despair and we really do owe them some kind of help for these issues,” says Park. “People are having profound spiritual struggles in their lives that can’t simply be linked to depression and medicated away. It’s more of an existential crisis. When you think about what our country asks soldiers to go and do and then think that there won’t be any consequences to their spiritual life as a result, it’s kind of ridiculous.”

The complete study can be found in the Archives of Suicide Research, a journal of the International Academy of Suicide Research.

Yale Professor Rani Hoff, director of the Northeast Program Evaluation Center within the VA’s Office of Mental Health Operations, was the study’ principal investigator. Dr. Marek Kopacz , a medical sociologist with the U.S. Department of Veterans Affairs VISN2 Center of Excellence for Suicide Prevention, was the study’s lead author. Hugh Crean, a research affiliate at the VISN2 Center, is also a co-author.

The study was supported by funding from the U.S. Department of Veterans Affairs.