Experiential avoidance is associated with medical and mental health diagnoses in a national sample of deployed Gulf War veterans

Health correlates of experiential and behavioral avoidance among trauma-exposed veterans

INTRODUCTION

Avoidance is a well-documented risk factor for poor mental and physical health outcomes. However, limited research has explored this relationship specifically among trauma-exposed veterans, a population known to be particularly prone to avoidance behavior. Conceptually, avoidance is often divided into two distinct but overlapping constructs - experiential avoidance (resisting distressing internal states) and behavioral avoidance (avoiding or changing experiences that elicit distress). In this exploratory survey study, we examined associations between behavioral and experiential avoidance and mental, physical, and cognitive functioning, as well as quality of life.

METHODS

Veterans with a trauma history (N = 89) completed a 121-item survey containing validated assessments to examine several mental and physical health and wellness-related variables. Correlations between experiential avoidance and outcome measures, and behavioral avoidance and outcome measures, were explored. Multivariable linear regression analyses were conducted to explore the association between experiential and behavioral avoidance on mental health outcomes. In addition, we conducted exploratory analyses in which we investigated these correlations in those who screened positive for PTSD versus those who did not, and between different types of behavioral avoidance and major outcomes.

RESULTS

Experiential avoidance was moderately correlated with distress from depressive symptoms, distress related to past trauma, and health-related and cognitive dysfunction. Experiential Avoidance was weakly correlated with distress from anxiety symptoms and poorer quality of life. Behavioral avoidance was moderately correlated with distress from depressive and anxiety symptoms, distress related to past trauma, and cognitive dysfunction, and was weakly correlated with health-related dysfunction and poorer quality of life. Results from multivariable analyses revealed that experiential avoidance was associated with greater distress related to depressive symptoms and past trauma, and behavioral avoidance was associated with greater distress related to anxiety symptoms, depressive symptoms, and past trauma.

CONCLUSIONS

Results suggest that avoidance negatively influences major domains of mental and physical health as well as functioning and health-related quality of life in trauma-exposed veterans. They further indicate that behavioral and experiential avoidance may be differentially linked to mental health outcomes. The results support the idea that avoidance may be an important marker for psychosocial functioning and may serve as a treatment target in trauma-exposed veterans.

Sleep Apnea Among Gulf War Veterans: An Examination of VA Utilization Rates, Treatment Initiation, and Health Outcomes

OBJECTIVES

Obstructive sleep apnea (OSA) among veterans is frequently underdiagnosed and undertreated. The present study sought to: 1) characterize the prevalence and rate of treatment of OSA among VA users and non-users and 2) examine the associations between diagnosed or probable OSA and key physical and mental health outcomes.

METHODS

Gulf-War I-era Veterans were recruited as part of a national survey assessing mental and physical health concerns, healthcare needs, and healthcare utilization. OSA diagnoses were self-reported while sleep apnea risk was assessed via the STOP-Bang. Veterans also completed questionnaires assessing overall health, pain, depression, PTSD, and psychosocial functioning.

RESULTS

1,153 veterans were included in the present analyses (Mean age = 58.81; 21.84% female). Compared to non-VA healthcare users, veterans receiving care at the VA were more likely to have been diagnosed with OSA (p < .001) and report receiving treatment for OSA (p = .005). Compared to veterans at low risk for OSA, veterans at elevated risk reported higher levels of pain (p = .001), depression (p = .02), and poorer psychosocial functioning (p < .001).

CONCLUSIONS

OSA diagnoses appear to be more common among VA healthcare users. Findings suggest that OSA remains underdiagnosed and associated with important physical and mental health consequences. Additional screening for OSA, especially among non-VA clinics, is warranted.

Love Is Not All You Need: Understanding the Association Between Relationship Status and Relationship Dysfunction With Self-Directed Violence in Veterans

INTRODUCTION

Research indicates that being married is associated with reduced risk of suicide and self-directed violence (SDV) relative to being divorced. Simultaneously, difficulties within relationships predict poorer health outcomes. However, research on relationship status rarely examines relationship functioning, obfuscating the joint contribution of these variables for SDV risk.

METHOD

Veterans (N = 1,049) completed a survey that included assessment of relationship status, relationship functioning, and SDV history. Logistic regression models tested how (a) relationship status, (b) relationship dysfunction, and (c) being divorced compared to being in a low- or high-dysfunction relationship were associated with SDV, controlling for several intrapersonal risk factors.

RESULTS

Veterans in a relationship did not differ in SDV history compared to divorced/separated veterans. However, more dysfunction within relationships was associated with greater odds of a history of SDV and suicidal cognitions. Finally, SDV histories were more likely among veterans endorsing high-dysfunction relationships compared with (a) low-dysfunction relationships and (b) divorced veterans.

CONCLUSION

It may be insufficient to only consider relationship status when evaluating interpersonal risk factors for SDV. A single item assessing relationship dysfunction was associated with enacted SDV and suicidal cognitions over and above intrapersonal risk factors. Integrating such single-item measures into clinical practice could improve identification and subsequent tailored intervention for veterans at greater risk for SDV.

Psychological flexibility in somatic symptom and related disorders: A case control study

A key diagnostic criterion of Somatic Symptom and related Disorders (SSD) comprises significant distress and excessive time-and-energy consuming thoughts, feelings, and behavior pertaining to somatic symptoms. This diagnostic criterion is lacking in central sensitivity syndromes (CSS), such as fibromyalgia, irritable bowel syndrome, and chronic fatigue syndrome. This strong emphasis on disturbed psychological processing of somatic symptoms, suggests that psychological flexibility is low in SDD. Psychological flexibility is defined as the ability to approach difficult or challenging internal states (thoughts, emotions, and bodily sensations) in a non-judgmental, mindful way, and being committed to pursue one's values. To clarify the potential significance of psychological flexibility in SSD, we examined its levels in 154 people referred to specialized treatment for SDD, as compared to reference groups from the general population encompassing 597 people with CSS and 1422 people without SSD or CSS (controls). Mean levels of psychological flexibility (adjusted for demographic covariates) were lowest for SSD and highest for controls (F = 154.5, p < 0.001, pη2 = 0.13). Percentages of people with low psychological flexibility (<0.8 SD below the mean of controls) were: SSD 74%, CSS 42%, controls 21%. In SSD, higher psychological flexibility was associated with better mental health (β = 0.56, p < 0.001), but interaction analysis rejected that psychological flexibility preserved health when having more severe somatic symptoms (β ≤ 0.08, p ≥ 0.10). The results indicate that lower psychological flexibility is a prevalent problem in SSD that is associated with lower mental health. This suggests that it is worthwhile to take account of psychological flexibility in SSD in screening, monitoring, and therapy.

Mental health treatment utilization among Gulf War era veterans with probable alcohol use disorder

INTRODUCTION

Alcohol use disorder (AUD) is prevalent among veterans, and excessive alcohol use is associated with significant mental and physical health consequences. Currently, the largest cohort of veterans seeking services at the VA are those from the 1990s Gulf War Era. This cohort of veterans is unique due to the nature of their deployment resulting in a myriad of unexplained symptoms collectively known as "Gulf War Illness" and higher rates of mental health problems. The present study sought to examine the association between probable AUD and mental health treatment utilization in a sample of 1126 (882 male) Gulf War-era veterans.

METHODS

Veterans completed a self-report survey including the AUDIT-C, questions about mental health treatment engagement, and demographic questions.

RESULTS

Results demonstrated that approximately 20 % of the sample screened positive for probable AUD, determined by standard AUDIT-C cutoff scores. Among those screening positive for AUD, 25 % reported engaging in mental health treatment in the past year. Veterans with probable AUD who use VA care had 3.8 times the odds of receiving mental health services than veterans not using VA care. Use of mental health services was associated with mental health comorbidity and identifying as Black/African American.

CONCLUSIONS

The results of the present study highlight a significant unmet need for mental health treatment among Gulf War-era veterans with AUD.

Experiential Avoidance, Pain, and Suicide Risk in a National Sample of Gulf War Veterans

OBJECTIVE

Pain confers risk for suicidal thoughts and behaviors. Experiential avoidance (EA), which is relevant to both pain and suicide risk, has not been studied as a potential mechanism for this relationship. The present study tested the hypothesis that pain indirectly impacts suicide risk through EA in a national sample of Gulf War veterans.

METHODS

Participants included a stratified random sample of United States veterans (N = 1,012, 78% male) who had served in the Gulf War region between August 1990 and July 1991. Validated scales were used to quantify levels of pain, EA, and suicide risk.

RESULTS

Regression analyses indicated independent associations between pain, EA, and suicide risk; moreover, the association between pain and suicide risk was no longer significant once EA was included in model. Bootstrapping analyses confirmed that EA partially accounted for the cross-sectional association between pain and suicide risk, independent of common co-occurring problems, such as depression, PTSD, and alcohol use disorder symptoms.

CONCLUSIONS

EA could be a key modifiable risk factor to target in people experiencing pain.

Crisis due to war: anxiety, depression and stress in the population of 13 Latin American countries

Sustainability may be at risk in a population that has altered health, according to Sustainable Development Goal 3 (SDG 3): Health and well-being. The ongoing conflict between Russia and Ukraine could jeopardize SDG 3, specifically the mental health of the population. The present study sought to determine the association between severe anxiety, depression and stress in population of 13 Latin American countries according to fear about the war conflict. It was a cross-sectional, analytical and multicenter study. Anxiety, depression and stress were measured with the DASS-21 test (Cronbach's Alpha: 0.97) and fear due to an armed crisis with a questionnaire already validated in Latin America (Cronbach's Alpha: 0.92), which was also adjusted for sex, age, education level and country of residence. Descriptive and analytical statistics were obtained. Of the 2,626 respondents, the main fear was that weapons of mass destruction would be used. In the multivariate models, strong associations were found between fear of a possible world-scale armed conflict and having severe or very severe levels of anxiety (aPR: 1.97; 95% CI: 1.64-2.36; value of p <0.001), depression (aPR: 1.91; 95% CI: 1.54-2.36; value of p <0.001) or stress (aPR: 2.05; 95% CI: 1.63-2.57; value of p <0.001). Sustainability linked to SDG 3, specifically mental health, is affected by this type of significant events, given the possible global war crisis that could trigger major events, even more so if added to the deterioration already experienced by COVID-19 in the Latin American region, insecurity and constant political uncertainty.

Nonsuicidal self-injury among veterans is associated with psychosocial impairment, suicidal thoughts and behaviors, and underutilization of mental health services

Nonsuicidal self-injury (NSSI) is a robust predictor of suicide attempts. However, understanding of NSSI and associated treatment utilization among Veterans is limited. Although impairment may be assumed, few studies examine the association between NSSI and psychosocial functioning, a core component of the rehabilitation framework of mental health. In a national survey of Veterans, current NSSI (n = 88) was associated with higher rates of suicidal thoughts and behaviors and more severe psychosocial impairment after adjusting for demographics and probable diagnoses of posttraumatic stress disorder, major depressive disorder, and alcohol use disorder, compared to Veterans without NSSI (n = 979). Only half of Veterans with NSSI were engaged with mental health services, with few appointments attended, suggesting that these Veterans are not receiving treatment interventions. Results underscore the adverse outcomes associated with NSSI. Underutilization of mental health services highlights the importance of screening for NSSI among Veterans to improve psychosocial outcomes.

Experiential Avoidance, Posttraumatic Stress Disorder, and Self-Injurious Thoughts and Behaviors: A Moderation Analysis in a National Veteran Sample

Experiential avoidance (EA) is associated with posttraumatic stress disorder (PTSD) and self-injurious thoughts and behaviors (SITBs) across different populations, and extant literature has demonstrated a strong relationship between PTSD and SITBs. However, no study has explored the potential moderating role EA plays in the association of PTSD with nonsuicidal self-injury (NSSI), suicidal ideation, and suicide attempts. The objective of the present study was to determine if EA would moderate the association with PTSD and SITBs such that the association between PTSD and individuals SITBs would be stronger among individuals with higher EA. In a large national sample of Gulf War Era veterans (N = 1,138), EA was associated with PTSD, lifetime and past-year NSSI, current suicidal ideation, and lifetime suicide attempts in bivariate analyses. Multivariate analyses detected a significant EA by PTSD interaction on lifetime NSSI (AOR = 0.96), past-year NSSI (AOR = 1.03), and suicide attempts (AOR =1.03). Probing of the interactions revealed that the respective associations between PTSD, lifetime and past-year NSSI, and suicide attempts were stronger at lower levels of EA (i.e., better), counter to our hypotheses. These preliminary findings contextualize the relationship between these variables in a Gulf War veterans sample and signal the need to further investigate these relationships. Further, these findings highlight the need for advancement in assessment and intervention of EA and SITBs.

The Prevalence, Humanistic Burden, and Health Care Impact of Irritable Bowel Syndrome Among United States Veterans

BACKGROUND & AIMS

Irritable bowel syndrome (IBS) in veterans is understudied. This study sought to investigate (1) prevalence of IBS; (2) phenotypic, environmental, and psychosocial factors associated with IBS; and (3) associations of IBS with health-related quality of life and health care use.

METHODS

From June 2018 to April 2020, we invited veterans to complete the Rome IV IBS questionnaire; Short Form-12; posttraumatic stress disorder (PTSD) checklist; Hospital Anxiety and Depression Scale; and questionnaires on general health, antibiotic use, infectious enteritis (IE), and health care use.

RESULTS

Among 858 veteran respondents, 244 (28.4%) met Rome IV IBS criteria (47.5% IBS with diarrhea, 16.8% IBS with constipation, 33.6% mixed IBS). IBS was associated with greater anxiety and depression and lower quality of life (all P < .001). Provisional PTSD, IE, and bowel problems after antibiotics were more common in IBS (all P < .001) as were multiple doctor visits (P < .01) and hospitalizations (P = .04). Comparisons across non-IBS and IBS subgroups revealed overall associations of psychological comorbidities (P < .01), multiple doctor visits (P < .01), hospitalizations (P = .03), IE (P < .01), and bowel problems after IE (P = .03) or antibiotics (P < .01) with subgroup. Highest anxiety and depression scores, PTSD, multiple doctor visits, hospitalizations, and bowel problems after IE were observed in IBS with constipation. In adjusted analyses, IBS was associated (all P < .001) with anxiety (odds ratio [OR], 3.47), depression (OR, 2.88), lower quality of life, PTSD (OR, 3.09), IE (OR, 4.44), bowel problems after antibiotics (OR, 1.84), multiple doctor visits (OR, 2.08), and hospitalizations (OR, 1.78).

CONCLUSIONS

IBS is prevalent among veterans and has a measurable impact on individuals and health care resources. Veterans with IBS may experience significant psychological impairment.

Complementary/integrative healthcare utilization in US Gulf-War era veterans: Descriptive analyses based on deployment history, combat exposure, and Gulf War Illness

Complementary and integrative health (CIH) approaches have gained empirical support and are increasingly being utilized among veterans to treat a myriad of conditions. A cluster of medically unexplained chronic symptoms including fatigue, headaches, joint pain, indigestion, insomnia, dizziness, respiratory disorders, and memory problems, often referred to as Gulf War Illness (GWI) prominently affect US Gulf War era (GWE) veterans, yet little is known about CIH use within this population. Using data collected as part of a larger study (n = 1153), we examined the influence of demographic characteristics, military experiences, and symptom severity on CIH utilization, and utilization differences between GWE veterans with and without GWI. Over half of the sample (58.5%) used at least one CIH modality in the past six months. Women veterans, white veterans, and veterans with higher levels of education were more likely to use CIH. GWE veterans with a GWI diagnosis and higher GWI symptom severity were more likely to use at least one CIH treatment in the past six months. Over three quarters (82.7%) of veterans who endorsed using CIH to treat GWI symptoms reported that it was helpful for their symptoms. Almost three quarters (71.5%) of veterans indicated that they would use at least one CIH approach if it was available at VA. Results provide a deeper understanding of the likelihood and characteristics of veterans utilizing CIH to treat health and GWI symptoms and may inform expansion of CIH modalities for GWE veterans, particularly those with GWI.

Nonsuicidal self-injury in veterans: Prevalence, clinical characteristics, and gender differences from a national cohort

Nonsuicidal self-injury (NSSI) is a robust predictor of suicidal thoughts and behaviors; however, while there are typically only small differences observed in the prevalence of NSSI between men and women, this condition has been largely overlooked and underestimated among men. Assessing NSSI methods more common in men may address misidentification as well as allow for more precise NSSI prevalence estimates. Survey data from a national sample of Gulf War I-Era veterans (N = 1063) was used to estimate the prevalence of NSSI and compare prevalence of NSSI methods between men and women veterans. Demographic and clinical correlates of NSSI engagement were also examined. The national lifetime prevalence rate of NSSI among Gulf War I-Era veterans was 22.40%, whereas the past year prevalence rate was 8.10%. In both men and women, wall/object punching was the most common NSSI method endorsed across the lifetime. Men had slightly higher overall NSSI prevalence rates compared with women. This study highlights the need to systematically assess NSSI, particularly among veterans, to better identify, and consequently treat, NSSI in men. This is the first available prevalence estimate of NSSI to include the assessment of wall/object punching in a national sample of adult veterans.

Cannabis use and suicide risk among Gulf War veterans

Cannabis use has been indicated as a risk factor for suicide in veterans. This study of Gulf War veterans tested the relationship between self-report past year cannabis use and (a) past year suicidal ideation and (b) risk for suicidal behavior. Data were from a national sample (N = 1126) of Gulf War veterans. Logistic regression models indicated cannabis use was associated with past year suicidal ideation and elevated risk for suicidal behavior, independent of key covariates. In corroboration with research on other military populations, this study indicates a potentially concerning association between cannabis use and suicide risk in Gulf War veterans.

Correlates and clinical associations of military sexual assault in Gulf War era U.S. veterans: Findings from a national sample

Military sexual assault (MSA) is a prevalent issue among military personnel that can have direct implications on postmilitary mental health. Gulf War era U.S. veterans represent the first cohort in which women veterans were integrated into most aspects of military service except for combat. The present study sought to build on prior studies by identifying characteristics associated with the occurrence of MSA and clinical correlates of MSA and examining how these differ between men and women. This study analyzed cross-sectional survey data from a national sample of treatment-seeking Gulf War era veterans. Participants (N = 1,153) reported demographic information, clinical outcomes, military background, and history of MSA. MSA was more common among female veterans (n = 100, 41.3%) than male veterans (n = 32, 3.6%). The odds of experiencing MSA were approximately 19 times higher for female veterans relative to their male peers, OR = 18.92, p < .001. Moreover, as expected, MSA was robustly associated with probable current posttraumatic stress disorder, probable current depression, and past-year suicidal ideation in female veterans, whereas combat exposure was robustly associated with these sequelae in male veterans. The present findings confirm that a large proportion of female veterans from the Gulf War era experienced MSA and highlight the deleterious correlates of MSA on veterans' mental health. Sex differences of correlates of MSA and subsequent clinical associations are highlighted.

The Veterans Health Administration's integrated model of care increases accessibility and delivery of mental health services

Depression and posttraumatic stress disorder (PTSD) are two of the most common mental health conditions experienced by veterans. It is unclear what individual and system level factors are associated with receiving mental health treatment for these concerns. Using a national sample of Gulf War Era veterans who endorsed lifetime diagnoses of either depression or PTSD (N = 425), regression analyses were used to predict past-year treatment utilization. Predictor variables were those indicated in the behavioral model of health care utilization, including predisposing demographic variables (e.g., age, race), enabling variables (e.g., service connection, enrollment in Veterans Health Administration [VHA]), and need-based variables (e.g., current symptom severity). VHA enrollment was associated with a three- and five-times higher odds of being treated for depression or PTSD, respectively. Income and symptom severity were also positively associated with treatment utilization. Among individuals with diagnoses of depression and/or PTSD, VHA enrollment was the strongest predictor of receiving mental health treatment for these diagnoses, controlling for all other variables in the model including recent contact with the health care system, current symptom severity, and the presence of other enabling resources. Results suggest that the VHA's integrated model of care increases accessibility and delivery of effective mental health services. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Comparing psychosocial functioning, suicide risk, and nonsuicidal self-injury between veterans with probable posttraumatic stress disorder and alcohol use disorder

BACKGROUND

Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) are each common among Unites States (U.S.) military veterans and frequently co-occur (i.e., PTSD+AUD). Although comorbid PTSD+AUD is generally associated with worse outcomes relative to either diagnosis alone, some studies suggest the added burden of comorbid PTSD+AUD is greater relative to AUD-alone than to PTSD-alone. Furthermore, nonsuicidal self-injury (NSSI) is more common among veterans than previously thought but rarely measured as a veteran psychiatric health outcome. This study sought to replicate and extend previous work by comparing psychosocial functioning, suicide risk, and NSSI among veterans screening positive for PTSD, AUD, comorbid PTSD+AUD, and neither disorder.

METHODS

This study analyzed data from a national sample of N = 1046 U.S. veterans who had served during the Gulf War. Participants self-reported sociodemographic, functioning, and clinical information through a mailed survey.

RESULTS

Veterans with probable PTSD+AUD reported worse psychosocial functioning across multiple domains compared to veterans with probable AUD, but only worse functioning related to controlling violent behavior when compared to veterans with probable PTSD. Veterans with probable PTSD+AUD reported greater suicidal ideation and NSSI than veterans with probable AUD, but fewer prior suicide attempts than veterans with probable PTSD.

LIMITATIONS

This study was cross-sectional, relied on self-report, did not verify clinical diagnoses, and may not generalize to veterans of other military conflicts.

CONCLUSIONS

Findings underscore the adverse psychiatric and functional outcomes associated with PTSD and comorbid PTSD+AUD, such as NSSI, and highlight the importance of delivering evidence-based treatment to this veteran population.