Treatment of posttraumatic stress disorder with prolonged exposure for primary care (PE-PC): Effectiveness and patient and therapist factors related to symptom change and retention

Prolonged exposure (PE) is a first-line treatment for posttraumatic stress disorder (PTSD) available in specialty mental health. PE for primary care (PE-PC) is a brief version of PE adapted for primary care mental health integration, composed of four-eight, 30-min sessions. Using retrospective data of PE-PC training cases from 155 Veterans Health Administration (VHA) providers in 99 VHA clinics who participated in a 4- to 6-month PE-PC training and consultation program, we examined patients' PTSD and depression severity across sessions via mixed effects multilevel linear modeling. Additionally, hierarchical logistic regression analysis was conducted to assess predictors of treatment dropout. Among 737 veterans, medium-to-large reductions in PTSD (intent-to-treat, Cohen's d = 0.63; completers, Cohen's d = 0.79) and small-to-medium reductions in depression (intent-to-treat, Cohen's d = 0.40; completers, Cohen's d = 0.51) were observed. The modal number of PE-PC sessions was five (SD = 1.98). Providers previously trained in both PE and cognitive processing therapy (CPT) were more likely than providers who were not trained in either PE or CPT to have veterans complete PE-PC (OR = 1.54). Veterans with military sexual trauma were less likely to complete PE-PC than veterans with combat trauma (OR = 0.42). Asian American and Pacific Islander veterans were more likely than White veterans to complete treatment (OR = 2.93). Older veterans were more likely than younger veterans to complete treatment (OR = 1.11). (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Flailing in telehealth co-therapy

The authors express themselves through a poem about their experiences with telehealth co-therapy. They explain their patient's resiliency, body language, and behavior. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Testing adaptive interventions to improve PTSD treatment outcomes in Federally Qualified Health Centers: Protocol for a randomized clinical trial

BACKGROUND

Posttraumatic stress disorder (PTSD) disproportionately affects low-income individuals and is untreated in 70% of those affected. One third of low-income Americans are treated in Federally Qualified Health Centers (FQHCs), which do not have the capacity to provide all patients with first-line treatments such as Prolonged Exposure (PE). To address this problem, FQHCs could use low-intensity interventions (e.g., Clinician-Supported PTSD Coach: CS PTSD Coach) and medium-intensity interventions (e.g., PE for Primary Care: PE-PC) to treat PTSD with fewer resources. However, some patients will still require high-intensity treatments (e.g., full-length PE) for sustained clinical benefit. Thus, there is a critical need to develop stepped-care models for PTSD in FQHCs.

METHOD

We are conducting a Sequential, Multiple Assignment, Randomized Trial (SMART) with 430 adults with PTSD in FQHCs. Participants are initially randomized to CS PTSD Coach or PE-PC. After four sessions, early responders step down to lower frequency interaction within their assigned initial treatment strategy. Slow responders are re-randomized to either continue their initial treatment strategy or step up to Full PE for an additional eight weeks. The specific aims are to test the effectiveness of initiating treatment with PE-PC versus CS PTSD Coach in reducing PTSD symptoms and to test the effectiveness of second-stage strategies (continue versus step-up to Full PE) for slow responders.

CONCLUSIONS

This project will provide critical evidence to inform the development of an effective stepped-care model for PTSD. Testing scalable, sustainable sequences of PTSD treatments delivered in low-resource community health centers will improve clinical practice for PTSD.

Marriage checkup in integrated primary care: A randomized controlled trial with active-duty military couples

OBJECTIVE

This study assessed the efficacy of the marriage checkup, as adapted to integrated primary care settings and active-duty military couples, for improving relationship health and depressive symptoms.

METHOD

Married couples (N = 244, Mage = 32.4, 67.6% Caucasian) in which at least one member was active-duty Air Force were recruited from bases across the U.S. via online advertisement, emails sent from medical clinics to enrolled beneficiaries, social media posts, and flyers, and randomly assigned to active treatment or waitlist control. Treatment and control couples were linked in pairs sequentially and pairs completed nine sets of questionnaires at baseline, 1-, and 6-month posttreatment. Outcome measures included the Couples Satisfaction Index, Intimate Safety Questionnaire, Responsive Attention Scale, Partner Compassion Scale, Communication Skills Test, and the Center for Epidemiologic Studies Depression Scale.

RESULTS

A three-level multilevel model indicated, after adjustment for multiple comparisons, treatment couples experienced statistically significant small-to-moderate improvements compared to the control group (Cohen's d from 0.21 to 0.55) at 1 month that were sustained at 6 months for relationship satisfaction, responsive attention, compassion toward their partners, communication skills, intimate safety, and depressive symptoms.

CONCLUSIONS

A longitudinal randomized control trial of the MC supports the hypothesis that the MC significantly improves relationship satisfaction, intimacy, communication, partner compassion, responsive attention, and depressive symptoms. Implications for theory, treatment, and dissemination are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Feasibility and Acceptability of Prolonged Exposure in Primary Care (PE-PC) for Posttraumatic Stress Disorder in Federally Qualified Health Centers: A Pilot Study

Posttraumatic stress disorder (PTSD) is a debilitating psychiatric disorder that affects 6% of U.S. adults, yet is treated in only 30% of affected individuals and even fewer low-income individuals. One third of the nation’s low-income individuals are treated in Federally Qualified Health Centers (FQHCs). Most of these facilities lack capacity to provide their patients with first-line, evidence-based treatments for PTSD such as Prolonged Exposure (PE). To address this problem, PE has been adapted for use in a primary care setting and demonstrated efficacy in a brief model for military service members (PE in Primary Care: PE-PC). The effectiveness of this treatment in civilian, low-resource settings such as FQHCs is unknown. This pilot study tested the feasibility and acceptability of PE-PC in 30 Michigan FQHC patients. High rates of therapy participation suggest that the intervention was feasible and acceptable. Semi-structured interview data from 10 patients and 5 FQHC providers indicated that the intervention was helpful and filled a critical need for effective PTSD treatment in the FQHC setting. Interviews also elucidated barriers such as transportation, provider training, and time commitment for patients and providers. These findings set the stage for a full-scale randomized controlled trial to test the effectiveness of PE-PC on PTSD symptoms in this low-resource, high-need setting.

Trial registry ClinicalTrials.gov Identifier: NCT03711266. October 18, 2018.

STRONG STAR and the Consortium to Alleviate PTSD: Shaping the future of combat PTSD and related conditions in military and veteran populations

The STRONG STAR Consortium (South Texas Research Organizational Network Guiding Studies on Trauma and Resilience) and the Consortium to Alleviate PTSD are interdisciplinary and multi-institutional research consortia focused on the detection, diagnosis, prevention, and treatment of combat-related posttraumatic stress disorder (PTSD) and comorbid conditions in military personnel and veterans. This manuscript outlines the consortia's state-of-the-science collaborative research model and how this can be used as a roadmap for future trauma-related research. STRONG STAR was initially funded for 5 years in 2008 by the U.S. Department of Defense's (DoD) Psychological Health and Traumatic Brain Injury Research Program. Since the initial funding of STRONG STAR, almost 50 additional peer-reviewed STRONG STAR-affiliated projects have been funded through the DoD, the U.S. Department of Veterans Affairs (VA), the National Institutes of Health, and private organizations. In 2013, STRONG STAR investigators partnered with the VA's National Center for PTSD and were selected for joint DoD/VA funding to establish the Consortium to Alleviate PTSD. STRONG STAR and the Consortium to Alleviate PTSD have assembled a critical mass of investigators and institutions with the synergy required to make major scientific and public health advances in the prevention and treatment of combat PTSD and related conditions. This manuscript provides an overview of the establishment of these two research consortia, including their history, vision, mission, goals, and accomplishments. Comprehensive tables provide descriptions of over 70 projects supported by the consortia. Examples are provided of collaborations among over 50 worldwide academic research institutions and over 150 investigators.

Demographic and Occupational Risk Factors Associated With Suicide-Related Aeromedical Evacuation Among Deployed U.S. Military Service Members

INTRODUCTION

Suicide is a significant problem in the U.S. military, with rates surpassing the U.S. general population as of 2008. Although there have been significant advances regarding suicide risk factors among U.S. military service members and veterans, there is little research about risk factors associated with suicide that could be potentially identified in theater. One salient study group consists of service members who receive a psychiatric aeromedical evacuation out of theater. The primary aims of this study were as follows: (1) determine the incidence of suicide-related aeromedical evacuation in deployed service members, (2) identify demographic and military characteristics associated with suicide-related aeromedical evacuation, and (3) evaluate the relationship between suicide-related aeromedical evacuation from a deployed setting and military separation.

MATERIALS AND METHODS

This was an archival analysis of U.S. Transportation Command Regulating and Command and Control Evacuation System and Defense Manpower Data Center electronic records of U.S. military service members (N = 7023) who were deployed to Iraq or Afghanistan and received a psychiatric aeromedical evacuation out of theater between 2001 and 2013. χ2 tests of independence and standardized residuals were used to identify cells with observed frequencies and proportions, respectively, that significantly differed from what would be expected by chance. In addition, odds ratios were calculated to provide context about the nature of any significant relationships.

RESULTS

For every 1000 psychiatric aeromedical evacuations that occurred between 2001 and 2013, 34.4 were suicide related. Gender, ethnicity, branch of service, occupation classification, and deployment theater were associated with suicide-related aeromedical evacuation (odds ratios ranged from 1.37 to 3.02). Overall, 53% of all service members who received an aeromedical evacuation for any psychiatric condition had been separated from the military for a variety of reasons (both voluntary and involuntary) upon record review in 2015. Suicide-related aeromedical evacuation was associated with a 37% increased risk of military separation compared to evacuation for another psychiatric condition (P < 0.02).

CONCLUSIONS

Findings provide novel information on risk factors associated with suicide-related aeromedical evacuation as well as military separation following a suicide-related aeromedical evacuation. In many cases, the psychiatric aeromedical evacuation of a service member for suicidal ideations and their subsequent separation from active duty is in the best interest of the individual and the military. However, the evacuation and eventual military separation can be costly for the military and the service member. Consequently, the military should focus on indicated prevention interventions for individuals who show sufficient early signs of crisis and functional problems so that specialized interventions can be used in theater to prevent evacuation. Indicated prevention interventions should start with leaders' awareness and mitigation of risk and, when feasible, evidence-based interventions for suicide risk provided by behavioral health (eg, brief cognitive behavioral therapy for suicide). Future research should evaluate the feasibility, safety, and efficacy of delivering suicide-related interventions in theater.

Addressing Relationship Health Needs in Primary Care: Adapting the Marriage Checkup for Use in Medical Settings with Military Couples

The overall objective of this study was to pilot the Marriage Checkup (MC), a brief intervention for enhancing marital resiliency tailored to a military population, for use by internal behavioral health consultants (IBHCs) working in an integrated primary care clinic. The MC was revised to fit into the fast-paced environment of primary care (e.g., streamlined to fit within three 30-min appointments), and military-relevant material was added to the content. IBHCs working in primary care were then trained to offer the intervention. Thirty participants were enrolled in the study and completed a relationship checkup and one-month follow-up questionnaires. Analysis of post-test and one-month follow-up data showed statistically significant improvements in participants' marital health compared to pre-treatment. The MC intervention appeared to be well received by both couples and IBHCs.

The risk for marital infidelity across a year-long deployment

Military deployment can create significant relationship strain. Although most couples navigate the challenges of deployment successfully, this period may render some couples more vulnerable to adverse relationship outcomes such as infidelity due to a convergence of factors including geographic separation and reduced emotional and physical intimacy. Despite anecdotal reports of increased rates of infidelity during deployment, empirical findings are lacking. This study used a prospective design to examine the prevalence and risk factors of infidelity across the deployment cycle including a year-long deployment to Iraq. A total of 63 married male Airmen were assessed both pre- and 6-9 months postdeployment. The rate of sexual infidelity prior to deployment (21%) was commensurate with the lifetime rate of sexual involvement outside the marriage in representative community samples of men. Across the deployment period, the prevalence of sexual infidelity was strikingly high (22.6%) compared with annual community estimates (1.5-4%; Allen et al., 2005). Findings demonstrated that service members with a prior history of separation, steps toward divorce, and relationship distress prior to deployment had elevated risk for infidelity over the deployment cycle. Moreover, roughly 75% of Airmen who experienced infidelity over the deployment cycle divorced by 6-9 months postdeployment whereas only 5% of service members without infidelity divorced during this same time period. Considering well-documented adverse impacts of infidelity and divorce, the current findings may assist in identifying military couples at risk for infidelity and informing targeted prevention or early intervention strategies for these couples prior to or immediately following deployment. (PsycINFO Database Record

Stepped-Care Approaches to Posttraumatic Stress Disorder: Sharpening Tools for the Clinician’s Toolbox

<p> Austern (2017) presents three composite Veteran case studies using Written Exposure Therapy (WET; Sloan, Lee, Litwack, Sawyer, &amp; Marx, 2013) as a first-level intervention in a larger stepped-care model for PTSD.  The relatively minimalist WET intervention may be appealing to Veterans with PTSD who have opted not to seek out more time and therapist-intensive treatments.  In addition, writing has been used effectively in other protocols as a method of achieving exposure to memories of traumatic experiences.  Austern’s three cases demonstrate a range of success in using WET to engage Veterans in evidence-based treatment and reduce suffering associated with PTSD.  We comment on the current status of the research literature on stepped-care models for PTSD, the potential value of incorporating Motivational Interviewing principles and specific homework tasks into these efforts, and the promise that abbreviated interventions and stepped-care approaches may hold for helping clinicians manage their clinical caseloads and avoid burnout.</p><p> </p>

Behavioral Treatment of Chronic Belching Due to Aerophagia in a Normal Adult

Aerophagia, or excessive air swallowing, is a potential cause of belching, flatulence, bloating, and abdominal pain and may contribute to a worsening of gastrointestinal (GI) disorders. A limited number of published reports of aerophagia treatment indicate that behavioral methods may be of benefit. A case report is presented describing the behavioral treatment of chronic belching due to aerophagia in an adult female. The collaborative application of single-participant design research helped identify open-mouth, diaphragmatic breathing and minimized swallowing as an effective intervention. Belching frequency was reduced from an average rate of 18 per 5-min interval during the baseline period to 3 per 5-min period after treatment. Results were maintained at an 18-month follow-up. Recommendations for the use of a brief treatment protocol with adults referred for chronic belching or other GI complaints attributed to aerophagia are discussed.

Biofeedback-Assisted Relaxation, Exposure, and Cognitive-Behavioral Treatment of Gastric Bypass Surgery Related Anxiety

An unusual case of a “food phobia,” which developed more than a year after the patient underwent a gastric bypass procedure, is described. A brief description of the normal digestive process and Roux-en-Y procedure is presented followed by a discussion of common surgical outcome, the patient’s presenting difficulties, assessment data, case conceptualization, and course of treatment. The casewas challenging because, as with all clinical health psychology cases, it is often difficult to tease out the physical and psychological aspects of the problem. It was also difficult to establish an exposure hierarchy due to the satiation effect of food. Progress was made, however, by applying known principles of behavior change to this novel complaint. The case demonstrates the utility of a comprehensive functional analysis as well as the impact of incorporating the patient’s strengths into the treatment plan.

Help-seeking among airmen in distressed relationships: Promoting relationship well-being

Although a substantial proportion of service members returning from a combat deployment report individual emotional and behavioral disorders as well as intimate relationship difficulties, previous studies indicate that only a minority actually seek mental health services. Little is known about factors that predict help-seeking in this population. We first review key findings from the literature on help-seeking in military and veteran populations, including mixed findings regarding the role of perceived stigma and attitudes toward mental health treatment. We then present data from a longitudinal study of United States Air Force Security Forces following a year-long high-risk deployment to Iraq-including findings regarding who seeks help, for what problems, and from which providers. We also examine whether these findings differ for Airmen in a married or committed relationship versus nonpartnered Airmen and, for the former group, whether findings differ for those in a distressed versus nondistressed relationship. Finally, we discuss implications of these findings for extending couple-based interventions to service members and veterans, and describe a multitiered "stepped" approach for promoting relationship resiliency.

Treatment of active duty military with PTSD in primary care: A follow-up report

First-line trauma-focused therapies offered in specialty mental health clinics do not reach many veterans and active duty service members with posttraumatic stress disorder (PTSD). Primary care is an ideal environment to expand access to mental health care. Several promising clinical case series reports of brief PTSD therapies adapted for primary care have shown positive results, but the long-term effectiveness with military members is unknown. The purpose of this study was to determine the long-term outcome of an open trial of a brief cognitive-behavioral primary care-delivered protocol developed specifically for deployment-related PTSD in a sample of 24 active duty military (15 men, 9 women). Measures of PTSD symptom severity showed statistically and clinically significant reductions from baseline to posttreatment that were maintained at the 6-month and 1-year follow-up assessments. Similar reductions were maintained in depressive symptoms and ratings of global mental health functioning.

Coming home: A prospective study of family reintegration following deployment to a war zone

The consequences of deployment extend beyond the service member to impact the entire family. The current investigation evaluated the unique challenges of family reintegration for partnered service members using a prospective design. In total, 76 partnered service members who deployed on a year-long, high-risk mission to Iraq were assessed across the entirety of the deployment cycle, i.e., pre-, during, and postdeployment. At follow-up, nearly 1 in 5 partnered service members reported moderate to severe difficulties in multiple aspects of family reintegration. Prospective interpersonal indicators such as preparations for deployment as a couple, shared commitment to the military, and predeployment relationship distress predicted postdeployment family reintegration difficulties. Significant interpersonal risk factors were medium to large in their effect sizes. Airmen's willingness to disclose deployment- and combat-related experiences, and postdeployment relationship distress served as concurrent interpersonal correlates of difficulties with family reintegration. Intrapersonal factors, including posttraumatic stress symptoms and alcohol misuse were concurrently related to challenges with family reintegration; predeployment alcohol misuse also predicted subsequent family reintegration difficulties. Additional analyses indicated that pre- and postdeployment relationship distress, combat disclosure, and postdeployment alcohol misuse each contributed to family reintegration when controlling for other intra- and interpersonal risk factors. Implications for prevention and early intervention strategies as well as future research are discussed.

Development of a multilevel prevention program for improved relationship functioning in active duty military members

The relationships and families of active duty (AD) service members have been tremendously strained by deployments and high operations' tempo. This study involves the first steps in developing a multilevel approach to preventing relationship problems that integrates universal, selective, and indicated prevention/intervention. Such an approach has tremendous empirical support for parenting problems, but no similar program exists for couple problems. We conducted two studies with U.S. Air Force Security Forces members. Study 1 elicited the target population's topics of highest interest. For almost all topics, 70% to 95% of participants who desired information reported being underserved by current prevention offerings (i.e., not receiving needed information). Using the top topics generated in Study 1, we developed prevention information/action planning sheets on 18 relationship issues. In Study 2, we had AD members who gave feedback on the form and content of the sheets. Overall, AD members believed that the sheets were moderately to very useful and were presented well, had pithy but comprehensive information and conveyed the content well. Results imply that a multilevel approach may be a useful complement to formal services in meeting underserved military members' needs and that further research and development of this dissemination vector for evidence-based information is warranted.

Predictors of Suicidal Ideation Across Deployment: A Prospective Study

OBJECTIVE

Concurrent and prospective predictors of suicidal ideation were examined in a sample of 318 United States Air Force Security Forces across a 1-year deployment in Iraq and 6- to 9-month follow-up.

METHOD

Participants included 294 male and 24 female Airmen ranging in age from 18 to 46 years, predominantly (67%) Caucasian. Measures included self-reports of postdeployment suicidal ideation, posttraumatic stress and depressive symptoms, alcohol use, combat experiences, relationship distress, social support, and postdeployment readjustment.

RESULTS

Problem drinking before deployment prospectively predicted postdeployment suicidal ideation in univariate analyses. Depressive symptoms and problem drinking were significant independent predictors of postdeployment suicidal ideation. Findings demonstrated a ninefold increase in suicidal ideation among service members with even mild depressive symptoms if moderate problem drinking was also present.

CONCLUSIONS

Predeployment problem drinking may serve as a modifiable target for early intervention of suicidal ideation. Findings illuminate the compound risk of comorbid depressive symptoms and moderate problem drinking in predicting suicidal ideation.

Intimate partner communication from the war zone: a prospective study of relationship functioning, communication frequency, and combat effectiveness

This study examined (a) the association between relationship functioning prior to and during deployment, and the frequency of communication during deployment; and (b) the association between relationship functioning and depression during deployment and their influence on service members' ratings of duty performance. Participants were 144 partnered Airmen assessed immediately before and during a one-year high-risk deployment to Iraq. Results showed an overall high frequency of partner communication during deployment. High relationship distress at predeployment predicted lower frequency of communication during deployment. Changes in relationship distress from before deployment to during deployment independently predicted frequency of communication, above and beyond predeployment distress levels. Level of relationship distress and depression during deployment independently predicted service members' ratings of impact on duty performance.

Impact of combat deployment on psychological and relationship health: a longitudinal study

Although previous research has indicated an elevated prevalence of posttraumatic stress disorder (PTSD) and other mental health problems among veterans of Operations Iraqi Freedom and Enduring Freedom following deployment, most of this research has been cross-sectional and has focused on a limited range of military groups and outcome criteria. This investigation was a longitudinal study of U.S. Air Force security forces assigned to a year-long high-threat ground mission in Iraq to determine the degree to which airmen's emotional and behavioral health and committed relationships were adversely impacted by an extended deployment to a warzone. Participants were a cohort of 164 security forces airmen tasked to a 365-day deployment to train Iraqi police. Airmen completed study measures both prior to and 6-9 months following deployment. Rates of deterioration in individual and interpersonal adjustment were both significant and medium to large in magnitude of effect, d = 0.43 to 0.90. Results suggest that the negative effects of deployment are related to levels of traumatic experiences and do not spontaneously remit within the first 6-9 months following return from deployment-particularly among those service members having relatively lower levels of social support.

Smokeless tobacco use in military personnel

Military personnel are more than twice as likely as civilians to use smokeless tobacco (ST), and recent studies indicate that military prevalence rates are rising. However, few studies have examined factors related to ST use in the military. The present study evaluated the characteristics of ST use in 785 active duty military personnel. The results indicated that the average age of initiation was 17.7 years, participants had used ST for 12.3 years, and they used approximately four tins or pouches of tobacco per week. Army personnel were more likely than Air Force personnel to be older, to have used ST longer, and to be heavier users. Officers had used ST longer than enlisted personnel and were more likely to have had a recent quit attempt. Enlisted personnel were more than three times as likely to report concurrent cigarette smoking. These results indicate that there are significant differences in ST use patterns in military personnel, and cessation programs should be tailored to meet these differences.

Four-year prospective study of military trainees returned to duty following a mental health evaluation

The purpose of the study was to determine the long-term outcome for military trainees referred for a mental health evaluation during basic training. Participants were 261 Air Force basic trainees seen for a mental health evaluation during January through October 1997 and returned to duty. Frequency and type of discharge from the military were documented for participants during a 4-year follow-up period. The results showed that two-thirds of the study sample failed to complete their obligated tour of duty. Most discharges occurred within a 100-day period from the time of the evaluation. Common discharge types were physical condition interfering with performance of duty, entry-level performance and conduct, fraudulent entry, and character or behavior disorder. Implications of the findings for mental health providers working in a military training environment are discussed.

Pilot evaluation of a population-based health intervention for reducing use of smokeless tobacco

Smokeless tobacco (ST) use has been associated with numerous negative health consequences, yet the prevalence of ST has increased dramatically since the 1970s. Young males in the military are at an elevated risk for ST use relative to the general population. Sixty active-duty male participants were identified as ST users during their annual preventive health screening and randomly assigned to minimal-contact intervention or usual care. Intervention participants were proactively contacted by phone and recruited, using a motivational interviewing style, for a cessation program consisting of a treatment manual, video, and two supportive phone calls from a cessation counselor. Sixty-five per cent (20/31) agreed to participate in the minimal-contact intervention. Three- and 6-month follow-up contacts found that the cessation rates reported by intervention participants were double those reported by participants receiving usual care (41% vs. 17% at 3 months, 37% vs. 19% at 6 months). These pilot study data suggest that proactive recruitment using a motivational interviewing approach to offer a treatment provides a good opportunity to reduce the use of ST in military settings.

Job satisfaction, occupational stress, and personality characteristics of Air Force military training instructors

The authors present findings from the preliminary stage of a research program intended to improve the selection and retention of U.S. Air Force military training instructors (MTIs). Data derived from an initial sample of 100 incumbent instructors are discussed. Global job satisfaction and occupational stress levels, along with normal personality traits measured by the Revised NEO Personality Inventory, are presented. Results indicate a wide range of reported job satisfaction and stress among MTIs, with a sizable proportion indicating that they would not volunteer for this duty again. Several personality characteristics appear to be salient in distinguishing satisfied and adaptive MTIs from those who are unsatisfied and coping poorly. The authors outline plans for the long-term continuation and expansion of the project to develop an empirically based selection system for the MTI career field.

Readministration of the MMPI-2 following defensive invalidation in a military job applicant sample

Job applicants whose response style on the Minnesota Multiphasic Personality Inventory-2 (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer) is excessively defensive create a dilemma for psychologists working in personnel selection settings. Clinical guidelines recommend the profile be considered uninterpretable, but the absence of usable testing data could lead to the elimination of otherwise qualified candidates. Readministering the MMPI-2 with altered instructions to reduce defensive responding has been suggested as an alternative. This option has lacked empirical support until recently. One study (Butcher, Morfitt, Rouse, & Holden, 1997) evaluated the effects of altered instructions on retest validity in a civilian job applicant sample, with the majority of participants obtaining valid and normal profiles on retest. The purpose of this study was to determine if these results would be replicated in a military job applicant sample. Participants were 97 military personnel who completed the MMPI-2 as part of application for selection to instructor duty. Forty-seven participants had obtained invalid profiles and retook the MMPI-2 after receiving instructions intended to reduce defensiveness. The results showed that 83% of retested participants obtained valid profiles on the second MMPI-2. The second test results were very similar in profile to those obtained from a comparison group of 50 participants whose initial MMPI-2 results were valid. The findings are discussed in terms of study limitations and future research directions.

Stress management training for military trainees returned to duty after a mental health evaluation: effect on graduation rates

A significant proportion of people entering the military are discharged within the first 6 months of enlistment. Mental health related problems are often cited as the cause of discharge. This study evaluated the utility of stress inoculation training in helping reduce the attrition of a sample of Air Force trainees at risk for discharge from basic military training. Participants were 178 trainees referred for a psychological evaluation from basic training. Participants were randomly assigned to a 2-session stress management group or a usual-care control condition. Compared with past studies that used less rigorous methodology, this study did not find that exposure to stress management information increased the probability of graduating basic military training. Results are discussed in terms of possible reasons for the lack of treatment effects and directions for future research.

Stress management training for military trainees returned to duty after a mental health evaluation: effect on graduation rates

A significant proportion of people entering the military are discharged within the first 6 months of enlistment. Mental health related problems are often cited as the cause of discharge. This study evaluated the utility of stress inoculation training in helping reduce the attrition of a sample of Air Force trainees at risk for discharge from basic military training. Participants were 178 trainees referred for a psychological evaluation from basic training. Participants were randomly assigned to a 2-session stress management group or a usual-care control condition. Compared with past studies that used less rigorous methodology, this study did not find that exposure to stress management information increased the probability of graduating basic military training. Results are discussed in terms of possible reasons for the lack of treatment effects and directions for future research.

Predicting outcome of military basic training for individuals referred for psychological evaluation

We examined outcome data for 632 U.S. Air Force personnel who were referred for psychological evaluation during Basic Military Training (BMT) but who were subsequently returned to BMT to determine what proportion graduated. We analyzed motivational, biographical, and psychological testing variables, using logistic regression to develop a model predictive of training outcome. The results demonstrated that a relatively small number of variables could predict outcome with close to 70% accuracy. Level of optimism regarding training, history of physical abuse, and frequency of visits to the trainee health clinic were major contributors to the model. MMPI-2 (Hathaway & McKinley, 1989) Scales D and Sc also remained in the model but added little to its power. The findings are generally consistent with prior research on normal military populations, except that some factors previously linked to adjustment, such as sex and ethnicity, were found to be unrelated to training outcome in this population.

Mental health attrition from Air Force basic military training

The Department of Defense invests considerable money in recruiting and training new military recruits who are discharged for mental health reasons before completing their first enlistment, often within the first 6 months of active duty. The purpose of this study was to provide a description of 1,138 Air Force recruits referred for a mental health evaluation while in basic military training. Variables examined include dispositions, demographic features, diagnoses, mental health history, and attitude and motivation characteristics. Findings show that trainees recommended for discharge often had a history of depression, expressed a lack of motivation to continue in the military, were reporting suicidal ideation, and typically had withheld information on their mental health history during their Military Entrance Processing Station processing. The results are discussed in terms of potential strategies for reducing mental health attrition in Air Force basic military training.

Critical incident stress intervention following fatal aircraft mishaps

This article offers guidelines for conducting preventive mental health interventions using a Critical Incident Stress Debriefing (CISD) model with Air Force and other aviation communities that have experienced a fatal aircraft mishap. The guidelines are based on the authors' experiences in providing assistance to several hundred active duty military personnel and their families following two separate mishaps. The article outlines the basics of the CISD model, briefly describes the two mishaps, and then discusses the lessons learned.

Discrepancies between self-reported smoking and carboxyhemoglobin: an analysis of the second national health and nutrition survey

Environmental, self-report, and demographic factors mediated the relationship between self-reported cigarette smoking and carboxyhemoglobin among 2114 smokers and 3918 nonsmokers. Self-reported nonsmokers with carboxyhemoglobin levels between 2% and 3% were more likely to be self-reported ex-smokers, to live in a larger community, and to be younger, less educated, and male than were self-reported nonsmokers with carboxyhemoglobin levels of less than 2%. Self-reported nonsmokers with strong evidence of cigarette consumption (carboxyhemoglobin level greater than 3%) were more likely to be self-reported ex-smokers, younger, less educated, and non-White than were nonsmokers with carboxyhemoglobin levels of less than 2%.

Contributions of sibling relations to the adaptation of youths with insulin-dependent diabetes mellitus

Associations among sibling relations and the psychosocial and illness-specific adaptation of youths (N = 66) with insulin-dependent diabetes mellitus (IDDM) were examined. The findings suggest that sibling relations, especially sibling conflict, contribute an independent source of variance above and beyond that contributed by demographic characteristics, sibling constellation variables, and important dimensions of family relations in predicting the youths' adaptation. High family-life stress and high sibling status/power contributed unique variance in predicting internalizing behaviors, and male gender and sibling conflict contributed independently to externalizing problems. Sibling conflict also contributed unique variance to the youth's general self-esteem, along with social class and family cohesion, and to their adjustment to IDDM. Data suggest that parent-child dyads and sibling dyads represent interrelated and independent subsystems within the family, and that both subsystems may influence the psychosocial functioning of youths with IDDM.

Contributions of sibling relations to the adaptation of youths with insulin-dependent diabetes mellitus

Associations among sibling relations and the psychosocial and illness-specific adaptation of youths (N = 66) with insulin-dependent diabetes mellitus (IDDM) were examined. The findings suggest that sibling relations, especially sibling conflict, contribute an independent source of variance above and beyond that contributed by demographic characteristics, sibling constellation variables, and important dimensions of family relations in predicting the youths' adaptation. High family-life stress and high sibling status/power contributed unique variance in predicting internalizing behaviors, and male gender and sibling conflict contributed independently to externalizing problems. Sibling conflict also contributed unique variance to the youth's general self-esteem, along with social class and family cohesion, and to their adjustment to IDDM. Data suggest that parent-child dyads and sibling dyads represent interrelated and independent subsystems within the family, and that both subsystems may influence the psychosocial functioning of youths with IDDM.

Coping styles in youths with insulin-dependent diabetes mellitus

The relationships between two coping styles (i.e., use of personal and interpersonal resources; ventilation and avoidance) and two health outcomes (i.e., adherence and metabolic control) were evaluated in 135 youths with insulin-dependent diabetes mellitus (IDDM). Individual characteristics (i.e., age, duration of illness) and contextual variables (i.e., stress, family relations) were used to predict coping styles. Poor adherence to treatment, older adolescent age, and long duration of IDDM were correlated with ventilation and avoidance coping. Youths with short duration of IDDM were more likely to cope through the use of personal and interpersonal resources, although this strategy was not associated with health outcomes. A multiple regression analysis indicated that high ventilation and avoidance coping was predicted by high stress, low family cohesion, and older adolescent age. In addition, the interaction between family adaptability and duration of IDDM significantly predicted ventilation and avoidance coping.

Factors associated with participation, attrition, and outcome in a smoking cessation program at the workplace

Despite their growing popularity, worksite health-promotion programs have generally been characterized as having low participation rates, high attrition rates, and modest outcomes. This investigation identified the predictors of participation, attrition, and outcome of worksite smoking-cessation program. Subjects were regular cigarette smokers recruited from two worksites. Of 66 eligible smokers in the two worksites, 44 (67%) agreed to participate in the program. Fifty-five percent (24 of 44) of these completed the program. Of those completing the program, 29% had quit smoking by posttest and 17% were abstinent at the 6-month follow-up. Results indicated that a different set of variables predicted participation, attrition, and outcome. The significant predictors of smokers who participated were the length of cessation in previous abstinence attempts, the number of years they smoked, and the belief regarding personal vulnerability in contracting a smoking-related disease. Levels of pretest carbon monoxide along with attitudes regarding the adoption of smoking restrictions in the worksite predicted attrition. Posttest cessation was related to nicotine levels of cigarette brand smoked at pretest and pretest beliefs regarding postcessation weight gain. Abstinence at the 6-month follow-up was predicted by the number of co-workers who smoked and pretest concerns related to postcessation weight gain. The results are discussed in terms of future evaluation and intervention efforts.

Factors associated with participation, attrition, and outcome in a smoking cessation program at the workplace

Despite their growing popularity, worksite health-promotion programs have generally been characterized as having low participation rates, high attrition rates, and modest outcomes. This investigation identified the predictors of participation, attrition, and outcome of worksite smoking-cessation program. Subjects were regular cigarette smokers recruited from two worksites. Of 66 eligible smokers in the two worksites, 44 (67%) agreed to participate in the program. Fifty-five percent (24 of 44) of these completed the program. Of those completing the program, 29% had quit smoking by posttest and 17% were abstinent at the 6-month follow-up. Results indicated that a different set of variables predicted participation, attrition, and outcome. The significant predictors of smokers who participated were the length of cessation in previous abstinence attempts, the number of years they smoked, and the belief regarding personal vulnerability in contracting a smoking-related disease. Levels of pretest carbon monoxide along with attitudes regarding the adoption of smoking restrictions in the worksite predicted attrition. Posttest cessation was related to nicotine levels of cigarette brand smoked at pretest and pretest beliefs regarding postcessation weight gain. Abstinence at the 6-month follow-up was predicted by the number of co-workers who smoked and pretest concerns related to postcessation weight gain. The results are discussed in terms of future evaluation and intervention efforts.