A qualitative study of military service members undergoing medical separation

OBJECTIVE

Little research explores military perspectives on medical disability-related transition. A qualitative study sought to understand transition experiences of United States military Service members found unfit for duty following medical and physical evaluation boards (MEBs and PEBs).

METHODS

Confidential telephone interviews were conducted with 25 current and prior Service members. Participants were asked to share their experiences before, during, and after the MEB and PEB processes. Interview questions explored (1) health conditions that prompted the medical disability evaluation, (2) reactions to being recommended for separation, (3) transition-related stress and challenges, and (4) coping strategies. Salient themes were identified across chronological narratives.

RESULTS

Participants expressed that debilitating physical (e.g., injury) and/or mental (e.g., post-traumatic stress disorder) illnesses prompted their medical evaluation. In response to the unfit for duty notice, some participants reported emotional distress (e.g., anxiety, anger) connected to uncertainty about the future. Other participants reported relief connected to a sense of progression toward their medical disability claim status. Transition stress included the length of the MEB/PEB process, impact of the COVID-19 pandemic on the process, financial stress, impact on family life, and compounded effect of these stressors on emotional distress, including depression and suicidal thoughts. Participants reported using adaptive (e.g., psychotherapy) and maladaptive (e.g., excessive drinking) strategies to cope with stress.

CONCLUSION

Preliminary reports of emotional distress and transition stress following unfit for duty notices highlight the need for increased support and interventions to facilitate adaptive coping strategies during this vulnerable period.

Special Operations Cognitive Agility Training (SOCAT) for Special Operations Forces and spouses

Increasingly complex and unpredictable personnel and operational demands require Special Operations Forces (SOF) members and their families to remain flexible, adaptive, and resilient within ever-changing circumstances. To mitigate the impact of these stressors on psychological health and fitness, researchers and educators at the Uniformed Services University of the Health Sciences (USUHS) developed Special Operations Cognitive Agility Training (SOCAT), a cognitive performance optimization program supported by the United States Special Operations Command (USSOCOM) Preservation of the Force and Family (POTFF). The goal of SOCAT is to enhance cognitive agility, defined as the ability to deliberately adapt cognitive processing strategies in accordance with dynamic shifts in situational and environmental demands, in order to facilitate decision making and adapt to change. Overall, SOCAT emphasizes optimal cognitive performance across different contexts - as well as across various stages of the military lifecycle - to serve as a buffer against biopsychosocial vulnerabilities, environmental and social stressors, military operational demands, and behavioral health problems, including suicide. This paper reviews foundational research behind SOCAT, mechanisms through which SOCAT is anticipated to build psychological resilience, and describes the process of developing and tailoring SOCAT for active duty SOF members and spouses. Limitations and future directions, including an ongoing, randomized controlled program evaluation, are discussed.

Social Support and Social Stress Among Suicidal Inpatients at Military Treatment Facilities: A Multidimensional Investigation

ABSTRACT

The associations between social support and stress with internalizing symptoms (depressive symptoms and hopelessness) and hazardous drinking were tested in an inpatient sample of suicidal military personnel. Baseline data from a randomized clinical trial were analyzed. Different sources of support and stressors in the social context of military personnel were differentially linked to internalizing symptoms and hazardous drinking. In the full sample ( n = 192), family and nonfamily support were both inversely associated with internalizing symptoms but not hazardous drinking. Family stress was positively associated with internalizing symptoms. In a subsample of service members who had a history of deployment ( n = 98), postdeployment social support was protective against internalizing symptoms, whereas deployment harassment was associated with increased odds of hazardous drinking. Results underscore the need for assessment of various dimensions of social support and stress to guide case formulation and optimize strategies to support patients' mental well-being and adaptive coping.

Pilot Evaluation of the Online 'Chaplains-CARE' Program: Enhancing Skills for United States Military Suicide Intervention Practices and Care

Chaplains frequently serve as first responders for United States military personnel experiencing suicidal thoughts and behaviors. The Chaplains-CARE Program, a self-paced, e-learning course grounded in suicide-focused cognitive behavioral therapy principles, was tailored for United States military chaplains to enhance their suicide intervention skills. A pilot program evaluation gathered 76 Department of Defense (DoD), Veterans Affairs (VA), and international military chaplain learners' responses. Most learners indicated that the course was helpful, easy to use, relevant, applicable, and that they were likely to recommend it to other chaplains. Based on open-ended responses, one-quarter (25.0%) of learners indicated that all content was useful, and over one-quarter (26.3%) of learners highlighted the usefulness of the self-care module. One-third (30.3%) of learners reported the usefulness of the interactive e-learning features, while others (26.3%) highlighted the usefulness of chaplains' role play demonstrations, which portrayed counseling scenarios with service members. Suggested areas of improvement include specific course adaptation for VA chaplains and further incorporation of experiential learning and spiritual care principles. The pilot findings suggest that Chaplains-CARE Online was perceived as a useful suicide intervention training for chaplains. Future training can be enhanced by providing experiential, simulation-based practice of suicide intervention skills.

Help-seeking among psychiatrically hospitalized military personnel at risk for suicide

INTRODUCTION

Promoting help-seeking is a key suicide prevention strategy. Yet, research on help-seeking patterns by high-risk individuals is limited. This study examined help-seeking among United States military Service members admitted for psychiatric inpatient care.

METHODS

Participants were active duty Service members (N = 111) psychiatrically hospitalized for a suicide-related event. Data were collected as part of a larger randomized controlled trial. Reported types and perceived helpfulness of resources sought 30 days before hospitalization were examined. Hierarchical binary logistic regressions were used to examine associations among types of helping resources, mental health treatment stigma, and perceived social support.

RESULTS

Approximately 90% of participants sought help prior to hospitalization, most frequently from behavioral health providers and friends. Accessed resources were generally considered helpful. Adjusting for covariates, mental health treatment stigma was not associated with seeking help from any resource type. Higher perceived social support was associated with greater likelihood of help-seeking from a friend (OR = 1.08, p = 0.013 [95% CI = 1.02, 1.14]). Marital status, education level, and organizational barriers were associated with specific types of resources, and/or not seeking help.

CONCLUSION

Help-seeking is a complex human behavior. Promoting help-seeking among vulnerable subgroups requires further understanding of multiple interconnected factors.

Cognitive flexibility and suicide risk indicators among psychiatric inpatients

Cognitive flexibility has been linked with positive psychological health outcomes, whereas cognitive rigidity has been linked with suicide risk. We examined associations among cognitive flexibility and certain suicide risk indicators among a sample of patients psychiatrically hospitalized for suicide risk (n = 40). Data were collected during two pilot randomized controlled trials. At baseline, cognitive flexibility was not associated with depressive symptoms, hopelessness, or severity of lifetime worst point suicide ideation. At 3-months post psychiatric discharge, higher baseline cognitive flexibility predicted significantly lower depressive symptoms and worst point suicide ideation in the past month, but did not predict lower hopelessness.

Understanding the clinical characteristics of lesbian, gay, and bisexual military service members and adult beneficiaries within an inpatient psychiatric sample

BACKGROUND

Limited knowledge exists regarding targets for suicide-focused care among high-risk United States (U.S.) civilian and military sexual minorities.

PURPOSE

This study aimed to understand the demographic and clinical characteristics of a suicidal sexual minority sample, psychiatrically hospitalized in military treatment facilities, to advance future targeted care for this vulnerable subgroup.

METHODS

Secondary analysis of baseline data from a multisite psychotherapy randomized controlled trial was performed comparing those who self-identified as lesbian, gay, or bisexual (LGB; n = 39) to heterosexual participants (n = 170).

RESULTS

LGB participants were more likely than heterosexual participants to be younger, female, never married, and enlisted rank. LGB participants reported significantly lower family support, higher perceived burdensomeness, lower acquired capability for suicide, and were twice as likely to report that they could not control their suicidal thoughts. LGB and heterosexual participants reported similar levels of other suicide risk indicators and similar lifetime suicidal ideation and attempt histories.

CONCLUSIONS

Compared to heterosexual participants, LGB participants reported increased risk indicators for suicide yet similar lifetime suicidal ideation and attempt histories. Suicide prevention programs should address the unique needs of this vulnerable subgroup. Interventions targeting family support, perceived burdensomeness, and controllability of suicidal thoughts may be promising.

A latent class analysis of physical, emotional, and sexual abuse history among suicidal inpatients

OBJECTIVE

Physical, emotional, and sexual abuse are subtypes of childhood abuse that may persist into adulthood. This study applied latent class analysis to describe the pattern of co-occurrence of these three abuse subtypes during childhood and adulthood and examined latent class differences in psychosocial characteristics and three types of suicide attempt history (aborted, interrupted, and actual).

METHODS

Data were drawn from a high-risk sample of 115 military service members and adult beneficiaries who were psychiatrically hospitalized following a suicide-related crisis.

RESULTS

Three latent classes were identified: Multiple and Persistent Abuse (Class One: 29.6%), Childhood Physical and Persistent Emotional Abuse (Class Two: 27.0%), and Minimal Abuse (Class Three: 43.5%). Females were more likely than males to report a history of Multiple and Persistent Abuse. After controlling for gender, the Multiple and Persistent Abuse Class had higher scores of depressive symptoms and hazardous drinking, poorer sleep quality, and increased social stress than the Minimal Abuse Class. Moreover, the Multiple and Persistent Abuse Class was associated with increased likelihood of lifetime interrupted suicide attempt (Odds Ratio [OR] = 3.81, 95% CI = 1.20, 12.07) and actual suicide attempt (OR = 3.65, 95% CI = 1.23, 10.85), and had the greatest number of total actual suicide attempt (1.82 times on average).

CONCLUSION

Co-occurrence of multiple subtypes of abuse across development is associated with higher psychosocial risk and history of suicide attempt. The assessment of specific subtypes of abuse and their timing may inform case conceptualization and the management of suicide risk among psychiatric inpatients.

Three department of defense-funded public health approaches to reduce military suicide

BACKGROUND

Suicide is a serious and growing public health concern, both for the United States (U.S.) and for the Department of Defense (DoD).

METHODS

Using the social-ecological framework, we provide examples of how three newly developed, DoD-funded pilots/programs have incorporated a public health approach to help prevent military suicide.

KEY RESULTS

The first two programs demonstrate how non-clinical, community-based approaches can be tailored to specific military subgroups at the individual, relational, and community levels. These programs include a universal suicide prevention program developed for Special Operations service members, spouses, and mental health providers, and a selective suicide prevention program pilot developed for military chaplains to support them in their role as a "gateway" to care for distressed service members, improve mental health and chaplaincy collaboration, and prevent burnout. The third program illustrates how the creation of and policy of a methodology/infrastructure to conduct standardized, theory-driven suicide death reviews across the DoD may inform the DoD public health approach to surveillance, review, and synthesis of suicide data, informed by the social-ecological model. Potential program limitations and evaluation efforts are discussed.

CONCLUSION

Future prevention approaches should enhance coordination and communication between DoD, VA, and community organizations to enhance multi-level suicide prevention programming for military personnel, veterans, and civilians.

Evaluating Suicide Risk Using the Reasons for Dying-Reasons for Living (RFD-RFL) Index in a Military Psychiatric Inpatient Setting

The present study aimed to explore reasons for dying (RFD) and reasons for living (RFL) among suicidal inpatients, conceptualize the RFD-RFL index, and examine whether suicide risk indicators were associated with the RFD-RFL index scores. Participants were military personnel (N = 167) psychiatrically hospitalized following a suicide-related crisis who provided baseline data as part of a randomized controlled trial. Family was the most commonly reported RFL (39.7%) and was the top ranked RFL for 65.9% of participants. The most frequently endorsed RFD categories included general descriptors of self (26.9%), general statements about escape (19.7%), and others/relationships (19.1%). Greater RFD-RFL index scores were associated with a greater wish to die relative to wish to live, greater hopelessness, and with a history of lifetime multiple suicide attempts. Endorsing more RFD relative to RFL may indicate heightened suicide risk. Results of this study identify the characteristics of RFD and RFL among a high-risk, military sample, and provide preliminary support for the clinical utility of evaluating the quantities of RFD and RFL. Clinicians are encouraged to explore RFD and RFL when working with suicidal patients. Future research may explore military-specific RFD and evaluate the validity of the proposed RFD-RFL index.

Digital Peer Support Mental Health Interventions for People With a Lived Experience of a Serious Mental Illness: Systematic Review

BACKGROUND

Peer support is recognized globally as an essential recovery service for people with mental health conditions. With the influx of digital mental health services changing the way mental health care is delivered, peer supporters are increasingly using technology to deliver peer support. In light of these technological advances, there is a need to review and synthesize the emergent evidence for peer-supported digital health interventions for adults with mental health conditions.

OBJECTIVE

The aim of this study was to identify and review the evidence of digital peer support interventions for people with a lived experience of a serious mental illness.

METHODS

This systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) procedures. The PubMed, Embase, Web of Science, Cochrane Central, CINAHL, and PsycINFO databases were searched for peer-reviewed articles published between 1946 and December 2018 that examined digital peer support interventions for people with a lived experience of a serious mental illness. Additional articles were found by searching the reference lists from the 27 articles that met the inclusion criteria and a Google Scholar search in June 2019. Participants, interventions, comparisons, outcomes, and study design (PICOS) criteria were used to assess study eligibility. Two authors independently screened titles and abstracts, and reviewed all full-text articles meeting the inclusion criteria. Discrepancies were discussed and resolved. All included studies were assessed for methodological quality using the Methodological Quality Rating Scale.

RESULTS

A total of 30 studies (11 randomized controlled trials, 2 quasiexperimental, 15 pre-post designs, and 2 qualitative studies) were included that reported on 24 interventions. Most of the studies demonstrated feasibility, acceptability, and preliminary effectiveness of peer-to-peer networks, peer-delivered interventions supported with technology, and use of asynchronous and synchronous technologies.

CONCLUSIONS

Digital peer support interventions appear to be feasible and acceptable, with strong potential for clinical effectiveness. However, the field is in the early stages of development and requires well-powered efficacy and clinical effectiveness trials.

TRIAL REGISTRATION

PROSPERO CRD42020139037; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID= 139037.

Inpatient psychiatric care following a suicide-related hospitalization: A pilot trial of Post-Admission Cognitive Therapy in a military medical center

OBJECTIVE

Individuals with a recent suicidal crisis are typically admitted for inpatient psychiatric care. However, targeted inpatient interventions for suicide prevention remain sparse. Thus, this pilot randomized controlled trial evaluated a brief inpatient cognitive behavioral protocol, Post-Admission Cognitive Therapy (PACT) for the prevention of suicide.

METHODS

United States service members and beneficiaries (N = 24) psychiatrically hospitalized at a military medical center due to a recent suicidal crisis were randomized to receive either PACT plus Enhanced Usual Care (PACT + EUC) or EUC alone. Blinded follow-up assessments were conducted at one-, two-, and three-months post discharge. The degree of change and variability of response to PACT for repeat suicide attempt(s) (primary outcome), as well as depression, hopelessness, and suicide ideation (secondary outcomes) were examined.

RESULTS

Significant between-group differences in re-attempt status were not found. Reliable Change Index analyses indicated that among the most clinically severe participants, a greater proportion of PACT + EUC participants compared with EUC participants met criteria for clinically significant reductions on depression (40% versus 25%), hopelessness (67% versus 50%), suicide ideation (45% versus 33%), and posttraumatic stress symptomatology (40% versus 25%).

CONCLUSIONS

PACT is a promising inpatient cognitive behavioral intervention for suicide risk reduction. The efficacy of PACT is currently being evaluated in a well-powered multi-site randomized controlled trial.

Hazardous drinking and clinical correlates among suicidal patients receiving psychiatric inpatient care at military medical settings

BACKGROUND

To describe prevalence and identify clinical correlates of hazardous drinking among suicidal inpatients at military medical settings.

METHOD

Data were drawn from the baseline assessment of a multisite randomized controlled trial of Post-Admission Cognitive Therapy (PACT). Participants were military Service members or adult beneficiaries (N = 218) who were admitted to inpatient care following a suicide-related crisis. Hazardous alcohol use in the past year was assessed using the Alcohol Use Disorder Identification Test (AUDIT).

RESULTS

The average AUDIT score was 6.78 (SD = 7.87), with 28.9% reporting hazardous drinking (scored ≥8 on the AUDIT). Hazardous drinkers were more likely than nonhazardous drinkers to meet diagnosis of Substance Use Disorder (SUD; Odds Ratio [OR] = 5.96, 95% confidence intervals [CI] = 2.13, 16.71). Hazardous drinking was neither associated with measures of suicide ideation nor aborted or interrupted suicide attempt. However, hazardous drinkers had greater risk of having both single (RRR [Relative Risk Ratio] = 2.55, 95% CI = 1.18, 5.50) and multiple actual suicide attempts (RRR = 2.38, 95% CI = 1.06, 5.32) than nonhazardous drinkers. The association between hazardous drinking and single (but not multiple) actual suicide attempt remained significant after controlling for gender, depressive symptoms, hopelessness, Post-Traumatic Stress Disorder, and SUD (adjusted RRR = 2.48, 95% CI = 1.09, 5.65).

CONCLUSIONS

A history of actual suicide attempt is associated with hazardous alcohol use among suicidal psychiatric inpatients. Assessment of drinking and drug use may inform case conceptualization and treatment of suicide-related behaviors in psychiatric inpatient settings.

Typologies of Suicide: A Critical Literature Review

This review highlights proposed suicide typologies and identifies areas of future research. The current study is an illustrative, rather than exhaustive, qualitative review of theoretical and empirically derived typologies of suicide decedents. Theoretical and empirical typologies of suicide delineate between groups of suicide decedents based on individual, motivational, psychiatric, interpersonal, socio-demographic, and other variables. Certain core themes emerge across theoretical typologies including escape, aggression, intrapsychic pain, and relational concerns. Empirical typologies have identified unique patterns of life stressors, mental health history, health care utilization, and suicide method among suicide decedents. Future research should build on existing typological models of suicide to delineate when, and for whom, particular typologies of suicide may inform targeted prevention efforts. Researchers and clinicians should consider the characteristics and needs of particular high-risk groups when translating typological research into meaningful suicide prevention and intervention.

Suicide Typologies in the United States Air Force: A Hierarchical Cluster Analysis

OBJECTIVE

This study describes characteristics of United States Air Force (USAF) suicide decedents and determines subgroups.

METHOD

Retrospective review of demographic, psychiatric, event-related, and psychosocial variables for USAF suicide decedents in the Suicide Event Surveillance System database was conducted between February 1999 and July 2009 (N = 376). Hierarchical cluster analysis was used to determine initial clusters and cluster centroids.

RESULTS

Analyses identified three clusters. Cluster 1 (n = 149) individuals were mostly single or divorced, E-1-E-6 rank, living alone, and less likely to have psychiatric disorder diagnoses or engage with most helping resources. Cluster 2 (n = 126) decedents were mostly married, living with a partner, higher ranking, and least likely to communicate suicide intent. Cluster 3 (n = 101) individuals were mostly E-4-E-6 rank, with the highest rates of most psychiatric diagnoses, previous suicide-related events, engagement with multiple helping resources, communication of intent, and psychosocial precipitants. Clusters differed significantly in marital status, rank, psychiatric diagnoses, precipitants, service utilization, previous suicide-related events, risk factors, communication of intent, location and method of death, and residential status.

CONCLUSIONS

This study identifies empirically based suicide typologies within a military decedent sample. While further research and replications of findings are needed, these typologies have clinical and policy implications for military suicide prevention.

Lack of Emotional Awareness is Associated with Thwarted Belongingness and Acquired Capability for Suicide in a Military Psychiatric Inpatient Sample

OBJECTIVE

To examine potential links between facets of impulsivity and emotion dysregulation to components of the Interpersonal-Psychological Theory of Suicide (thwarted belongingness, perceived burdensomeness, and acquired capability) among U.S. military personnel.

METHOD

The current study performed secondary data analysis from a randomized control trial testing the efficacy of a cognitive therapy for 134 service members (71.64% male, 68.66% Caucasian; mean age: 30.14) admitted to a psychiatric inpatient unit for a suicide-related crisis. We utilized the Difficulties in Emotion Regulation Scale, the Barratt Impulsivity Scale, the Acquired Capability for Suicide Scale, and the Interpersonal Needs Questionnaire.

RESULTS

All emotion dysregulation dimensions and one impulsivity facet (attentional) were positively correlated with perceived burdensomeness and thwarted belongingness. Lack of emotional awareness was positively associated with acquired capability. After controlling for depression, hopelessness, and demographic covariates, lack of emotional awareness was significantly associated with both thwarted belongingness and acquired capability, but not perceived burdensomeness, and impulsivity dimensions did not link to any variable of interest.

CONCLUSIONS

Findings imply that individuals with reduced emotional awareness may have difficulty cultivating interpersonal bonds and be more vulnerable to elevated acquired capability. Lack of emotional awareness may be a potential contributor to both suicidal desire and capability.

Pilot trial of post-admission cognitive therapy: Inpatient program for suicide prevention

Suicide remains a significant public health problem for the United States military. Trauma-related diagnoses such as acute stress disorder (ASD) or posttraumatic stress disorder (PTSD) may exacerbate suicide risk, particularly among service members psychiatrically hospitalized following suicide-related events. To date, treatments to address suicide risk and trauma symptomatology among service members within inpatient milieus have been nonexistent. To address this gap, a randomized controlled pilot trial of Post-Admission Cognitive Therapy (PACT) was conducted to evaluate a targeted cognitive-behavioral program among traumatized military personnel (N = 36) hospitalized following a recent suicide attempt. All participants met criteria for ASD or PTSD and were randomly assigned to receive either PACT and enhanced usual care (PACT + EUC) or EUC alone. PACT consisted of six 60- to 90-min individual psychotherapy sessions, adapted from Brown et al.'s (2005) cognitive therapy protocol for suicide prevention. Blinded follow-up assessments were conducted at 1-, 2-, and 3-months postpsychiatric discharge. The primary outcome was days until repeat suicide attempt. Secondary outcomes included depression, hopelessness, suicide ideation, and PTSD symptoms. Participants did not significantly differ in reattempt status. However, based on reliable change index analyses, a greater proportion of PACT + EUC versus EUC participants met criteria for clinically significant change on measures of depression (100% vs. 78%), hopelessness (83% vs. 57%), and PTSD symptom severity (100% vs. 38%), but not for suicide ideation (60% vs. 67%). PACT is an innovative inpatient protocol, currently under evaluation in a well-powered multisite RCT for its efficacy in reducing subsequent suicidal behaviors. (PsycINFO Database Record

Suicide ideation and self-efficacy to avoid suicidal action among psychiatrically hospitalized military personnel

Individuals with suicide ideation require self-efficacy to avoid engagement in suicidal behaviors. Low self-efficacy has been examined as a risk indicator for suicidal behaviors. The Self-Efficacy to Avoid Suicidal Action (SEASA) scale assesses self-efficacy to resist suicidal urges and was originally evaluated in a sample of adults receiving treatment for substance use disorders. The goal of this study was to explore the link between suicide ideation and self-efficacy to avoid suicidal action among a high-risk group of psychiatric inpatients. Military personnel psychiatrically hospitalized following a suicide-related event (N = 139) completed a modified version of the SEASA and provided a full history of suicidal behaviors. Data were analyzed using multiple linear regression. Severity of worst time point suicide ideation, endorsement of any current suicide ideation, and history of multiple lifetime suicide attempts were associated with lower self-efficacy to avoid suicidal action. Self-efficacy to avoid engagement in suicidal action is a belief that can be strengthened and practiced within evidence-based treatments such as cognitive behavior therapy for suicide prevention. Thus, providers are encouraged to target this type of self-efficacy in case conceptualization and treatment planning. Future research on how self-efficacy to avoid suicidal action can be effectively measured are needed.

Impulse control difficulties while distressed: A facet of emotion dysregulation links to Non-Suicidal Self-Injury among psychiatric inpatients at military treatment facilities

Links between emotion dysregulation, suicide ideation, and suicidal versus non-suicidal self-injury (NSSI) are poorly understood within military samples. United States service members and beneficiaries (N = 186), psychiatrically hospitalized following a suicidal crisis, completed the Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004), and reported lifetime suicide ideation, attempts, and NSSI. We expected that emotion dysregulation would positively associate with worst lifetime suicide ideation, multiple suicide attempt status, and lifetime NSSI. Suicide ideation severity and multiple suicide attempts did not associate with DERS components. Notably, difficulties with impulse control (feeling out of control while distressed) was positively associated with NSSI history. Theoretical models that clearly describe the role of emotion dysregulation in suicidal thoughts, its progression to suicidal actions, and NSSI are needed to advance clinical care for this highly vulnerable group. Longitudinal and micro-longitudinal study designs require further investigation.

The Link between Posttraumatic Stress Disorder and Functionality among United States Military Service Members Psychiatrically Hospitalized Following a Suicide Crisis

Posttraumatic stress disorder (PTSD) is one of the most commonly diagnosed psychiatric disorders in the United States and has been linked to suicidal thoughts and behaviors, yet the role of a PTSD diagnosis on functional impairment among suicidal individuals remains unknown. This study examined the association between PTSD status and functional impairment among military psychiatric inpatients admitted for acute suicide risk (N = 166) with a lifetime history of at least one suicide attempt. Measures of functionality included: (1) alcohol use; (2) sleep quality; (3) social problem-solving; and (4) work and social adjustment. Thirty-eight percent of the sample met criteria for PTSD. Women were more likely than men to meet criteria for PTSD (p = 0.007), and participants who met PTSD criteria had significantly more psychiatric diagnoses (p < 0.001). Service members who met PTSD criteria reported more disturbed sleep (p = 0.003) and greater difficulties with work and social adjustment (p = 0.004) than those who did not meet PTSD criteria. However, functionality measures were not significantly associated with PTSD status after controlling for gender and psychiatric comorbidity. Gender and number of psychiatric comorbidities other than PTSD were significant predictors of PTSD in logistic regression models across four functionality measures. Future studies should assess the additive or mediating effect of psychiatric comorbidities in the association between impaired functioning and PTSD. Clinicians are encouraged to assess and address functionality during treatment with suicidal individuals, paying particular attention to individuals with multiple psychiatric diagnoses.

Intimate partner relationship stress and suicidality in a psychiatrically hospitalized military sample

OBJECTIVE

Suicide among United States service members is a significant public health concern. Intimate partner relationship stress may contribute to suicide risk, as a failed or failing relationship is the most commonly documented stressor preceding military suicide attempts and deaths. However, little is known about the manner by which relationship stressors are associated with the experience of military suicidality.

METHODS

A sample of 190 psychiatrically hospitalized military personnel and adult dependents enrolled in an ongoing randomized controlled trial evaluating the efficacy of an inpatient cognitive behavioral treatment for suicidality were included in this study. Analyses examined depression, hopelessness, and suicidality among participants with (n = 105) and without (n = 85) self-reported romantic relationship stress.

RESULTS

Over half (55%) of the sample reported current romantic relationship stress. Compared to participants without current romantic relationship stress, results indicated that individuals reporting current romantic relationship stress were more hopeless (AOR = 1.07 (95% CI: 1.01-1.12), p = 0.020), more likely to endorse multiple suicide attempts (AOR = 1.96 (95% CI: 1.01-3.79), p = 0.046), had higher overall suicide risk (AOR = 2.49, (95% CI: 1.03-6.06), p = 0.044), and were more likely to report that the reason for their suicidality was at least in part to get a reaction from others.

CONCLUSIONS

Findings suggest romantic relationship stress is associated with greater suicide risk, and have clinical implications for suicide prevention and intervention. Future research may examine mechanisms and pathways between romantic relationship stress, suicidality, and prevention and intervention strategies.

Non-Suicidal Self-Injury Elevates Suicide Risk among United States Military Personnel with Lifetime Attempted Suicide

Military psychiatric inpatients with and without a lifetime history of non-suicidal self-injury (NSSI), combined with a history of at least one suicide attempt, were compared on suicide ideation severity, number of suicide attempts, and Interpersonal-Psychological Theory of Suicide variables. Data were derived from baseline assessments performed in a psychotherapy randomized controlled trial. Lifetime history of NSSI and lifetime number of suicide attempts were assessed using the Columbia Suicide Severity Rating Scale (C-SSRS; Posner et al., 2011 ). Individuals with versus without a combined lifetime history of attempted suicide and NSSI showed significant elevations on thwarted belongingness and acquired capability for suicide. No significant between-group differences were found on perceived burdensomeness, frequency, duration, and controllability of suicide ideation, or number of lifetime suicide attempts. A history of NSSI, above and beyond attempted suicide, appears to increase service members' social alienation and acquired capability for suicide.

Outpatient Mental Health Treatment Utilization and Military Career Impact in the United States Marine Corps

Service members (SM) are at increased risk of psychiatric conditions, including suicide, yet research indicates SMs believe seeking mental health treatment may negatively impact their military careers, despite a paucity of research examining actual career impacts. This study examined the link between seeking outpatient mental health (MH) treatment and military career impacts within the United States Marine Corps. In Phase 1, a retrospective medical record review of outpatient MH treatment-seeking Marines (N = 38) was conducted. In Phase 2, a sample of outpatient MH treatment-seeking Marines (N = 40) was matched to a non-treatment-seeking sample of Marines (N = 138) to compare career-progression. In Phase 1, there were no significant links between demographic, military, and clinical characteristics and referral source or receipt of career-affecting treatment recommendations. In Phase 2, MH treatment-seeking Marines in outpatient settings were more likely than matched controls to be separated from the military (95.0% versus 63.0%, p = 0.002), but no more likely to experience involuntary separation. MH treatment-seeking Marines were more likely to have documented legal action (45.0% versus 23.9%, p = 0.008) and had a shorter time of military service following the index MH encounter than matched controls (p < 0.001). Clinical, anti-stigma, and suicide prevention policy implications are discussed.

Dysfunctional personality disorder beliefs and lifetime suicide attempts among psychiatrically hospitalized military personnel

BACKGROUND

Personality disorders (PDs) are associated with an increased risk for suicide. However, the association between PDs and suicide risk has not been examined among military personnel. This study evaluated whether endorsement of different PD dysfunctional beliefs was associated with lifetime suicide attempt status.

METHODS AND MATERIALS

Cross-sectional data were collected during the baseline phase of a randomized controlled trial, evaluating the efficacy of an inpatient cognitive behavior therapy protocol for the prevention of suicide. Participants (N = 185) were military service members admitted for inpatient psychiatric care following a suicide-related event. MANOVA and Poisson regression evaluated the association between each type of PD dysfunctional belief and the number of suicide attempts.

RESULTS

Service members' PBQ subscale scores for borderline (p = 0.049) and histrionic PD dysfunctional beliefs (p = 0.034) significantly differed across those with suicide ideation only, single attempt, and multiple attempts. Upon further analysis, histrionic PD dysfunctional beliefs scores were significantly higher among those with multiple suicide attempts than those with single attempts. One point increase of dependent (Incidence Risk Ratio = 1.04, p = 0.009), narcissistic (IRR = 1.07, p < 0.001), and paranoid PD dysfunctional beliefs (IRR = 1.04, p = 0.002) was associated with a greater number of lifetime suicide attempts.

CONCLUSIONS

Assessment and targeting dependent, narcissistic, paranoid, borderline, and histrionic beliefs as part of a psychosocial intervention will be useful.

An Examination of United States Air Force Suicide Decedents Based on Documented Suicide Attempt Histories

In this study, we compared United States military decedents who died by suicide on their first attempt with decedents who had made multiple attempts. Death investigation files for 217 United States Air Force (USAF) personnel who died by suicide between 1996 and 2006 were coded for demographic, psychosocial, and psychiatric characteristics. Among USAF suicide decedents, 77% died by suicide on their first attempt and 23% had a documented history of at least one prior attempt. Decedents with a history of prior attempts were more likely to have an interpersonal stressor within 3 months of death and were twice as likely to have a documented Axis I diagnosis. There were few differences between military suicide decedents based on history of prior attempts. Further research is needed to inform military suicide prevention endeavors.

Motor impulsivity differentiates between psychiatric inpatients with multiple versus single lifetime suicide attempts

A history of multiple suicide attempts conveys greater risk for suicide than a single attempt. Impulsivity may partially explain the association between multiple attempts and increased risk. We examined trait impulsivity, ability to engage in goal-directed behaviors, and impulse control among psychiatrically hospitalized United States military personnel and their dependents. Individuals with a history of multiple versus single attempts had significantly higher motor impulsivity, indicating spur of the moment action. Providers are encouraged to directly assess and treat motor impulsivity among suicidal individuals. Further research should explore whether motor impulsivity is a mechanism of change in psychosocial suicide prevention interventions.

Behavioural interventions to reduce sexual risk for HIV in heterosexual couples: a meta-analysis

OBJECTIVES

The current study was conducted to synthesise evaluations of couple-based HIV prevention interventions, assess the efficacy of these interventions in reducing sexual risk, and identify moderators of intervention efficacy.

METHODS

A comprehensive literature search identified 29 interventions (22 reports; N=5168 couples) that met the inclusion criteria, including enrolment of both members of a heterosexual couple, measurement of condom use at baseline and follow-up, and sufficient statistical information to calculate effect sizes. Effect sizes were analysed using fixed-effects and random-effects assumptions; factors related to intervention efficacy were identified using metaregression.

RESULTS

Overall, there were significant increases in condom use from baseline to follow-up (d+=0.78, 95% CI 0.48 to 1.09) and significant decreases in partner concurrency (d+=0.37, 95% CI 0.13 to 0.60). Condom use increased to a greater extent when studies were conducted toward the beginning of the epidemic, were located in countries scoring lower on the Human Development Index, enrolled serodiscordant couples, and delivered intervention content in multiple contexts. Couples who had been together longer, reported higher incidence of sexually transmitted infection, were provided voluntary counselling and testing, and provided outcome measures during face-to-face interviews also reported larger increases in condom use.

CONCLUSIONS

Couple-based interventions are efficacious in reducing unprotected sex within the context of romantic relationships. Future research should continue to improve risk reduction for couples.

The efficacy of exercise in reducing depressive symptoms among cancer survivors: a meta-analysis

INTRODUCTION

The purpose of this meta-analysis was to examine the efficacy of exercise to reduce depressive symptoms among cancer survivors. In addition, we examined the extent to which exercise dose and clinical characteristics of cancer survivors influence the relationship between exercise and reductions in depressive symptoms.

METHODS

We conducted a systematic search identifying randomized controlled trials of exercise interventions among adult cancer survivors, examining depressive symptoms as an outcome. We calculated effect sizes for each study and performed weighted multiple regression moderator analysis.

RESULTS

We identified 40 exercise interventions including 2,929 cancer survivors. Diverse groups of cancer survivors were examined in seven exercise interventions; breast cancer survivors were examined in 26; prostate cancer, leukemia, and lymphoma were examined in two; and colorectal cancer in one. Cancer survivors who completed an exercise intervention reduced depression more than controls, d(+) = -0.13 (95% CI: -0.26, -0.01). Increases in weekly volume of aerobic exercise reduced depressive symptoms in dose-response fashion (β = -0.24, p = 0.03), a pattern evident only in higher quality trials. Exercise reduced depressive symptoms most when exercise sessions were supervised (β = -0.26, p = 0.01) and when cancer survivors were between 47-62 yr (β = 0.27, p = 0.01).

CONCLUSION

Exercise training provides a small overall reduction in depressive symptoms among cancer survivors but one that increased in dose-response fashion with weekly volume of aerobic exercise in high quality trials. Depressive symptoms were reduced to the greatest degree among breast cancer survivors, among cancer survivors aged between 47-62 yr, or when exercise sessions were supervised.

Efficacy of HIV prevention interventions in Latin American and Caribbean nations, 1995-2008: a meta-analysis

This meta-analysis synthesized 37 HIV prevention interventions (from 28 studies) that were evaluated in Latin American and Caribbean nations. These studies were obtained through systematic searches of English, Spanish, and Portuguese-language databases available as of January 2009. Overall, interventions significantly increased knowledge (d = 0.40) and condom use (d = 0.25) but the effects varied widely. Interventions produced more condom use when they focused on high-risk individuals, distributed condoms, and explicitly addressed social-cultural components. The best-fitting models utilized factors related to geography, especially indices of a nations' human development index (HDI) and income inequality (i.e., Gini index). Interventions that provided at least 3 h of content succeeded better when HDI and income inequality were lower, suggesting that intensive HIV prevention activities succeed best where the need is greatest. Implications for HIV intervention development in Latin America and the Caribbean are discussed.