Institutional Betrayal and Closeness Among Women Veteran Survivors of Military Sexual Trauma: Associations with Self-Directed Violence and Mental Health Symptoms

Institutional betrayal is defined as harm caused by an institution to an individual in the context of trust and dependence. High institutional betrayal is associated with poorer health outcomes, and high levels of trust, dependence, or identification with the institution (institutional closeness) may exacerbate the negative effects of institutional betrayal. While military sexual trauma is prevalent among women Veterans and associated with high rates of institutional betrayal, studies of the impact of military sexual trauma-related institutional betrayal have been limited in size and scope and have not examined the potential role of institutional closeness. We conducted a secondary analysis of national survey data collected from women Veterans who screened positive for military sexual trauma (n = 229). Hierarchical logistic and linear regression were used to examine associations between predictor variables (institutional betrayal, institutional closeness, and their interaction) and outcomes of interest and adjusted for age, education, and military sexual assault history. Institutional betrayal was associated with increased odds of suicidal ideation and suicide attempt during or following military service, as well as more severe symptoms of depression and posttraumatic stress disorder (PTSD). Institutional betrayal was not associated with non-suicidal self-injury or lifetime substance misuse. Counter to hypotheses, institutional closeness did not moderate relationships between institutional betrayal and mental health symptoms or self-directed violence. Results underscore the necessity of preventing and addressing institutional betrayal among women Veterans who experience military sexual trauma.

Moving Beyond International Classification of Diseases Codes for the Retrospective Identification of Gender Diverse Veterans

Purpose: The Veterans Health Administration (VHA) systematically asks Veterans to self-report gender identity for documentation in their electronic health record. Veterans with transgender and gender diverse (TGD) identities experience higher rates of several health conditions compared to Veterans without minoritized gender identities. Historically, cohorts of TGD Veterans were built with International Classification of Diseases Version 10 (ICD-10) codes assigned during clinical encounters. We examined concordance between self-reported gender identity and relevant ICD-10 codes in VHA health records to inform use of these indicators for examining the health needs of TGD Veterans. Methods: TGD-related ICD-10 codes were compared to self-reported gender identity from more than 1.5 million Veterans (2019-2022). Results: Only 34% of TGD Veterans included through self-report had an ICD-10 code associated with transgender care. ICD-10 codes had low sensitivity and high specificity compared to self-reported gender. Conclusion: These findings suggest ICD-10 codes alone undercount the larger population of TGD Veterans in the VHA.

Suicide and suicidality in Australian Defence Force veterans: A systematic scoping review

OBJECTIVE

Increased suicidality and suicide deaths among veterans of the Australian Defence Force have gained recent prominence. A systematic scoping review was conducted to identify, summarise and synthesise the existing literature relating to Australian veteran suicide and suicidality, with the objective of identifying future research priorities.

METHODS

We conducted a PRISMA-compliant systematic search on PubMed/MEDLINE, Embase and CINAHL databases for all manuscripts reporting primary data on suicide and suicidality in Australian veterans. The search was supplemented by grey literature and a search of reference lists. Manuscripts of any study type, published in the English language since the Vietnam era, were eligible for inclusion.

RESULTS

A total of 26 articles and reports, utilising a variety of mostly quantitative approaches, were included in the review. Findings, especially in larger and more recent studies, indicate increased suicidality in the veteran population. Suicide deaths appeared to increase with transition out of the military. Mental illness was identified as an important risk factor for suicide and suicidality. Current service was identified as a protective factor against suicide. There was mixed evidence regarding the impact of operational deployment on suicide and suicidality.

CONCLUSIONS

Gaps were identified in relation to the relative contributions to risk from transition, the various psychosocial correlates (for example, relationships, finances, employment), pre-service factors and the extent to which these are causal or mediating in nature. A better understanding of health service utilisation would also aid in targeting preventive efforts. Future research in these areas is warranted.

The Effects of a Single-Session Virtual Rumination Intervention to Enhance Cognitive Functioning in Veterans With Subjective Cognitive Symptoms: Multimethod Pilot Study

BACKGROUND

Subjective cognitive concerns (SCCs) entail perceived difficulties in thinking or memory, often reported without substantial objective evidence of cognitive impairment. These concerns are prevalent among individuals with a history of brain injuries, neurological conditions, or chronic illnesses, contributing to both psychological distress and functional limitations. They are increasingly considered to be a risk factor for future objective decline. A considerable number of individuals reporting SCCs also exhibit mental health symptoms, such as a history of trauma, depression, or anxiety. Interventions that address modifiable emotional and cognitive factors related to SCC could improve functioning and quality of life. Therefore, the use of emotion regulation strategies, especially those directed at minimizing rumination, could serve as a promising focus for interventions aimed at mitigating subjective cognitive concerns in veteran populations.

OBJECTIVE

This pilot study explored the feasibility, acceptability, and preliminary efficacy of a brief, 1-session emotion regulation intervention called "Worry Less, Remember More." The Worry Less, Remember More intervention was designed to reduce rumination and improve subjective cognitive functioning in veterans with subjective cognitive changes (N=15).

METHODS

We randomized 15 veterans to either the active telehealth condition or waitlist control and completed the intervention. Participants were aged between 31 and 67 (mean 49.5, SD 10.1) years, and the sample was primarily male (12/15, 83%) and White (10/15, 67%). The most common diagnoses were posttraumatic stress disorder and depression. Following the intervention, veteran input was sought through semistructured interviews with a subset of 12 participants, examining feasibility, acceptability, and perceived efficacy. Preliminary efficacy was also measured using pre- and postintervention self-report measures.

RESULTS

Veterans reported that this intervention was acceptable, with 92% (11/12) of the sample reporting that they benefited from the intervention and would recommend the intervention to others with similar difficulties. Semistructured interviews revealed difficulties with feasibility, including problems with the remote consenting process, forgetting appointments, and needing additional strategies to remember to consistently use the interventions. The intervention improved self-reported cognitive symptoms on quantitative measures but did not improve self-reported rumination.

CONCLUSIONS

This pilot study establishes the preliminary feasibility, acceptability, and efficacy of the Worry Less, Remember More intervention for veterans with subjective cognitive symptoms. Future iterations of the intervention may benefit from simplifying the electronic consent process, providing reminders for appointments, and incorporating compensatory cognitive strategies to assist with using the telehealth system, as well as applying the strategies learned in the intervention. While future research is needed with larger samples, including nonveteran populations, the intervention may also be a useful clinical tool to bridge care between neuropsychology clinics and mental health treatment.

Adopting the RE-AIM analytic framework for rural program evaluation: experiences from the Advance Care Planning via Group Visits (ACP-GV) national evaluation

Introduction

To support rigorous evaluation across a national portfolio of grants, the United States Department of Veterans Affairs (VA) Office of Rural Health (ORH) adopted an analytic framework to guide their grantees' evaluation of initiatives that reach rural veterans and to standardize the reporting of outcomes and impacts. Advance Care Planning via Group Visits (ACP-GV), one of ORH's Enterprise-Wide Initiatives, also followed the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. ACP-GV is a national patient-centered intervention delivered in a large, veterans integrated healthcare system. This manuscript describes how RE-AIM was used to evaluate this national program and lessons learned from ORH's annual reporting feedback to ACP-GV on their use of the framework to describe evaluation impacts.

Methods

We used patient, provider, and site-level administrative health care data from the VA Corporate Data Warehouse and national program management databases for federal fiscal years (FY) spanning October 1, 2018-September 30, 2023. Measures included cumulative and past FY metrics developed to assess program impacts.

Results

RE-AIM constructs included the following cumulative and annual program evaluation results. ACP-GV reached 54,167 unique veterans, including 19,032 unique rural veterans between FY 2018 to FY 2023. During FY 2023, implementation adherence to the ACP-GV model was noted in 91.7% of program completers, with 55% of these completers reporting a knowledge increase and 14% reporting a substantial knowledge increase (effectiveness). As of FY 2023, 66 ACP-GV sites were active, and 1,556 VA staff were trained in the intervention (adoption). Of the 66 active sites in FY 2023, 27 were sites previously funded by ORH and continued to offer ACP-GV after the conclusion of three years of seed funding (maintenance).

Discussion

Lessons learned developing RE-AIM metrics collaboratively with program developers, implementers, and evaluators allowed for a balance of clinical and scientific input in decision-making, while the ORH annual reporting feedback provided specificity and emphasis for including both cumulative, annual, and rural specific metrics. ACP-GV's use of RE-AIM metrics is a key step towards improving rural veteran health outcomes and describing real world program impacts.

Dental implant failures in Utah and US veteran cohorts

INTRODUCTION

Approximately, 5.5 million dental implants are estimated to be surgically placed in the United States yearly, with an anticipated long-term failure rate ranging from 3% to 10%. At the Salt Lake City Dental Clinic within the Department of Veterans Affairs (VHA), specific protocols have been established to mandate that clinicians present every dental implant case for review by a committee. To understand the effectiveness of this approach, a comparative data analysis was undertaken to compare local dental implant failure data against national VHA data.

METHODS

Leveraging electronic health records of veterans spanning from 2000 to 2021, we gathered procedural records related to dental implant placement or failure, demographic information, and medical history for individuals who received dental care at various dental clinics within the nationwide VHA network. Subsequently, statistical analyses were conducted using mixed-effects Poisson regression models with cluster-robust standard errors. Incident rate ratios (IRRs) for Utah-specific and nationwide cohorts were ascertained.

RESULTS

The Utah VHA dental clinical data showed that there was a slightly lower prevalence of implant failure at 6.7% compared to the national cohort, which had a rate of 6.9%. The implant level failure rates were also low, with 4.20 (confidence interval [CI]: 3.68, 4.81) per 1000 implant placements per year for Utah cohorts. The adjusted IRR indicated a relative 16% reduction in risk among Utah Veterans (IRR 0.84, 95% CI [0.76-0.92]; p < 0.001).

CONCLUSIONS

The stringent protocols in place at Salt Lake City, which integrate evidence-based practices and expert opinion for evaluating patient suitability for dental implant placement and subsequent care, contributed to the reduced risk among Utah Dental Clinic veterans pool compared to veterans of other states.

Impact of Tracheostomy Timing Within the National Veterans Affairs Population

OBJECTIVE

There is a lack of a definitive study in the literature comparing early versus late tracheostomy and exploring the impact of tracheostomy timing on patient outcomes. This study may help guide treatment paradigms and contribute to a consensus for optimal tracheostomy timing.

METHODS

A retrospective review was performed comparing early versus late timing of tracheostomy placement and their respective outcomes. The authors used data provided by VA Informatics and Computing Infrastructure (VINCI) to find patients who received a tracheostomy at any VA Medical Center in the United States. There were a total of 25,334 tracheostomies in the database which satisfied our criteria. These occurred between the years 1999 and 2022. Propensity score matching assessed 17,074 tracheostomies, 8537 in either group. The median age of patients in the matched groups was 66 years, and approximately 97.4% of patients were male. Early tracheostomy timing was defined as the placement of the tracheostomy within 10 days of intubation. Outcomes included post-tracheostomy intensive care unit (ICU) days, post-tracheostomy hospital days, successful ventilator weaning, and all-cause mortality.

RESULTS

Early tracheostomy was associated with significantly fewer ICU days and hospital days, and the early group experienced higher rates of successful ventilator weaning. Survival analysis of data within 5 years of tracheostomy showed that early tracheostomy was associated with significantly lower hazard for all-cause mortality.

CONCLUSION

Our results add to the body of evidence that an earlier transition to mechanical ventilation by tracheostomy confers benefits in patient morbidity and mortality as well as resource utilization.

LEVEL OF EVIDENCE

3 Laryngoscope, 2024.

Weight Loss Outcomes in a Veterans Affairs Pharmacotherapy-based Weight Management Clinic

Context

Despite a high prevalence of obesity in the veteran population, antiobesity medications (AOMs) have been underused in the Veterans Health Administration. Real-world reports on outcomes when AOMs have been used in veterans is limited.

Objective

To analyze weight loss outcomes from a local Veterans Health Administration pharmacotherapy-based weight management clinic (WMC).

Methods

This was a retrospective cohort study of veterans enrolled in a local WMC for 15 months from August 2016 through September 2018 and followed through November 2019. Patients were offered 1 of 5 available AOMs based on their comorbidities. Factors associated with weight loss (5% or more weight loss) were assessed.

Key results

A total of 159 patients were seen in a WMC, 149 (93.7%) veterans were prescribed an AOM, and 129 returned for follow-up. Overall, 61/129 (47%) patients achieved 5% or greater weight loss and 28/129 (22%) achieved 10% or greater weight loss within 15 months. Clinically significant weight loss (%) over the first 15 months was achieved with phentermine/topiramate ER (-6.3%) and liraglutide (-7.5%), but not with orlistat (-3.9%) and lorcaserin (-3.6%). Comorbid obstructive sleep apnea was negatively associated with achieving ≥5% weight loss.

Conclusion

Phentermine/topiramate ER and liraglutide were found to be effective AOMs among veterans. Further work is needed to mitigate barriers to AOM initiation given the continued rise in obesity.

Considering the psychological experience of amputation and rehabilitation for military veterans: a systematic review and metasynthesis of qualitative research

PURPOSE

Research highlights the differences and unique experiences of military veterans experiencing amputation compared to civilians. This review aimed to synthesise qualitative research exploring the experience of amputation and rehabilitation among existing or previous members of the military.

METHODS

A systematic search of six databases (PsycINFO, AMED, MEDLINE, CINAHL, Web of Science and Scopus) was undertaken in March 2022. The results of 17 papers reporting 12 studies published between 2009 and 2022 were synthesised using a meta-ethnographic approach to generate new interpretations reflecting the experiences of members of the military who have experienced limb loss.

RESULTS

Three themes were developed from the data: (1) Making the physical and psychological transition to life after amputation; (2) The role of the military culture in rehabilitation; and (3) The impact of relationships and the gaze of others during rehabilitation and beyond.

CONCLUSIONS

Military veterans with limb loss experience difficulties in navigating civilian healthcare systems and gaining appropriate support away from the military. Rehabilitation professionals, with psychological training or mentoring, involved in the care of military veterans following amputation could offer psychological support during the transition to civilian life and targeted therapies to veterans experiencing high levels of pain, and facilitate peer support programmes.

Evaluating Suicide Risk Stratification in Outpatient Settings: A Vignette-Based Approach

Suicide risk assessment and stratification are a key suicide prevention strategy in mental health care systems that treat military service members and veterans. The aim of the current mixed-method project was to address a gap in our knowledge as to how therapists make these important clinical decisions. This manuscript reports the results of a project during which six vignettes were developed reflecting varying levels of risk according to the Rocky Mountain MIRECC Risk Stratification Table. Mental health therapists were asked to evaluate the risk level of each vignette, determine a treatment disposition, and provide justification for their ratings. The results of the study indicate that therapists can reliably evaluate risk, but that treatment planning tended to be based more on vignette-specific factors than essential features of the risk model. The qualitative findings revealed variations in the definition and perception of foundational concepts, suggesting a need for further research and training in these domains. Overall, the results support the use of vignettes as a method to assess clinical decision-making and provide several areas for further training and research.

Veterans After Receiving Battlefield Acupuncture at One Medical Center

This study reports on 54 homeless and 53 stably housed veterans who received battlefield acupuncture (BFA) between September 2018 and October 2022. Linear mixed-effects regressions were used to examine change in overall pain score and how pain impacted four areas: (1) activity, (2) sleep, (3) mood, and (4) stress over the course of 8 weeks from the baseline visit at one BFA clinic. Results indicated significant reductions in the impact of pain on activity, sleep, and stress among both homeless and housed veterans. Although overall pain levels were not significantly impacted, further research on the impact of BFA on homeless populations is warranted.

Outdoor light at night and depressive symptoms in male veterans: a multicenter cross-sectional study in China

Previous studies have indicated depression was associated with environmental exposures, but evidence is limited for the association between outdoor light at night (LAN) and depression. This study aims to examine the association between long-term outdoor LAN exposure and depressive symptoms using data from the Chinese Veteran Clinical Research platform. A total of 6445 male veterans were selected from 277 veteran communities in 18 cities of China during 2009‒2011. Depressive symptoms were evaluated using the Chinese version of the Center for Epidemiological Studies Depression scale. Outdoor LAN was estimated using the Global Radiance Calibrated Nighttime Lights data. The odds ratio and 95% confidence intervals of depressive symptoms at the high level of outdoor LAN exposure against the low level during the 1 years before the investigation was 1.49 (1.15, 1.92) with p-value for trend < 0.01, and those associated with per interquartile range increase in LAN exposure was 1.22 (1.06, 1.40).

Sleep disorders and cancer incidence: examining duration and severity of diagnosis among veterans

Introduction

Sleep disruption affects biological processes that facilitate carcinogenesis. This retrospective cohort study used de-identified data from the Veterans Administration (VA) electronic medical record system to test the hypothesis that patients with diagnosed sleep disorders had an increased risk of prostate, breast, colorectal, or other cancers (1999-2010, N=663,869). This study builds upon existing evidence by examining whether patients with more severe or longer-duration diagnoses were at a greater risk of these cancers relative to those with a less severe or shorter duration sleep disorder.

Methods

Incident cancer cases were identified in the VA Tumor Registry and sleep disorders were defined by International Classification of Sleep Disorder codes. Analyses were performed using extended Cox regression with sleep disorder diagnosis as a time-varying covariate.

Results

Sleep disorders were present among 56,055 eligible patients (8% of the study population); sleep apnea (46%) and insomnia (40%) were the most common diagnoses. There were 18,181 cancer diagnoses (41% prostate, 12% colorectal, 1% female breast, 46% other). The hazard ratio (HR) for a cancer diagnosis was 1.45 (95% confidence interval [CI]: 1.37, 1.54) among those with any sleep disorder, after adjustment for age, sex, state of residence, and marital status. Risks increased with increasing sleep disorder duration (short [<1-2 years] HR: 1.04 [CI: 1.03-1.06], medium [>2-5 years] 1.23 [1.16-1.32]; long [>5-12 years] 1.52 [1.34-1.73]). Risks also increased with increasing sleep disorder severity using cumulative sleep disorder treatments as a surrogate exposure; African Americans with more severe disorders had greater risks relative to those with fewer treatments and other race groups. Results among patients with only sleep apnea, insomnia, or another sleep disorder were similar to those for all sleep disorders combined.

Discussion

The findings are consistent with other studies indicating that sleep disruption is a cancer risk factor. Optimal sleep and appropriate sleep disorder management are modifiable risk factors that may facilitate cancer prevention.

Evaluation of telehealth administration of MMPI symptom validity scales

INTRODUCTION

Telehealth assessment (TA) is a quickly emerging practice, offered with increasing frequency across many different clinical contexts. TA is also well-received by most patients, and there are numerous guidelines and training opportunities which can support effective telehealth practice. Although there are extensive recommended practices, these guidelines have rarely been evaluated empirically, particularly on personality measures. While existing research is limited, it does generally support the idea that TA and in-person assessment (IA) produce fairly equitable test scores. The MMPI-3, a recently released and highly popular personality and psychopathology measure has been the subject of several of those experimental or student (non-client) based studies; however, no study to date has evaluated these trends within a clinical sample. This study empirically tests for differences in TA and IA test scores on the MMPI-3 validity scores when following recommended administration procedures.

METHOD

Data were from a retrospective chart review. Veterans (n = 550) who underwent psychological assessment in a Veterans Affairs Medical Center ADHD evaluation clinic were contrasted between in person and telehealth assessment modalities on the MMPI-2-RF and MMPI-3. Groups were compared using t tests, chi square, and base rates.

RESULTS

Results suggest that there were minimal differences in elevation rates or mean scores across modality, supporting the use of TA.

CONCLUSIONS

This study's findings support the use of the MMPI via TA with ADHD evaluations, Veterans, and in neuro/psychological evaluation settings more generally. Observed elevation rates and mean scores of this study were notably different from those seen in other VA service clinics sampled nationally, which is an area of future investigation.

Pain Care Disparities and the Use of Virtual Care Among Racial-Ethnic Minority Groups During COVID-19

BACKGROUND AND OBJECTIVE

COVID-19 led to an unprecedented reliance on virtual modalities to maintain care continuity for patients living with chronic pain. We examined whether there were disparities in virtual specialty pain care for racial-ethnic minority groups during COVID-19.

DESIGN AND PARTICIPANTS

This was a retrospective national cohort study with two comparison groups: primary care patients with chronic pain seen immediately prior to COVID-19 (3/1/19-2/29/20) (N = 1,649,053) and a cohort of patients seen in the year prior (3/1/18-2/28-19; n = 1,536,954).

MAIN MEASURES

We assessed use of telehealth (telephone or video) specialty pain care, in-person care specialty pain care, and any specialty pain care for both groups at 6 months following cohort inclusion. We used quasi-Poisson regressions to test associations between patient race and ethnicity and receipt of care.

KEY RESULTS

Prior to COVID-19, there were Black-White (RR = 0.64, 95% CI [0.62, 0.67]) and Asian-White (RR = 0.63, 95% CI [0.54, 0.75]) disparities in telehealth use, and these lessened during COVID-19 (Black-White: RR = 0.75, 95% CI [0.73, 0.77], Asian-White: RR = 0.81, 95% CI [0.74, 0.89]) but did not disappear. Individuals identifying as American Indian/Alaska Native used telehealth less than White individuals during early COVID-19 (RR = 0.98, 95% CI [0.85, 1.13] to RR = 0.87, 95% CI [0.79, 0.96]). Hispanic/Latinx individuals were less likely than non-Hispanic/Latinx individuals to use telehealth prior to COVID-19 but more likely during early COVID-19 (RR = 0.70, 95% CI [0.66, 0.75] to RR = 1.06, 95% CI [1.02, 1.09]). Disparities in virtual pain care occurred over the backdrop of overall decreased specialty pain care during the early phase of the pandemic (raw decrease of n = 17,481 specialty care encounters overall from pre-COVID to COVID-era), including increased disparities in any VA specialty pain care for Black (RR = 0.81, 95% CI [0.80, 0.83] to RR = 0.79, 95% CI [0.77, 0.80]) and Asian (RR = 0.91, 95% CI [0.86, 0.97] to RR = 0.88, 95% CI [0.82, 0.94]) individuals.

CONCLUSIONS

Disparities in virtual specialty pain care were smaller during the early phases of the COVID-19 pandemic than prior to the pandemic but did not disappear entirely, despite the rapid growth in telehealth. Targeted efforts to increase access to specialty pain care need to be concentrated among racial-ethnic minority groups.

Fiduciary assignment as a potential intervention for substance use disorder: a retrospective chart review

Background: Assignment of fiduciaries to veterans with disability payments is an intervention thought to improve quality of life; however, in veterans who use substances, a proportion of these payments may be misspent on drugs and/or alcohol. While fiduciary assignment may reduce funds available to purchase substances, clinical efficacy of this intervention in the management of substance use disorders has not been rigorously demonstrated.Objectives: The purpose of this study is to evaluate changes in clinical status before and after fiduciary assignment.Methods: This was a retrospective chart review of 50 (44 male, 6 female) veterans who were assigned a fiduciary and determined to have a substance use disorder (SUD). SUD-related data including outpatient and inpatient treatment, toxicology testing, and measures of psychosocial functioning for the three years before and after fiduciary assignment were extracted and compared.Results: Veterans were found to have higher rates of any form of employment after fiduciary assignment (Wilcoxon, Signed Ranked S-statistic = 0.22, pr = 0.02). Two changes in measures of substance use were found after fiduciary assignment. There was a reduction in positive screens for heroin (tstatistic = -2.7, p = .01), but an increase in positive screens for fentanyl (t statistic = 2.53, p = .02). There were some potentially clinically but not statistically significant trends in increased adherence with mental health appointments, number of medical hospitalizations, and rates of employment post-fiduciary assignment.Conclusions: Understanding the clinical impact of fiduciary assignment for veteran's benefits is desirable but still pending at this time.

Increasing chaplain support for veterans at high risk for suicide through targeted outreach: A quality improvement initiative

The Department of Veterans Affairs (VA) has prioritized improving the identification of veterans at risk for suicide and ensuring adequate staffing of personnel to assist veterans in need. It is imperative that suicide prevention efforts make use of the full range of available resources, including diverse professionals with distinctive skillsets. Chaplains are engaged in suicide prevention efforts in VA, but the literature lacks examples of chaplain-involved suicide prevention efforts that clearly describe how chaplains are engaged, the training and/or qualifications chaplains possess in the area of suicide prevention, and the reach and impact of such efforts. The purpose of this report is to describe the development and implementation of a novel, innovative, and ongoing chaplain-led suicide prevention outreach initiative for veterans at high risk for suicide. Results indicated the program was feasible and supported at the systems level, and chaplains were able to collaboratively sustain outreach efforts over the course of a year. Chaplain suicide prevention outreach was found to be acceptable to veterans, who overwhelmingly indicated openness to and appreciation for outreach. Chaplains can address the spiritual crisis underlying suicidality, bolster spiritual protective factors, and are a part of holistic care. Considerations for implementation and future investigation are discussed.

Sex differences in US military personnel with insomnia, obstructive sleep apnea, or comorbid insomnia and obstructive sleep apnea

STUDY OBJECTIVES

The aim of this study was to evaluate sex-related differences in symptoms of sleep disorders, sleep-related impairment, psychiatric symptoms, traumatic brain injury, and polysomnographic variables in treatment-seeking military personnel diagnosed with insomnia, obstructive sleep apnea (OSA), or comorbid insomnia and OSA (COMISA).

METHODS

Participants were 372 military personnel (46.2% women, 53.8% men) with an average age of 37.7 (standard deviation = 7.46) years and median body mass index of 28.4 (5.50) kg/m2. Based on clinical evaluation and video-polysomnography, participants were diagnosed with insomnia (n = 118), OSA (n = 118), or COMISA (n = 136). Insomnia severity, excessive daytime sleepiness, sleep quality, nightmare disorder, sleep impairment, fatigue, posttraumatic stress disorder, anxiety, depression symptoms, and traumatic brain injury were evaluated with validated self-report questionnaires. Descriptive statistics, parametric and nonparametric t-tests, and effect sizes were used to assess sex differences between men and women.

RESULTS

There were no significant differences between women and men with insomnia or OSA in sleep-related symptoms, impairment, or polysomnography-based apnea-hypopnea index. Military men with COMISA had a significantly greater apnea-hypopnea index as compared to military women with COMISA, but women had greater symptoms of nightmare disorder, posttraumatic stress disorder, and anxiety.

CONCLUSIONS

In contrast to civilian studies, minimal differences were observed in self-reported sleep symptoms, impairment, and polysomnography metrics between men and women diagnosed with the most frequent sleep disorders in military personnel (ie, insomnia, OSA, or COMISA) except in those with COMISA. Military service may result in distinct sleep disorder phenotypes that differ negligibly by sex.

CITATION

Mysliwiec V, Pruiksma KE, Matsangas P, et al. Sex differences in US military personnel with insomnia, obstructive sleep apnea, or comorbid insomnia and obstructive sleep apnea. J Clin Sleep Med. 2024;20(1):17-30.

Secure Messaging Intervention in Patients Starting New Antidepressant to Promote Adherence: Pilot Randomized Controlled Trial

BACKGROUND

There are a range of effective pharmacological and behavioral treatments for depression. However, approximately one-third of patients discontinue antidepressants within the first month of treatment and 44% discontinue them by the third month of treatment. The major reasons reported for discontinuation were side effect burden, patients experiencing that the medications were not working, and patients wanting to resolve their depression without using medication.

OBJECTIVE

This study tested the acceptability, feasibility, and preliminary effectiveness of an SMS messaging intervention designed to improve antidepressant adherence and depression outcomes in veterans. The intervention specifically targeted the key reasons for antidepressant discontinuation. For example, the secure message included reminders that it can take up to 6 weeks for an antidepressant to work, or prompts to call their provider should the side effect burden become significant.

METHODS

This pilot was a 3-armed randomized controlled trial of 53 veterans undergoing depression treatment at the Iowa City Veterans Affairs Health Care System. Veterans starting a new antidepressant were randomized to secure messaging only (SM-Only), secure messaging with coaching (SM+Coach), or attention control (AC) groups. The intervention lasted 12 weeks with follow-up assessments of key outcomes at 6 and 12-weeks. This included a measure of antidepressant adherence, depressive symptom severity, and side effect burden.

RESULTS

The 2 active interventions (SM-Only and SM+Coach) demonstrated small to moderate effect sizes (ESs) in improving antidepressant adherence and reducing side effect burden. They did not appear to reduce the depressive symptom burden any more than in the AC arm. Veteran participants in the SM arms demonstrated improved medication adherence from baseline to 12 weeks on the Medication Adherence Rating Scale compared with those in the AC arm, who had a decline in adherence (SM-Only: ES=0.09; P=.19; SM+Coach: ES=0.85; P=.002). Depression scores on the 9-Item Patient Health Questionnaire decreased for all 3 treatment arms, although the decline was slightly larger for the SM-Only (ES=0.32) and the SM+Coach (ES=0.24) arms when compared with the AC arm. The 2 intervention arms indicated a decrease in side effects on the Frequency, Intensity, and Burden of Side Effects Ratings, whereas the side effect burden for the AC arm increased. These differences indicated moderate ES (SM-Only vs AC: ES=0.40; P=.07; SM+Coach: ES=0.54; P=.07).

CONCLUSIONS

A secure messaging program targeting specific reasons for antidepressant discontinuation had small-to-moderate ES in improving medication adherence. Consistent with prior research, the intervention that included brief synchronic meetings with a coach appeared to have a greater benefit than the SMS-alone intervention. Veterans consistently engaged with the SMS messaging in both treatment arms throughout the study period. They additionally provided feedback on which texts were most helpful, tending to prefer messages providing overall encouragement rather than specific wellness recommendations.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03930849; https://clinicaltrials.gov/study/NCT03930849.

Moral injury: understanding Swedish veterans who are assessed but not diagnosed with PTSD

This article is based on an interview study of 24 Swedish veterans who experienced deteriorating mental health and increased suffering without meeting the criteria for a PTSD diagnosis. With no clinical answers as to the cause of their deteriorating mental health, they have been thrown into a veteran's health limbo. The analysis was based on an inductive logic. A key finding of the analysis was a kind of deep-seated permanent moral conflict that could be conceptualized as moral injury. Such an injury can give rise to intense guilt, shame, anxiety, anger, dejection, bitterness, identity issues and more. The results section of the article details five different yet for the sample representative cases of moral injury and their implications. The notion of moral injury is linked to Mead's division of the self into an I and me, where me is the socially constructed part of the self that is charged with the morality of a group. Thus, a moral me played a key role in the development of moral injury. The conceptual apparatus illustrates a new way of understanding experiences that can create suffering and negatively impact a veteran's mental health. Future research is encouraged that examines this topic, national designs for addressing moral injury, screening for moral injury, and methods for healing included.

military veterans: results from a 10-year, population-based, observational cohort study

BACKGROUND

Understanding the interplay between psychosocial factors and polygenic risk scores (PRS) may help elucidate the biopsychosocial etiology of high alcohol consumption (HAC). This study examined the psychosocial moderators of HAC, determined by polygenic risk in a 10-year longitudinal study of US military veterans. We hypothesized that positive psychosocial traits (e.g. social support, personality traits, optimism, gratitude) may buffer risk of HAC in veterans with greater polygenic liability for alcohol consumption (AC).

METHODS

Data were analyzed from 1323 European-American US veterans who participated in the National Health and Resilience in Veterans Study, a 10-year, nationally representative longitudinal study of US military veterans. PRS reflecting genome-wide risk for AC (AUDIT-C) was derived from a Million Veteran Program genome-wide association study (N = 200 680).

RESULTS

Among the total sample, 328 (weighted 24.8%) had persistent HAC, 131 (weighted 9.9%) had new-onset HAC, 44 (weighted 3.3%) had remitted HAC, and 820 (weighted 62.0%) had no/low AC over the 10-year study period. AUDIT-C PRS was positively associated with persistent HAC relative to no/low AC [relative risk ratio (RRR) = 1.43, 95% confidence interval (CI) = 1.23-1.67] and remitted HAC (RRR = 1.63, 95% CI = 1.07-2.50). Among veterans with higher AUDIT-C PRS, greater baseline levels of agreeableness and greater dispositional gratitude were inversely associated with persistent HAC.

CONCLUSIONS

AUDIT-C PRS was prospectively associated with persistent HAC over a 10-year period, and agreeableness and dispositional gratitude moderated this association. Clinical interventions designed to target these modifiable psychological traits may help mitigate risk of persistent HAC in veterans with greater polygenic liability for persistent HAC.

Military burn pit exposure and airway disease: Implications for our Veteran population

Millions of veterans have been exposed to burn pit smoke during combat deployments throughout the last three decades. Toxic compounds present in burn pit fumes that may cause or exacerbate upper and lower airway diseases include dioxins, polyaromatic hydrocarbons, and particulate matter, among others. There have been several observational studies evaluating the potential role of burn pit exposure in the development of a multitude chronic health conditions, and the veterans Administration has established the Airborne Hazards and Open Burn Pit Registry in 2014. However, specific causality of airway disease from burn pits has been difficult to prove, and there are multiple barriers toward etiologic research. Preclinical models have demonstrated airway dysfunction and inflammation but modeling human exposures remains challenging. Here, we review the current literature on the potential impact of burn pit exposure on chronic airway disease.

The Prevalence of Nonsuicidal Self-Injury in Military Personnel: A Systematic Review and Meta-Analysis

Military service members and veterans (SMVs) are at risk for self-directed violence, including nonsuicidal self-injury (NSSI). While NSSI is an important construct worthy of independent study, it is understudied among SMVs and, when included in research, typically examined in the context of suicide risk. Consequently, lifetime prevalence rate estimates of NSSI among SMVs vary. This Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review and meta-analysis estimated the average lifetime NSSI prevalence among SMVs and explored demographic and methodological factors that may account for observed variability. Based on a search of Ovid MEDLINE, Embase, PsycINFO, and Web of Science, 47 samples from 42 articles across five countries met inclusion criteria. Results revealed an average NSSI lifetime prevalence rate of 15.76% among SMVs. Significantly higher prevalence rates were observed among clinical (28.14%) versus community (11.28%) samples and studies using interviews to assess NSSI (23.56%) versus self-report (13.44%) or chart review (7.84%). Lifetime prevalence increased as publication year increased and decreased as sample size increased. In contrast to prior literature, prevalence rates were comparable between active-duty SMVs, and studies collecting data anonymously versus those that did not. Lifetime prevalence was not moderated by age, gender, race, country, primary research focus, quality of NSSI operationalization, or whether NSSI methods were assessed. Findings suggest NSSI is a pervasive problem among military personnel, particularly within clinical settings, highlighting the need for systematic assessment of this important but understudied clinical phenomenon among SMVs. Further research is necessary to elucidate additional risk factors for NSSI among SMVs, including trauma exposure.

Culturally Centered Implementation of Video Telehealth for Rural Native Veterans

Introduction: Native American Veterans are the most rural and experience heightened risk for mental health (MH) challenges while facing significant health care inequities and access barriers. Rural Native Veterans (RNVs) have experienced historical loss and racial discrimination, contributing to mistrust of Veterans Health Administration (VHA) and other Federal systems. Telemedicine, including video telehealth (VTH), can improve access to MH care for RNVs by addressing barriers. Understanding the cultural context and existing community resources can improve engagement and implementation efforts with RNVs. Objective: This article describes a model of culturally centered MH care and a flexible implementation approach, Personalized Implementation of Virtual Treatments for Rural Native Veterans (PIVOT-RNV), used to disseminate the model. Methods: Participants included four VHA sites serving large RNV populations where PIVOT-RNV was applied to expand the availability of virtual solutions, including VTH, for RNVs. A mixed methods formative evaluation tracked VTH utilization and used provider and RNV feedback to inform iterative process improvements. Results: Where PIVOT-RNV was used, number of providers using VTH with RNVs, number of unique RNVs receiving MH care through VTH, and number of VTH encounters with RNVs grew annually. Provider and RNV feedback highlighted the importance of addressing the unique barriers and cultural context of RNVs. Conclusions: PIVOT-RNV demonstrates promise for improving implementation of virtual treatments and access to MH care for RNVs. The integration of implementation science within a cultural safety framework helps address specific barriers to adoption of virtual treatments for RNVs. Next steps include expanding PIVOT-RNV efforts at additional sites.

Efficacy of an Internet-Delivered Intervention for Improving Insomnia Severity and Functioning in Veterans: Randomized Controlled Trial

BACKGROUND

Despite a growing evidence base that internet-delivered cognitive behavioral therapy for insomnia (iCBT-I) is associated with decreased insomnia severity, its efficacy has been minimally examined in veterans.

OBJECTIVE

The objective of this study was to evaluate the efficacy of an unguided iCBT-I (Sleep Healthy Using the Internet [SHUTi]) among veterans.

METHODS

We conducted a single-blind, randomized controlled trial in Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans eligible for Veterans Health Administration care. Participants were randomly assigned (1:1) to receive SHUTi (a self-guided and interactive program) or an Insomnia Education Website (IEW) that provided nontailored and fixed insomnia information. Web-based assessments were administered at baseline, postintervention, 6 months postintervention, and 1 year postintervention. The primary outcome was self-reported insomnia severity (Insomnia Severity Index [ISI]). Secondary outcomes were self-reported mental and physical health functioning (Veterans RAND 36-item Health Survey). Exploratory outcomes comprised sleep diary parameters.

RESULTS

Of the 231 randomized participants (mean age 39.3, SD 7.8 years; 170/231, 73.5% male sex; 26/231, 11.3% Black; 172/231, 74.5% White; 10/231, 4.3% multiracial; and 17/231, 7.4% other; 36/231, 15.6% Hispanic) randomized between April 2018 and January 2019, a total of 116 (50.2%) were randomly assigned to SHUTi and 115 (49.8%) to the IEW. In intent-to-treat analyses, SHUTi participants experienced significantly larger ISI decreases compared with IEW participants at all time points (generalized η2 values of 0.13, 0.12, and 0.10, respectively; all P<.0001). These corresponded to estimated larger differences in changes of -3.47 (95% CI -4.78 to -2.16), -3.80 (95% CI -5.34 to -2.27), and -3.42 (95% CI -4.97 to 1.88) points on the ISI for the SHUTi group. SHUTi participants experienced significant improvements in physical (6-month generalized η2=0.04; P=.004) and mental health functioning (6-month and 1-year generalized η2=0.04; P=.009 and P=.005, respectively). Significant sleep parameter improvements were noted for SHUTi (all P<.05), though the pattern and magnitude of these reductions varied by parameter. No adverse events were reported.

CONCLUSIONS

Self-administered iCBT-I was associated with immediate and long-term improvements in insomnia severity. Findings suggest that leveraging technology to meet insomnia treatment demands among veterans may be a promising approach.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03366870; https://clinicaltrials.gov/ct2/show/NCT03366870.

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).

Veterans and Nonveterans Coping With Stress During 4 Months of COVID-19

PURPOSE

Identifying how people have been coping with stress during the COVID-19 pandemic allows us to anticipate how the population may react to similar stressors over time. In this study, we assessed patterns of coping styles among veterans and nonveterans, and stability and change in these strategies at 3 time points during the pandemic.

METHODS

Using an online survey platform, we circulated a questionnaire at 3 time points during the period when COVID-19 vaccines became widely available (December 2-27, 2020; January 21-February 6, 2021; and March 8-23, 2021). The questionnaire asked participants about their extent of use of 11 coping strategies, and symptoms of anxiety and depression.

RESULTS

A total of 2,085 participants (50.8% veterans) completed the questionnaire at 1 or more time points and 930 participants (62.8% veterans) completed it at all 3 time points. Cluster analysis identified 3 distinct coping styles: adaptive, distressed, and disengaged. Compared with nonveterans, veterans more commonly had adaptive and disengaged coping styles, and less commonly had a distressed coping style. The majority of the cohort (71.3%) changed coping style at least once during the study period. Participants who used the same coping style across all 3 time points reported lower levels of anxiety and depression.

CONCLUSIONS

Our data demonstrate a need to better understand the dynamic nature of coping with pandemic-level stressors across time. We did not find patterns of change in coping styles, but our findings point to potential advantages of stability in coping style. It is possible that less adaptive styles that are more stable may be advantageous for mental health. This research has implications for supporting patients dealing with stress in family medicine.

"I wish people could come together like we have," patient and provider perspectives on VA residential PTSD treatment

Although most posttraumatic stress disorder (PTSD) care in the Veterans health administration (VHA) is provided on an outpatient basis, the VHA has 40 residential rehabilitation treatment programs (RRTPs) designed to treat Veterans who require more intensive and closely monitored care. Unfortunately, the clinical outcomes of these programs are modest, and previous attempts to identify key drivers of outcomes have uncovered few modifiable factors. The present study, informed by the model of resources, life events and changes in psychological state, was designed to identify factors associated with treatment response among RRTP patients and providers. Semistructured interviews were conducted with 24 patients and 12 providers at three regional RRTPs, using interview guides based on the theoretical model. Data were analyzed using rapid analysis. Results showed that patients and providers agreed on several factors critical to RRTP success. These factors included the provision of evidence-based psychotherapy (EBP), support and understanding from fellow patients, and skill and support from providers. Patients and providers also noted the importance of psychological flexibility, openness, and willingness to change. Patients who experienced less symptom improvement over the course of treatment were more likely to report poor therapeutic alliance. These findings underscore the importance of continued emphasis on EBP delivery but also suggest that RRTPs might find additional ways to capitalize on the residential milieu to encourage engagement in treatment and a focus on therapeutic change. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Validation of Military Occupational Specialty as a Proxy for Blast Exposure Using the Salisbury Blast Interview

Abstract Evaluating large data sets precludes the ability to directly measure individual experiences, instead relying on proxies to infer certain constructs. Blast exposure is a construct of study currently in its infancy, resulting in diverse definitions and measurements across studies. The purpose of the present study was to validate military occupational specialty (MOS) as a proxy for blast exposure in combat veterans. A total of 256 veterans (86.33% male) completed the Salisbury Blast Interview (SBI) and Mid-Atlantic Mental Illness Research Education and Clinical Center (MIRECC) Assessment of Traumatic Brain Injury (MMA-TBI). MOS was collected through record review and categorized into low and high risk for blast exposure. Chi-square analyses and t tests compared SBI metrics between MOS categories. Receiver operating characteristic (ROC) analyses evaluated the diagnostic accuracy of MOS category in determining blast exposure severity. Veterans in high-risk MOS were more likely to have experienced blast and deployment TBI (ps < 0.001) than were those in low-risk MOS. ROC analyses indicated good specificity (81.29-88.00) for blast and deployment TBI outcomes, suggesting that low-risk MOS is generally associated with an absence of blast and deployment TBI outcomes. Sensitivity was low (36.46-51.14), indicating that MOS risk level was not a good predictor of the presence of these outcomes. Results demonstrate that high-risk MOSs will identify individuals with blast exposure and deployment TBI history whereas low-risk MOSs will capture a highly variable group. Accuracy of MOS categorization was not acceptable for diagnostic-level tests; however, results support its use as a screening measure for a history of exposure to blast, use in epidemiological studies, and considerations for military policy.

standard prolonged exposure therapy for PTSD in military personnel and veterans: 12-month follow-up of a non-inferiority randomised controlled trial

BACKGROUND

The utilisation of massed therapy for treating posttraumatic stress disorder (PTSD) is gaining strength, especially prolonged exposure. However, it is unknown whether massed prolonged exposure (MPE) is non-inferior to standard prolonged exposure (SPE) protocols in the long term. The current study aimed to assess whether MPE was non-inferior to SPE at 12 months post-treatment, and to ascertain changes in secondary measure outcomes.

METHODS

A multi-site non-inferiority randomised controlled trial (RCT) compared SPE with MPE in 12 clinics. The primary outcome was PTSD symptom severity (CAPS-5) at 12 months post-treatment commencement. Secondary outcome measures included symptoms of depression, anxiety, anger, disability, and quality of life at 12 weeks and 12 months post-treatment commencement. Outcome assessors were blinded to treatment allocation. The intention-to-treat sample included 138 Australian military members and veterans and data were analysed for 134 participants (SPE = 71, MPE = 63).

RESULTS

Reductions in PTSD severity were maintained at 12 months and MPE remained non-inferior to SPE. Both treatment groups experienced a reduction in depression, anxiety, anger, and improvements in quality of life at 12 weeks and 12 months post-treatment commencement. Treatment effects for self-reported disability in the SPE group at 12 weeks were not maintained, with neither group registering significant effects at 12 months.

CONCLUSIONS

The emergence of massed protocols for PTSD is an important advancement. The current study provides RCT evidence for the longevity of MPE treatment gains at 12 months post-treatment commencement and demonstrated non-inferiority to SPE. Promisingly, both treatments also significantly reduced the severity of comorbid symptoms commonly occurring alongside PTSD.

Posttraumatic sleep disturbances in veterans: A pilot randomized controlled trial of cognitive behavioral therapy for insomnia and imagery rehearsal therapy

OBJECTIVES

Posttraumatic stress disorder (PTSD) is associated with sleep disturbances including insomnia and nightmares. This study compared cognitive behavioral therapy for insomnia (CBT-I) with CBT-I combined with imagery rehearsal therapy (IRT) for nightmares to evaluate if the combined treatment led to greater reductions in trauma-related sleep disturbances in Australian veterans.

METHODS

Veterans with diagnosed PTSD, high insomnia symptom severity, and nightmares (N = 31) were randomized to eight group CBT-I sessions or eight group CBT-I + IRT sessions. Self-reported sleep, nightmare, and psychological measures (primary outcome: Pittsburgh Sleep Quality Index), and objective actigraphy data were collected; the effect of obstructive sleep apnea (OSA) risk on treatment outcomes was also examined.

RESULTS

No treatment condition effects were detected for the combined treatment compared to CBT-I alone, and no moderating effect of OSA risk was detected. On average, participants from both groups improved on various self-report measures over time (baseline to 3 months posttreatment). Despite the improvements, mean scores for sleep-specific measures remained indicative of poor sleep quality. There were also no significant differences between the groups on the actigraphy indices.

CONCLUSIONS

The findings indicate that there is potential to optimize both treatments for veterans with trauma-related sleep disturbances.

Marital Quality and Loneliness Among Aging Vietnam-Era Combat Veterans: The Moderating Role of PTSD Symptom Severity

OBJECTIVES

We examined links between marital quality and loneliness among aging veterans and explored whether veterans' PTSD symptom severity moderated these associations.

METHODS

Data came from 269 Vietnam-Era combat veterans who had a spouse/partner (M age = 60.50). Utilizing two waves of data spanning six years, we estimated multiple regression models that included positive and negative marital quality, PTSD symptom severity, and loneliness in 2010 as predictors of loneliness in 2016.

RESULTS

Facets of positive (but not negative) marital quality were associated with veterans' loneliness. Companionship - spousal affection and understanding - was associated with lower subsequent loneliness among veterans with low/moderate - but not high - PTSD symptom severity. Conversely, sociability - the degree to which one's marriage promotes socializing with others - was associated with lower subsequent loneliness regardless of PTSD symptom severity.

CONCLUSIONS

Companionship and sociability were each associated with veterans' subsequent loneliness. Whereas benefits of companionship were attenuated at higher levels of PTSD symptom severity, benefits of sociability were not.

CLINICAL IMPLICATIONS

For veterans with higher PTSD symptoms, recommending mental health treatment to decrease symptom severity may help them to reap the benefits of close/intimate relationships. However, bolstering veterans' social participation more broadly may provide an additional means of reducing their loneliness.

Mobile and Web-Based Partnered Intervention to Improve Remote Access to Pain and Posttraumatic Stress Disorder Symptom Management: Recruitment and Attrition in a Randomized Controlled Trial

BACKGROUND

Increasing access to nonpharmacological interventions to manage pain and posttraumatic stress disorder (PTSD) is essential for veterans. Complementary and integrative health (CIH) interventions can help individuals manage symptom burden with enhanced accessibility via remotely delivered health care. Mission Reconnect (MR) is a partnered, self-directed intervention that remotely teaches CIH skills.

OBJECTIVE

The purpose of this paper is to describe the recruitment, onboarding phase, and attrition of a fully remote randomized controlled trial (RCT) assessing the efficacy of a self-directed mobile and web-based intervention for veterans with comorbid chronic pain and PTSD and their partners.

METHODS

A total of 364 veteran-partner dyads were recruited to participate in a mixed methods multisite waitlist control RCT. Qualitative attrition interviews were conducted with 10 veterans with chronic pain and PTSD, and their self-elected partners (eg, spouse) who consented but did not begin the program.

RESULTS

At the point of completing onboarding and being randomized to the 2 treatment arms, of the 364 recruited dyads, 97 (26.6%) failed to complete onboarding activities. Reported reasons for failure to complete onboarding include loss of self-elected partner buy-in (n=8, 8%), difficulties with using remote data collection methods and interventions (n=30, 31%), and adverse health experiences unrelated to study activities (n=23, 24%). Enrolled veterans presented at baseline with significant PTSD symptom burden and moderate-to-severe pain severity, and represented a geographically and demographically diverse population. Attrition interviews (n=10) indicated that misunderstanding MR including the intent of the intervention or mistaking the surveys as the actual intervention was a reason for not completing the MR registration process. Another barrier to MR registration was that interviewees described the mailed study information and registration packets as too confusing and excessive. Competing personal circumstances including health concerns that required attention interfered with MR registration. Common reasons for attrition following successful MR registration included partner withdrawal, adverse health issues, and technological challenges relating to the MR and electronic data collection platform (Qualtrics). Participant recommendations for reducing attrition included switching to digital forms to reduce participant burden and increasing human interaction throughout the registration and baseline data collection processes.

CONCLUSIONS

Challenges, solutions, and lessons learned for study recruitment and intervention delivery inform best practices of delivering remote self-directed CIH interventions when addressing the unique needs of this medically complex population. Successful recruitment and enrollment of veterans with chronic pain and PTSD, and their partners, to remote CIH programs and research studies requires future examination of demographic and symptom-associated access barriers. Accommodating the unique needs of this medically complex population is essential for improving the effectiveness of CIH programs. Disseminating lessons learned and improving access to remotely delivered research studies and CIH programs is paramount in the post-COVID-19 climate.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03593772; https://clinicaltrials.gov/ct2/show/NCT03593772.

Association of Atherosclerotic Cardiovascular Disease, Hypertension, Diabetes, and Hyperlipidemia With Gulf War Illness Among Gulf War Veterans

BACKGROUND

Approximately 30% of the 700 000 Gulf War veterans report a chronic symptom-based illness of varying severity referred to as Gulf War illness (GWI). Toxic deployment-related exposures have been implicated in the cause of GWI, some of which contribute to metabolic dysregulation and lipid abnormalities. As this cohort ages, the relationship between GWI and atherosclerotic cardiovascular disease (ASCVD) is a growing concern. We evaluated associations between GWI and ASCVD, diabetes, hyperlipidemia, and hypertension in veterans of the Gulf War (1990-1991).

METHODS AND RESULTS

Analysis of survey data collected in 2014 to 2016 from a national sample of deployed Gulf War veterans (n=942) and Veterans Health Administration electronic health record data (n=669). Multivariable logistic regression models tested for associations of GWI with self-reported ASCVD, diabetes, hyperlipidemia, and hypertension, controlling for confounding factors. Separate models tested for GWI associations with ASCVD and risk factors documented in the electronic health record. GWI was associated with self-reported hypertension (adjusted odds ratio [aOR], 1.67 [95% CI, 1.18-2.36]), hyperlipidemia (aOR, 1.46 [95% CI, 1.03-2.05]), and ASCVD (aOR, 2.65 [95% CI, 1.56-4.51]). In the subset of veterans with electronic health record data, GWI was associated with documented diabetes (aOR, 2.34 [95% CI, 1.43-3.82]) and hypertension (aOR, 2.84 [95% CI, 1.92-4.20]). Hyperlipidemia and hypertension served as partial mediators of the association between GWI and self-reported ASCVD.

CONCLUSIONS

Gulf War veterans with GWI had higher odds of hyperlipidemia, hypertension, diabetes, and ASCVD compared with Gulf War veterans without GWI. Further examination of the mechanisms underlying this association, including a possible shared exposure-related mechanism, is necessary.

Recruiting Sexual and Gender Minority Veterans for Health Disparities Research: Recruitment Protocol of a Web-Based Prospective Cohort Study

BACKGROUND

The Health for Every Veteran Study is the first Veterans Health Administration-funded, nationwide study on lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) veterans' health that relies exclusively on primary recruitment methods. This study aimed to recruit 1600 veterans with diverse sexual and gender identities to study the mental health and health risk behaviors of this population. A growing body of literature highlights the health inequities faced by LGBTQ+ veterans when compared with their heterosexual or cisgender peer groups. However, there is little to no guidance in the health disparities literature describing the recruitment of LGBTQ+ veterans.

OBJECTIVE

This paper provides an overview of the recruitment methodology of Health for Every Veteran Study. We describe the demographics of the enrolled cohort, challenges faced during recruitment, and considerations for recruiting LGBTQ+ veterans for health research.

METHODS

Recruitment for this study was conducted for 15 months, from September 2019 to December 2020, with the goal of enrolling 1600 veterans evenly split among 8 sexual orientation and gender identity subgroups: cisgender heterosexual women, cisgender lesbian women, cisgender bisexual women, cisgender heterosexual men, cisgender gay men, cisgender bisexual men, transgender women, and transgender men. Three primary recruitment methods were used: social media advertising predominantly through Facebook ads, outreach to community organizations serving veterans and LGBTQ+ individuals across the United States, and contracting with a research recruitment company, Trialfacts.

RESULTS

Of the 3535 participants screened, 1819 participants met the eligibility criteria, and 1062 completed the baseline survey to enroll. At baseline, 25.24% (268/1062) were recruited from Facebook ads, 40.49% (430/1062) from community outreach, and 34.27% (364/1062) from Trialfacts. Most subgroups neared the target enrollment goals, except for cisgender bisexual men, women, and transgender men. An exploratory group of nonbinary and genderqueer veterans and veterans with diverse gender identities was included in the study.

CONCLUSIONS

All recruitment methods contributed to significant portions of the enrolled cohort, suggesting that a multipronged approach was a critical and successful strategy in our study of LGBTQ+ veterans. We discuss the strengths and challenges of all recruitment methods, including factors impacting recruitment such as the COVID-19 pandemic, negative comments on Facebook ads, congressional budget delays, and high-volume surges of heterosexual participants from community outreach. In addition, our subgroup stratification offers important disaggregated insights into the recruitment of specific LGBTQ+ subgroups. Finally, the web-based methodology offers important perspectives not only for reaching veterans outside of the Veterans Health Administration but also for research studies taking place in the COVID-19-impacted world. Overall, this study outlines useful recruitment methodologies and lessons learned to inform future research that seeks to recruit marginalized communities.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/43824.

Implementing a Social Needs Screening and Referral Program Among Veterans: Assessing Circumstances & Offering Resources for Needs (ACORN)

BACKGROUND

The Department of Veterans Affairs (VA) healthcare system routinely screens Veterans for food insecurity, housing instability, and intimate partner violence, but does not systematically screen for other health-related social needs (HRSNs).

OBJECTIVES

To (1) develop a process for systematically identifying and addressing Veterans' HRSNs, (2) determine reported prevalence of HRSNs, and (3) assess the acceptability of HRSN screening among Veterans.

DESIGN

"Assessing Circumstances and Offering Resources for Needs" (ACORN) is a Veteran-tailored HRSN screening and referral quality improvement initiative. Veterans were screened via electronic tablet for nine HRSNs (food, housing, utilities, transportation, legal needs, social isolation, interpersonal violence, employment, and education) and provided geographically tailored resource guides for identified needs. Two-week follow-up interviews with a purposive sample of Veterans explored screening experiences.

PARTICIPANTS

Convenience sample of Veterans presenting for primary care at a VA urban women's health clinic and suburban community-based outpatient clinic (October 2019-May 2020).

MAIN MEASURES

Primary outcomes included prevalence of HRSNs, Veteran-reported acceptability of screening, and use of resources guides. Data were analyzed using descriptive statistics, chi-square tests, and rapid qualitative analysis.

KEY RESULTS

Of 268 Veterans screened, 50% reported one or more HRSNs. Social isolation was endorsed most frequently (29%), followed by educational needs (19%), interpersonal violence (12%), housing instability (9%), and utility concerns (7%). One in five Veterans reported at least one form of material hardship. In follow-up interviews (n = 15), Veterans found screening acceptable and felt VA should continue screening. No Veterans interviewed had contacted recommended resources at two-week follow-up, although several planned to use resource guides in the future.

CONCLUSION

In a VA HRSN screening and referral program, Veterans frequently reported HRSNs, felt screening was important, and thought VA should continue to screen for these needs. Screening for HRSNs is a critical step towards connecting patients with services, identifying gaps in service delivery, and informing future resource allocation.

Brief relationship support as a selective suicide prevention intervention: Piloting the Relationship Checkup in veteran couples with relationship and mental health concerns

INTRODUCTION

Close relationship problems play a key role in many contemporary theories of suicide. However, the potential of relationship support in suicide prevention is understudied. This study explores the feasibility, safety, acceptability, and promise of utilizing the 3-session Relationship Checkup (RC) in veterans with mental health and romantic relationship concerns.

METHODS

We conducted a single-arm pilot of telehealth RC in veterans with a positive mental health screen and their romantic partners. Couples completed baseline and post-treatment assessments of study outcomes.

RESULTS

Feasibility analyses showed we were able to recruit an elevated-risk sample (30% history of attempts or interrupted attempts), take them through the service (90% treatment completion), and had minimal harm events (no suicidal behavior, no physical harm in arguments). Multimethod acceptability analyses suggested high satisfaction with the program, though some desired more intensive services. Couples reported improvements in relationship functioning, emotional intimacy, thwarted belongingness, depression, and posttraumatic stress. Perceived burdensomeness only improved for identified patients and drinking did not change for either partner.

CONCLUSION

The RC is a feasible, safe, and acceptable strategy for providing relationship support to couples at elevated risk. Although further randomized trials are needed, RC shows promise to reduce relationship-level and individual-level suicide risk factors.

The Role of Companion Dogs in the VA Maryland Health Care System Whole Health(y) GeroFit Program

GeroFit is a gym-based exercise program that promotes health and wellness among older sedentary veterans. The aims of the current study were to determine whether providing a companion dog as an alternative to gym-based exercise would similarly affect whole health outcomes. A total of 15 (n = 15) veterans (62 ± 11 years of age; 13 of 15 >54 years of age) underwent physical function testing, completed global and whole health questionnaires, and wore an accelerometer for 7 days before (baseline) and 3 months after a dog came into their home. The participants completed the Pet Attachment Scale (PAS), Dog Owner-Specific Quality of Life (DOQOL), and Canine Behavioral Assessment and Research questionnaires at 3 months. Cardiorespiratory endurance, lower body strength, daily steps, and time spent engaging in moderate physical activity all increased compared to the baseline levels. Body weight decreased among veterans whose body mass index was ≥30 (n = 11). The PAS and DOQOL scores indicated high attachment and positive effects on quality of life after having a dog in the home, with all veterans agreeing that having a dog improved the number of social activities they performed. We conclude that providing a companion dog to veterans not inclined to participate in gym-based exercise is an effective alternative method of promoting health and wellness in this population.

Association of interleukin-6 with suicidal ideation in veterans: a longitudinal perspective

Introduction

Studies showing associations between inflammation in suicide are typically cross-sectional. Present study investigated how cytokine levels track with suicidal ideation and severity longitudinally.

Methods

Veterans with a diagnosis of major depressive disorder (MDD) with or without suicide attempt history (MDD/SA n = 38, MDD/NS n = 41) and non-psychiatric non-attempter controls (HC n = 33) were recruited, MDD/SA and HC groups were followed longitudinally at 3 months and 6 months. Blood plasma was collected and processed using Luminex Immunology Multiplex technology.

Results

Significant differences in depression severity (BDI) and suicidal ideation severity (SSI) were observed across all groups at study entry, wherein MDD/SA group had the highest scores followed by MDD/NS and HC, respectively. Cytokines IL-1β, IL-4, TNF-α, IFN-γ, and IL-6 were examined at study entry and longitudinally, with IL6 levels differing significantly across the groups (p = 0.0123) at study entry. Significant differences in changes in cytokine levels between depressed attempters and the control group were detected for IL-6 (interaction F1,91.77 = 5.58, p = 0.0203) and TNF-α (F1,101.73 = 4.69, p = 0.0327). However, only depressed attempters showed a significant change, in IL-6 and TNF-α levels, decreasing over time [IL-6: b = -0.04, 95% CI = (-0.08, -0.01), p = 0.0245 and TNF-α: b = -0.02, 95% CI = (-0.04, -0.01), p = 0.0196]. Although IL-6 levels were not predictive of suicidal ideation presence [OR = 1.34, 95% CI = (0.77, 2.33), p = 0.3067], IL-6 levels were significantly associated with suicidal ideation severity (b = 0.19, p = 0.0422).

Discussion

IL-6 was not associated with presence of suicidal ideation. IL-6 however, was associated with severity of ideation, suggesting that IL-6 may be useful in clinical practice, as an objective marker of heightened suicide risk.

Experiences of Veteran and Civilian Patients in Exploratory Yoga Sessions for Chronic Pain: A Qualitative Study

Background

Yoga integrates all aspects of self, with biological, mental, intellectual, and spiritual elements. The practice of yoga aligns with the biopsychosocial model of health and, as such, it can be instrumental in pain treatment.

Aims

The purpose of this qualitative study was to explore perceptions regarding the yoga sessions for chronic pain through thematic content analysis with comparison of gender, veteran or civilian status, and delivery methods.

Methods

Patients with chronic pain attended a 5-week intensive interdisciplinary chronic pain management program at the Michael G. DeGroote Pain Clinic. Participants were asked to complete six open-ended questions following four weekly 1-h yoga classes, through in-person or virtual delivery. Survey responses were thematically and separately analyzed by reviewers.

Results

Forty-one (N = 41) participants (56% males, 71% veterans) with an average age of 50.87 (SD 10.10) years provided comments. Nine themes emerged: (1) mind and body are one through yoga practices; (2) meaningful practice of yoga basics is productive for range of motion/movement, tension in joints, and chronic pain; (3) yoga classes provide an enjoyable process of learning; (4) yoga reminds patients of their physical capabilities; (5) routine practices lead to improvements; (6) yoga improved on strategies for chronic pain; (7) yoga can be adapted for each patient; (8) mindset improves to include positive thinking, better focus, and willingness to try new things; and (9) improvements exist for the current yoga programming.

Conclusion

Findings of the current study were nine qualitative themes that present the experience of patients with chronic pain in the yoga sessions.

Evil, Constructed: A Salient Part of an Emerging Spiritual Veteran Identity

This article investigated constructions of evil among deployed Swedish veterans. Six cases were used to demonstrate common themes of these constructions: humans are capable of everything; anyone can be violated, even killed; evil and cruelty comes in many forms; coldness/cynicism; exhausting to witness suffering and pain; and existential rumination. The impact of these can affect a veteran's identity and their notions of self. However, processing encounters with evil is seen, in some Christian perspectives, as an essential prerequisite for spiritual growth, and this might be potentially important to supporting the emergence of spiritual veteran identities. A pastoral care giver or military chaplain can serve as an existential conversation partner who can assist veterans when approaching such experiences and their potential impact. This may be especially fertile in secular contexts, where pastoral wisdom and ontological approaches can be hard to find in the everyday lives of veterans.

Evaluating a Smartphone App (MeT4VeT) to Support the Mental Health of UK Armed Forces Veterans: Feasibility Randomized Controlled Trial

BACKGROUND

Previous research demonstrates that less than 50% of military veterans experiencing mental health difficulties seek formal support. Veterans often struggle to identify problems as mental health difficulties. In addition, they may fail to recognize the need for support before reaching a crisis point and face difficulties navigating care pathways to access support.

OBJECTIVE

A feasibility trial was conducted to assess a novel digital smartphone app (Mental Health Toolkit for Veterans Project [MeT4VeT]) for UK Armed Forces (UKAF) veterans experiencing mental health difficulties. The trial aimed to explore the feasibility and acceptability of trial procedures for a later randomized controlled trial (RCT) and to assess the acceptability of the MeT4VeT app.

METHODS

Participants were recruited at UK military medical centers, by advertising on social media, and through veteran third-sector organizations between February and November 2021, and assessed for eligibility (male, owned a smartphone, served at least 2 years in the UKAF, left the UKAF within the last 2 years, not undertaking formal mental health treatment). Eligible participants were assigned, on a 1:1 ratio, to either the intervention group (full app) or a control group (noninteractive app with signposting information). Three key objectives were determined a priori to assess the practicality of running an RCT including an assessment of recruitment and retention, evaluation of the technical app delivery and measurement processes, and acceptability and usability of the intervention.

RESULTS

In total, 791 individuals completed the participant information sheet, of which 261 (33%) were ineligible, 377 (48%) declined or were unable to be contacted for consent, and 103 (13%) did not download the app or complete the baseline measures. Of this, 50 participants completed baseline measures and were randomly assigned to the intervention group (n=24) or the control group (n=26). The trial was effective at enabling both the technical delivery of the intervention and collection of outcome measures, with improvements in mental health demonstrated for the intervention group from baseline to the 3-month follow-up. Recruitment and retention challenges were highlighted with only 50 out of the 530 eligible participants enrolled in the trial. The acceptability and usability of the MeT4VeT app were generally supported, and it was reported to be a useful, accessible way for veterans to monitor and manage their mental health.

CONCLUSIONS

The results highlighted that further work is needed to refine recruitment processes and maintain engagement with the app. Following this, an RCT can be considered to robustly assess the ability of the app to positively affect mental health outcomes indicated within this trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05993676; https://clinicaltrials.gov/ct2/show/NCT05993676.

Relationship Factors in Internet-Delivered Psychological Interventions for Veterans Experiencing Postpartum Depression: Qualitative Analysis

BACKGROUND

Internet-delivered psychological interventions (IPIs) have been shown to be effective for a variety of psychological concerns, including postpartum depression. Human-supported programs produce better adherence and larger effect sizes than unsupported programs; however, what it is about support that affects outcomes is not well understood. Therapeutic alliance is one possibility that has been found to contribute to outcomes; however, the specific mechanism is not well understood. Participant perspectives and qualitative methodology are nearly absent from the IPI alliance research and may help provide new directions.

OBJECTIVE

In this study, we aimed to provide participant perspectives on engagement with an IPI for postpartum depression to help inform alliance research, development of new IPIs, and inform resource allocation.

METHODS

A qualitative methodology was used to explore participant perspectives of veteran women's engagement with the MomMoodBooster program, a human-supported internet-delivered intervention for postpartum depression. Participants were asked 4 open-ended questions with the 3-month postintervention survey, "In what ways did you find the MomMoodBooster most helpful?" "How do you think the MomMoodBooster could have been improved?" "In what ways did you find the personal coach calls to be helpful?" and "How do you think the personal coach calls could have been improved?"

RESULTS

Data were collected from 184 participants who responded to at least 1 of the open-ended questions. These were analyzed using thematic analysis and a process of reaching a consensus among coders. The results suggest that not only the engagement with the support person is perceived as a significant contributor to participant experiences while using the MomMoodBooster content but also the relationship factors are particularly meaningful. The results provide insights into the specific qualities of the support person that were perceived as most impactful, such as warmth, empathy and genuineness, and feeling normalized and supported. In addition, the results provide insight into the specific change processes that can be targeted through support interactions, such as encouraging self-reflection and self-care and challenging negative thinking.

CONCLUSIONS

These data emphasize the importance of relationship factors between support persons and an IPI program for postpartum depression. The findings suggest that focusing on specific aspects of the alliance and the therapeutic relationship could yield fruitful directions for the training of support personnel and for future alliance-based research of internet-delivered treatments.

Use of a Smartphone-Based Medication Adherence Platform to Improve Outcomes in Uncontrolled Type 2 Diabetes Among Veterans: Prospective Case-Crossover Study

BACKGROUND

Medication nonadherence is a problem that impacts both the patient and the health system.

OBJECTIVE

The objective of this study was to evaluate the impact of a novel smartphone app with patient-response-directed clinical intervention on medication adherence and blood glucose control in noninsulin-dependent patients with type 2 diabetes mellitus (T2DM).

METHODS

We enrolled 50 participants with T2DM not on insulin with smartphones from a rural health care center in Northern Nevada for participation in this case-crossover study. Participants underwent a standard of care arm and an intervention arm. Each study arm was 3 months long, for a total of 6 months of follow-up. Participants had a hemoglobin A1c (HbA1c) lab draw at enrollment, 3 months, and 6 months. Participants had monthly "medication adherence scores" (MAS) and "Self-Efficacy for Appropriate Medication Use Scale" (SEAMS) questionnaires completed at baseline and monthly for the duration of the study. Our primary outcomes of interest were the changes in HbA1c between study arms. Secondary outcomes included the evaluation of the difference in the proportion of participants achieving a clinically meaningful reduction in HbA1c and the difference in the number of participants requiring diabetes therapy escalation between study arms. Exploratory outcomes included the analysis of the variation in medication possession ratio (MPR), MAS, and SEAMS during each study arm.

RESULTS

A total of 30 participants completed both study arms and were included in the analysis. Dropouts were higher in participants enrolled in the standard of care arm first (9/25, 36% vs 4/25, 16%). Participants had a median HbA1c of 9.1%, had been living with T2DM for 6 years, had a median age of 66 years, and had a median of 8.5 medications. HbA1c reduction was 0.69% in the intervention arm versus 0.35% in the standard of care arm (P=.30). A total of 70% (21/30) of participants achieved a clinically meaningful reduction in HbA1c of 0.5% in the app intervention arm versus 40% (12/30) in the standard of care arm (odds ratio 2.29, 95% CI 0.94-5.6; P=.09). Participants had higher odds of a therapy escalation while in the standard of care arm (18/30, 60% vs 5/30, 16.7%, odds ratio 4.3, 95% CI 1.2-15.2; P=.02). The median MPR prior to enrollment was 109%, 112% during the study's intervention arm, and 102% during the standard of care arm. The median real-time MAS was 93.2%. The change in MAS (1 vs -0.1; P=.02) and SEAMS (1.9 vs -0.2; P<.001) from baseline to month 3 was higher in the intervention arm compared to standard of care.

CONCLUSIONS

A novel smartphone app with patient-response-directed provider intervention holds promise in the ability to improve blood glucose control in complex non-insulin-dependent T2DM and is worthy of additional study.

Post-Traumatic Stress Disorder and End-of-Life Care: A Well-Being Review

Post-Traumatic Stress Disorder can be a debilitating comorbidity for a patient on end-of-life care. Combat veterans make up a vast majority of patients diagnosed with Post-Traumatic Stress Disorder and are therefore a vulnerable group requiring a comprehensive approach to their health care management. This paper addresses certain challenges the hospice and palliative care providers may encounter and offers solutions to ensure the patients maintain a high quality of life.

Situational stress and suicide attempt behavior in Army soldiers and veterans: Insights from the Army Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study

INTRODUCTION

Prevention of suicide-related behaviors is considered a top clinical priority within the Departments of Veterans Affairs and Defense. Despite previous literature attesting to the likely importance of situational stress as a key correlate of acute changes in suicide risk, longitudinal research into associations between situational stress and suicide-related outcomes among military personnel has been relatively limited.

METHODS

The current study examined associations between situational stress, recent suicide attempt, and future suicide attempt using data from 14,508 Army soldiers and recently discharged veterans enrolled in the Army Study to Assess Risk and Resilience in Servicemembers-Longitudinal Studies (STARRS-LS).

RESULTS

Recent situational stress was more common among recently discharged veterans (vs. soldiers), those with a recent suicide attempt (vs. those without), and those with a subsequent suicide attempt (vs. those without). Job loss was more closely associated with suicide attempts among soldiers, whereas financial crisis, police contact, and death, illness, or injury of close others were more closely associated with suicide attempts among recently discharged veterans.

CONCLUSION

Findings further highlight situational stress as a salient risk factor for suicide-related outcomes among military personnel, particularly among recently discharged veterans. Implications for screening and treatment of at-risk military personnel are discussed.

Social support over time for men and women veterans with and without complex trauma histories

Social support is closely linked to health, but little is known about United States (U.S.) veterans' social support over time and factors that may influence their support trajectories. This study investigates social support over time for U.S. men and women Post-9/11 veterans in relation to trauma history and gender. A secondary analysis of longitudinal cohort data from the Survey of Experiences of Returning Veterans (SERV), which employed a repeated-measures longitudinal design using five waves of data (baseline, 3, 6, 9, 12 months) with 672 combat veterans. Results from random intercept multilevel models found no significant gender differences in social support over time. Veterans with complex trauma histories were at risk for lower social support across waves. A stability trend was also observed; specifically, at baseline, veterans who started with high support maintained their level over time whereas veterans who started with deficits in social support remained low over time. Veterans identifying as African American or Latinx, and those with lower annual incomes, reported lower support compared to White and higher-income veterans. Furthermore, low social support was significantly associated with severe posttraumatic stress symptoms and active suicidal ideation across 12 months. SERV utilized a nonrandom sampling method that may reduce generalizability of findings. There is also potential for residual confounding by factors related to both social support levels and time since discharge that were not available in this data set. Findings have implications for developing clinical and community interventions intended to support veterans as they transition back to the community. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Traumatic Brain Injury and Long-Term Risk of Stroke Among US Military Veterans

BACKGROUND

Traumatic brain injury (TBI) is associated with significant morbidity, but the association of TBI with long-term stroke risk in diverse populations remains less clear. Our objective was to examine the long-term associations of TBI with stroke and to investigate potential differences by age, sex, race and ethnicity, and time since TBI diagnosis.

METHODS

Retrospective cohort study of US military veterans aged 18+ years receiving healthcare in the Veterans Health Administration system between October 1, 2002 and September 30, 2019. Veterans with TBI were matched 1:1 to veterans without TBI on age, sex, race and ethnicity, and index date, yielding 306 796 veterans with TBI and 306 796 veterans without TBI included in the study. In primary analyses, Fine-Gray proportional hazards models adjusted for sociodemographics and medical/psychiatric comorbidities were used to estimate the association between TBI and stroke risk, accounting for the competing risk of mortality.

RESULTS

Participants were a mean age of 50 years, 9% were female, and 25% were of non-White race and ethnicity. Overall, 4.7% of veterans developed a stroke over a median follow-up of 5.2 years. Veterans with TBI had 1.69 times (95% CI, 1.64-1.73) increased risk of any stroke (ischemic or hemorrhagic) compared to veterans without TBI. This increased risk was highest in the first-year post-TBI diagnosis (hazard ratio [HR], 2.16 [95% CI, 2.03-2.29]) but remained elevated for 10+ years. Similar patterns were observed for secondary outcomes, with associations of TBI with hemorrhagic stroke (HR, 3.92 [95% CI, 3.59-4.29]) being stronger than with ischemic stroke (HR, 1.56 [95% CI, 1.52-1.61]). Veterans with both mild (HR, 1.47 [95% CI, 1.43-1.52]) and moderate/severe/penetrating injury (HR, 2.02 [95% CI, 1.96-2.09]) had increased risk of stroke compared to veterans without TBI. Associations of TBI with stroke were stronger among older compared to younger individuals (P interaction-by-age<0.001) and were weaker among Black veterans compared to other race and ethnicities (P interaction-by-race<0.001).

CONCLUSIONS

Veterans with prior TBI are at increased long-term risk for stroke, suggesting they may be an important population to target for primary stroke prevention measures.