Predicting Homelessness Among Transitioning U.S. Army Soldiers

INTRODUCTION

This study develops a practical method to triage Army transitioning service members (TSMs) at highest risk of homelessness to target a preventive intervention.

METHODS

The sample included 4,790 soldiers from the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS) who participated in 1 of 3 Army STARRS 2011-2014 baseline surveys followed by the third wave of the STARRS-LS online panel surveys (2020-2022). Two machine learning models were trained: a Stage-1 model that used administrative predictors and geospatial data available for all TSMs at discharge to identify high-risk TSMs for initial outreach; and a Stage-2 model estimated in the high-risk subsample that used self-reported survey data to help determine highest risk based on additional information collected from high-risk TSMs once they are contacted. The outcome in both models was homelessness within 12 months after leaving active service.

RESULTS

Twelve-month prevalence of post-transition homelessness was 5.0% (SE=0.5). The Stage-1 model identified 30% of high-risk TSMs who accounted for 52% of homelessness. The Stage-2 model identified 10% of all TSMs (i.e., 33% of high-risk TSMs) who accounted for 35% of all homelessness (i.e., 63% of the homeless among high-risk TSMs).

CONCLUSIONS

Machine learning can help target outreach and assessment of TSMs for homeless prevention interventions.

Gender Differences in Connecting Veterans to Care Through the Veterans Crisis Line: A Mixed Methods Evaluation of Referrals to Suicide Prevention Coordinators

BACKGROUND

Suicide is a major public health crisis within the US military veteran community, with distinct gender differences in suicide risk and behavior. The Veterans Crisis Line (VCL) is a component of the Veterans Health Administration (VHA) suicide prevention program; through VCL, veterans may be referred to a VHA Suicide Prevention Coordinator (SPC) to arrange follow-up care. Research shows that engagement with an SPC is a strong protective factor in reducing veteran suicide risk.

METHODS

We evaluated SPC referral acceptance and assessed correlates of SPC referral decline using VCL administrative data for contacts: (1) made between January 1, 2018, through December 31, 2019; (2) by veterans contacting VCL on their own behalf; (3) with gender identified; and (4) current thoughts of suicide. Then, among a subsample of 200 veterans, evenly distributed by gender, we examined data from call synopsis notes to identify reasons given for veterans declining an SPC referral.

RESULTS

We found it was generally callers rated as lower risk by responders, and callers with loneliness as a reason for contacting VCL, who more frequently declined the SPC referral. An analysis of reasons given for declining SPC referral found that concerns with/about Veterans Affairs care were a key concern, particularly among women veterans articulating specific negative care experiences. Other reasons for referral decline included managing the veteran's needs directly on the call or via alternative resources.

CONCLUSION

The VCL as an intervention provides an important opportunity to re-engage vulnerable veterans into care, one that may be more challenging for women veterans.

Sensitivity of health records for self-reported nonfatal drug and alcohol overdose

BACKGROUND AND OBJECTIVES

Public health surveillance for overdose sometimes depends on nonfatal drug overdoses recorded in health records. However, the proportion of total overdoses identified through health record systems is unclear. Comparison of overdoses from health records to those that are self-reported may provide insight on the proportion of nonfatal overdoses that are not identified.

METHODS

We conducted a cohort study linking survey data on overdose from a national survey of Veterans to United States Department of Veterans Affairs (VA) health records, including community care paid for by VA. Self-reported overdose in the prior 3 years was compared to diagnostic codes for overdoses and substance use disorders in the same time period.

RESULTS

The sensitivity of diagnostic codes for overdose, compared to self-report as a reference standard for this analysis, varied by substance: 28.1% for alcohol, 23.1% for sedatives, 12.0% for opioids, and 5.5% for cocaine. There was a notable concordance between substance use disorder diagnoses and self-reported overdose (sensitivity range 17.9%-90.6%).

DISCUSSION AND CONCLUSIONS

Diagnostic codes in health records may not identify a substantial proportion of drug overdoses. A health record diagnosis of substance use disorder may offer a stronger inference regarding the size of the population at risk. Alternatively, screening for self-reported overdose in routine clinical care could enhance overdose surveillance and targeted intervention.

SCIENTIFIC SIGNIFICANCE

This study suggests that diagnostic codes for overdose are insensitive. These findings support consideration of alternative approaches to overdose surveillance in public health.

Gender Differences in the Predictors of Suicide-related Morbidity Among Veterans Reporting Current Housing Instability

BACKGROUND

Veterans experiencing housing instability are at increased risk of suicide. Research is needed to identify gender differences in the predictors of both suicidal ideation and suicide attempt, particularly among Veterans who are unstably housed.

OBJECTIVES

The objective of the present study was to explore whether correlates of suicide-related morbidity among unstably housed Veterans vary by gender and identify implications for improved care for these Veterans.

METHODS

The study cohort included 86,325 Veterans who reported current housing instability between October 1, 2013, and September 30, 2016. This cross-sectional study assessed differences in demographic and outcome variables by gender using χ2 analyses and a series of multiple logistic regressions predicting suicidal ideation and suicide attempt, stratified by gender.

RESULTS

Among unstably housed female Veterans, being younger than 40 years was associated with more than double the odds of having an indicator of suicidal ideation and >12 times the odds of having an indicator of a suicide attempt. The effect sizes associated with age were much less pronounced among unstably housed male Veterans. The presence of mental health and substance use conditions as well as a positive screen for military sexual trauma were associated with increased risk of suicide morbidity among both women and men.

CONCLUSIONS

Intervention and prevention among unstably housed Veterans may be complicated by unpredictable living situations; further research should explore tailored interventions to address the complex needs of unstably housed Veterans and how suicide prevention can be woven throughout.

Preventing Suicide Among Homeless Veterans: A Consensus Statement by the Veterans Affairs Suicide Prevention Among Veterans Experiencing Homelessness Workgroup

Background:

Suicidal self-directed violence among Veterans experiencing homelessness remains a significant public health concern. To prevent suicide in this population, concerted clinical and research efforts remain necessary.

Objective:

This paper serves as a consensus statement by the recently-formed Department of Veterans Affairs (VA) Suicide Prevention among Veterans Experiencing Homelessness Workgroup. We provide a brief overview of current initiatives to prevent suicide among Veterans experiencing homelessness. We also discuss methods of studying this complex subset of the Veteran population, as well as future research endeavors necessary to inform gaps in understanding.

Conclusions:

Veterans experiencing homelessness are a complex subset of the Veteran population whose risk for suicide may be exacerbated by a number of factors (e.g., multimorbidity, rurality). While the VA has implemented a number of initiatives to prevent suicide among Veterans experiencing homelessness (e.g., universal screening for suicidal ideation and recent suicide attempts, Suicide Prevention Gatekeeper Training), there is a continued need to understand how best to tailor these initiatives to Veterans experiencing homelessness. Moreover, because Veterans experiencing homelessness often access a number of services within the community (e.g., community-based clinics, homeless shelters), collaboration between the VA and community is necessary.

Housing Instability Characteristics Among Transgender Veterans Cared for in the Veterans Health Administration, 2013-2016

Objectives. To characterize housing instability among transgender veterans using Veterans Health Administration (VHA) health care in the United States.Methods. We used administrative data on veterans screened for housing instability from 2013 to 2016; participants included 5717 transgender veterans and 17 133 cisgender veterans. We defined housing instability by a positive screen or VHA Homeless Program use. We identified gender from medical records, reflecting either birth sex or gender identity. We identified transgender identity through transgender-related International Classification of Diseases, Ninth Revision and Tenth Revision codes. A multiple logistic regression assessed the association of transgender identity with housing instability.Results. Prevalence of housing instability was nearly 3 times higher among transgender veterans than among cisgender veterans (19.9% vs 6.7%; P < .001). The difference persisted when we adjusted for sociodemographics (adjusted odds ratio = 2.32; 95% confidence interval = 2.09, 2.57). Transgender veterans experiencing housing instability were more likely than cisgender veterans to be women, younger, unmarried, and White.Conclusions. Transgender veterans experience housing instability more frequently than do cisgender veterans. An increased focus on transgender identity is critical for reducing veteran homelessness.

Capsid protein determinants involved in cell-to-cell and long distance movement of tobacco etch potyvirus

The tobacco etch potyvirus (TEV) capsid protein (CP) is necessary for cell-to-cell and long distance transport of the virus in plants. In this study, the transport phenotypes of TEV mutants containing CPs with a substitution of the highly conserved Ser122 (termed S122W) within the core domain, or with a deletion of sequences encoding 17 amino acid residues comprising most of the variable C-terminal domain (delta C), were analyzed. The S122W and delta C mutant genomes were amplified to levels comparable to parental virus in protoplasts. The S122W mutant was encapsidation-defective, although in transgenic plants expressing wild-type CP a small number of virions were observed after prolonged incubation. Cells infected by the delta C mutant produced virions, indicating that the C-terminal domain is not necessary for encapsidation. The mutants exhibited unique defects in cell-to-cell and long distance movement in plants. The S122W mutant was confined to single, primarily inoculated epidermal cells in nontransgenic plants, but the cell-to-cell movement defect was rescued efficiently by transgenic CP. Long distance movement of this mutant was also rescued in transgenic plants, but accumulation in systemically infected tissue was low compared to parental virus. The delta C mutant exhibited a slow cell-to-cell movement phenotype in inoculated leaves and a complete inability to move systemically in nontransgenic plants. Transgenic CP was able to rescue partially the slow cell-to-cell movement defect of the delta C mutant, but not the long distance transport defect. Taken together with previous results, these data suggest that the core domain of TEV CP provides a function essential during cell-to-cell movement and that the variable N- and C-terminal regions exposed on the virion surface are necessary for long distance transport. In addition, trans-inhibition models are presented to account for the widely differing transgenic complementation efficiencies of the various movement-defective mutants.