Divergent trends in accidental deaths since return from an Afghanistan/Iraq deployment among army soldiers

PURPOSE

Accidental death is a leading cause of mortality among military members and Veterans; however, knowledge is limited regarding time-dependent risk following deployment and if there are differences by type of accidental death.

METHODS

Longitudinal cohort study (N = 860,930) of soldiers returning from Afghanistan/Iraq deployments in fiscal years 2008-2014. Accidental deaths (i.e., motor vehicle accidents [MVA], accidental overdose, other accidental deaths), were identified through 2018. Crude and age-adjusted mortality rates, rate ratios, time-dependent hazard rates and trends postdeployment were compared across demographic and military characteristics.

RESULTS

During the postdeployment observation period, over one-third of deaths were accidental; most were MVA (46.0 %) or overdoses (37.9 %). Across accidental mortality categories (all, MVA, overdose), younger soldiers (18-24, 25-29) were at higher risk compared to older soldiers (40+), and females at lower risk than males. MVA death rates were highest immediately postdeployment, with a significant decreasing hazard rate over time (annual percent change [APC]: -6.5 %). Conversely, accidental overdose death rates were lowest immediately following deployment, with a significant increasing hazard rate over time (APC: 9.9 %).

CONCLUSIONS

Observed divergent trends in risk for the most common types of accidental deaths provide essential information to inform prevention and intervention planning for the immediate postdeployment transition and long-term.

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.

Associations of Military-Related Traumatic Brain Injury With New-Onset Mental Health Conditions and Suicide Risk

Importance

Research to identify the direct and indirect associations of military-related traumatic brain injury (TBI) with suicide has been complicated by a range of data-related challenges.

Objective

To identify differences in rates of new-onset mental health conditions (ie, anxiety, mood, posttraumatic stress, adjustment, alcohol use, and substance use disorders) among soldiers with and without a history of military-related TBI and to explore the direct and indirect (through new-onset mental health disorders) associations of TBI with suicide.

Design, Setting, and Participants

This retrospective cohort study used data from the Substance Use and Psychological Injury Combat Study (SUPIC) database. Demographic, military, and health data from the Department of Defense within SUPIC were compiled and linked with National Death Index records to identify deaths by suicide. Participants included US Army soldiers who returned from an Afghanistan or Iraq deployment. Data were analyzed from September to December 2022.

Exposures

Military-related TBI.

Main Outcomes and Measures

The outcome of interest was suicide. Secondary outcomes were incidence of new-onset mental health conditions. Mediation analyses consisted of accelerated failure time (AFT) models in conjunction with the product of coefficients method. The 6 new-onset mental health diagnosis categories and the 2 or more categories variable were each considered separately as potential mediators; therefore, a total of 14 models plus the overall AFT model estimating the total effect associated with TBI in suicide risk were fit.

Results

The study included 860 892 soldiers (320 539 soldiers [37.2%] aged 18-24 at end of index deployment; 766 454 [89.0%] male), with 108 785 soldiers (12.6%) with at least 1 documented TBI on their military health record. Larger increases in mental health diagnoses were observed for all conditions from before to after documented TBI, compared with the matched dates for those without a history of TBI, with increases observed for mood (67.7% vs 37.5%) and substance use (100% vs 14.5%). Time-to-suicide direct effect estimates for soldiers with a history of TBI were similar across mediators. For example, considering new-onset adjustment disorders, time-to-suicide was 16.7% faster (deceleration factor, 0.833; 95% CI, 0.756-0.912) than for soldiers without a history of TBI. Indirect effect estimates of associations with TBI were substantial and varied across mediators. The largest indirect effect estimate was observed through the association with new-onset substance use disorder, with a time to suicide 63.8% faster (deceleration factor, 0.372; 95% CI, 0.322-0.433) for soldiers with a history of TBI.

Conclusions and Relevance

In this longitudinal cohort study of soldiers, rates of new-onset mental health conditions were higher among individuals with a history of TBI compared with those without. Moreover, risk for suicide was both directly and indirectly associated with history of TBI. These findings suggest that increased efforts are needed to conceptualize the accumulation of risk associated with multiple military-related exposures and identify evidence-based interventions that address mechanisms associated with frequently co-occurring conditions.

The association among insomnia symptom severity, comorbid symptoms, and suicidal ideation in two veteran cohorts meeting diagnostic criteria for insomnia disorder

OBJECTIVE

Examine the association between insomnia symptom severity and suicidal ideation (SI), after adjusting for clinical comorbidity in veterans meeting diagnostic criteria for insomnia disorder.

METHODS

Secondary data analyses of psychometrically validated baseline assessments of depression, posttraumatic stress disorder (PTSD), and anxiety symptoms from two online insomnia intervention randomized clinical trials (n = 232; n = 80) were conducted. Multiple linear regression was used to determine the association between insomnia symptom severity and SI, after controlling for clinical comorbidity and demographics.

RESULTS

Insomnia symptom severity was significantly correlated with comorbid depression, PTSD, and anxiety symptoms in both cohorts and significantly correlated with SI in one. After controlling for demographics and clinical comorbidity, insomnia symptom severity was not significantly associated with SI in linear regression models.

CONCLUSION

Findings extend insomnia-suicide research by providing evidence that insomnia symptom severity may not confer a unique risk for SI above comorbid mental health symptoms in veterans meeting diagnostic criteria for insomnia disorder.

Morally injurious combat events as an indirect risk factor for postconcussive symptoms among veterans: The mediating role of posttraumatic stress

OBJECTIVE

Psychosocial factors, including combat-related distress (e.g., posttraumatic stress disorder [PTSD]), contribute to postconcussive symptoms (PCS) among veterans with mild traumatic brain injury (mTBI). However, research on risk factors for PCS has focused solely on life-threatening combat experiences, neglecting the morally injurious dimension of combat-related trauma and associated implications for treatment. Morally injurious events (MIEs) are associated with PTSD symptoms among veterans, a robust risk factor of PCS. Nonetheless, the interplay between MIEs, PTSD symptoms, and PCS remains poorly understood. We sought to investigate MIEs as an indirect risk factor for PCS among Veterans with mTBI.

METHOD

This cross-sectional study of 145 veterans with mTBI used path analysis to investigate whether PTSD symptoms mediated the relationship between MIEs (transgressions and betrayals) and PCS (mood-behavioral, vestibular-sensory, and cognitive domains) among 145 veterans with mTBI. We used the Moral Injury Event Scale, PTSD Checklist-Civilian Version, and Neurobehavioral Symptom Inventory to measure MIEs, PTSD, and PCS, respectively.

RESULTS

Perceived transgressions were indirectly associated with mood-behavioral (β = .21, p = .005), vestibular-sensory (β = .17, p = .005), and cognitive PCS (β = .20, p = .005), as mediated by PTSD. Greater transgressions were associated with more severe PTSD (β = .27, p = .003), and greater PTSD was associated with more severe mood-behavioral (β = .79, p < .001), vestibular-sensory (β = .64, p < .001), and cognitive PCS (β = .73, p < .001). Betrayals were not indirectly associated with PCS.

CONCLUSIONS

Findings offer preliminary support for responses to MIEs being a modifiable risk factor for PCS among veterans. Interventions designed to foster veterans' recovery by targeting the unique emotions and beliefs associated with MIEs may be indicated. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Time-dependent suicide rates among Army soldiers returning from an Afghanistan/Iraq deployment, by military rank and component

BACKGROUND

To date, knowledge is limited regarding time-dependent suicide risk in the years following return from deployment and whether such rates vary by military rank (i.e., enlisted, officer) or component (i.e., active duty, National Guard, reserve). To address these gaps in knowledge, the objectives of this study were to determine and compare postdeployment suicide rates and trends (percent change over time), and hazard rates for Army soldiers, by rank and component (measured at the end of the deployment).

METHODS

Longitudinal cohort study of 860,930 Army soldiers returning from Afghanistan/Iraq deployment in fiscal years 2008-2014 from the Substance Use and Psychological Injury Combat study. Death by suicide was observed from the end of the first deployment in the study period through 2018 (i.e., the most recently available mortality data) for up to 11 years of follow-up. Analyses were conducted in 2021-2022.

RESULTS

Adjusting for age, lowest-ranking Junior Enlisted (E1-E4) soldiers had a suicide rate 1.58 times higher than Senior Enlisted (E5-E9)/Warrant Officers (95% CI [1.24, 2.01]) and 2.41 times higher than Officers (95% CI [1.78, 3.29]). Suicide rates among lower-ranking enlisted soldiers remained elevated for 11 years postdeployment. Overall and annual postdeployment suicide rates did not differ significantly across components. Comparisons across rank and component for females were generally consistent with the full cohort results.

CONCLUSIONS

Lower-ranking enlisted soldiers had the highest rate of suicide, underscoring the importance of understanding rank as it relates to social determinants of health. For over a decade following Afghanistan/Iraq deployment, lower-enlisted rank during deployment was associated with an elevated rate of suicide; thereby suggesting that postdeployment prevention interventions targeting lower-ranking military members are warranted.

Parkinson's disease and suicide among individuals seeking care within the United States Veterans Health Administration

BACKGROUND

Independently, veterans and individuals with Parkinson's Disease (PD) are at increased risk for suicide. To our knowledge, the risk of suicide among veterans with PD has yet to be evaluated. This study aimed to examine the associations between PD and risk of suicide, as well as suicide means among those using Veteran Health Administration (VHA) services.

METHODS

Retrospective cohort study of individuals who used VHA services between 1/1/2001-12/31/2019. Cox proportional hazard models were used to estimate the hazard of suicide for those with PD relative to those without. A nested-case control study was carried out among the suicide decedents where logistic regression was used to assess the relationship between PD and suicide by firearms versus suicide by any other means.

RESULTS

The unadjusted hazard of death by suicide for those with a PD diagnosis, relative to those without, was 1.51 (95% CI: 1.32-1.72, p < 0.0001), and was still significant after controlling for age/gender, and psychiatric/chronic physical health diagnoses (HR: 1.50; 95% CI: 1.32-1.72, p < 0.0001; HR:1.21, 95% CI:1.06-1.38, p = 0.006, respectively). Compared to the non-PD cohort, the PD group also had higher rates of mood, anxiety, and psychotic disorders. There was no significant difference between the method of suicide for those with PD versus those without PD (p = 0.60). Most suicide deaths among both cohorts were firearm-related (PD = 78.9%, No-PD = 80.3%).

CONCLUSIONS

PD is associated with an elevated risk for suicide. Based on the high rate of deaths by firearm, increased efforts to facilitate lethal means safety among veterans is warranted.

Suicide After Stroke in the United States Veteran Health Administration Population

OBJECTIVE

To evaluate risk for suicide among veterans with a history of stroke, seeking care within the Veterans Health Administration (VHA), we analyzed existing clinical data.

DESIGN

This retrospective cohort study was approved and performed in accordance with the local Institutional Review Board. Veterans were identified via the VHA's Corporate Data Warehouse. Initial eligibility criteria included confirmed veteran status and at least 90 days of VHA utilization between fiscal years 2001-2015. Cox proportional hazards models were used to assess the association between history of stroke and suicide. Among those veterans who died by suicide, the association between history of stroke and method of suicide was also investigated.

SETTING

VHA.

PARTICIPANTS

Veterans with at least 90 days of VHA utilization between fiscal years 2001-2015 (N=1,647,671). Data from these 1,647,671 veterans were analyzed (1,405,762 without stroke and 241,909 with stroke).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Suicide and method of suicide.

RESULTS

The fully adjusted model, which controlled for age, sex, mental health diagnoses, mild traumatic brain injury, and modified Charlson/Deyo Index (stroke-related diagnoses excluded), demonstrated a hazard ratio of 1.13 (95% confidence interval, 1.02-1.25; P=.02). The majority of suicides in both cohorts was by firearm, and a significantly larger proportion of suicides occurred by firearm in the group with stroke than the cohort without (81.2% vs 76.6%).

CONCLUSIONS

Findings suggest that veterans with a history of stroke are at increased risk for suicide, specifically by firearm, compared with veterans without a history of stroke. Increased efforts are needed to address the mental health needs and lethal means safety of veterans with a history of stroke, with the goal of improving function and decreasing negative psychiatric outcomes, such as suicide.

Suicide among veterans with amyotrophic lateral sclerosis

BACKGROUND

The purpose of this study was to estimate the risk of death by suicide for those with amyotrophic lateral sclerosis (ALS) seeking care within the Veterans Health Administration (VHA).

METHODS

This was a retrospective, cohort study. Extended Cox regression models were used to compare the hazard of suicide between the ALS and the unexposed groups.

RESULTS

The hazard of suicide was 3.98 times higher for those with ALS than for those without (95% confidence interval [CI] , 2.64-6.00; P < .0001). After adjusting for covariates, those with ALS remained at increased risk (hazard ratio, 3.48; 95% CI, 2.31-5.24; P < .001).

CONCLUSIONS

Among those seeking care in the VHA, individuals with ALS are at increased risk for dying by suicide. Additional suicide prevention efforts, including strategies for reducing access to lethal means, are warranted.

Risk Factors for Suicide in a National Sample of Veterans With Multiple Sclerosis

OBJECTIVES

To examine risk factors in the year before suicide in a national sample of United States veterans with multiple sclerosis (MS), as well as means of suicide and receipt of mental health services prior to death.

DESIGN

Case control study. Individuals in the Veterans Affairs MS National Data Repository were linked to the National Death Index Plus to obtain death records, including specific causes of death. Participants were veterans with MS who died by suicide and randomly selected nonsuicide MS controls (5 per participant) who were alive at the time of the index suicide. Mental health disorders and medical comorbidities were identified in the year before death for suicides and during the identical time period for controls.

SETTING

Veterans Health Administration.

PARTICIPANTS

Veterans (N=426) who received treatment for MS in the United States Veterans Health Administration between 1999 and 2011. There were 71 deaths by suicide and 355 randomly selected controls.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Suicide.

RESULTS

Results from the adjusted multivariable model suggest that the following factors were associated with an increased risk for suicide: male sex (odds ratio [OR], 3.60; 95% confidence interval [CI], 1.35-9.42), depression (OR, 1.82; 95% CI, 1.03-3.23), and alcohol use disorder (OR, 3.10; 95% CI, 1.38-6.96). Half (50.7%) had a mental health appointment in the year before suicide. The primary means of suicide was by firearm (62.0%).

CONCLUSIONS

Routine assessment of suicide risk in individuals with MS is warranted, particularly for those with recent history of depression or alcohol use disorder.

Efficacy of the Home-Based Mental Health Evaluation (HOME) Program for Engaging Patients in Care After Hospitalization

OBJECTIVE

The risk of suicide is elevated in the days and weeks after discharge from a psychiatric hospitalization, and lack of treatment engagement posthospitalization is also associated with suicide. The authors sought to determine whether the Home-Based Mental Health Evaluation [HOME] Program is efficacious in helping patients engage in care after psychiatric hospitalization.

METHODS

This study was a nonrandomized, controlled, two-arm (HOME Program versus enhanced care as usual [E-CARE]) trial that took place at four Department of Veterans Affairs medical centers. Participants (N=302) were patients admitted to a psychiatric inpatient unit. The HOME Program consists of phone- and home-based contacts that include suicide risk assessment, safety planning, and problem-solving around barriers to care. The primary outcome was treatment engagement, as documented in the electronic medical record.

RESULTS

Veterans in the HOME Program group were 1.33 (95% confidence interval [CI]=1.29-1.37) times more likely to engage in treatment, compared with veterans in the E-CARE group (p<0.001). HOME Program participants were estimated to have attended 55% more individual appointments (95% CI=12%-113%, p=0.02), compared with those in the E-CARE group. The adjusted difference in median time to treatment engagement was 15 days (95% CI=3.5-27.0) such that HOME Program participants engaged in treatment more quickly than participants at the E-CARE sites.

CONCLUSIONS

Findings suggest that participation in the HOME Program can help individuals at high risk of suicide engage in care after psychiatric hospitalization.

Characterization of lifetime TBIs in a cohort of recently deployed soldiers: The warrior strong study

OBJECTIVE

To describe and characterize the lifetime history of traumatic brain injury (TBI) among active duty soldiers returning from deployment to Afghanistan or Iraq.

METHOD

Data were extracted from a larger parent study that was conducted at two large United States Army bases between 2009 and 2014 during Post-Deployment Health Assessment. The sample included 1,060 soldiers who sustained at least one TBI during their lifetime.

RESULTS

The Ohio State University TBI-Identification Method interview was administered to characterize individuals' total lifetime history of TBI. Soldiers reported sustaining a median of 2 lifetime TBIs. Slightly more than half of the sample without a most recent deployment-related TBI still reported a history of a lifetime TBI (some of which occurred during previous deployments). Most lifetime injuries reported were of mild severity; however, 6% of individuals reported a history of moderate/severe TBI. Blast was the most frequent mechanism associated with recent deployment-related mild TBIs.

CONCLUSION

Findings suggest that soldiers who screened positive, as well as those who screened negative, for a history of TBI during their recent deployment still endorsed a lifetime history of TBI. Future research is needed to explore the functional impact of multiple TBIs over one's lifetime to help inform screening, assessment, and treatment among military personnel. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Veteran Participation in Intensive Suicide Research Protocols: No Evidence of Iatrogenic Effects

Suicide research remains fraught with ethical and methodological issues, including researchers' reservations about conducting intensive suicide research protocols due to potential iatrogenic effects and liability concerns. Such issues significantly impede scientific inquiry related to suicide. To date, no research has explored potential iatrogenic effects of intensive, nontreatment suicide research among Veterans. This study aimed to fill this gap. It was hypothesized that participation in suicide-specific protocols would not significantly increase risk among Veterans. Veterans completed self-reports, structured interviews, and rigorous suicide-specific tasks (Study A, N = 34; Study B, N = 18; Study C, N = 119). Findings indicated there were no significant differences in pre- and postassessment suicide risk variables (all ps > .05). Estimated mean change for "urge to harm self" was -0.24 (95% confidence interval [CI]: -0.60, 0.13), -0.28 (CI: -0.56, 0.01), and -0.01 (CI: -0.09, 0.07) and "intent to harm self" was -0.18 (95% CI: -0.45, 0.10), 0 (CI: -0.17, 0.17), and 0.01 (CI: -0.04, 0.06) for Studies A, B, and C, respectively. Results indicated the respective protocols did not produce iatrogenic effects. The current findings are discussed with attention to safety-monitoring techniques that may reduce iatrogenic effects and considerations for future researchers.

Relationship between traumatic brain injury history and recent suicidal ideation in Iraq/Afghanistan-era veterans

This study evaluated whether a history of traumatic brain injury (TBI) was associated with increased risk for recent suicidal ideation (SI) after accounting for demographics, depression, posttraumatic stress disorder (PTSD), and sleep quality. In terms of increased risk, we hypothesized that a history of lifetime TBI would be associated with increased recent SI when compared with no history of TBI; multiple injuries were also evaluated. The sample included Iraq and Afghanistan war-era veterans (n = 838) who served in the United States military since 9/2001 and completed a structured TBI interview. Approximately 50% reported a lifetime history of at least 1 TBI, and 17.9% met criteria for current major depressive disorder (MDD). SI over the past week per the Beck Scale for Suicide Ideation was the primary outcome. Demographics, current MDD and posttraumatic stress disorder (PTSD) per Structured Clinical Interview of DSM-IV Axis I Disorders, sleep quality per Pittsburgh Sleep Quality Index, and TBI history per structured interview were included in all statistical models. Current depression and poor sleep quality were consistently associated with recent SI. A history of any TBI history across the life span was not associated with increased recent SI (OR = 1.35, 95% CI [0.83, 2.19]). However, a history of multiple TBIs compared with no history of TBI was associated with increased recent SI (OR = 1.76, 95% CI [1.01, 3.06]). Results support the assertion than an accumulation of injuries amplifies risk. Severity of injury and deployment injuries were not significant factors. Among those with a history of 1 TBI, sleep, and depression, which may also be injury sequelae, may be salient treatment targets. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A Rasch analysis of the Neurobehavioral Symptom Inventory in a national cohort of Operation Enduring and Iraqi Freedom veterans with mild traumatic brain injury

This study investigated the dimensionality and measurement properties of the Neurobehavioral Symptom Inventory (NSI), a 22-item questionnaire of postconcussive symptoms, in a national sample of 9,679 Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) Veterans with mild traumatic brain injury. Dimensionality of the NSI was examined using exploratory factor analysis (EFA) and Rasch analysis. Rasch measurement properties, including overall fit, unidimensionality, item level statistics, and category functioning were examined for individual NSI symptom domains identified through EFA. Differential item functioning (DIF) analyses of subgroups based on gender and Posttraumatic Stress Disorder (PTSD) diagnosis were also conducted. Results showed that the NSI items are multidimensional and responses can be differentiated into 3 unidimensional domains reflecting Cognitive, Mood-Behavioral, and Vestibular-Sensory symptoms. All items in each of the 3 subscales demonstrated adequate fit to the Rasch model. In each domain, the item hierarchy was consistent with expectations regarding the theoretical ordering of symptoms. Some problems were observed regarding test targeting for all 3 subscales, such that items were generally concentrated around the mean ability level of the population. As such there were fewer items that differentiated between those at the upper and lower extremes of the scale. Differential item functioning (DIF) based on gender was noted for hearing difficulty. This item on average reflected a higher degree of severity for women than for men. There was no DIF based on PTSD status. Implications for using the NSI as an outcome measure are discussed. (PsycINFO Database Record

Reduced lateral prefrontal cortical volume is associated with performance on the modified Iowa Gambling Task: A surface based morphometric analysis of previously deployed veterans

Post-traumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) are two of the most common consequences of combat deployment. Estimates of comorbidity of PTSD and mTBI are as high as 42% in combat exposed Operation Enduring Freedom, Operation Iraqi Freedom and Operation New Dawn (OEF/OIF/OND) Veterans. Combat deployed Veterans with PTSD and/or mTBI exhibit deficits in classic executive function (EF) tasks. Similarly, the extant neuroimaging literature consistently indicates abnormalities of the ventromedial prefrontal cortex (vmPFC) and amygdala/hippocampal complex in these individuals. While studies examining deficits in classical EF constructs and aberrant neural circuitry have been widely replicated, it is surprising that little research examining reward processing and decision-making has been conducted in these individuals, specifically, because the vmPFC has long been implicated in underlying such processes. Therefore, the current study employed the modified Iowa Gambling Task (mIGT) and structural neuroimaging to assess whether behavioral measures related to reward processing and decision-making were compromised and related to cortical morphometric features of OEF/OIF/OND Veterans with PTSD, mTBI, or co-occurring PTSD/mTBI. Results indicated that gray matter morphometry in the lateral prefrontal cortex (lPFC) predicted performance on the mIGT among all three groups and was significantly reduced, as compared to the control group.

Moving Beyond Self-Report: Implicit Associations about Death/Life Prospectively Predict Suicidal Behavior among Veterans

Reliance on self-report limits clinicians' ability to accurately predict suicidal behavior. In this study the predictive validity of an objective measure, the death/suicide Implicit Association Test (d/sIAT), was tested among psychiatrically hospitalized veterans. Following acute stabilization, 176 participants completed the d/sIAT and traditional suicide risk assessments. Participants had similar d/sIAT scores regardless of whether they had recently attempted suicide. However, d/sIAT scores significantly predicted suicide attempts during the 6-month follow-up above and beyond other known risk factors for suicidal behavior (OR = 1.89; 95% CI: 1.15-3.12; based on 1SD increase). The d/sIAT may augment the accuracy of suicide risk assessment.

Responses to Traumatic Brain Injury Screening Questions and Suicide Attempts among Those Seeking Veterans Health Administration Mental Health Services

BACKGROUND

Psychometrically sound screening tools available to aid in the identification of lifetime history of traumatic brain injury (TBI) are limited. As such, the Traumatic Brain Injury-4 (TBI-4) was developed and implemented in a Veterans Health Administration (VHA) mental health clinic. To provide information regarding both the predictive validity and clinical utility of the TBI-4, the relationship between screening results and future suicide attempts was evaluated.

OBJECTIVE

The aim of this study was to determine whether a positive screen on the TBI-4 was associated with increased risk for suicide attempt within 1-year post screening.

METHODS

The TBI-4 was administered to 1,097 Veterans at the time of mental health intake. Follow-up data regarding suicide attempts for the year post-mental health intake were obtained from suicide behavior reports (SBRs) in Veteran electronic medical records (EMRs). Fisher's exact tests were used to determine the proportion of suicide attempts by TBI-4 status.

RESULTS

In the year post TBI-4 screening, significantly more Veterans who screened positive had a documented suicide attempt as compared to those who screened negative (p = 0.003).

CONCLUSION

Those with a positive TBI screen at mental health intake had a higher proportion of SBRs than those who screened negative for TBI. Findings provided further psychometric support for the TBI-4. Moreover, results suggest the inclusion of this screen could prove to be helpful in identifying those who may be at risk for future suicide attempt within 1-year post screening.

Methamphetamine induces the release of endothelin

Methamphetamine is a potent psychostimulant drug of abuse that increases release and blocks reuptake of dopamine, producing intense euphoria, factors that may contribute to its widespread abuse. It also produces severe neurotoxicity resulting from oxidative stress, DNA damage, blood-brain barrier disruption, microgliosis, and mitochondrial dysfunction. Intracerebral hemorrhagic and ischemic stroke have been reported after intravenous and oral abuse of methamphetamine. Several studies have shown that methamphetamine causes vasoconstriction of vessels. This study investigates the effect of methamphetamine on endothelin-1 (ET-1) release in mouse brain endothelial cells by ELISA. ET-1 transcription as well as endothelial nitric oxide synthase (eNOS) activation and transcription were measured following methamphetamine treatment. We also examine the effect of methamphetamine on isolated cerebral arteriolar vessels from C57BL/6 mice. Penetrating middle cerebral arterioles were cannulated at both ends with a micropipette system. Methamphetamine was applied extraluminally, and the vascular response was investigated. Methamphetamine treatment of mouse brain endothelial cells resulted in ET-1 release and a transient increase in ET-1 message. The activity and transcription of eNOS were only slightly enhanced after 24 hr of treatment with methamphetamine. In addition, methamphetamine caused significant vasoconstriction of isolated mouse intracerebral arterioles. The vasoconstrictive effect of methamphetamine was attenuated by coapplication of the endothelin receptor antagonist PD145065. These findings suggest that vasoconstriction induced by methamphetamine is mediated through the endothelin receptor and may involve an endothelin-dependent pathway.

Military Service and Suicidal Thoughts and Behaviors in a National Sample of College Students

Background: As a result of the post-9/11 GI Bill, increasing numbers of veterans are enrolling in college. However, little is known regarding suicidal outcomes among this group. In prior research, college student veterans reported high rates of suicidal ideation and attempt. Nonetheless, no research has examined whether military service is associated with increased suicide risk among college students. Aims: Our primary aims were to examine whether a history of military service was related to past-year suicidal ideation, plan, and attempt among college students. On the basis of previous research with college students, we hypothesized that students with a history of military service (i.e., current or prior) would report a higher percentage of past-year suicidal ideation, plan, and attempt. Our secondary aims were to examine the associations between military service and major depression and nonsuicidal self-injury. Method: Our sample included 3,290 college students with and without a history of military service who participated in the Healthy Minds Study in 2011 and 2012. Results: Military service was not significantly associated with past-year suicidal ideation, plan, or attempt. Students without a history of military service were more likely to report nonsuicidal self-injury. There was no significant difference in screening positive for major depression. Conclusions: These findings conflict with previous research that identified student veterans as being at elevated risk.

Challenges associated with screening for traumatic brain injury among US veterans seeking homeless services

We identified the prevalence of traumatic brain injury (TBI) among homeless veterans and assessed the TBI-4, a screening tool created to identify TBI history. Between May 2010 and October 2011, 800 US veterans from two hospitals, one eastern (n = 122) and one western (n = 678) completed some or all measures. Findings suggested that 47% of veterans seeking homeless services had a probable history of TBI (data for prevalence obtained only at the western hospital). However, psychometric results from the screening measure suggested that this may be an underestimate and supported comprehensive assessment of TBI in this population.

Learning the "numbers game" of today's contact lens fitting: clinical and business pearls

A "chair time model" for contact lens pricing is a valuable administrative tool. Relative sagittal depth is an easy comparison to use when evaluating the theoretical fit of one soft lens versus another. Biological oxygen apparent transmissibility (BOAT) and a calculated value of oxygen transmissibility (Dk/L) are two totally different assessments and the significance of BOAT will need to be clinically tested over time.

Extended wear soft contact lenses: to market or not to market

1. Today, cosmetic extended wear lenses have numerous aliases; continuous wear, provisional extended wear, and flexible wear, all referring to the same products, but on a relative scale of wearing time. Cosmetic extended wear lenses are elective and differ from the medical necessity of extended wear that few patients require. Refractive surgery has made significant advances in the cosmetic extended wear lens market. 2. Despite growing conservatism, positive marketing kept growing the EW philosophy for almost a decade until the FDA laid down some new rules, including a 1-week maximum for overnight wear. Coincidentally, this mandate came with the advent of the disposable lens in 1989. Since then, 1-week EW with disposable contacts has proved to be a safer modality for cosmetic EW; however, the concern of corneal complications continues to decline the market. 3. Patients risk a microbial ulcerative keratitis secondary to cosmetic EW. If daily wear contact lens options or occasional part-time EW is not amenable to the patient, refer the patient to an experienced refractive surgeon. Today, patients have more healthful vision choices than ever before.

Ophthalmology's interaction with the Internet (you say, 'Internet what?')

1. You can be connected to the information Highway by a local phone call. So, you will have a monthly charge for your access, but not a more expensive phone bill. 2. Mail lists are discussion groups; actually, they are "computer remailers." When you join a mail list, your e-mail address is entered into a computer, along with a group of people with common interest on the Net. 3. The World Wide Web is the graphical and multimedia part of the Internet--color, sound, video, and all! To access the World Wide Web, you'll need a browser. A browser is a piece of software that allows you to look at all the Web's various home pages and websites. Organizations, individuals, universities, and corporations have Web addresses (called URLs) that allow you to look at their "roadside stand" on this Information Highway.

Monocular diplopia: contact lens related warpage?

1. Always do a corneal topography on difficult-to-fit corneas. Use the Tangential map for a true picture of the overall cornea and the corneal cap. Use the Absolute Scale maps to rule out abnormally steep or flat regions in the cornea and for accurate comparisons of both eyes. 2. Understand that fitting a myopic presbyope with contact lenses will have a subset of problems related to accommodation, opposed to fitting a hyperope. 3. If a contact lens is required to make the corneal surface more regular, consider soft lenses, especially if a monocular is needed. The comfort difference in the contact lens eye versus the normal eye will minimal, compared to a gas-permeable lens fit.