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.

Alcohol consumption and dependence risk among male and female Veterans: Trajectories and predictors

BACKGROUND

With few exceptions, previously conducted research on hazardous drinking among Veterans has employed samples in which the majority of participants identify as male. In addition, past studies have solely focused on alcohol consumption, rather than associated risk for dependence. In this study, we expanded upon the extant literature by investigating sex differences in trajectories and predictors of change in alcohol consumption and dependence risk among post-9/11 Veterans.

METHODS

A national sample of 1649 Veterans (50.0% female) were recruited in a five-wave longitudinal study that followed Veterans for up to 16 years after deployment. We used growth curve modeling to investigate trajectories of change in alcohol consumption and dependence risk among men and women Veterans. We examined predictors of growth, including demographics, support and resources, psychiatric symptoms, and trauma exposure.

RESULTS

Among male Veterans, alcohol consumption and dependence risk remained stagnant, which is in contrast to past work using non-Veteran samples. For female Veterans, consumption exhibited initial reductions that decelerated, and dependence risk reduced at a continuous rate. PTSD diagnosis was a significant predictor of individual differences in growth for men. Psychiatric symptoms (i.e., PTSD diagnosis, probable depression diagnosis, suicidal ideation) and psychosocial functioning were significant predictors of decreasing alcohol use for women.

CONCLUSIONS

Results highlight important sex differences in patterns and predictors of change in alcohol consumption and dependence risk among post-9/11 Veterans. Findings are discussed in relation to screening for hazardous alcohol use and intervention strategies in this at-risk population.

Development and initial validation of the Mount Sinai Resilience Scale

OBJECTIVE

The construct of psychological resilience has received increasing attention in the mental health field. This article describes the development and initial validation of a novel self-report resilience scale, which addresses gaps in the resilience measurement literature by assessing thoughts and behaviors that help promote resilience rather than traits, and simultaneously evaluating multiple factors previously associated with resilience.

METHOD

Following consensus meetings focused on scale development, we conducted an online study (n = 1,864) of U.S. adults to develop and validate an initial version of the Mount Sinai Resilience Scale (MSRS).

RESULTS

An exploratory factor analysis in a random 50% of the sample suggested a seven-factor solution; this solution was then generally supported by a follow-up confirmatory factor analysis in the remaining 50% of the sample. After removing poor-fitting items, a revised 24-item scale correlated in the expected directions with established measures of perceived resilience and resilience-related constructs (e.g., social support and optimism).

CONCLUSIONS

Collectively, the results of this study provide initial support for the convergent and discriminant validity of the MSRS and describe its factor structure. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Design of a hybrid implementation effectiveness cluster randomized controlled trial of delivering written exposure therapy for PTSD in underserved primary care settings

INTRODUCTION

Posttraumatic stress disorder (PTSD) results in substantial costs to society. Prevalence of PTSD among adults is high, especially among those presenting to primary care settings. Evidence-based psychotherapies (EBPs) for PTSD are available but dissemination and implementation within primary care settings is challenging. Building Experience for Treating Trauma and Enhancing Resilience (BETTER) examines the effectiveness of integrating Written Exposure Therapy (WET) within primary care collaborative care management (CoCM). WET is a brief exposure-based treatment that has the potential to address many challenges of delivering PTSD EBPs within primary care settings.

METHODS

The study is a hybrid implementation effectiveness cluster-randomized controlled trial in which 12 Federally Qualified Health Centers (FQHCs) will be randomized to either CoCM plus WET (CoCM+WET) or CoCM only with 60 patients within each FQHC. The primary aim is to evaluate the effectiveness of CoCM+WET to improve PTSD and depression symptom severity. Secondary treatment outcomes are mental and physical health functioning. The second study aim is to examine implementation of WET within FQHCs using FQHC process data and staff interviews pre- and post-intervention. Exploratory aims are to examine potential moderators and mediators of the intervention. Assessments occur at baseline, and 3- and 12-month follow-up.

CONCLUSION

The study has the potential to impact practice and improve clinical and public health outcomes. By establishing the effectiveness and feasibility of delivering a brief trauma-focused EBP embedded within CoCM in primary care, the study aims to improve PTSD outcomes for underserved patients.

TRIAL REGISTRATION

(Clinicaltrials.govNCT05330442).

The effect of time since index trauma on trauma-related beliefs

OBJECTIVE

Greater duration of negative trauma-related beliefs may inhibit improvements in these cognitions during posttraumatic stress disorder (PTSD) treatment. The goal of the current study was to examine the impact of time since trauma on change in negative trauma-related beliefs during PTSD treatment.

METHOD

A sample of 126 adults diagnosed with PTSD were randomized to Cognitive Processing Therapy (CPT) or Written Exposure Therapy (WET) and completed the Posttraumatic Cognitions Inventory (PTCI) at pretreatment and 6, 12, 24, 36, and 60 weeks following the first treatment session.

RESULTS

Consistent with past findings, negative cognitions related to the self, others, and self-blame decreased during and after trauma-focused therapy. Greater time since the trauma was associated with less improvement in negative trauma-related beliefs about the world and less early improvement in negative trauma-related beliefs about the self and self-blame. The effect of time since trauma on reduction in negative trauma-related beliefs about the world was stronger among participants randomized to CPT.

CONCLUSIONS

These results indicate that trauma-focused therapies become less potent in reducing trauma-related beliefs as time progresses since trauma exposure, particularly in CPT, for beliefs about the world. Results indicate PTSD treatment should be provided in closer proximity to trauma exposure before negative trauma-related beliefs become inflexible. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

An empirical investigation of definitions of subthreshold posttraumatic stress disorder

Subthreshold posttraumatic stress disorder (PTSD) has long been recognized as an important construct that identifies a subgroup of individuals who report significant PTSD symptoms and associated disability but do not endorse enough symptoms to meet the criteria for a full PTSD diagnosis. Different investigators have defined subthreshold PTSD in various ways, making it difficult to interpret findings across studies. To address this problem, we systematically compared individuals who met criteria for nine different subthreshold PTSD definitions with individuals diagnosed with either full PTSD or no PTSD (i.e., failed to meet the criteria for a subthreshold definition) with respect to prevalence and associated clinical outcomes of interest. Participants were 1,082 veterans enrolled in the Veterans After Discharge Longitudinal Registry. PTSD and subthreshold PTSD diagnostic status were determined using the Structured Clinical Interview for DSM-5 (SCID-5) and validated self-report instruments were used to assess clinical outcomes. Across outcomes, subthreshold definitions generally identified a group of participants that was distinguishable from participants in both the PTSD and no PTSD groups, rs = .02-.47. We discuss the benefits and drawbacks of various subthreshold definitions and highlight the need for additional work evaluating these definitions across additional outcomes and samples. In the interim, we propose a working case definition of subthreshold PTSD as meeting any three of the four DSM-5 symptom criteria (i.e., Criteria B, C, D, and E) along with Criterion A and Criteria F-H. The results suggest subthreshold PTSD is a clinically meaningful construct.

Estimated Average Treatment Effect of Psychiatric Hospitalization in Patients With Suicidal Behaviors: A Precision Treatment Analysis

Importance

Psychiatric hospitalization is the standard of care for patients presenting to an emergency department (ED) or urgent care (UC) with high suicide risk. However, the effect of hospitalization in reducing subsequent suicidal behaviors is poorly understood and likely heterogeneous.

Objectives

To estimate the association of psychiatric hospitalization with subsequent suicidal behaviors using observational data and develop a preliminary predictive analytics individualized treatment rule accounting for heterogeneity in this association across patients.

Design, Setting, and Participants

A machine learning analysis of retrospective data was conducted. All veterans presenting with suicidal ideation (SI) or suicide attempt (SA) from January 1, 2010, to December 31, 2015, were included. Data were analyzed from September 1, 2022, to March 10, 2023. Subgroups were defined by primary psychiatric diagnosis (nonaffective psychosis, bipolar disorder, major depressive disorder, and other) and suicidality (SI only, SA in past 2-7 days, and SA in past day). Models were trained in 70.0% of the training samples and tested in the remaining 30.0%.

Exposures

Psychiatric hospitalization vs nonhospitalization.

Main Outcomes and Measures

Fatal and nonfatal SAs within 12 months of ED/UC visits were identified in administrative records and the National Death Index. Baseline covariates were drawn from electronic health records and geospatial databases.

Results

Of 196 610 visits (90.3% men; median [IQR] age, 53 [41-59] years), 71.5% resulted in hospitalization. The 12-month SA risk was 11.9% with hospitalization and 12.0% with nonhospitalization (difference, -0.1%; 95% CI, -0.4% to 0.2%). In patients with SI only or SA in the past 2 to 7 days, most hospitalization was not associated with subsequent SAs. For patients with SA in the past day, hospitalization was associated with risk reductions ranging from -6.9% to -9.6% across diagnoses. Accounting for heterogeneity, hospitalization was associated with reduced risk of subsequent SAs in 28.1% of the patients and increased risk in 24.0%. An individualized treatment rule based on these associations may reduce SAs by 16.0% and hospitalizations by 13.0% compared with current rates.

Conclusions and Relevance

The findings of this study suggest that psychiatric hospitalization is associated with reduced average SA risk in the immediate aftermath of an SA but not after other recent SAs or SI only. Substantial heterogeneity exists in these associations across patients. An individualized treatment rule accounting for this heterogeneity could both reduce SAs and avert hospitalizations.

The PTSD Criterion A debate: A brief history, current status, and recommendations for moving forward

Posttraumatic stress disorder (PTSD) Criterion A, also known as the "stressor criterion," has been a major source of debate ever since PTSD was added to the third edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM) in 1980. Since then, the traumatic stress field has held an ongoing debate about how to best define Criterion A and the events that it covers. Because of the COVID-19 pandemic and recent race-based incidents, the Criterion A debate has been reinvigorated. In this paper, we review briefly the history of Criterion A and changes in its language across different editions of the DSM. We then describe the four main positions held by scholars involved in the Criterion A debate and carefully examine the support for those positions. We conclude by offering recommendations for moving forward.

Is adequate dose adequate? An examination of the impact of psychotherapy on posttraumatic stress disorder symptoms utilizing Veterans Health Administration medical records

Prior studies on individuals with posttraumatic stress disorder (PTSD) defined an adequate dose of psychotherapy as receiving at least nine sessions within a 15-week period. Yet, few studies have examined whether this definition of adequate dose is associated with meaningful change in PTSD symptoms over an extended period. To examine whether an adequate dose of individual or group psychotherapy was associated with PTSD symptom improvement, we identified mental health outpatient visits in the electronic medical record for a cohort of veterans enrolled in Veterans Health Administration (VHA) services (N = 1,649) across 5 years. Using latent growth curve modeling, we estimated the effect of receiving an adequate dose of psychotherapy on the PTSD symptom course. Among the sample, 992 participants (60.16%) received at least one individual therapy session and 506 participants (30.7%) received at least one group therapy session; of those, 226 (22.78%) received an adequate dose of individual therapy and 212 (41.9%) received an adequate dose of group therapy, respectively. An adequate individual therapy dose, but not group therapy dose, was associated with a decrease in PTSD Checklist for DSM-5 (PCL-5) scores over time. This improvement was extremely gradual (average of 1.57 PCL-5 point decrease per year). Adequate dose of psychotherapy, defined as nine sessions of routine psychotherapy over 15 weeks, is associated with minimal symptom change. This suggests that commonly used definitions of adequate dose have minimal clinical utility. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Trauma exposure and transdiagnostic distress: Examining shared and posttraumatic stress disorder-specific associations

We examined transdiagnostic and posttraumatic stress disorder (PTSD)-specific associations with multiple forms of trauma exposure within a nationwide U.S. sample (N = 1,649, 50.0% female) of military veterans overselected for PTSD. A higher-order Distress factor was estimated using PTSD, major depressive disorder (MDD), and generalized anxiety disorder (GAD) symptoms as indicators. A structural equation model spanning three assessment points over an average of 3.85 years was constructed to examine the unique roles of higher-order Distress and PTSD-specific variance in accounting for the associations between trauma exposure, measured using the Life Events Checklist (LEC) and Deployment Risk and Resiliency Inventory Combat subscale (DRRI-C), and psychosocial impairment. The results suggest the association between trauma exposure and PTSD symptoms was primarily mediated by higher-order distress (70.7% of LEC effect, 63.2% of DRRI-C effect), but PTSD severity retained a significant association with trauma exposure independent of distress, LEC: β = .10, 95% CI [.06, .13]; DRRI-C: β = .11, 95% CI [.07, .14]. Both higher-order distress, β = .31, and PTSD-specific variance, β = .36, were necessary to account for the association between trauma exposure and future impairment. Findings suggest that trauma exposure may contribute to comorbidity across a range of internalizing symptoms as well as to PTSD-specific presentations.

Minimal important difference metrics and test-retest reliability of the PTSD Checklist for DSM-5 with a primary care sample

The PTSD Checklist for DSM-5 (PCL-5) is a measure of posttraumatic stress disorder (PTSD) symptom severity that is widely used for clinical and research purposes. Although previous work has examined metrics of minimal important difference (MID) of the PCL-5 in veteran samples, no work has identified PCL-5 MID metrics among adults in primary care in the United States. In this secondary analysis, data were evaluated from primary care patients (N = 971) who screened positive for PTSD and participated in a large clinical trial in federally qualified health centers in three U.S. states. Participants primarily self-identified as women (70.2%) and White (70.3%). We calculated test-retest reliability using clinic registry data and multiple distribution- and anchor-based metrics of MID using baseline and follow-up survey data. Test-retest reliability (Pearson's r, Spearman's ρ, intraclass correlation coefficient) ranged from adequate to excellent (.79-.94), with the shortest time lag demonstrating the highest reliability estimate. The MID for the PCL-5 was estimated using multiple approaches. Distribution-based approaches indicated an MID range of 8.5-12.5, and anchor-based approaches indicated an MID range of 9.8-11.7. Taken together, the MID metrics indicate that PCL-5 change scores of 9-12 likely reflect real change in PTSD symptoms and indicate at least an MID for patients, whereas PCL-5 change scores of 5 or less likely are not reliable. These findings can help inform clinicians using the PCL-5 in similar populations to track patient responses to treatment and help researchers interpret PCL-5 score changes in clinical trials.

Benchmarking secondary outcomes to posttraumatic stress disorder symptom change in response to cognitive processing and written exposure therapy for posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) has high comorbidity with other psychiatric conditions, including depression, generalized anxiety, and suicidality. Evidence-based treatments (EBTs) for PTSD are effective at reducing PTSD symptoms. However, evidence on the impact of PTSD EBTs on comorbid conditions is mixed and often uses pre-post analyses, which disregards PTSD symptom response. This study replicated and extended prior work on benchmarking quality of life to PTSD symptom response to a broader range of secondary outcomes using a research-based metric of clinically meaningful PTSD symptom change. Ninety-five active duty military members seeking treatment for PTSD participated in a randomized noninferiority trial examining two cognitive behavioral therapies for PTSD: Written Exposure Therapy and Cognitive Processing Therapy. Participants completed clinician-administered and self-rating assessments at baseline and 10 weeks post-first treatment session and were classified as PTSD treatment responders or nonresponders. Data were analyzed using generalized linear mixed effects models with repeated measures with fixed effects of time and PTSD symptom response category. PTSD treatment responders experienced significant improvements in secondary outcomes; nonresponders demonstrated statistically significant, but not clinically meaningful, comorbid symptom change. Our findings provide evidence that successfully treating PTSD symptoms may also positively impact psychiatric comorbidity.

An Item Response Theory Analysis of the Clinician-Administered PTSD Scale for DSM-5 Among Veterans

We used item response theory (IRT) analysis to examine Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) item performance using data from three large samples of veterans (total N = 808) using both binary and ordinal rating methods. Relative to binary ratings, ordinal ratings provided good coverage from well below to well above average within each symptom cluster. However, coverage varied by cluster, and item difficulties were unevenly distributed within each cluster, with numerous instances of redundancy. For both binary and ordinal scores, flashbacks, dissociative amnesia, and self-destructive behavior items showed a pattern of high difficulty but relatively poor discrimination. Results indicate that CAPS-5 ordinal ratings provide good severity coverage and that most items accurately differentiated between participants by severity. Observed uneven distribution and redundancy in item difficulty suggest there is opportunity to create an abbreviated version of the CAPS-5 for determining PTSD symptom severity, but not DSM-5 PTSD diagnosis, without sacrificing precision.

A practical risk calculator for suicidal behavior among transitioning U.S. Army soldiers: results from the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS)

BACKGROUND

Risk of suicide-related behaviors is elevated among military personnel transitioning to civilian life. An earlier report showed that high-risk U.S. Army soldiers could be identified shortly before this transition with a machine learning model that included predictors from administrative systems, self-report surveys, and geospatial data. Based on this result, a Veterans Affairs and Army initiative was launched to evaluate a suicide-prevention intervention for high-risk transitioning soldiers. To make targeting practical, though, a streamlined model and risk calculator were needed that used only a short series of self-report survey questions.

METHODS

We revised the original model in a sample of n = 8335 observations from the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS) who participated in one of three Army STARRS 2011-2014 baseline surveys while in service and in one or more subsequent panel surveys (LS1: 2016-2018, LS2: 2018-2019) after leaving service. We trained ensemble machine learning models with constrained numbers of item-level survey predictors in a 70% training sample. The outcome was self-reported post-transition suicide attempts (SA). The models were validated in the 30% test sample.

RESULTS

Twelve-month post-transition SA prevalence was 1.0% (s.e. = 0.1). The best constrained model, with only 17 predictors, had a test sample ROC-AUC of 0.85 (s.e. = 0.03). The 10-30% of respondents with the highest predicted risk included 44.9-92.5% of 12-month SAs.

CONCLUSIONS

An accurate SA risk calculator based on a short self-report survey can target transitioning soldiers shortly before leaving service for intervention to prevent post-transition SA.

Written Exposure Therapy vs Prolonged Exposure Therapy in the Treatment of Posttraumatic Stress Disorder: A Randomized Clinical Trial

Importance

Evidence-based treatments for posttraumatic stress disorder (PTSD) exist, but all require 8 to 15 sessions and thus are less likely to be completed than brief treatments. Written exposure therapy (WET) is a brief and efficacious treatment that has not been directly compared with prolonged exposure therapy (PE), a more time-intensive, exposure-based treatment.

Objective

To determine whether WET is noninferior to PE in treating PTSD among veterans.

Design, Setting, and Participants

A randomized noninferiority clinical trial was conducted between September 9, 2019, and April 30, 2022. Participants were 178 veterans with PTSD presenting to 1 of 3 Veterans Affairs medical centers. Inclusion criteria consisted of a primary diagnosis of PTSD and stable medication. Exclusion criteria included current psychotherapy for PTSD, high suicide risk, active psychosis, unstable bipolar disorder, and severe cognitive impairment. Independent evaluations were conducted at baseline and 10, 20, and 30 weeks after the first treatment session. Data were analyzed from January 1 to March 31, 2023.

Interventions

Participants assigned to WET (n = 88) received five to seven 45- to 60-minute sessions. Participants assigned to PE (n = 90) received eight to fifteen 90-minute sessions. The WET sessions included 30 minutes of writing-based imaginal exposure conducted in session, whereas PE sessions included 40 minutes of in-session imaginal exposure and between-session in vivo exposures.

Main Outcomes and Measures

The primary outcome was change in PTSD symptom severity measured with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) from baseline to the 20-week assessment; noninferiority was defined as a less than 10-point difference between the 2 treatment groups. Difference in treatment dropout was also examined.

Results

Of the 178 participants, 134 (75.3%) were men, and the mean (SD) age was 44.97 (13.66) years. In terms of race, 37 participants (20.8%) were Black, 112 (62.9%) were White, 11 (6.2%) were more than 1 race, and 18 (10.1%) were of other race (including American Indian or Alaska Native, Asian, and Native Hawaiian or Other Pacific Islander [some participants did not specify their race when selecting the category "other"]); in terms of ethnicity, 19 participants (10.7%) were Hispanic. Changes in PTSD symptom severity from baseline to all subsequent assessments among individuals randomized to WET were noninferior relative to individuals randomized to PE. The largest difference between treatments was observed at 10 weeks and was in favor of WET (mean difference, 2.42 [95% CI, 0.35-1.46] points). Participants were significantly less likely to drop out of WET compared with PE (11 [12.5%] vs 32 [35.6%]; χ2 = 12.91; Cramer V = 0.27).

Conclusions and Relevance

In this study, WET was noninferior to PE in PTSD symptom change and was associated with significantly less attrition. Findings suggest that WET may transcend previously observed barriers to PTSD treatment for both patients and clinicians.

Trial Registration

ClinicalTrials.gov Identifier: NCT03962504.

Early predictors of chronic posttraumatic stress disorder symptom trajectories in U.S. Army soldiers deployed to the Iraq war zone

The course of posttraumatic stress disorder (PTSD) symptoms varies among veterans of war zones, but sources of variation in long-term symptom course remain poorly understood. Modeling of symptom growth trajectories facilitates the understanding of predictors of individual outcomes over time. Although growth mixture modeling (GMM) has been applied to military populations, few studies have incorporated both predeployment and follow-up measurements over an extended time. In this prospective study, 1,087 U.S. Army soldiers with varying military occupational specialties and geographic locations were assessed before and after deployment to the Iraq war zone, with long-term follow-up assessment occurring at least 5 years after return from deployment. The primary outcome variable was the PTSD Checklist-Civilian Version summary score. GMM yielded four latent profiles, characterized as primarily asymptomatic (n = 194, 17.8%); postdeployment worsening symptoms (n = 84, 7.7%); mild symptoms (n = 320, 29.4%); and preexisting, with a chronic postdeployment elevation of symptoms (n = 489, 45.0%). Regression models comparing the primarily asymptomatic class to the symptomatic classes revealed that chronic symptom classes were associated with higher degrees of stress exposure, less predeployment social support, military reservist or veteran status at the most recent assessment, and poorer predeployment visual memory, ORs = 0.98-2.90. PTSD symptom course varies considerably over time after military deployment and is associated with potentially modifiable biopsychosocial factors that occur early in its course in addition to exposures and military status.

Psychometric Properties of the Self-Injurious Thoughts and Behaviors Interview-Short Form Among U.S. Active Duty Military Service Members and Veterans

We assessed the interrater reliability, convergent validity, and discriminant validity of the Self-Injurious Thoughts and Behaviors Interview-Short Form (SITBI-SF) in a sample of 1,944 active duty service members and veterans seeking services for posttraumatic stress disorder (PTSD) and related conditions. The SITBI-SF demonstrated high interrater reliability and good convergent and discriminant validity. The measurement properties of the SITBI-SF were comparable across service members and veterans. Approximately 8% of participants who denied a history of suicidal ideation on the SITBI-SF reported suicidal ideation on a separate self-report questionnaire (i.e., discordant responders). Discordant responders reported significantly higher levels of PTSD symptoms than those who denied suicidal ideation on both response formats. Findings suggest that the SITBI-SF is a reliable and valid interview-based measure of suicide-related thoughts and behaviors for use with military service members and veterans. Suicide risk assessment might be optimized if the SITBI-SF interview is combined with a self-report measure of related constructs.

Comparing the Prevalence of Probable DSM-IV and DSM-5 Posttraumatic Stress Disorder in a Sample of U.S. Military Veterans Using the PTSD Checklist

Posttraumatic stress disorder (PTSD) changed substantially when Diagnostic and Statistical Manual of Mental Disorders transitioned from fourth (DSM-IV) to fifth (DSM-5) edition. Hoge et al. found that although diagnostic prevalence remained consistent across nomenclatures, diagnostic concordance was low (55%). Study goals were to examine both the generalizability of these findings and whether either diagnosis systematically excluded patients. U.S. veterans (N = 1,171) who completed the PTSD Checklist for DSM-IV (PCL-S) and DSM-5 (PCL-5) were classified as: probable PTSD on both measures; probable PTSD on PCL-S only; probable PTSD on PCL-5 only; or no PTSD on either measure. Diagnostic prevalence was equivalent. Unlike Hoge et al.'s findings, diagnostic concordance was high (91.3%). Furthermore, observed demographic and severity differences were driven by disparities between veterans in the no PTSD versus the probable PTSD groups, not diagnostic changes. Findings suggest translatability across measures and that diagnostic changes do not systematically exclude patients.

DSM-5 criterion-a-based trauma types in service members and veterans seeking treatment for posttraumatic stress disorder

OBJECTIVE

In posttraumatic stress disorder (PTSD), the assumption of the equipotentiality of traumas ignores potentially unique contexts and consequences of different traumas. Accordingly, Stein et al. (2012) developed a reliable typing scheme in which assessors categorized descriptions of traumatic events into six "types": life threat to self (LTS), life threat to other, aftermath of violence (AV), traumatic loss, moral injury by self (MIS), and moral injury by other (MIO). We extended this research by validating the typing scheme using participant endorsements of type, rather than assesor-based types. We examined the concordance of participant and assesor types, frequency, and validity of participant-based trauma types by examining associations with baseline mental and behavioral health problems.

METHOD

Interviewers enrolled military personnel and veterans (N = 1,443) in clinical trials of PTSD and helped them select the most currently distressing Criterion-A trauma. Participants and, archivally, assessors typed the distressing aspect(s) of this experience.

RESULTS

AV was the most frequently participant-endorsed type, but LTS was the most frequently rated worst part of an event. Although participants endorsed MIS and MIO the least frequently, these were associated with worse mental and behavioral health problems. The agreement between participants and assessors regarding the worst part of the event was poor.

CONCLUSION

Because of discrepancies between participant and assessor typologies, clinical researchers should use participants' ratings, and these should trump assessor judgment. Differences in pretreatment behavioral and mental health problems across some participant-endorsed trauma types partially support the validity of the participant ratings. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Associations of vulnerability to stressful life events with suicide attempts after active duty among high-risk soldiers: results from the Study to Assess Risk and Resilience in Servicemembers-longitudinal study (STARRS-LS)

BACKGROUND

The transition from military service to civilian life is a high-risk period for suicide attempts (SAs). Although stressful life events (SLEs) faced by transitioning soldiers are thought to be implicated, systematic prospective evidence is lacking.

METHODS

Participants in the Army Study to Assess Risk and Resilience in Servicemembers (STARRS) completed baseline self-report surveys while on active duty in 2011-2014. Two self-report follow-up Longitudinal Surveys (LS1: 2016-2018; LS2: 2018-2019) were subsequently administered to probability subsamples of these baseline respondents. As detailed in a previous report, a SA risk index based on survey, administrative, and geospatial data collected before separation/deactivation identified 15% of the LS respondents who had separated/deactivated as being high-risk for self-reported post-separation/deactivation SAs. The current report presents an investigation of the extent to which self-reported SLEs occurring in the 12 months before each LS survey might have mediated/modified the association between this SA risk index and post-separation/deactivation SAs.

RESULTS

The 15% of respondents identified as high-risk had a significantly elevated prevalence of some post-separation/deactivation SLEs. In addition, the associations of some SLEs with SAs were significantly stronger among predicted high-risk than lower-risk respondents. Demographic rate decomposition showed that 59.5% (s.e. = 10.2) of the overall association between the predicted high-risk index and subsequent SAs was linked to these SLEs.

CONCLUSIONS

It might be possible to prevent a substantial proportion of post-separation/deactivation SAs by providing high-risk soldiers with targeted preventive interventions for exposure/vulnerability to commonly occurring SLEs.

An examination of the criterion-related validity of varying methods of indexing clinically significant change in posttraumatic stress disorder treatment

OBJECTIVE

Clinicians, patients, and researchers need benchmarks to index individual-level clinically significant change (CSC) to guide decision making and inferences about treatment efficacy. Yet, there is no consensus best practice for determining CSC for posttraumatic stress disorder (PTSD) treatments. We examined criterion-related validity of the most common approach-Jacobson and Truax's (J&T; 1991) procedures for indexing CSC. We generated and compared four methods of calculating the J&T indices of CSC (two sets of sample-specific inputs, putatively norm-referenced benchmarks, and a combination of sample-specific and norm-referenced criteria) with respect to their association with a criterion index of quality of life (QoL).

METHOD

Participants were 91 women Veterans enrolled in a randomized clinical trial for PTSD who completed self-report measures on PTSD symptoms and various domains of QoL and functioning, pre- and posttreatment. For each of the four methods used to calculate CSC, the QoL composite was regressed onto the CSC categories.

RESULTS

All methods explained large variance in change in QoL. Across all methods, participants categorized as unchanged had smaller changes in QoL, compared with those who improved or had probable recovery. The norm-referenced benchmarks accounted for the relatively largest amount of variance in QoL, but categorized the fewest patients as having made CSC.

CONCLUSIONS

The J&T methodology for indexing CSC in PTSD symptoms has criterion-related validity, and a norm-referenced benchmark appears to be the most potent. However, the norm-referenced parameters may be overly specific, potentially leading to an underestimate of improvement. Research is needed to test the generalizability of these results. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Longitudinal PTSD network structure: measuring PTSD symptom networks over 5 years

BACKGROUND

Network modeling has been applied in a range of trauma-exposed samples, yet results are limited by an over reliance on cross-sectional data. The current analyses used posttraumatic stress disorder (PTSD) symptom data collected over a 5-year period to estimate a more robust between-subject network and an associated symptom change network.

METHODS

A PTSD symptom network is measured in a sample of military veterans across four time points (Ns = 1254, 1231, 1106, 925). The repeated measures permit isolating between-subject associations by limiting the effects of within-subject variability. The result is a highly reliable PTSD symptom network. A symptom slope network depicting covariation of symptom change over time is also estimated.

RESULTS

Negative trauma-related emotions had particularly strong associations with the network. Trauma-related amnesia, sleep disturbance, and self-destructive behavior had weaker overall associations with other PTSD symptoms.

CONCLUSIONS

PTSD's network structure appears stable over time. There is no single 'most important' node or node cluster. The relevance of self-destructive behavior, sleep disturbance, and trauma-related amnesia to the PTSD construct may deserve additional consideration.

Evaluation of a Model to Target High-risk Psychiatric Inpatients for an Intensive Postdischarge Suicide Prevention Intervention

Importance

The months after psychiatric hospital discharge are a time of high risk for suicide. Intensive postdischarge case management, although potentially effective in suicide prevention, is likely to be cost-effective only if targeted at high-risk patients. A previously developed machine learning (ML) model showed that postdischarge suicides can be predicted from electronic health records and geospatial data, but it is unknown if prediction could be improved by adding additional information.

Objective

To determine whether model prediction could be improved by adding information extracted from clinical notes and public records.

Design, Setting, and Participants

Models were trained to predict suicides in the 12 months after Veterans Health Administration (VHA) short-term (less than 365 days) psychiatric hospitalizations between the beginning of 2010 and September 1, 2012 (299 050 hospitalizations, with 916 hospitalizations followed within 12 months by suicides) and tested in the hospitalizations from September 2, 2012, to December 31, 2013 (149 738 hospitalizations, with 393 hospitalizations followed within 12 months by suicides). Validation focused on net benefit across a range of plausible decision thresholds. Predictor importance was assessed with Shapley additive explanations (SHAP) values. Data were analyzed from January to August 2022.

Main Outcomes and Measures

Suicides were defined by the National Death Index. Base model predictors included VHA electronic health records and patient residential data. The expanded predictors came from natural language processing (NLP) of clinical notes and a social determinants of health (SDOH) public records database.

Results

The model included 448 788 unique hospitalizations. Net benefit over risk horizons between 3 and 12 months was generally highest for the model that included both NLP and SDOH predictors (area under the receiver operating characteristic curve range, 0.747-0.780; area under the precision recall curve relative to the suicide rate range, 3.87-5.75). NLP and SDOH predictors also had the highest predictor class-level SHAP values (proportional SHAP = 64.0% and 49.3%, respectively), although the single highest positive variable-level SHAP value was for a count of medications classified by the US Food and Drug Administration as increasing suicide risk prescribed the year before hospitalization (proportional SHAP = 15.0%).

Conclusions and Relevance

In this study, clinical notes and public records were found to improve ML model prediction of suicide after psychiatric hospitalization. The model had positive net benefit over 3-month to 12-month risk horizons for plausible decision thresholds. Although caution is needed in inferring causality based on predictor importance, several key predictors have potential intervention implications that should be investigated in future studies.

Early intervention using written exposure therapy for PTSD and AUD symptoms following sexual assault: Description of design and methodology

The co-occurrence of posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) is common following sexual assault and associated with more severe symptomology and increased likelihood of sexual revictimization. Integrated interventions aimed at reducing PTSD and AUD symptoms following recent sexual assault are needed and should address barriers to care and early treatment termination. The proposed study will test a novel, brief (5 to 7 sessions) intervention that integrates Written Exposure Therapy for PTSD and Cognitive Behavioral Therapy for AUD, and is initiated within the first six weeks post-assault. In Phase 1, qualitative analysis of content gathered during focus groups with treatment providers will be conducted to inform intervention development. In Phase 2, a proof-of-concept pilot study (n = 10) of the intervention, Substance Use Skills Training and Exposure Post-Sexual Assault (STEPS), will be conducted. In Phase 3, a pilot randomized controlled trial (RCT) among 54 recent sexual assault survivors will be implemented using the updated manualized STEPS intervention to evaluate feasibility and preliminary efficacy in reducing PTSD and AUD symptoms. Ecological momentary assessments will be used to assess daily alcohol use, craving, affect, intrusions and avoidance. The effects of STEPS on commonly associated symptoms (e.g., depression, substance use) will be examined. The proposed study has the potential to make a significant public health impact by advancing knowledge on the link between sexual assault and co-occurring PTSD and AUD and informing early intervention efforts for this high-risk population.

Identifying correlates of suicide ideation during the COVID-19 pandemic: A cross-sectional analysis of 148 sociodemographic and pandemic-specific factors

The coronavirus disease 2019 (COVID-19) pandemic has created a global health crisis, with disproportionate effects on vulnerable sociodemographic groups. Although the pandemic is showing potential to increase suicide ideation (SI), we know little about which sociodemographic characteristics or COVID-19 experiences are associated with SI. Our United States-based sample (n = 837 adults [mean age = 37.1 years]) completed an online survey during August-September 2020. The study utilized an online convenience sample from a prior study, which was enriched for exposure to trauma and experiences of posttraumatic stress symptoms. We assessed SI using the Beck Depression Inventory-II. Traditional (i.e., logistic regression) and machine learning (i.e., LASSO, random forest) methods evaluated associations of 148 self-reported COVID-19 factors and sociodemographic characteristics with current SI. 234 participants (28.0%) reported SI. Twenty items were significantly associated with SI from logistic regression. Of these 20 items, LASSO identified seven sociodemographic characteristics (younger age, lower income, single relationship status, sexual orientation other than heterosexual as well as specifically identifying as bisexual, non-full-time employment, and living in a town) and six COVID-19 factors (not engaging in protective COVID-19 behaviors, receiving mental health treatment (medication and/or psychotherapy) due to the COVID-19 pandemic, socializing during the pandemic, losing one's job due to COVID-19, having a friend with COVID-19, and having an acquaintance with COVID-19) associated with SI. Random forest findings were largely consistent with LASSO. These findings may inform multidisciplinary research and intervention work focused on understanding and preventing adverse mental health outcomes such as SI during and in the aftermath of the pandemic.

Identifying factors associated with elevated suicidal intent among U.S. military veterans

OBJECTIVE

Suicidal intent is a risk factor for engagement in suicidal behavior, use of violent means, and suicide mortality. Yet, scarce research has examined factors associated with suicidal intent among U.S. military veterans, a population at high risk for suicide. This study examined vulnerability factors associated with suicidal intent in a population-based sample of U.S. veterans.

METHODS

Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a representative sample of 4069 U.S. veterans. Analyses estimated the prevalence of current suicidal intent (i.e., veterans' report that they would likely attempt suicide in the future) and examined factors most strongly associated with suicidal intent.

RESULTS

Forty-nine veterans (1.4%; 95% confidence interval = 1.0-1.8%) reported suicidal intent. Recurrent past-year suicidal ideation (≥2 times), low dispositional gratitude, current depression, current insomnia, childhood sexual abuse, and a prior suicide attempt were most strongly associated with suicidal intent (7.1-50.1% of the total explained variance). Veterans with several of these co-occurring factors were at highest risk for suicidal intent; of veterans with 0, ≥1, ≥2, ≥3, and ≥4 of these factors, 0.1%, 4.4%, 10.8%, 19.5%, and 28.1% reported suicidal intent, respectively.

DISCUSSION

Specific vulnerability factors, particularly when co-occurring, may increase veterans' intention of attempting suicide. Findings underscore the importance for clinicians to continuously assess suicidal intent when working with this population, particularly as veterans' reports of suicidal thinking increases.

Network analysis of mild traumatic brain injury, persistent neurobehavioral and psychiatric symptoms, and functional disability among recent-era United States veterans

Recent-era U.S. veterans are clinically complex, with a high prevalence of co-occurring mild traumatic brain injury (mTBI), psychiatric conditions, and behavioral dysfunction. The current study examined the direct and indirect associations between mTBI and persistent neurobehavioral, psychiatric, and functional disability symptoms among recent-era U.S. veterans and service members (n = 648). We evaluated the postconcussive syndrome (PCS) potential causal model with two network analysis modeling approaches. Separate analyses were conducted for military mTBI and lifetime mTBI. An exploratory factor analysis was conducted to limit topological overlap in the network analysis. The most influential symptoms (i.e., the unique variables most strongly associated with the rest of the network) in the military mTBI network were behavioral disengagement, expected influence (EI) = 1.10; cognitive difficulties, EI = 1.08; agitation/irritability, EI = 1.05; and PTSD-related reexperiencing and avoidance symptoms, EI = 0.98. After accounting for other symptoms, mTBI was only minimally informative, EI = 0.34. Additionally, military mTBI did not moderate the association between symptoms or the overall connectivity of the network. The results for lifetime mTBI were consistent with those for military mTBI. The present analyses identified a variety of behavioral, cognitive, and emotional symptoms that play an important role in understanding comorbidity and daily functioning among recent-era U.S. veterans. Associations between cumulative mTBI that occurred in civilian or military settings were indirect and relatively small in magnitude. The current results add to a growing literature raising doubts about the PCS model.

Using electronic medical record diagnostic codes to identify veterans with posttraumatic stress disorder

Researchers studying posttraumatic stress disorder (PTSD) often use diagnostic codes within electronic medical records (EMRs) to identify individuals with the disorder. This study evaluated the performance of algorithms for defining PTSD based on International Classification of Diseases (ICD) code use within EMR data. We used data from a registry of U.S. veterans for whom both structured interview data and Veterans Health Administration EMR data were available. Using interview-diagnosed PTSD as the reference criterion, we calculated diagnostic accuracy statistics for algorithms that required the presence of at least one and up to seven encounters in which a PTSD diagnosis was present in EMR data within any clinical source, mental health clinic, or specialty PTSD clinic. We evaluated algorithm accuracy in the total sample (N = 1,343; 64.1% with PTSD), within a subsample constrained to lower PTSD prevalence (n = 712; 32.3% with PTSD), and as a function of demographic characteristics. Algorithm accuracy was influenced by PTSD prevalence. Results indicated that higher thresholds for the operationalization of PTSD may be justified among samples in which PTSD prevalence is lower. Requiring three PTSD diagnoses from a mental health clinic or four diagnoses from any clinical source may be a suitable minimum standard for identifying individuals with PTSD in EMRs; however, accuracy may be optimized by requiring additional diagnoses. The performance of many algorithms differed as a function of educational attainment and age, suggesting that samples of individuals with PTSD developed based on EMR ICD codes may skew toward including older, less-educated veterans.

Posttraumatic stress disorder-related anhedonia as a predictor of psychosocial functional impairment among United States veterans

Prior research suggests that anhedonia symptoms related to posttraumatic stress disorder (PTSD; i.e., diminished interest, detachment from others, and difficulty experiencing positive emotions) are consistently associated with a higher degree of impairment in psychosocial functioning beyond that associated with other PTSD symptoms. Unfortunately, much of this research has used cross-sectional study designs; relied upon outdated DSM diagnostic criteria; and failed to control for potentially confounding variables, such as the presence of co-occurring depression. This study used data from Waves 2 and 4 (n = 1,649) of the Veterans' After-Discharge Longitudinal Registry (Project VALOR), a longitudinal dataset of U.S. Army and Marine veterans. As measured using the Inventory of Psychosocial Functioning, Wave 4 psychosocial functioning was regressed on seven PTSD symptom factors at Wave 2 (i.e., intrusions, avoidance, negative affect, anhedonia, externalizing behaviors, anxious arousal, and dysphoric arousal) and potential Wave 2 confounds. The Anhedonia factor, β = .123, most strongly predicted later psychosocial functional impairment beyond the impact of other PTSD symptom factors, βs = -.076-.046. Clinical implications of these findings are also discussed.

Family-Involved Mental Health Care Among OEF/OIF Veterans With and Without PTSD Using VHA Administrative Records

Prior research indicates that veterans are interested in including family members in health care and that family-inclusive mental health treatment can improve treatment outcomes. Consequently, the Veterans Health Administration's (VHA) directive requires providers to offer family-inclusive mental health services to veterans. However, the extent to which veterans engage in family-inclusive mental health services at the VHA remains unclear. Using data from a longitudinal registry of male and female veterans with and without posttraumatic stress disorder, we examined the extent to which veterans included family members in their mental health care and predictors of engagement in family-involved therapy visits using VHA administrative records over a 5-year time span. Of the 1,329 veterans who received mental health care during the study, 8.4% received a family therapy visit-the number of visits per veteran ranged from 1 to 34. Results from logistic regressions indicate that relative to White veterans, Black veterans were 61.0% less likely to receive a family-involved therapy visit. Married veterans or veterans living with a partner, and veterans with poor romantic relationship functioning, were more likely to receive a family-involved therapy visit. These findings indicate that only a small percentage of veterans received a family therapy visit across 5 years. Efforts to understand barriers to family-involved therapy visits and strategies to increase engagement in family-involved visits may improve clinical outcomes and promote patient-centered care.

Prospective Associations of Military Discharge Characterization with Post-active Duty Suicide Attempts and Homelessness: Results from the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS)

INTRODUCTION

Active duty service members transitioning to civilian life can experience significant readjustment stressors. Over the past two decades of the United States' longest sustained conflict, reducing transitioning veterans' suicidal behavior and homelessness became national priorities. However, it remains a significant challenge to identify which service members are at greatest risk of these post-active duty outcomes. Discharge characterization, which indicates the quality of an individual's military service and affects eligibility for benefits and services at the Department of Veterans Affairs, is a potentially important indicator of risk.

MATERIALS AND METHODS

This study used data from two self-report panel surveys of the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS) (LS1: 2016-2018, n = 14,508; and LS2: 2018-2019, n = 12,156), which were administered to respondents who previously participated while on active duty in one of the three Army STARRS baseline self-report surveys (2011-2014): the New Soldier Study (NSS), a survey of soldiers entering basic training; All Army Study, a survey of active duty soldiers around the world; and the Pre-Post Deployment Study, a survey of soldiers before and after combat deployment. Human Subjects Committees of the participating institutions approved all recruitment, informed consent, and data collection protocols. We used modified Poisson regression models to prospectively examine the association of discharge characterization (honorable, general, "bad paper" [other than honorable, bad conduct, dishonorable], and uncharacterized [due to separation within the first 180 days of service]) with suicide attempt (subsample of n = 4334 observations) and homelessness (subsample of n = 6837 observations) among those no longer on active duty (i.e., separated or deactivated). Analyses controlled for other suicide attempt and homelessness risk factors using standardized risk indices that were previously developed using the LS survey data.

RESULTS

Twelve-month prevalence rates of self-reported suicide attempts and homelessness in the total pooled LS sample were 1.0% and 2.9%, respectively. While not associated with suicide attempt risk, discharge characterization was associated with homelessness after controlling for other risk factors. Compared to soldiers with an honorable discharge, those with a bad paper discharge had an increased risk of homelessness in the total sample (relative risk [RR] = 4.4 [95% CI = 2.3-8.4]), as well as within subsamples defined by which baseline survey respondents completed (NSS vs. All Army Study/Pre-Post Deployment Study), whether respondents had been separated (vs. deactivated), and how much time had elapsed since respondents were last on active duty.

CONCLUSIONS

There is a robust association between receiving a bad paper discharge and post-separation/deactivation homelessness. Policies that enhance transition assistance and access to mental healthcare for high-risk soldiers may aid in reducing post-separation/deactivation homelessness among those who do not receive an honorable discharge.

Non-response to questions about suicide ideation and attempts among veterans: Results from the National Health and Resilience in Veterans Study

OBJECTIVES

Veterans who decline to provide information on their history of self-injurious thoughts and behaviors (SITBs) may be at elevated suicide risk. We examined associations between non-response to a question assessing lifetime SITBs and proxy variables of suicide risk.

METHODS

In this population-based cross-sectional study of 4069 US veterans, responses to the Suicidal Behaviors Questionnaire-Revised were examined to group veterans into one of three categories: (1) denied lifetime SITBs, (2) reported lifetime SITBs, or (3) declined to respond.

RESULTS

Overall, 69.5% of veterans denied a SITB history, 29.5% reported a SITB history, and 1.0% declined to provide information regarding SITBs. In adjusted analyses, veterans who declined to provide information on SITBs were significantly more likely than veterans who explicitly denied lifetime SITBs to screen positive for posttraumatic stress disorder; report lifetime non-suicidal self-injury; and report elevated levels of total trauma burden, externalizing behaviors, loneliness, received social support, and provided social support. Across these constructs, veterans who declined to provide SITB information were statistically indistinguishable from veterans who explicitly reported lifetime SITBs.

CONCLUSIONS

Veterans who decline to provide information about suicidal thoughts and behaviors may represent a covert group at elevated risk for suicide.

Examining multiple features of episodic future thinking and episodic memory among suicidal adults

BCKGROUND

Theories of suicide suggest that suicidal ideation (SI) results in part from difficulty imagining the future, which itself relies on the ability to remember the past. The present study examines multiple components of episodic future thinking and memory including event richness, which is commonly measured within the cognitive literature but has not previously been assessed with suicidal individuals.

METHODS

Here, we tested the associations between SI and episodic future thinking and episodic memory across two studies (Study 1, n = 25; Study 2, n = 141): the first with a healthy comparison group and the second with a psychiatric comparison group.

RESULTS

Future event richness yielded large but statistically non-significant deficits in the SI group relative to healthy controls in Study 1 after controling the false discovery rate. The most robust effects for future thinking emerged in the case of perceived duration of future events, such that the SI group (vs. psychiatric comparison) imagined future events as longer-lasting in Study 2. Across both studies, episodic memory was unrelated to SI, and neither episodic future thinking nor memory predicted future SI.

CONCLUSION

Episodic future thinking may better distinguish individuals with SI history from psychiatric controls when compared with episodic memory, but that this effect is limited to select components of future thinking.

The role of PTSD symptom clusters and criterion in predicting future high-risk drug and alcohol use among returning veteran men and women

The prevalence of co-occurring posttraumatic stress disorder (PTSD) and substance use disorder (SUD) remains exceptionally high among returning veterans, with numerous studies linking PTSD, but not specific PTSD symptoms, to future SUD risk. Further explication of PTSD symptom effects on future SUD risk will likely promote intervention development and refinement while offsetting SUD risk. Accordingly, In this study we explored the prospective associations between PTSD symptom clusters, symptoms, and future SUD risk and use of specific drug classes. Returning veterans (N = 1,295; M_age = 42.3, SD = 9.89; 51% female; 66.8% White) completed structured diagnostic interviews to assess PTSD symptoms and self-report measures of substance use 14-36 months later (M = 24.59, SD = 2.97). Hyperarousal and reckless/self-destructive symptoms specifically predicted future high-risk drug use and binge drinking behavior, and avoidance of internal stimuli (i.e., of trauma memories, thoughts, and feelings) differentiated individuals classified as high-risk for alcohol use based on their AUDIT total score. Further, negative alterations in cognition and mood predicted future opioid (i.e., nightmares) and stimulant use (i.e., flashbacks), whereas concentration difficulties were inversely associated with future binge drinking. This longitudinal study identified prospective and enduring associations between specific PTSD symptom clusters, symptoms, and future high-risk substance use patterns among returning veterans. Accordingly, careful assessment of specific PTSD criteria and differential motivations for substance use is warranted, along with tailored interventions to offset risk for opioid, stimulant, and alcohol use among returning veterans. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Concordance in PTSD symptom change between DSM-5 versions of the Clinician-Administered PTSD Scale (CAPS-5) and PTSD Checklist (PCL-5)

The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) versions of the Clinician-Administered PTSD Scale (CAPS-5) and PTSD Checklist (PCL-5) are widely used PTSD measures. Researchers and clinicians routinely use both measures in tandem to quantify symptom change, despite substantive instrumentation differences beyond administration modality, and absent a theoretical rationale or differential hypotheses for the two measures. The degree to which these measures provide comparable estimates of symptom change is unknown. This study examined concordance in change between CAPS-5 and PCL-5 scores over time. Participants were male veterans (N = 198) randomly assigned to one of two group PTSD treatments. We administered both the CAPS-5 and PCL-5 at baseline, midtreatment, immediately posttreatment, and 3-, 6-, and 12-month posttreatment. Results indicated that CAPS-5 and PCL-5 scores changed over time in a similar manner, as evidenced by generally parallel repeated-measures effect sizes, highly correlated slopes of change (r = .878), and similar associations with improvements in measures of depression and psychosocial functioning. However, the two measures did not produce identical estimates of symptom change. Estimates of symptom improvement were somewhat less concordant at posttreatment follow-up assessments; by the 12-month posttreatment assessment, changes in CAPS-5 scores from baseline indicated somewhat greater symptom improvement than changes in PCL-5 scores (CAPS-5 ESsg = -0.67, PCL-5 ESsg = -0.53). Collectively, results indicate that CAPS-5 and PCL-5 scores produce similar but not identical estimates of PTSD symptom change. Thus, although PCL-5 scores closely approximate symptom change estimated by CAPS-5 scores, the two measures are not interchangeable. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A prospective examination of health care costs associated with posttraumatic stress disorder diagnostic status and symptom severity among veterans

Posttraumatic stress disorder (PTSD) is associated with increased health care costs; however, most studies exploring this association use PTSD diagnostic data in administrative records, which can contain inaccurate diagnostic information and be confounded by the quantity of service use. We used a diagnostic interview to determine PTSD diagnostic status and examined associations between PTSD symptom severity and health care costs and utilization, extracted from Veteran Health Administration (VHA) administrative databases. Using a nationwide longitudinal sample of U.S. veterans with and without PTSD (N = 1,377) enrolled in VHA health care, we determined the costs and utilization of mental health and non-mental health outpatient, pharmacy, and inpatient services for 1 year following cohort enrollment. Relative to veterans without PTSD, those with PTSD had higher total health care, B = 0.47; mental health clinic care, B = 0.72; non-mental health clinic care, B = 0.30; and pharmacy costs, B = 0.72, ps < .001. More severe PTSD symptoms were associated with mental health clinic care costs, B = 0.12; non-mental health clinic care costs, B = 0.27; and higher odds of inpatient, B = 0.63, and emergency service use, B = 0.39, p < .001-p = .012. These findings indicate that veterans' PTSD status, determined by a clinician-administered semistructured diagnostic interview, was associated with higher health care costs and increased use of mental health and non-mental health clinic services. The findings also suggest that more severe PTSD is associated with increased costs and utilization, including costly emergency and inpatient utilization.

Physical inactivity, cigarette smoking, and psychiatric comorbidity among veterans with posttraumatic stress disorder

BACKGROUND

Posttraumatic stress disorder (PTSD) is associated with physical inactivity and cigarette smoking. However, little is known about the degree to which comorbid psychiatric conditions affect the odds of physical inactivity and smoking among individuals with PTSD.

OBJECTIVE

To examine associations between PTSD, comorbid psychiatric conditions (depression, anxiety, or hazardous alcohol/substance use), physical inactivity and smoking among military veterans.

METHOD

This was a cross-sectional analysis of data on U.S. veterans from Project VALOR (Veterans' After-discharge Longitudinal Registry; n = 1140). Logistic regressions examined associations between PTSD, comorbid psychiatric conditions, physical inactivity, and cigarette smoking.

RESULTS

PTSD was associated with increased odds of being physically inactive (odds ratio [OR] = 2.08, p < .001) and a current smoker (OR = 1.39, p = .037), relative to no PTSD. PTSD with cooccurring depression was associated with increased odds for physical inactivity (OR = 2.68, p < .001) and smoking (OR = 1.78, p = .003), relative to PTSD only. PTSD with anxiety was associated with physical inactivity (OR = 2.17, p < .001), whereas cooccurring alcohol (OR = 1.60, p = .023) and substance use (OR = 2.00, p = .001) were associated with smoking. Additionally, numerous combinations of PTSD plus multiple conditions (e.g., PTSD + depression + anxiety) further increased the odds of physical inactivity and smoking (p < .05).

CONCLUSIONS

Greater numbers of psychiatric comorbidities increase the odds of physical inactivity and cigarette smoking among veterans with PTSD. Physical inactivity and cigarette smoking are important predictors of cardiovascular and metabolic disease, and PTSD rarely occurs without psychiatric comorbidity. Thus, additional longitudinal research is needed to determine the impact of these associations, as they have clear physical and mental health implications. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Longitudinal course of mental health symptoms among veterans with and without cannabis use disorder

OBJECTIVE

Cannabis use disorder (CUD) is the most common non-alcohol related substance use disorder (SUD) in the United States and is especially prevalent among returning veterans. The long-term mental health correlates of CUD remain unknown, which is significant given the rise in legalization and also recreational and medicinal cannabis use nationally.

METHOD

Using a gender-balanced, national sample of 1,649 veterans (n = 115 with CUD; 75.2% White; M age = 37.49, SD = 9.88), we used latent growth curve modeling to examine posttraumatic stress disorder (PTSD) symptom severity, depressive symptoms, generalized anxiety, alcohol use, and psychosocial functioning between veterans with versus without a prior diagnosis of CUD over five time points, spanning an average of 7 years.

RESULTS

Returning veterans with CUD compared to those without reported higher alcohol use, depression, anxiety, PTSD symptom severity, and worse psychosocial functioning at baseline. We observed nonlinear change across each outcome. We also found that CUD moderated change in alcohol use (quadratic: b = -.129, p < .001) and PTSD symptoms (quadratic: b = -.280, p = .019), such that individuals with CUD evidenced decelerated change and worse outcomes relative to veterans without a previously documented CUD diagnosis. Trajectories of depression, anxiety, and psychosocial functioning were similar across individuals with versus without CUD.

CONCLUSIONS

In the first long-term and longitudinal evaluation of mental health and alcohol use course among returning veterans, CUD was associated with worse and more persistent alcohol use and PTSD symptom severity over time. These data have implications for clinical assessment, case conceptualization, and treatment of veterans and may inform efforts to offset risk for hazardous drinking and PTSD following a diagnosis of CUD. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Examining unique and prospective relationships among self-injurious thoughts and behaviors and posttraumatic stress disorder: a network analysis in two trauma-exposed samples

BACKGROUND

As self-injurious thoughts and behaviors (SITB) remain a pressing public health concern, research continues to focus on risk factors, such as posttraumatic stress disorder (PTSD). Network analysis provides a novel approach to examining the PTSD-SITB relationship. This study utilized the network approach to elucidate how individual PTSD symptoms may drive and maintain SITB.

METHODS

We estimated cross-sectional networks in two samples of trauma-exposed adults (Sample 1: N = 349 adults; Sample 2: N = 1307 Veterans) to identify PTSD symptoms that may act as bridges to SITB. Additionally, we conducted a cross-lagged panel network in Sample 2 to further clarify the temporal relationship between PTSD symptoms and SITB during a 2-year follow-up. Finally, in both samples, we conducted logistic regressions to examine the utility of PTSD symptoms in prospectively predicting SITB, over a 15-day period (Sample 1) and over a 2-year period (Sample 2), allowing us to examine both short- and long-term prediction.

RESULTS

Two PTSD symptoms (i.e. negative beliefs and risky behaviors) emerged as highly influential on SITB in both cross-sectional networks. In the cross-lagged panel network, distorted blame emerged as highly influential on SITB over time. Finally, risky behaviors, unwanted memories, and psychological distress served as the strongest predictors of SITB across the two samples.

CONCLUSIONS

Overall, our results suggest that treatments targeting negative beliefs and risky behaviors may prevent SITB in community and Veteran populations, whereas treatments targeting distorted blame and unwanted memories may help reduce SITB for individuals with a history of combat trauma.

Predicting suicide attempts among U.S. Army soldiers after leaving active duty using information available before leaving active duty: results from the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS)

Suicide risk is elevated among military service members who recently transitioned to civilian life. Identifying high-risk service members before this transition could facilitate provision of targeted preventive interventions. We investigated the feasibility of doing this by attempting to develop a prediction model for self-reported suicide attempts (SAs) after leaving or being released from active duty in the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS). This study included two self-report panel surveys (LS1: 2016-2018, LS2: 2018-2019) administered to respondents who previously participated while on active duty in one of three Army STARRS 2011-2014 baseline self-report surveys. We focus on respondents who left active duty >12 months before their LS survey (n = 8899). An ensemble machine learning model using predictors available prior to leaving active duty was developed in a 70% training sample and validated in a 30% test sample. The 12-month self-reported SA prevalence (SE) was 1.0% (0.1). Test sample AUC (SE) was 0.74 (0.06). The 15% of respondents with highest predicted risk included nearly two-thirds of 12-month SAs and over 80% of medically serious 12-month SAs. These results show that it is possible to identify soldiers at high post-transition self-report SA risk before the transition. Future model development is needed to examine prediction of SAs assessed by administrative data and using surveys administered closer to the time of leaving active duty.

Posttraumatic Stress Disorder in US Military Veterans: Results From the 2019-2020 National Health and Resilience in Veterans Study

Objective: The US military veteran population is changing rapidly, and contemporary data on the prevalence of DSM-5 posttraumatic stress disorder (PTSD) are lacking. The DSM-5 clarified PTSD Criterion A to delineate direct and indirect trauma exposures, but effects on the conditional probability of PTSD and functional impairment remain unknown. The objectives of this study were to provide contemporary estimates of PTSD prevalence and conditional probabilities in the US military veteran population, determine the likelihood of developing PTSD following direct versus indirect exposures to potentially traumatic events (PTEs), and examine the effects of direct and indirect PTEs and PTSD on functional impairment. Methods: Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study (NHRVS), an online survey of a nationally representative sample of US military veterans conducted from November 2019 to March 2020 (median completion date: November 21, 2019). Trauma exposures were assessed with the Life Events Checklist-5 and PTSD with the PTSD Checklist for DSM-5. Results: The weighted prevalence of lifetime PTSD was 9.4% (95% CI, 8.5%-10.3%) and of past-month PTSD was 5.0% (95% CI, 4.3%-5.7%). Direct PTEs were associated with increased odds of lifetime (odds ratio [OR] = 1.36; 95% CI, 1.30-1.42) and past-month PTSD (OR = 1.38; 95% CI, 1.31-1.46), but indirect PTEs were not (lifetime OR = 1.01; 95% CI, 1.00-1.03; past-month OR = 0.99; 95% CI, 0.97-1.00). Both PTSD (unstandardized B = 6.11, SE = 0.35) and direct PTEs (unstandardized B = 0.13, SE = 0.04), but not indirect PTEs, were significantly associated with functional impairment after adjustment for demographic and psychiatric variables. Conclusions: The prevalence of lifetime PTSD in US military veterans (9.4%) is slightly higher than 2016 estimates (6.9%-8.1%). Direct and indirect PTEs are prevalent in US military veterans, with only direct PTEs associated with higher conditional probability of past-month PTSD and greater functional impairment.

Posttraumatic stress disorder symptoms associated with protective and risky behaviors for coronavirus disease 2019

OBJECTIVE

Psychiatric disorders increase risk for contracting coronavirus disease 2019 (COVID-19), but we know little about relationships between psychiatric symptoms and COVID-19 risky and protective behaviors. Posttraumatic stress disorder (PTSD) has been associated with increased propensity to engage in risky behaviors, but may also be associated with increased COVID-19 protective behaviors due to increased threat sensitivity and social isolation.

METHOD

We examined associations of PTSD symptoms with COVID-19-related protective and risky behaviors using data from a cross-sectional online United States study among 845 US adults in August through September 2020. PTSD symptoms (PTSD Checklist-5), sociodemographics, COVID-19-related experiences and vulnerabilities, and past 30-day engagement in 10 protective and eight risky behaviors for COVID-19 were assessed via self-report. We examined associations between PTSD symptoms and COVID-19 protective and risky behaviors with linear regressions, adjusting for covariates.

RESULTS

Probable PTSD and higher PTSD symptom severity were associated with greater engagement in protective behaviors, but also greater engagement in risky behaviors. Associations were only slightly attenuated by adjustment for COVID-19 exposures and perceived likelihood and severity of COVID-19. Associations varied by PTSD clusters: intrusions and arousal were associated with both more protective and more risky behaviors, whereas negative cognitions or mood was associated only with more risky, and avoidance only with more protective, behaviors.

CONCLUSION

Higher PTSD symptoms were associated with engagement in more protective but also more risky behaviors for COVID-19. Mental health should be considered in the design of public health campaigns dedicated to limiting infectious disease spread. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Effect of Written Exposure Therapy vs Cognitive Processing Therapy on Increasing Treatment Efficiency Among Military Service Members With Posttraumatic Stress Disorder: A Randomized Noninferiority Trial

IMPORTANCE

Posttraumatic stress disorder (PTSD) occurs more commonly among military service members than among civilians; however, despite the availability of several evidence-based treatments, there is a need for more efficient evidence-based PTSD treatments to better address the needs of service members. Written exposure therapy is a brief PTSD intervention that consists of 5 sessions with no between-session assignments, has demonstrated efficacy, and is associated with low treatment dropout rates, but prior randomized clinical trials of this intervention have focused on civilian populations.

OBJECTIVE

To investigate whether the brief intervention, written exposure therapy, is noninferior in the treatment of PTSD vs the more time-intensive cognitive processing therapy among service members diagnosed with PTSD.

DESIGN, SETTING, AND PARTICIPANTS

The study used a randomized, noninferiority design with a 1:1 randomization allocation. Recruitment for the study took place from August 2016 through October 2020. Participants were active-duty military service members diagnosed with posttraumatic stress disorder. The study was conducted in an outpatient setting for service members seeking PTSD treatment at military bases in San Antonio or Killeen, Texas.

INTERVENTIONS

Participants received either written exposure therapy, which consisted of 5 weekly sessions, or cognitive processing therapy, which consisted of 12 twice-weekly sessions.

MAIN OUTCOMES AND MEASURES

Participants were assessed at baseline and at 10, 20, and 30 weeks after the first treatment session. The primary outcome measure was PTSD symptom severity assessed with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). Noninferiority was defined as the difference between the 2 groups being less than the upper bound of the 1-sided 95% CI-specified margin of 10 points on the CAPS-5.

RESULTS

Overall, 169 participants were included in the study. Participants were predominantly male (136 [80.5%]), serving in the Army (167 [98.8%]), with a mean (SD) age of 34 (8) years. Eighty-five participants were randomly assigned to written exposure therapy, with 65 (76.5%) completing all treatment sessions, and 84 to cognitive processing therapy, with 47 (54.8%) completing all treatment sessions. Findings indicated that written exposure therapy was noninferior to cognitive processing therapy, with the largest difference in change in outcome between the treatment conditions of 3.96 points on the outcome measure. The 1-sided 95% CI upper limit was less than 10 points across time points in both groups and ranged from 4.59 at week 30 to 6.81 at week 10. Within-condition effect sizes ranged from a Cohen d of 0.48 for the written exposure therapy group in the intention-to-treat analysis at week 10 to 0.95 for the cognitive processing therapy group in the per-protocol analysis at week 10, and between-condition effect size ranged from 0.06 in the intention-to-treat analysis at week 30 to 0.22 in the per-protocol analysis at week 10.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, support was found for an effective and more efficient PTSD treatment approach for service members. Future research should determine who does and does not benefit from PTSD treatment to best maximize treatment outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03033602.

Comparison of Prolonged Exposure vs Cognitive Processing Therapy for Treatment of Posttraumatic Stress Disorder Among US Veterans: A Randomized Clinical Trial

IMPORTANCE

Posttraumatic stress disorder (PTSD) is a prevalent and serious mental health problem. Although there are effective psychotherapies for PTSD, there is little information about their comparative effectiveness.

OBJECTIVE

To compare the effectiveness of prolonged exposure (PE) vs cognitive processing therapy (CPT) for treating PTSD in veterans.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial assessed the comparative effectiveness of PE vs CPT among veterans with military-related PTSD recruited from outpatient mental health clinics at 17 Department of Veterans Affairs medical centers across the US from October 31, 2014, to February 1, 2018, with follow-up through February 1, 2019. The primary outcome was assessed using centralized masking. Tested hypotheses were prespecified before trial initiation. Data were analyzed from October 5, 2020, to May 5, 2021.

INTERVENTIONS

Participants were randomized to 1 of 2 individual cognitive-behavioral therapies, PE or CPT, delivered according to a flexible protocol of 10 to 14 sessions.

MAIN OUTCOMES AND MEASURES

The primary outcome was change in PTSD symptom severity on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) from before treatment to the mean after treatment across posttreatment and 3- and 6-month follow-ups. Secondary outcomes included other symptoms, functioning, and quality of life.

RESULTS

Analyses were based on all 916 randomized participants (730 [79.7%] men and 186 [20.3%] women; mean [range] age 45.2 [21-80] years), with 455 participants randomized to PE (mean CAPS-5 score at baseline, 39.9 [95% CI, 39.1-40.7] points) and 461 participants randomized to CPT (mean CAPS-5 score at baseline, 40.3 [95% CI, 39.5-41.1] points). PTSD severity on the CAPS-5 improved substantially in both PE (standardized mean difference [SMD], 0.99 [95% CI, 0.89-1.08]) and CPT (SMD, 0.71 [95% CI, 0.61-0.80]) groups from before to after treatment. Mean improvement was greater in PE than CPT (least square mean, 2.42 [95% CI, 0.53-4.31]; P = .01), but the difference was not clinically significant (SMD, 0.17). Results for self-reported PTSD symptoms were comparable with CAPS-5 findings. The PE group had higher odds of response (odds ratio [OR], 1.32 [95% CI, 1.00-1.65]; P < .001), loss of diagnosis (OR, 1.43 [95% CI, 1.12-1.74]; P < .001), and remission (OR, 1.62 [95% CI, 1.24-2.00]; P < .001) compared with the CPT group. Groups did not differ on other outcomes. Treatment dropout was higher in PE (254 participants [55.8%]) than in CPT (215 participants [46.6%]; P < .01). Three participants in the PE group and 1 participant in the CPT group were withdrawn from treatment, and 3 participants in each treatment dropped out owing to serious adverse events.

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found that although PE was statistically more effective than CPT, the difference was not clinically significant, and improvements in PTSD were meaningful in both treatment groups. These findings highlight the importance of shared decision-making to help patients understand the evidence and select their preferred treatment.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01928732.

Reliable and clinically significant change in the clinician-administered PTSD Scale for DSM-5 and PTSD Checklist for DSM-5 among male veterans

We calculated the reliable change index (RCI) and clinically significant change (CSC) values for two widely used measures of posttraumatic stress disorder (PTSD): The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and the PTSD Checklist for DSM-5 (PCL-5) and examined how symptom changes at these thresholds related to improvements in psychosocial functioning. We used data from three independent samples of male military veterans, including two randomized controlled trials for PTSD (N = 198 for Sample 1 and N = 102 for Sample 2) and a cross-sectional study of primary care patients (N = 228). For Sample 1, within-person change in CAPS-5 and PCL-5 scores of ≥ 13 and 15, respectively, was indicative of reliable change. For Sample 2, within-person change in CAPS-5 and PCL-5 scores of ≥ 12 and 18, respectively, was indicative of reliable change. Scores of ≤ 8 and 28 on the CAPS-5 and PCL-5, respectively, indicated a participant is more likely to belong to the non-PTSD population than the PTSD population (i.e., clinically significant change) in both Samples 1 and 2. Participants who exhibited reliable or CSC reported significantly better psychosocial functioning at all posttreatment assessments than those who did not. Results provide thresholds for identifying clinically meaningful PTSD symptom change using these measures. Care should be taken to interpret these values appropriately and relative to numerous other definitions for meaningful symptom change. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Clusters of COVID-19 protective and risky behaviors and their associations with pandemic, socio-demographic, and mental health factors in the United States

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Protective and risky behaviors for COVID-19 cluster in a U.S.-based sample.

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Behavior classes had differing patterns of socio-demographics and pandemic exposure.

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Posttraumatic stress and anxiety were elevated among protective and risky classes.

Individual behaviors are critical for preventing the spread of coronavirus disease 2019 (COVID-19) infection. Given that both protective and risky behaviors influence risk of infection, it is critical that we understand how such behaviors cluster together and in whom. Using a data-driven approach, we identified clusters of COVID-19-related protective and risky behaviors and examined associations with socio-demographic, pandemic, and mental health factors. Data came from a cross-sectional online U.S. nationwide study of 832 adults with high levels of pre-pandemic trauma. Latent class analysis was performed with ten protective (e.g., washing hands, wearing masks) and eight risky (e.g., attending indoor restaurants, taking a flight) behaviors for COVID-19. Then, we examined distributions of socio-demographic and pandemic factors across behavior classes using ANOVA or Chi-square tests, and associations between mental health factors (depressive, anxiety, posttraumatic stress symptoms) and behavior classes using multinomial logistic regression. We identified four classes, including three classes with relatively low risky but high (28.8%), moderate (33.5%) and minimal (25.5%) protective behaviors and one high risky behaviors class with associated moderate protective behaviors (12.1%). Age, sexual orientation, political preference, and most pandemic factors differed significantly across behavior classes. Anxiety and posttraumatic stress symptoms, but not depression, were higher in the High Risk, but also Highly and Moderately Protective classes, relative to Minimally Protective. Prevention and intervention efforts should examine constellations of protective and risky behaviors to comprehensively understand risk, and consider current anxiety and posttraumatic stress symptoms as potential risk indicators.

A Comparison of Dimensional and Categorical Approaches to Characterizing the Association Between Posttraumatic Stress Disorder and Future Suicide Attempts

The present study compared the utility of categorical (i.e., diagnostic status) and dimensional (i.e., symptom severity) approaches to measuring posttraumatic stress disorder (PTSD) in predicting future suicide attempts among participants in a nationwide, longitudinal study of U.S. military veterans who were deployed in support of operations in Iraq or Afghanistan after the September 11, 2001, terrorist attacks (9/11) and were enrolled in Veterans Health Administration services (N = 1,649). Following an initial assessment of PTSD symptoms, we assessed for suicide attempts at two subsequent time points (M = 28.74 months, SD = 8.72 and M = 55.11 months, SD = 6.89 following the initial assessment). Between the initial and final assessments, 125 participants (7.58%) made at least one suicide attempt. All categorical and dimensional indicators of PTSD predicted suicide attempts at both time points except the categorical indicator for reexperiencing symptoms. Categorical indicators predicting suicide attempts demonstrated excellent sensitivity but poor specificity and overall accuracy. The point along the continuum at which PTSD symptom severity was most accurate regarding the prediction of future suicide attempts was well above the threshold previously established as indicating a probable diagnosis. Although this score was less sensitive than diagnostic indicators, it demonstrated greater specificity and overall accuracy in predicting future suicide attempts. The present results indicate that veterans whose PTSD symptoms satisfy the diagnostic criteria have a higher risk of future suicide attempts, but this risk appears to be even higher for veterans with symptom levels above the diagnostic threshold.

Temporal sequences of suicidal and nonsuicidal self-injurious thoughts and behaviors among inpatient and community-residing military veterans

BACKGROUND

Suicidal and nonsuicidal self-injurious thoughts and behaviors (SITBs) are major health concerns among military veterans yet little is known about the temporal relations among these outcomes. This study examined the temporal relations between suicidal and nonsuicidal SITBs among higher-risk veterans. Specifically, we identified when SITBs emerged and evaluated the role of nonsuicidal self-injury (NSSI) in the medical lethality of suicide attempts (SA), relative risk, and survival time of suicidal SITBs (i.e., suicide ideation [SI], suicide plan, SA).

METHOD

Cross-sectional data were collected from two samples examining suicide risk among veterans receiving inpatient psychiatric care (n = 157) and community-residing veterans with current depression and/or past month SI (n = 200). Participants completed an interview to assess SITBs.

RESULTS

SITBs emerged between ages 14-28 years with behaviors emerging, on average, earlier among inpatient veterans. The time lag between SITBs was not significantly different between groups. Inpatient veterans had a significantly shorter time lag from SI to SA. NSSI history predicted an increase in relative risk for all suicidal SITBs and shorter survival time. There was no association between NSSI history and medical lethality of the most serious SA for both groups.

LIMITATIONS

Limitations included use of cross-sectional, retrospective self-report with age-of-onset endorsed in years and not all SITBs were assessed (e.g., passive SI).

CONCLUSIONS

Veterans with a NSSI history are at high risk for suicidal SITBs and have a shorter survival time. Results showed thoughts (i.e., NSSI thoughts, SI) emerged before behavior (i.e., NSSI, SA) and NSSI emerged before SA.