Veteran suicide prevention learning collaborative: implementation strategy and processes.

The majority of Veterans who died by suicide in 2021 had not recently used Veterans Health Administration (VA) services. A public health approach to Veteran suicide prevention has been prioritized as part of the VA National Strategy for Preventing Veteran Suicide. Aligned with this approach, VA's Patient Safety Center of Inquiry-Suicide Prevention Collaborative piloted a Veteran suicide prevention learning collaborative with both clinical and non-clinical community agencies that serve Veterans. The VA COmmunity LeArning CollaboraTive (CO-ACT) uses a quality improvement framework and facilitative process to support community organizational implementation of evidence-based and best practice suicide prevention strategies to achieve this goal. This paper details the structure of CO-ACT and processes by which it is implemented. This includes the CO-ACT toolkit, an organizational self-assessment, a summary of recommendations, creation of a blueprint for change, selection of suicide prevention program components, and an action plan to guide organizations in implementing suicide prevention practices. CO-ACT pilot outcomes are reported in a previous publication.

Sequenced treatment effectiveness for posttraumatic stress (STEPS) trial: A protocol for a pragmatic comparative effectiveness trial with baseline results.

BACKGROUND: There have only been two efficacy trials reporting a head-to-head comparison of medications and psychotherapy for PTSD, and neither was conducted in primary care. Therefore, this protocol paper describes a pragmatic trial that compares outcomes of primary care patients randomized to initially receive a brief trauma-focused psychotherapy or a choice of three antidepressants. In addition, because there are few trials examining the effectiveness of subsequent treatments for patients not responding to the initial treatment, this pragmatic trial also compares the outcomes of those switching or augmenting treatments. METHOD: Patients screening positive for PTSD (n = 700) were recruited from the primary care clinics of 7 Federally Qualified Health Centers (FQHC) and 8 Department of Veterans Affairs (VA) Medical Centers and randomized in the ratio 1:1:2 to one of three treatment sequences: 1) selective serotonin reuptake inhibitor (SSRI) followed by augmentation with Written Exposure Therapy (WET), 2) SSRI followed by a switch to serotonin-norepinephrine reuptake inhibitor (SNRI), or 3) WET followed by a switch to SSRI. Participants complete surveys at baseline, 4 months, and 8 months. The primary outcome is PTSD symptom severity as measured by the PTSD Checklist (PCL-5). RESULTS: Average PCL-5 scores (M = 52.8, SD = 11.1) indicated considerable severity. The most common bothersome traumatic event for VA enrollees was combat (47.8%), and for FQHC enrollees was other (28.2%), followed by sexual assault (23.4%), and child abuse (19.8%). Only 22.4% were taking an antidepressant at baseline. CONCLUSION: Results will help healthcare systems and clinicians make decisions about which treatments to offer to patients.

Quantifying relational change in community organisations participating in a Veteran suicide prevention learning collaborative: a social network analysis.

BACKGROUND: Veteran suicide remains a significant issue, as 17.5 Veterans die by suicide each day. The US Department of Veteran Affairs (VA) has implemented a robust suicide prevention program within its integrated behavioural health system. Further, the VA has increasingly contributed to suicide prevention in community settings, where a large proportion of Veterans receive health care and social services. One component integral to preventing suicide among Veterans receiving community services is ensuring that organisations are equipped with the latest evidence-based Veteran-specific suicide prevention strategies. METHODS: The Patient Safety Center of Inquiry-Suicide Prevention Collaborative piloted a Veteran suicide prevention learning collaborative in the Denver/Colorado Springs, CO region, spanning 16 months as a multimodal initiative to integrate community organisations and assist them in implementing Veteran suicide prevention strategies used within VA. Agencies completed social network analysis surveys at baseline (T1), year 1 (T2) and 16 months (T3) to examine social networks, partnerships and collaborations among community organisations and the VA over time. RESULTS: The quantity of learning collaborative relationships increased from 30 at T1 to 41 at T3 while the quality of relationships deepened over time from awareness and cooperative to more coordinated and integrated. CONCLUSION: Improvement in relationship quantity and quality facilitates community organisation engagement in collaborating to strengthen their Veteran suicide prevention programming. Learning collaboratives work with the individual organisation for intraorganisational facilitation of implementing suicide prevention strategies and engage and enhance interorganisational partnerships. This multimodal intervention can engage community organisations and provide a stronger safety net for Veterans at risk for suicide.

Suicide Prevention Programming: Comparing Four Prominent Frameworks.

OBJECTIVE: Suicide is a significant public health concern. About 48,000 individuals died by suicide in 2021 in the United States, and approximately one in 100 deaths globally are due to suicide. Continuing efforts in program development and evaluation are vital to preventing suicide. Multiple frameworks have been developed to reduce suicide rates, but they have not been compared to assess their comprehensiveness, nor have their components been classified. METHODS: In 2019, the authors conducted a narrative review of the literature and identified four major frameworks for suicide prevention: the U.S. Department of Veterans Affairs (VA) Suicide Prevention Program, the Defense Suicide Prevention Program of the U.S. Department of Defense, Zero Suicide in Health and Behavioral Health Care, and the technical package developed by the Centers for Disease Control and Prevention. Program components for these frameworks were identified and classified by using two prevention strategy classification systems: the National Academy of Medicine's (NAM's) continuum-of-care model and the Substance Abuse and Mental Health Services Administration's (SAMHSA's) prevention model. RESULTS: The cross-program comparison revealed that no single program included all components of suicide prevention programs. However, the VA program was the most comprehensive in terms of the number of components and their spread across prevention strategy classifications. The programs used few components categorized under NAM's promotion or selective prevention strategy classifications. The SAMHSA prevention strategy classifications of information dissemination, community-based processes, and positive alternatives were also used infrequently. CONCLUSIONS: Organizations, health care systems, and policy makers may use these findings as they develop, improve, and implement suicide prevention programs.

Living With Toxic Wounds: The Voices and Visual Self-Representations of Gulf War Veterans.

Operations Desert Shield and Storm occurred over 30 years ago, yet many of those who were deployed continue to experience chronic and debilitating symptoms, now recognized as Gulf War Illness (GWI). While efforts have been made to explore clinical treatments for GWI, misperceptions and skepticism about its complex nature and a lack of consensus on its etiology impede progress in this area. A critical necessity remains to better understand the experiences, needs, and concerns of veterans with GWI. In this qualitative research study, 40 Gulf War veterans were interviewed about their perceptions regarding symptoms of physical health, cognitive functioning, quality of life, and the quality of care received. In addition, they depicted their experiences through an artistic elicitation collage. Through a grounded theory method, key findings indicated that there are remaining hurdles, such as challenging symptoms, persisting unknowns about the illness, and variations in treatment quality. Veterans have mostly managed and coped with GWI, but they voice the need for acknowledgment and support. The main implication from this study is the significance of both clinical and institutional validation and recognition of the GWI experience as well as the need for specific support systems.

A pilot of a veteran suicide prevention learning collaborative among community organizations: Initial results and outcomes.

INTRODUCTION: Veteran suicide remains an ongoing public health concern in need of fresh, community-based initiatives. The Department of Veterans Affairs (VA) has built an enterprise-wide integrated behavioral health system that has pioneered numerous suicide prevention methods. However, most Veterans receive healthcare outside the VA, from organizations that may not be equipped to address Veteran suicide risk. One solution is implementing a VA/community suicide prevention learning collaborative to support organizations in implementing suicide prevention best practices for Veterans. Although learning collaboratives have a history of supporting improved patient safety in healthcare systems, to our knowledge, none have focused on Veteran suicide prevention. METHOD: The current quality improvement project sought to pilot a VA/community suicide prevention learning collaborative in the broader Denver and Colorado Springs areas with 13 organizations that served, interacted with, or employed Veterans. RESULTS: The collaborative had a large footprint in the region, with organizations interacting with over 24,000 community members and over 5000 Veterans. Organizations implemented 92 Veteran suicide prevention program components within a 16-month period. Overall, the learning collaborative made significant strides in Veteran suicide prevention. CONCLUSION: Findings suggest that this method facilitates rapid implementation of Veteran suicide prevention practices and may be promising for accelerating uptake within communities.

COVID-19 and Lifetime Experiences of Trauma, Moral Injury, and Institutional Betrayal Among Healthcare Providers.

OBJECTIVE: The aim of the study is to increase understanding regarding healthcare provider experiences with psychological trauma, moral injury, and institutional betrayal, both over the lifetime and during the COVID-19 pandemic. METHODS: The study employed a cross-sectional design to understand traumatic experiences, moral injury, and institutional betrayal among medical and mental health providers. Participants were asked to identify an index trauma, and experiences were coded qualitatively using categories for traumatic events, moral injury, and institutional betrayal. RESULTS: Results revealed that experiences of trauma, moral injury, and institutional betrayal were common in relation to the pandemic, as were prepandemic histories of traumatic exposures. Findings indicate that trauma exposure was a work hazard for healthcare providers during the pandemic, which could result in negative long-term mental health outcomes. CONCLUSIONS: Future research is needed to explore potential long-term negative outcomes among healthcare providers.

Veteran Experiences With Suicide Ideation, Suicide Attempt, and Social Support in Safety Planning Within the Department of Veterans Affairs.

INTRODUCTION: This evaluation examined the role of safety plans, one of a host of clinical suicide prevention interventions available for veterans through the United States Department of Veterans Affairs' national network of health care facilities managed by the Veterans Health Administration (VHA). MATERIALS AND METHODS: Interviews were conducted with veterans who had experienced suicidal ideation or a suicide attempt since enrolling in the Department of Veterans Affairs health care system (N = 29). Topics included negative life experiences, triggers for suicidal ideation or a suicide attempt, ability to recall and utilize safety plans in crisis, safety plan elements found most and least useful, and improvements to safety planning. RESULTS: Eighteen (62.07%) of the veterans in the sample had attempted suicide. Drug use was by far the most triggering and overdose was the most negative life event to subsequent ideation or attempt. Although all at-risk veterans should have a safety plan, only 13 (44.38%) created a safety plan, whereas 15 (51.72%) could not recall ever creating a safety plan with their provider. Among those who did recall making a safety plan, identifying warning signs was the most remembered portion. The most useful safety plan elements were: recognizing warning signs, supportive people and distracting social settings, names and numbers of professionals, giving the veteran personal coping strategies, options for using the plan, and keeping their environment safe. For some veterans, safety plans were seen as insufficient, undesirable, not necessary, or lacking a guarantee. The suggested improvements included involving concerned significant others, specific actions to take in a crisis, and potential barriers and alternatives. CONCLUSIONS: Safety planning is a critical component in suicide prevention within VHA. However, future research is needed to ensure safety plans are accessible, implemented, and useful to veterans when in crisis.

Perceived Family Support Buffers the Impact of PTSD-Depression Symptoms on Suicidal Ideation in College Students.

Students reporting symptoms of posttraumatic stress disorder (PTSD) and depression are at increased risk for suicidal ideation, putting them at greater risk for suicidal behavior and attempts. Perceived social support is a robust protective factor against the impact of PTSD and depression on suicidal ideation in college students, however different forms of social support (family, friends, significant others) may have greater influence on this association. In the current study, the influence of the different types of perceived social support on the relationship between PTSD-depression symptoms and suicidal ideation in college students were examined. College students (N = 928; 71% female) were recruited in part of a cross-sectional survey study examining the role of mental health on education functioning. A hierarchical regression indicated that PTSD-depression symptoms (b = .27, p < .001) and perceived family support (b = -.04, p < .01) were significantly associated with current suicidal ideation, while perceived support from friends (b = -.02, p = .417) and significant others (b = -.01, p = .301) were not. Perceived family support interacted with PTSD-depression symptoms (b = -.03, p < .05) to weaken the positive influence of symptoms on current suicidal ideation. Perceived family support appears to be the significant component of social support that moderates the relationship between PTSD-depression symptoms and suicidal ideation. Future research should focus on strengthening family support as a potential mechanism to mitigate suicide risk among college students who may be away from their families for the first time.

Associations between nonfatal firearm injuries and risk of subsequent suicide among Veteran VA users: A retrospective cohort study.

BACKGROUND: Suicide is a leading cause of death in the United States, particularly among Veterans. Nonfatal firearm injuries may indicate subsequent risk of suicide and, thus, provide important opportunities for prevention in emergency departments and other health care settings. We used a retrospective cohort design to analyze associations between nonfatal firearm injuries and subsequent suicide among all Veterans who used U.S. Department of Veterans Affairs (VA) health care, nationally, between 2010 and 2019. METHODS: We linked VA health care and mortality data to identify VA users, nonfatal firearm injuries, and deaths. International Classification of Diseases (ICD)-10th Revision cause-of-death codes were used to identify suicides. Veterans' firearm injuries and their intent were categorized using cause-of-injury codes from the ICD Clinical Modification-9th and 10th Revisions systems. Using bivariable and multivariable regression, we estimated risk of subsequent suicide among Veterans with, versus without, nonfatal firearm injuries. Among Veterans with nonfatal firearm injuries, we examined characteristics associated with subsequent suicide; electronic health record (chart) reviews explored documentation about firearm access among those who died. RESULTS: Among 9,817,020 VA-using Veterans, 11,503 experienced nonfatal firearm injuries (64.9% unintentional, 12.3% intentional self-harm, 18.5% assault). Of these, 69 (0.6%) subsequently died by suicide (42 involving firearms). The odds of subsequent suicide among Veterans with, versus without, nonfatal firearm injuries were 2.4 (95% confidence interval 1.9-3.0); odds were only slightly attenuated in multivariable modeling. Among Veterans with nonfatal firearm injuries, those with depression or substance use disorder diagnoses had twice the odds of subsequent suicide than those without. Chart reviews identified small proportions of suicide decedents who were assessed for (21.7%), and/or counseled about (15.9%), firearm access. CONCLUSIONS: Findings suggest that Veterans' nonfatal firearm injuries, regardless of injury intent, may be important but underutilized opportunities for suicide prevention. Future work should explore mechanisms to reduce risk among these patients.

Associations Among PTSD, Cognitive Functioning, and Health-Promoting Behavior in Post-9/11 Veterans.

INTRODUCTION: PTSD is associated with negative health behaviors that increase chronic disease risk, yet health behaviors and their determinants are not well investigated in this context. One understudied mechanism of health behaviors is cognitive functioning. Deficits in cognitive functioning may undermine engagement in health-promoting behavior, thereby increasing the negative impact of PTSD. We tested three hypotheses: (1) Greater PTSD symptom severity is associated with less health-promoting behavior; (2) greater PTSD symptom severity is associated with poorer cognitive functioning across verbal memory, processing speed, attention, and executive functioning domains; and (3) verbal memory and executive functioning exhibit indirect effects on the relationship between PTSD and health-promoting behavior. MATERIALS AND METHODS: We examined associations between PTSD symptom severity (Clinician-Administered PTSD Scale for DSM-IV), cognitive functioning, and health-promoting behavior (Health-Promoting Lifestyle Profile II) in 124 post-9/11 veterans (average age = 37.82; 85.5% male; 63.7% White; 18.5% Black; 26.6% Hispanic). Cognitive domains examined included verbal memory (California Verbal Learning Test), processing speed (Digit Symbol Coding), attention and working memory (Digit Span), and executive functions (Trail Making Test and Stroop Interference). RESULTS: Regression analyses indicated that greater PTSD symptom severity was associated with less health-promoting behavior (B = -.0101, SE = 0.0016, P < .0001; R2 = 0.3052). Path analyses revealed that verbal learning and memory partially accounted for this relationship (R2 = 0.037- 0.043; P < .05). CONCLUSIONS: Therapeutic targeting of these relationships may have implications for the prevention of long-term disease impact in veterans; longitudinal research is needed to elucidate the potential impact on chronic disease.

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.

Massed vs Intensive Outpatient Prolonged Exposure for Combat-Related Posttraumatic Stress Disorder: A Randomized Clinical Trial.

Importance: Improved, efficient, and acceptable treatments are needed for combat-related posttraumatic stress disorder (PTSD). Objective: To determine the efficacy of 2 compressed prolonged exposure (PE) therapy outpatient treatments for combat-related PTSD. Design, Setting, and Participants: This randomized clinical trial was conducted among military personnel and veterans at 4 sites in Texas from 2017 to 2019. Assessors were blinded to conditions. Data were analyzed from November 2020 to October 2022. Interventions: The interventions were massed-PE, which included 15 therapy sessions of 90 minutes each over 3 weeks, vs intensive outpatient program PE (IOP-PE), which included 15 full-day therapy sessions over 3 weeks with 8 treatment augmentations. The IOP-PE intervention was hypothesized to be superior to massed-PE. Main Outcomes and Measures: Coprimary outcomes included the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) (CAPS-5) and the PTSD Checklist for DSM-5 (PCL-5) administered at baseline and posttreatment follow-ups. Measures ranged from 0 to 80, with higher scores indicating greater severity. Diagnostic remission and reliable change were secondary outcomes. Results: Among 319 military personnel and veterans screened, 234 were randomized (mean [SD] age, 39.20 [7.72] years; 182 [78%] male participants), with 117 participants randomized to IOP-PE and 117 participants randomized to massed-PE. A total of 61 participants (26%) were African American, 58 participants (25%) were Hispanic, and 102 participants (44%) were White; 151 participants (65%) were married. Linear mixed-effects models found that CAPS-5 scores decreased in both treatment groups at the 1-month follow-up (IOP-PE: mean difference, -13.85 [95% CI, -16.47 to -11.23]; P < .001; massed-PE: mean difference, -14.13 [95% CI, -16.63 to -11.62]; P < .001). CAPS-5 change scores differed from 1- to 6-month follow-ups (mean difference, 4.44 [95% CI, 0.89 to 8.01]; P = .02). PTSD symptoms increased in massed-PE participants during follow-up (mean difference, 3.21 [95% CI, 0.65 to 5.77]; P = .01), whereas IOP-PE participants maintained treatment gains (mean difference, 1.23 [95% CI, -3.72 to 1.27]; P = .33). PCL-5 scores decreased in both groups from baseline to 1-month follow-up (IOP-PE: mean difference, -21.81 [95% CI, -25.57 to -18.04]; P < .001; massed-PE: mean difference, -19.96 [95% CI, -23.56 to -16.35]; P < .001) and were maintained at 6 months (IOP-PE: mean change, -0.21 [95% CI, -3.47 to 3.06]; P = .90; massed-PE: mean change, 3.02 [95% CI, -0.36 to 6.40]; P = .08). Both groups had notable PTSD diagnostic remission at posttreatment (IOP-PE: 48% [95% CI, 36% to 61%] of participants; massed-PE: 62% [95% CI, 51% to 73%] of participants), which was maintained at 6 months (IOP-PE: 53% [95% CI, 40% to 66%] of participants; massed-PE: 52% [95% CI, 38% to 66%] of participants). Most participants demonstrated reliable change on the CAPS-5 (61% [95% CI, 52% to 69%] of participants) and the PCL-5 (74% [95% CI, 66% to 81%] of participants) at the 1-month follow-up. Conclusions and Relevance: These findings suggest that PE can be adapted into compressed treatment formats that effectively reduce PTSD symptoms. Trial Registration: ClinicalTrials.gov Identifier: NCT03529435.

The influence of cannabis use disorder on post-traumatic stress disorder symptoms, depression symptoms, and non-suicidal self-injury among college students.

Objective: The interrelationships between cannabis use disorder (CUD), post-traumatic stress disorder (PTSD) and depressive symptoms, and non-suicidal self-injury (NSSI) were examined. Participants: Undergraduates (N = 363) who reported using cannabis within the past six months were recruited. Method: Mediation analyses was conducted to examine if CUD symptoms were indirectly associated with greater risk for engagement in current NSSI through more severe PTSD and depression symptoms. A factor comprised of PTSD-depression symptoms was created given PTSD and depression symptoms were highly correlated. Results: Greater CUD symptom severity indirectly increased risk for current NSSI via more severe PTSD-depression symptoms, after accounting for gender and alcohol use disorder symptoms. Conclusion: The current study provides preliminary evidence for the negative consequences of CUD on college students' mental health symptoms and engagement in NSSI, and future longitudinal research is needed to examine the dynamic relationships between CUD, PTSD-depression symptoms, and NSSI over time.

A brief report on the temporal relations between social functioning and behavioral health among veterans.

Using a four-wave longitudinal design, three competing hypotheses (i.e., social selection, social causation, and reciprocal causation) were tested pertaining to the relation between social functioning and several indices of behavioral health [i.e., post-traumatic stress symptoms (PTSS), distress, and alcohol-related problems] among military veterans exposed to trauma. Across two latent growth curve analyses, data largely supported longitudinal links between improved social functioning and positive behavioral health, often indicating that the improvements in social functioning frequently precede improvements in behavioral health. Overall, findings underscore the merit of directly targeting social functioning as part of mental health treatment among trauma-exposed individuals.

The effects of loneliness and psychological flexibility on veterans' substance use and physical and mental health functioning during the COVID-19 pandemic.

During the COVID-19 pandemic, social isolation was a common experience as people were trying to keep themselves and others safe from infection. Veterans with problematic substance use are at particular risk of the consequences of social isolation. This study evaluated the nature of social interactions during the COVID-19 pandemic and the effects of loneliness and psychological flexibility on self-reported substance use and physical and mental health functioning among U.S. veterans who reported problematic substance use. Data from 409 veterans with self-reported substance use concerns were obtained via a cross-sectional online survey. Results showed that many veterans who engaged in problematic substance use during the COVID-19 pandemic reported a number of social supports during this period and frequent communication with others, but still felt lonelier during the pandemic. In regression analyses, higher levels of loneliness were associated with more negative impacts of the pandemic, greater substance use, and poorer physical and mental health functioning. Psychological flexibility demonstrated significant unique variance in explaining mental health functioning during the pandemic after accounting for loneliness, but not for substance use or physical functioning. For veterans with high levels of loneliness, high levels of psychological flexibility were associated with a lower negative impact on quality of life due to the pandemic, but for veterans with low levels of loneliness, differing levels of psychological flexibility were not significantly associated with the negative impact of COVID-19. Overall, loneliness and psychological flexibility appear to be highly associated with the negative impact of COVID-19 on veterans with problematic substance use.

Affective states and nonsuicidal self-injury (NSSI): Results from an ecological momentary assessment study of veterans with NSSI disorder.

BACKGROUND: The affective states most strongly associated with nonsuicidal self-injury (NSSI) remain poorly understood, particularly among veterans. This study used ecological momentary assessment (EMA) to examine relationships between affect ratings and NSSI urges and behaviors among veterans with NSSI disorder. METHODS: Participants (N = 40) completed EMA entries via mobile phone for 28 days (3722 total entries). Entries included intensity ratings for five basic affective states, as well as NSSI urges and behaviors, during the past 4 hours. RESULTS: Bivariate analyses indicated that each affect variable was significantly associated with both NSSI urges and behaviors. Angry/hostile and sad were most strongly associated with both NSSI urges and behaviors. A multivariate regression revealed that angry/hostile, disgusted with self, and happy (inversely related) were contemporaneously (within the same period) associated with NSSI behaviors, whereas all five basic affective states were contemporaneously associated with NSSI urges. In a lagged model, angry/hostile and sad were associated with subsequent NSSI urges but not behaviors. CONCLUSIONS: Findings highlight the relevance of particular affective states to NSSI and the potential utility of targeting anger in treatments for NSSI among veterans. There is a need for future EMA research study to further investigate temporal relationships between these variables.

A common language for Gulf War Illness (GWI) research studies: GWI common data elements.

AIMS: The Gulf War Illness programs (GWI) of the United States Department of Veteran Affairs and the Department of Defense Congressionally Directed Medical Research Program collaborated with experts to develop Common Data Elements (CDEs) to standardize and systematically collect, analyze, and share data across the (GWI) research community. MAIN METHODS: A collective working group of GWI advocates, Veterans, clinicians, and researchers convened to provide consensus on instruments, case report forms, and guidelines for GWI research. A similar initiative, supported by the National Institute of Neurologic Disorders and Stroke (NINDS) was completed for a comparative illness, Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS), and provided the foundation for this undertaking. The GWI working group divided into two sub-groups (symptoms and systems assessment). Both groups reviewed the applicability of instruments and forms recommended by the NINDS ME/CFS CDE to GWI research within specific domains and selected assessments of deployment exposures. The GWI CDE recommendations were finalized in March 2018 after soliciting public comments. KEY FINDINGS: GWI CDE recommendations are organized in 12 domains that include instruments, case report forms, and guidelines. Recommendations were categorized as core (essential), supplemental-highly recommended (essential for specified conditions, study types, or designs), supplemental (commonly collected, but not required), and exploratory (reasonable to use, but require further validation). Recommendations will continually be updated as GWI research progresses. SIGNIFICANCE: The GWI CDEs reflect the consensus recommendations of GWI research community stakeholders and will allow studies to standardize data collection, enhance data quality, and facilitate data sharing.

STRONG STAR and the Consortium to Alleviate PTSD: Shaping the future of combat PTSD and related conditions in military and veteran populations.

The STRONG STAR Consortium (South Texas Research Organizational Network Guiding Studies on Trauma and Resilience) and the Consortium to Alleviate PTSD are interdisciplinary and multi-institutional research consortia focused on the detection, diagnosis, prevention, and treatment of combat-related posttraumatic stress disorder (PTSD) and comorbid conditions in military personnel and veterans. This manuscript outlines the consortia's state-of-the-science collaborative research model and how this can be used as a roadmap for future trauma-related research. STRONG STAR was initially funded for 5 years in 2008 by the U.S. Department of Defense's (DoD) Psychological Health and Traumatic Brain Injury Research Program. Since the initial funding of STRONG STAR, almost 50 additional peer-reviewed STRONG STAR-affiliated projects have been funded through the DoD, the U.S. Department of Veterans Affairs (VA), the National Institutes of Health, and private organizations. In 2013, STRONG STAR investigators partnered with the VA's National Center for PTSD and were selected for joint DoD/VA funding to establish the Consortium to Alleviate PTSD. STRONG STAR and the Consortium to Alleviate PTSD have assembled a critical mass of investigators and institutions with the synergy required to make major scientific and public health advances in the prevention and treatment of combat PTSD and related conditions. This manuscript provides an overview of the establishment of these two research consortia, including their history, vision, mission, goals, and accomplishments. Comprehensive tables provide descriptions of over 70 projects supported by the consortia. Examples are provided of collaborations among over 50 worldwide academic research institutions and over 150 investigators.

Dynamics of risk: Recent changes in psychological inflexibility precede subsequent changes in returning US veterans' posttraumatic stress.

OBJECTIVES: As a malleable risk-factor, psychological inflexibility is implicated in the development and maintenance of posttraumatic stress symptoms (PTS). Unfortunately, limited research has addressed whether changes in psychological inflexibility are antecedent to changes in PTS severity over time, or whether such changes are mutually dependent. METHODS: Utilizing bivariate latent difference score modeling, this longitudinal study sequenced intraindividual changes in psychological inflexibility and PTS severity within a sample of 305 returning US veterans. Veterans' self-reported psychological inflexibility and PTS severity were assessed quarterly over 1 year. RESULTS: Results indicated that early reductions in psychological inflexibility potentiated later declines in veterans' PTS severity, accounting for veterans' prior levels of psychological inflexibility and PTS severity. CONCLUSIONS: These findings underscore the unique role of changes in psychological inflexibility as an important mechanism of change in PTS severity and provide empirical support for an antecedent model of the role of psychological inflexibility in PTS recovery.