A Mobile App for Postoperative Pain Management Among Older Veterans Undergoing Total Knee Arthroplasty: Mixed Methods Feasibility and Acceptability Pilot Study.

BACKGROUND: Prescription opioid misuse risk is disproportionate among veterans; military veterans wounded in combat misuse prescription opioids at an even higher rate (46.2%). Opioid misuse is costly in terms of morbidity, mortality, and humanitarian and economic burden and costs the Civilian Health and Medical Program of the Department of Veterans Affairs more than US $1.13 billion annually. Preventing opioid misuse at the time of prescription is a critical component in the response to the opioid crisis. The CPMRx mobile app has been shown to decrease the odds of opioid misuse during the postoperative period. OBJECTIVE: The overarching purpose of this feasibility pilot study was to explore whether deploying a mobile app (CPMRx) to track postoperative pain and medication use is feasible in a Department of Veterans Affairs medical center. In support of this goal, we had four complementary specific aims: (1) determine the technological and logistical feasibility of the mobile app, (2) assess the acceptability of the mobile app to participants, (3) measure demand for and engagement with the mobile app, and (4) explore the potential use of the mobile app to patients and providers. METHODS: Participants (N=10) were veterans undergoing total knee arthroplasty within the Veterans Health Administration provided with the CPMRx app to self-manage their pain during their 7-day at-home recovery following surgery. CPMRx uses scientifically validated tools to help clinicians understand how a patient can use the least amount of medication while getting the most benefit. The suite of software includes a mobile app for patients that includes a behavioral health intervention and a clinical decision support tool for health care providers that provides feedback about pain and medication use trends. Patients filled out paper questionnaires regarding acceptability at their postoperative follow-up appointment. RESULTS: Overall, quantitative measures of acceptability were high. The average rating for the amount of time required to use the app was 4.9 of 5 (5="very little"), and the average rating for ease of use was 4.4 of 5 (5="very easy"). Open-ended questions also revealed that most participants found ease of use to be high. Demand and engagement were high as well with a mean number of mobile app entries of 34.1 (SD 20.1) during the postoperative period. There were no reported technological or logistical issues with the mobile app. Participants took an average of 25.13 (SD 14.37) opioid tablets to manage their postoperative pain. CONCLUSIONS: Results of this study revealed that the use of a mobile app for pain and medication management during postoperative recovery was both feasible and acceptable in older veterans undergoing total knee arthroplasty within the Veterans Health Administration. The wide variation in opioid consumption across participants revealed the potential use of the mobile app to provide actionable insights to clinicians if adopted more widely.

Effect of Stellate Ganglion Block Treatment on Posttraumatic Stress Disorder Symptoms: A Randomized Clinical Trial.

Importance: This is the first multisite, randomized clinical trial of stellate ganglion block (SGB) outcomes on posttraumatic stress disorder (PTSD) symptoms. Objective: To determine whether paired SGB treatments at 0 and 2 weeks would result in improvement in mean Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) total symptom severity scores from baseline to 8 weeks. Design, Setting, and Participants: This multisite, blinded, sham-procedure, randomized clinical trial used a 2:1 SGB:sham ratio and was conducted from May 2016 through March 2018 in 3 US Army Interdisciplinary Pain Management Centers. Only physicians performing the procedures and the procedure nurses were aware of the intervention (but not the participants or assessors); their interactions with the participants were scripted and limited to the 2 interventions. Active-duty service members on stable psychotropic medication dosages who had a PTSD Checklist-Civilian Version (PCL-C) score of 32 or more at screening were included. Key exclusion criteria included a prior SGB treatment, selected psychiatric disorders or substance use disorders, moderate or severe traumatic brain injury, or suicidal ideation in the prior 2 months. Interventions: Paired right-sided SGB or sham procedures at weeks 0 and 2. Main Outcomes and Measures: Improvement of 10 or more points on mean CAPS-5 total symptom severity scores from baseline to 8 weeks, adjusted for site and baseline total symptom severity scores (planned a priori). Results: Of 190 screened individuals, 113 (59.5%; 100 male and 13 female participants; mean [SD] age, 37.3 [6.7] years) were eligible and randomized (74 to SGB and 39 to sham treatment), and 108 (95.6% of 113) completed the study. Baseline characteristics were similar in the SGB and sham treatment groups, with mean (SD) CAPS-5 scores of 37.6 (11.2) and 39.8 (14.4), respectively (on a scale of 0-80); 91 (80.0%) met CAPS-5 PTSD criteria. In an intent-to-treat analysis, adjusted mean total symptom severity score change was -12.6 points (95% CI, -15.5 to -9.7 points) for the group receiving SGB treatments, compared with -6.1 points (95% CI, -9.8 to -2.3 points) for those receiving sham treatment (P = .01). Conclusions and Relevance: In this trial of active-duty service members with PTSD symptoms (at a clinical threshold and subthreshold), 2 SGB treatments 2 weeks apart were effective in reducing CAPS-5 total symptom severity scores over 8 weeks. The mild-moderate baseline level of PTSD symptom severity and short follow-up time limit the generalizability of these findings, but the study suggests that SGB merits further trials as a PTSD treatment adjunct. Trial Registration: ClinicalTrials.gov identifier: NCT03077919.

Perceptions of High-Risk Situations for Sexual Assault: Gender Differences in the U.S. Air Force.

This study explored U.S. Air Force service members' perceptions of high-risk situations for sexual assault victimization. Qualitative data were collected from 52 active duty Airmen, including sexual assault survivors and general population officers and enlisted personnel. Participants were recruited through posted flyers, base-wide e-mail messages, and referrals from the Sexual Assault Response Coordinator's office. Content analysis was used to summarize participants' opinions and experiences. High-risk situations for all Airmen included excessive alcohol use, specific physical settings, and situations associated with work assignments. High-risk situations identified frequently by male and female sexual assault survivors and female (but not male) general population Airmen included power imbalance; isolation in the workplace and social settings; and youth, inexperience, and unfamiliarity with the military environment. Female Airmen identified workplaces with a predominance of men or being one of very few women in a group as a high-risk situation for sexual assault victimization. And female sexual assault survivors identified implicit but unwarranted trust between Airmen as a high-risk situation. This study provides new insight into gender differences in high-risk situations for sexual assault victimization, and the data can help policymakers better prevent sexual assault by appropriately tailoring and timing sexual assault risk reduction training.

Trends in mental health outcomes and combat exposure among US marines returning from Iraq, Afghanistan or other deployments, 2004-13.

BACKGROUND: As of 2015, more than 2.7 million US military Veterans have served in support of the Global War on Terror. The negative sequelae associated with deployment stressors and related traumas are well-documented. Although data on mental health issues are routinely collected from service members returning from deployment, these data have not been made publicly available, leaving researchers and clinicians to rely on convenience samples, outdated studies and small sample sizes. METHODS: Population-based data of US Marines returning from deployment between 2004 and 2013 were analyzed, using the Post-Deployment Health Assessment. RESULTS: Rates of Marines returning from Iraq who screened positive for depression ranged from 19.31 to 30.02%; suicidal ideation ranged from 0 to 1.44%. Marines screening positive for PTSD ranged from 3.00 to 12.41%; combat exposure ranged from 15.58 to 55.12%. Depression was indicated for between 12.54 and 30.04% of Marines returning from Afghanistan, while suicidal ideation ranged from 0 to 5.33%. PTSD percentages ranged from 6.64 to 18.18%; combat exposure ranged between 42.92 and 75%. CONCLUSION: Our results support the heterogeneity of experiences and mental health sequelae of service members returning from deployments. Outcomes for Afghanistan and Iraq Veterans fluctuate with changes in OPTEMPO across theaters over time.

Resilience as a moderating factor between stress and alcohol-related consequences in the Army National Guard.

Due to the current prolonged conflicts in Iraq and Afghanistan, members of the United States National Guard and Reserve have shifted from a historically support-based role to an integral segment of combat efforts. Clinical and epidemiological research studies conducted on both civilian and military populations have documented high rates of comorbidity of stress disorders and substance use disorders. It is widely understood that excessive alcohol use is an issue among military personnel. The aim of this paper is to describe risk factors for alcohol-related serious consequences in a study of Army National Guard service members, as well as the role of resilience in protecting against these risks. Members of the National Guard (N=320) participated in the survey. We conducted a multiple regression to predict alcohol-related serious consequences and a simple moderation analysis was performed. After controlling for race, education, and deployment history, several variables emerged as significant predictors of alcohol-related consequences. Higher stressors, lower resilience, younger age, being unmarried and not living as married, being male, and identifying as non-Hispanic were associated with higher levels of serious alcohol-related consequences. Results revealed that resilience significantly moderated the relationship between stress and alcohol-related consequences. This study furthers our understanding of the alcohol-stress relationship by contextualizing it in terms of behaviors related to alcohol, as opposed to measuring consumption only. Most importantly, our work extends prior research in its examination of resilience as a moderator of the relationship between stress and serious alcohol-related consequences.

Health-Related Coping Behaviors and Mental Health in Military Personnel.

BACKGROUND: Our previous research has highlighted the important link between coping behaviors and mental health symptoms in military personnel. This study seeks to extend these findings by examining each coping behavior and mental health issue individually. This study has four specific aims: (1) test cross-sectional relationships between coping and mental health at baseline and follow-up, (2) examine stability of each variable over time, (3) determine the predictive nature of baseline mental health and coping on subsequent mental health and coping, (4) assess the magnitude of each effect to evaluate the differential predictive value of coping behaviors and mental health symptoms. METHODS: A convenience sample of U.S. Army platoons of the 82nd Airborne was surveyed. We used a two-wave, cross-lagged autoregression design with structural equation modeling to disentangle elements of temporality and to examine the predictive value of mental health status vis-à-vis coping behaviors and vice versa. Separate analyses were performed with each coping strategy and each set of mental health symptoms. This design allowed for the analysis of two synchronous associations (i.e., cross-sectional correlations between the coping strategy and mental health symptoms at each time point), two autoregressive effects (i.e., baseline mental health predicting mental health at follow-up and baseline coping predicting coping at follow-up), and two cross-lagged effects (i.e., baseline coping strategy predicting mental health at follow-up and baseline mental health predicting follow-up coping). RESULTS: Results of descriptive statistics revealed that the most frequently reported coping behavior was thinking of a plan to solve the problem, followed by talking to a friend, engaging in a hobby, and exercising or playing sports. The least often endorsed coping behaviors were smoking marijuana or using illicit drugs and thinking about hurting or killing oneself, followed by having a drink or lighting up a cigarette. We verified many cross-sectional relationships between coping behaviors and mental health symptoms. Specifically, talking to a friend, exercising or playing sports, engaging in a hobby, and thinking of a plan were associated with fewer anxiety, perceived stress, and depression symptoms, whereas smoking a cigarette, having a drink, and thinking about hurting or killing oneself were associated with more anxiety, perceived stress, and depressive symptoms. Marijuana and illicit drug use was also associated with higher depressive symptoms. Saying a prayer was not significantly related to mental health. Only four cross-lagged effects were significant. Those who reported more depressive symptoms at Time 1 reported talking to friends and family less and exercising or playing sports less as coping behaviors at Time 2. Baseline perceived stress predicted less likelihood of engaging in a hobby at follow-up, whereas exercising or playing sports as a coping behavior at baseline predicted lower perceived stress at follow-up. DISCUSSION: This study expands the evidence for the associations between coping behaviors and psychological health or distress to specific mental health symptoms, particularly in military service members, and provides comparisons of magnitude of each association. Clinically, this knowledge is critical to more efficiently target behaviors with the greatest associations to mental health in military personnel.

Help-Seeking Behaviors Among Active-Duty Military Personnel: Utilization of Chaplains and Other Mental Health Service Providers.

Military chaplains not only conduct religious services, but also provide counseling and spiritual support to military service members, operating as liaisons between soldiers and mental health professionals. In this study, active-duty soldiers (N = 889) reported help-seeking behaviors and mental health. Using logistic regressions, we describe the issues for which soldiers reported seeking help, then outline the characteristics of those who are most likely to seek help from a chaplain. Of the soldiers who sought help from a chaplain within the previous year, 29.9% reported high levels of combat exposure, 50.8% screened positive for depression, 39.1% had probable PTSD, and 26.6% screened positive for generalized anxiety disorder. The participant's unit firing on the enemy, personally firing on the enemy, and seeing dead bodies or human remains predicted seeing a chaplain. Future research should examine ways to engage soldiers who have had more combat experiences with the chaplain community to address spiritual issues.