Bidirectional Associations Between Pain and Perceived Stress Among Veterans: Depressive Disorder as a Predisposing Factor.

OBJECTIVE: Military veterans who were injured in combat very often report pain along with co-occurring perceived stress and preexisting depressive disorder. The systems model of pain is a theoretical model suggesting that pain and perceived stress are bidirectionally associated at the within-person level, and associations are heightened among those with depressive disorder. However, the systems model of pain has not been adequately tested. Testing the systems model of pain could illuminate salient treatment targets for combat-injured veterans with pain and co-occurring psychological problems. METHODS: The present study empirically tests the systems model of pain among a sample of combat-injured veterans ( N = 902) surveyed five times during an 18-month period. We used a multigroup, autoregressive latent trajectory with structured residual statistical model to test the within-person associations between pain and perceived stress and determine whether associations differ between veterans with and without a positive screen for depressive disorder. RESULTS: In line with the systems model of pain, pain and perceived stress were bidirectionally associated only among combat-injured veterans with depressive disorder. Among such veterans, perceived stress was positively associated with subsequent pain ( b = 0.12; 95% confidence interval = 0.06-0.17), and pain was positively associated with subsequent perceived stress ( b = 0.44; 95% CI = 0.11-0.77). CONCLUSIONS: Our work highlights the interplay between pain and its psychological correlates among a particularly at-risk population. Clinicians addressing pain and perceived stress among combat-injured veterans should be prepared to identify and address depressive disorder.

Experiences of Sexual Harassment, Stalking, and Sexual Assault During Military Service Among LGBT and Non-LGBT Service Members.

Sexual victimization, including sexual harassment and assault, remains a persistent problem in the U.S. military. Service members identifying as lesbian, gay, bisexual, or transgender (LGBT) may face enhanced risk, but existing research is limited. We examined experiences of sexual harassment, stalking, and sexual assault victimization during service in a sample of LGBT and non-LGBT active duty service members. Service members who identified as LGBT (n = 227 LGB, n = 56 transgender) or non-LGBT (n = 276) were recruited using respondent-driven sampling for an online survey. Logistic regression models examined the correlates of sexual and stalking victimization. Victimization was common among LGBT service members, including sexual harassment (80.7% LGB, 83.9% transgender), stalking (38.6% LGB, 30.4% transgender), and sexual assault (25.7% LGB, 30.4% transgender). In multivariable models, LGB identity remained a significant predictor of sexual harassment, OR = 4.14, 95% CI [2.21, 7.78]; stalking, OR = 1.98, 95% CI [1.27, 3.11]; and assault, OR = 2.07, 95% CI [1.25, 3.41]. A significant interaction between LGB identity and sex at birth, OR = 0.34, 95% CI [0.13, 0.88], suggests an elevated sexual harassment risk among male, but not female, LGB service members. Transgender identity predicted sexual harassment and assault at the bivariate level only. These findings suggest that LGBT service members remain at an elevated risk of sexual and/or stalking victimization. As the military works toward more integration and acceptance of LGBT service members, insight into victimization experiences can inform tailored research and intervention approaches aimed at prevention and care for victims.

Military Sexual Assault as a Mediator of the Association Between Posttraumatic Stress Disorder and Depression Among Lesbian, Gay, and Bisexual Veterans.

Lesbian, gay, and bisexual (LGB) civilians report higher rates of sexual assault, posttraumatic stress disorder (PTSD), and depression compared to their heterosexual counterparts. In this study, we compared military sexual assault (MSA), PTSD, and depression in LGB individuals and their non-LGB peers in two community samples of veterans (N = 2,583). Participants were selected for inclusion if they identified as LGB (n = 110) and were matched 1 to 3 on gender and age with non-LGB veterans (n = 330). Chi-square analyses showed significant differences for LGB veterans compared to non-LGB veterans for experiencing MSA (32.7% vs. 16.4%, respectively), p < .001; probable PTSD (41.2% vs. 29.8%, respectively), p = .039; and probable depression (47.9% vs. 36.0%, respectively), p = .039. Multivariable logistic regression analyses showed LGB veterans were 1.93 times more likely to have experienced MSA compared to non-LGB veterans, 95% CI [1.30, 2.88], p = .001. The experience of MSA significantly mediated associations with probable PTSD, odds ratio (OR) = 1.43, 95% CI [1.13, 1.80], p = .003, and probable depression, OR = 1.32, 95% CI [1.07, 1.64], p = .009. As the experience of MSA fully mediates the presence of PTSD and depression among LGB veterans, we highly recommend health providers assess for MSA among LGB veterans, especially those who meet clinical thresholds for PTSD and depression.

Lesbian, Gay, Bisexual, and Transgender (LGBT) Service Members: Life After Don't Ask, Don't Tell.

Lesbian, gay, and bisexual service members can serve openly in the military with the repeal of the Don't Ask, Don't Tell policy. The fate of transgender service members remains uncertain as the policy preventing them from serving in the military remains under review. The health care needs of these populations remain for the most part unknown, with total acceptance and integration in the military yet to be achieved. In this paper, we review the literature on the health care needs of lesbian, gay, bisexual, and transgender (LGBT) service members, relying heavily on what is known about LGBT civilian and veteran populations. Significant research gaps about the health care needs of LGBT service members are identified, along with recommendations for closing those gaps. In addition, recommendations for improving LGBT acceptance and integration within the military are provided.

Sexual assault in the military.

Military sexual assault is a pervasive problem throughout the military services, despite numerous initiatives to end it. No doubt the military's lack of progress stems from the complexity of sexual assaults, yet in order to develop effective strategies and programs to end sexual assault, deep understanding and appreciation of these complexities are needed. In this paper, we describe the root causes and numerous myths surrounding sexual assault, the military cultural factors that may unintentionally contribute to sexual assault, and the uncomfortable issues surrounding sexual assault that are often ignored (such as the prevalence of male sexual assault within the military). We conclude by offering a broad, yet comprehensive set of recommendations that considers all of these factors for developing effective strategies and programs for ending sexual assault within in the military.

Suicides in the military: the post-modern combat veteran and the Hemingway effect.

Suicides in the military have increased over the last ten years. Much effort has been focused on suicide prevention and treatment, as well as understanding the reasons for the sharp increase in military suicides. Despite this effort, the definitive causes of military suicides remain elusive. Further, highly effective suicide prevention and treatment approaches have not yet been developed. The purpose of this article is to present a short review of the current state of suicide prevention interventions within the context of the military. The root causes of suicidal behavior and the role of combat in the military are each discussed. Interpersonal-psychological theory of suicide and the military transition theory are introduced as guiding frameworks for understanding suicides and suicidal behavior amongst active military personnel and military veterans. The article concludes with a set of recommendations for moving forward in understanding and addressing suicides in the military.

Mental health training with soldiers four months after returning from Iraq: randomization by platoon.

Military personnel report significant and increasing mental health problems in the months following return from combat. Nevertheless, studies have not assessed the impact of mental health training with this at-risk population. The present study evaluated the efficacy of a prototype mental health training module designed for U.S. soldiers 3-6 months after returning from combat; the module was a component of the Battlemind Training system. Soldiers (N = 1,645) were randomly assigned by platoon to 1 hour of training or a survey-only control group. Baseline surveys were conducted immediately before training; a training satisfaction survey was administered immediately after training, and a follow-up survey was administered 6 months later. Immediate postsession surveys were conducted with 681 subjects, and follow-up surveys were conducted with 542 soldiers. The Battlemind Training module received positive ratings from participants, and those who received it reported significantly better adjustment in terms of posttraumatic stress disorder symptoms, depression, and life satisfaction at follow-up compared to those in the survey-only control group. Changes in attitudes about the stigma of seeking mental health care were found immediately posttraining, but not at follow-up. The findings demonstrate that brief mental health training can be effective in reducing mental health systems with at-risk occupational groups.

Moral injury events and behavioral health outcomes among American veterans.

Among American veterans, the behavioral health impact of potentially morally injurious experiences (PMIEs) has recently garnered attention. There is heterogeneity in the types of experiences that are classified as PMIEs, and different PMIEs may be differentially associated with various outcomes. We aimed to explore heterogeneity in PMIEs among veterans, and whether PMIE classes are differentially associated with several behavioral health outcomes (i.e., symptoms of posttraumatic stress disorder, depression, anxiety, and anger). Data were from a survey study of veteran health attitudes and behavior (N=1004). We employed a Latent Class Analysis approach to identify sub-groups of participants with similar PMIE response patterns on the Moral Injury Events Scale and to determine the relationship between class membership and behavioral health outcomes. A 4-class solution best fit our data, with classes including (1) high all, (2) witnessed transgressions, (3) troubled by failure to act, and (4) moderate all. There was a link between class membership and behavioral health, with the high all class and moderate all classes consistently reporting especially poor outcomes. Our results are in line with cumulative stress models suggesting exposure to multiple forms of adversity may place individuals at particular risk of poor health and functioning. Clinicians working with veterans should screen for exposure to the full range of PMIE types and be prepared to address the multitude of behavioral health impacts.

Health and Service-related Impact of Sexual and Stalking Victimization During United States Military Service on LGBT Service Members.

Prior research among military personnel has indicated that sexual harassment, stalking, and sexual assault during military service are related to negative health sequelae. However, research specific to LGBT U.S. service members is limited. The current study aimed to explore the health, service utilization, and service-related impact of stalking and sexual victimization experiences in a sample of active-duty LGBT U.S. service members (N = 248). Respondent-driven sampling was used to recruit study participants. U.S. service members were eligible to participate if they were 18 years or older and active-duty members of the U.S. Army, U.S. Navy, U.S. Marine Corps, or U.S. Air Force. This study included a sizeable portion of transgender service members (N = 58, 23.4%). Sociodemographic characteristics, characteristics of military service, health, and sexual and stalking victimization in the military were assessed. Regression was used to examine relationships between health and service outcomes and sexual and stalking victimization during military service. Final adjusted models showed that experiencing multiple forms of victimization in the military increased the odds of visiting a mental health clinician and having elevated somatic symptoms, posttraumatic stress disorder symptomatology, anxiety, and suicidality. Sexual and stalking victimization during U.S. military service was statistically significantly related to the mental and physical health of LGBT U.S. service members. Interventions to reduce victimization experiences and support LGBT U.S. service members who experience these types of violence are indicated. Research that examines the role of LGBT individuals' experiences and organizational and peer factors, including social support, leadership characteristics, and institutional policies in the United States military is needed.

Effect of transition home from combat on risk-taking and health-related behaviors.

Transition home following a combat deployment involves a period of adjustment. Exploratory and confirmatory factor analyses of a new 16-item transition scale were conducted with 2 samples and resulted in 4 factors (Benefit, Appreciation, Anger/Alienation, and Guilt/Remorse). In Study 1 (N = 1,651), the number of combat events was positively related to Anger/Alienation 4 months later even after controlling for posttraumatic stress disorder (PTSD) symptoms, partial r = .18, p < .001. In Study 2 (N = 647), after controlling for PTSD symptoms, Anger/Alienation assessed at 4 months postdeployment predicted more risk-taking behaviors 4 months later, partial r = .10, p = .01. Appreciation predicted fewer unhealthy habits, partial r = -.13, p = .001, whereas Anger/Alienation predicted more unhealthy habits, partial r = .09, p = .024. Results demonstrate the importance of broadening the conceptualization of adjustment in combat veterans.

An Examination of Stalking Experiences During Military Service Among Female and Male Veterans and Associations With PTSD and Depression.

Stalking is associated with mental health concerns, although little is known about the influence of stalking and mental health concerns among veterans. This study evaluated stalking experienced during military service in two community-based, nonclinical samples of veterans (N = 1,980). Models explored (a) types of stalking, (b) characteristics of veterans who experienced stalking, and (c) the associations between stalking with posttraumatic stress disorder (PTSD) and depression. Types of stalking varied by sex; female veterans were significantly more likely to experience stalking than male veterans (58.5% vs. 34.6%, p < .001, respectively). Female veterans reported unwanted messages, emails, or phone calls (37.2%), and male veterans experienced someone showing up unannounced or uninvited (23.5%) most frequently. Stalking experiences also differed by age with female and male veterans 18 to 39 years old significantly more likely to have experienced stalking (p < .001 and p < .001, respectively) than veterans over age 40. Associations between prior stalking experiences and mental distress were found for both female and male veterans. Both female and male veterans who experienced stalking were significantly more likely to have probable PTSD (odds ratio [OR] = 1.88, 95% confidence interval [CI] = [1.04, 3.39] and OR = 3.08, 95% CI = [2.27, 4.18], respectively) and depression (OR = 2.54, 95% CI = [1.38, 4.58] and OR = 2.78, 95% CI = [2.05, 3.79], respectively). These findings highlight (a) the rates of stalking experienced during military service, (b) the need for assessment of stalking to inform treatment, and (c) lay the foundation for the Department of Defense (DoD) to further evaluate stalking among military populations.

Associations between symptoms of posttraumatic stress disorder, pain, and alcohol use disorder among OEF/OIF/OND veterans.

BACKGROUND: Alcohol use disorder (AUD) is prevalent among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND) veterans. Pain and posttraumatic stress disorder (PTSD) are highly comorbid and increase risk of AUD. Prior studies linking pain or PTSD to AUD have not explored interactions between pain and PTSD symptoms. METHODS: OEF/OIF/OND veterans (N = 1230) were recruited from social media websites for a cross-sectional study of health behavior. Pain was assessed using the Pain Outcomes Questionnaire. PTSD symptoms and PTSD symptom clusters were assessed using the Posttraumatic Stress Disorder Checklist for DSM-5. AUD symptoms were assessed with the AUD Identification Test. Linear regression models were used to test for main and interaction effects in the full sample and separately by sex. RESULTS: Both pain and PTSD symptoms were associated with increased AUD symptomology, though the relationship between pain and AUD was heighted at relatively low PTSD symptoms. With respect to PTSD symptom clusters, re-experiencing and negative cognitions and mood were associated with increased AUD symptomology. Interactions between pain and re-experiencing as well as pain and avoidance were revealed. Results for men mirrored the full sample, while an interaction between pain and negative cognitions and mood was associated with AUD in women. CONCLUSIONS: Results highlight associations between AUD, PTSD symptoms, and pain among veterans. While the relationship between pain and AUD appeared stronger in the context of low PTSD symptoms, both pain and PTSD symptoms were associated with increased AUD. Clinicians treating veterans with AUD should address the range of potential comorbidities.

Support for Transgender Military Service from Active Duty United States Military Personnel.

INTRODUCTION: Most transgender individuals are banned from serving in and joining the U.S. military. Historically, exclusions and limits have been placed on women, people of color, and sexual minority people seeking to serve and advance within the U.S. military. However, both history and prior research demonstrate that diversity contributes to social and institutional advancement within both U.S. and international militaries. METHODS: We used an adapted respondent-driven sampling (RDS) approach to recruit transgender and cisgender heterosexual and LGB active duty military members in a first-of-its-kind study funded by the Department of Defense. We recruited 540 active duty service members serving one of the four major branches of the U.S. military between August 2017 and March 2018. We examined data from 486 heterosexual cisgender and LGB cisgender service members to understand their support for transgender people serving in the U.S. military. RESULTS: Findings indicate broad support for transgender military service across all four branches of the military and military ranks, with some statistically significant differences in support emerging by gender, sexual orientation, and race/ethnicity. DISCUSSION: Results suggest that the ban, in part, based on a belief that transgender service members degrade unit readiness, contradicts our findings of broad support for transgender service among active duty service members. POLICY IMPLICATIONS: Policies limiting transgender service in the U.S. military should be lifted given these data.

Time-driven battlemind psychological debriefing: a group-level early intervention in combat.

Military personnel who experience combat-related events are more likely to report mental health problems yet few early interventions have been designed to do more than assess those with problems or treat those with diagnoses. Psychological debriefing is one early intervention technique that has been used with military populations to reduce symptoms across entire groups. Although there are several different kinds of debriefings, this article describes time-driven Battlemind Psychological Debriefing procedures for use during a combat deployment. The five phases include: Introduction, Event, Reactions, Self and Buddy Aid, and Battlemind Focus. The paper reviews implementation guidelines, scientific support for Battlemind Psychological Debriefing, and feedback from military behavioral health providers in Iraq. Comparisons with other military debriefing models identify unique features and how Battlemind Psychological Debriefing is integrated into the larger Battlemind Training system.

Moving Beyond Housing: Service Implications for Veterans Entering Permanent Supportive Housing.

As a result of efforts to end homelessness among U.S. veterans, more former service members are entering permanent supportive housing (PSH). While PSH has been successfully used to house homeless veterans, more research is needed about services beyond housing placement and retention. This study uses the Gelberg-Andersen behavioral model for vulnerable populations to determine associations between predisposing, enabling, and need characteristics and recent service use (i.e., services to satisfy basic needs, occupational development, financial, healthcare, mental health) among unaccompanied homeless veterans (N=126) entering PSH in Los Angeles. Among the significant findings, as indicated using univariable logistic regression models, were veterans who had incarceration histories were more likely to utilize basic needs services, compared to those without incarceration histories. Veterans who received an honorable discharge were more likely to utilize occupational development services, compared to veterans with other discharge statuses. Veterans who had a case manager were more likely to utilize mental health services than those without a case manager, while those who received social security were less likely to utilize mental health services compared to veterans who did not receive social security. Veterans who met criteria for a psychological disability and veterans who met criteria for probable PTSD were more likely to use basic needs services and mental health services than veterans who fell below these thresholds. Clinical implications for social workers including "equal access to services," "enhancing economic stability," "providing safe and affordable housing with trauma-informed services," and "training service social workers to deliver well-informed linkages and services" are discussed.

The stigma of mental health problems in the military.

The present review addresses the perceived stigma associated with admitting a mental health problem and seeking help for that problem in the military. Evidence regarding the public stigma associated with mental disorders is reviewed, indicating that the public generally holds negative stereotypes toward individuals with psychological problems, leading to potential discrimination toward these individuals. The internalization of these negative beliefs results in self-stigma, leading to reduced self-esteem and motivation to seek help. Even if soldiers form an intention to seek help for their psychological difficulty, barriers to mental health care may prevent the soldier from receiving the help they need. An overall model is proposed to illustrate how the stigma associated with psychological problems can prevent soldiers getting needed help for psychological difficulties and proposed interventions for reducing stigma in a civilian context are considered for military personnel.

Expanding the Understanding of Risk Behavior Associated With Homelessness Among Veterans.

INTRODUCTION: To advance large-scale efforts to end veteran homelessness, an understanding of factors that contribute to housing insecurity is necessary. Common risk behaviors (e.g., substance use and risky sexual practices) are associated with lengthier experiences of homelessness among the general homeless population, but less understood among homeless veterans. Additionally, whether emerging risk behaviors among veterans (e.g., sensation seeking and aggression) are associated with lengthy homeless experiences is unknown. MATERIALS AND METHODS: Data were drawn from a sample of Los Angeles County veterans surveyed using a mixed nonprobability sampling strategy, which included recruiting veterans via national and local veterans service organizations, college organizations, and social media campaigns. Measures aligning with factors of sensation seeking (reckless driving, gambling, suicidal ideation); substance use (alcohol misuse, tobacco use, driving while intoxicated); risky sexual practices (risking getting a sexually transmitted disease); and aggression (looking to start a fight) were tested in multivariate, multinomial logistic regression analyses to determine their association with varying lengths of homelessness in the past year (less than 1 month, 2-6 months, 6 months to 1 year). RESULTS: Risking getting a sexually transmitted disease, gambling, suicidal ideation, alcohol misuse, tobacco use, driving while intoxicated, and looking to start a fight were associated with 6 or more months of homelessness. Several indicators of risk were associated with brief periods of homelessness, including gambling and looking to start a fight. Although a clear exposure-response effect was not detected with risk behaviors, results suggested there may be some wavering of engagement in risk behaviors over time. CONCLUSION: Findings suggest sensation seeking and aggression risk behaviors should be included in risk assessments and prevention efforts along with substance use and risky sexual practices to reduce veterans' risk of becoming homeless and reducing risk of chronic homelessness. Further research is needed to understand the trajectory of these risk behaviors and the mechanisms that underlie the association between these risk behaviors and homelessness for veterans.

Self-engagement, stressors, and health: a longitudinal study.

The authors examined whether engagement in a performance domain could buffer or exacerbate the consequences of different stressors. Soldiers completed measures of engagement in work, work demands (days training, work hours, and subjective work overload), and symptoms at two time periods. Engagement in work interacted with days training and work hours at Time 1 to predict health symptoms at Time 2 (after controlling Time 1 outcomes). Soldiers highly engaged in their jobs were less likely to report negative consequences under high levels of training/work hours in comparison to soldiers disengaged from their jobs. However, engagement in work interacted with work overload in the opposite manner, with high levels of engagement potentiating the relationship between overload and reports of health symptoms. Engagement in a domain appears to buffer individuals from stressors that do not undermine performance but may exacerbate the impact of stressors that compromise performing well in the domain.

The impact of deployment length and experience on the well-being of male and female soldiers.

This study examined the effects of stressor duration (deployment length) and stressor novelty (no prior deployment experience) on the psychological health of male and female military personnel returning from a peacekeeping deployment. The sample consisted of men (n = 2,114) and women (n = 1,225) surveyed for symptoms of depression and posttraumatic stress. The results confirmed the hypotheses. Longer deployments and 1st-time deployments were associated with an increase in distress scores. However, the relationship between deployment length and increased distress was found only for male soldiers. The findings demonstrate the importance of considering the impact of exposure to long-term occupational stressors and confirm, in part, previous research that has demonstrated a different stress response pattern for men and women.

How leaders can influence the impact that stressors have on soldiers.

The present review addresses the importance of leader behaviors in influencing the extent to which various stressors soldiers experience (e.g., high workload and lack of sleep) are related to different types of strains (e.g., psychological health, poor job satisfaction, and low morale). Research conducted by the Walter Reed Army Institute of Research (WRAIR) in the area of leadership is reviewed. Researchers at the WRAIR have examined the role of leadership as a predictor of stress, as a buffer against the negative effects of stress, and as a variable that predicts or enables variables that have been found to decrease the adverse effects of stress (e.g., role clarity, self-efficacy, and job engagement). A key strength of the WRAIR program of research is the use of multilevel modeling to examine how perceptions of leadership at the unit level are related to unit and individual soldier well-being and motivation.