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.

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.

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.

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.

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.

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.

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.

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.

Development and validation of the Durham Risk Score for estimating suicide attempt risk: A prospective cohort analysis.

BACKGROUND: Worldwide, nearly 800,000 individuals die by suicide each year; however, longitudinal prediction of suicide attempts remains a major challenge within the field of psychiatry. The objective of the present research was to develop and evaluate an evidence-based suicide attempt risk checklist [i.e., the Durham Risk Score (DRS)] to aid clinicians in the identification of individuals at risk for attempting suicide in the future. METHODS AND FINDINGS: Three prospective cohort studies, including a population-based study from the United States [i.e., the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) study] as well as 2 smaller US veteran cohorts [i.e., the Assessing and Reducing Post-Deployment Violence Risk (REHAB) and the Veterans After-Discharge Longitudinal Registry (VALOR) studies], were used to develop and validate the DRS. From a total sample size of 35,654 participants, 17,630 participants were selected to develop the checklist, whereas the remaining participants (N = 18,024) were used to validate it. The main outcome measure was future suicide attempts (i.e., actual suicide attempts that occurred after the baseline assessment during the 1- to 3-year follow-up period). Measure development began with a review of the extant literature to identify potential variables that had substantial empirical support as longitudinal predictors of suicide attempts and deaths. Next, receiver operating characteristic (ROC) curve analysis was utilized to identify variables from the literature review that uniquely contributed to the longitudinal prediction of suicide attempts in the development cohorts. We observed that the DRS was a robust prospective predictor of future suicide attempts in both the combined development (area under the curve [AUC] = 0.91) and validation (AUC = 0.92) cohorts. A concentration of risk analysis found that across all 35,654 participants, 82% of prospective suicide attempts occurred among individuals in the top 15% of DRS scores, whereas 27% occurred in the top 1%. The DRS also performed well among important subgroups, including women (AUC = 0.91), men (AUC = 0.93), Black (AUC = 0.92), White (AUC = 0.93), Hispanic (AUC = 0.89), veterans (AUC = 0.91), lower-income individuals (AUC = 0.90), younger adults (AUC = 0.88), and lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) individuals (AUC = 0.88). The primary limitation of the present study was its its reliance on secondary data analyses to develop and validate the risk score. CONCLUSIONS: In this study, we observed that the DRS was a strong predictor of future suicide attempts in both the combined development (AUC = 0.91) and validation (AUC = 0.92) cohorts. It also demonstrated good utility in many important subgroups, including women, men, Black, White, Hispanic, veterans, lower-income individuals, younger adults, and LGBTQ individuals. We further observed that 82% of prospective suicide attempts occurred among individuals in the top 15% of DRS scores, whereas 27% occurred in the top 1%. Taken together, these findings suggest that the DRS represents a significant advancement in suicide risk prediction over traditional clinical assessment approaches. While more work is needed to independently validate the DRS in prospective studies and to identify the optimal methods to assess the constructs used to calculate the score, our findings suggest that the DRS is a promising new tool that has the potential to significantly enhance clinicians' ability to identify individuals at risk for attempting suicide in the future.

Experiential avoidance is associated with medical and mental health diagnoses in a national sample of deployed Gulf War veterans.

A substantial minority of deployed Gulf War veterans developed posttraumatic stress disorder (PTSD), depression, and several chronic illnesses. Although military combat and exposure to certain nuclear, biological, and chemical agents (NBCs) increase risk for post-deployment health problems, they do not fully explain many Gulf War veteran health diagnoses and are not viable treatment targets. Experiential avoidance (EA; one's unwillingness to remain in contact with unpleasant internal experiences) is a modifiable psychosocial risk factor associated with PTSD and depression in veterans as well as pain and gastrointestinal diseases in the general population. In this study, we recruited a national sample of deployed Gulf War veterans (N = 454) to test the hypothesis that greater EA would be significantly associated with higher lifetime odds of PTSD, depression, "Gulf War Illness" (GWI/CMI), and other chronic illnesses common in this veteran cohort. Participants completed a self-report battery assessing demographic, military-related, and health-related information. Multivariate analyses showed that after adjusting for age, sex, race, combat exposure, and NBC exposure, worse EA was associated with higher lifetime odds of PTSD, depression GWI/CMI, gastrointestinal problems, irritable bowel syndrome, arthritis, fibromyalgia, and chronic fatigue syndrome (ORs ranged 1.25 to 2.89; effect sizes ranged small to large), but not asthma or chronic obstructive pulmonary disease. Our findings suggest medical and mental health providers alike should assess for EA and potentially target EA as part of a comprehensive, biopsychosocial approach to improving Gulf War veterans' health and wellbeing. Study limitations and future research directions are also discussed.

Nonsuicidal Self-Injury Disorder, Borderline Personality Disorder, and Lifetime History of Suicide Attempts among Male and Female Veterans with Mental Health Disorders.

BACKGROUND: Expanding on research that has identified nonsuicidal self-injury (NSSI) as a strong predictor of suicide risk, the present study examined NSSI disorder (NSSID) and borderline personality disorder (BPD) as unique contributors to lifetime suicide attempts. To our knowledge, the present study represents the first exploration of these associations among veterans. METHODS: Participants included 124 male (74%) and female (26%) veterans diagnosed with at least one mental health disorder. Posttraumatic stress disorder (93%) and major depression (86%) were the most common mental health diagnoses. Large proportions of the sample met criteria for NSSID (48%) and BPD (40%). Suicide attempts were reported by 28% of the sample. Chi-square tests determined the bivariate associations among NSSID, BPD, history of suicide attempts, and other variables. Significant diagnostic (i.e., MDD, BPD, and NSSID) and demographic (i.e., age) characteristics were included as covariates in a logistic regression model examining the associations of BPD and NSSID with suicide attempts. RESULTS: BPD, Χ2=11.1, p<0.001, and NSSID, Χ2=13.9, p<0.001, were uniquely associated with suicide attempts. When all significant predictors were included in the final model, only NSSID emerged as a significant contributor to suicide attempts, OR = 4.9, p < 0.001. LIMITATIONS: Causality cannot be determined from cross-sectional analyses. CONCLUSION: These findings highlight NSSID as a powerful and unique correlate of suicide attempts among veterans, beyond the associations of established diagnostic risk factors. Improving our understanding of the relationship between NSSID and suicide risk has the potential to inform suicide prevention efforts and improve clinical outcomes among veterans.

The effects of posttraumatic stress disorder symptoms on educational functioning in student veterans.

Posttraumatic stress disorder (PTSD) occurs at high rates among student veterans and is known to negatively impact educational functioning; however, the unique effects of PTSD are less clear, given that PTSD is highly comorbid with many other conditions that could potentially affect educational functioning. The present study had two objectives: (a) to determine the impact of PTSD symptom severity on educational functioning after accounting for demographic variables, traumatic brain injury, and commonly co-occurring mental health conditions; and (b) to identify which symptom clusters of PTSD have the greatest impact on educational functioning. Educational functioning and other commonly occurring mental health conditions were assessed cross-sectionally among 90 student veterans. Traumatic brain injury and major depressive disorder (MDD) were initially associated with impaired educational functioning; however, after adding PTSD into the final model, only PTSD (ß = .44, p < .001) and MDD (ß = .31, p = .001) remained associated with educational impairment. Follow-up analyses indicated that the reexperiencing symptom cluster was most strongly associated with impaired educational functioning (ß = .28, p = .031). Overall, these results suggest that PTSD symptoms-especially reexperiencing symptoms-may be a driving force behind impaired educational impairment, even after accounting for other commonly co-occurring mental health conditions. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Factor Structure and Initial Validation of a Brief Measure of Perceived Emotional and Physical Distress Tolerance in Post-9/11 US Veterans.

Distress tolerance (i.e., perceived or actual capacity to tolerate aversive internal states) has received considerable research attention as a transdiagnostic risk-factor underlying the development and maintenance of psychopathology. Lower levels of emotional distress tolerance have been linked to psychopathology (e.g. Posttraumatic Stress Disorder) within Military populations; however, the association of physical distress tolerance to psychopathology in this population has been under-researched. This research gap may be due in part to a paucity of comprehensive, temporally stable and brief measures of distress tolerance that have been validated within Military populations, which may hinder further examination and refinement of the construct. Addressing this problem, the current study evaluates the psychometric properties of a novel and brief measure of emotional and physical distress tolerance in a sample of United States post-9/11 Veterans. Participants were 307 Veterans (Mage= 38.9, 67.7% male) who completed the 10-item Distress Tolerance Inventory at baseline and annual follow-up. Exploratory structural equation modeling was used to examine the optimal latent factor structure and longitudinal invariance of the DTI measurement model, along with correlational analyses to examine the convergent properties of the DTI subscales. The DTI reflected a longitudinally invariant two-factor structure (emotional and physical distress tolerance), with excellent internal consistency and preliminary evidence of convergent validity. Thus, the DTI represents a brief, reliable and temporally stable measure of physical and emotional distress tolerance.

Resilience facilitates adjustment through greater psychological flexibility among Iraq/Afghanistan war veterans with and without mild traumatic brain injury.

OBJECTIVES: Although many Iraq/Afghanistan warzone veterans report few problems with adjustment, a substantial proportion report debilitating mental health symptoms and functional impairment, suggesting the influence of personal factors that may promote adjustment. A significant minority also incur warzone-related traumatic brain injury (TBI), the majority of which are of mild severity (mTBI). We tested direct and indirect pathways through which a resilient personality prototype predicts adjustment of warzone veterans with and without mTBI over time. METHOD: A sample of 264 war veterans (181 men) completed measures of lifetime and warzone-related TBIs, personality traits, psychological adjustment, quality of life, and functional impairment. Social support, coping, and psychological flexibility were examined as mediators of the resilience-adjustment relationship. Instruments were administered at baseline, 4-, 8-, and 12-month assessments. Structural equation models accounted for combat exposure and response style. RESULTS: Compared with a nonresilient personality prototype, a resilient prototype was directly associated with lower PTSD, depression, and functional disability, and higher quality of life at all time-points. Warzone mTBIs frequency was associated with higher scores on a measure of functional disability. Indirect effects via psychological flexibility were observed from personality to all outcomes, and from warzone-related mTBIs to PTSD, depression, and functional disability, at each time-point. CONCLUSIONS: Several characteristics differentiate veterans who are resilient from those who are less so. These findings reveal several factors through which a resilient personality prototype and the number of mTBIs may be associated with veteran adjustment. Psychological flexibility appears to be a critical modifiable factor in veteran adjustment. (PsycINFO Database Record (c) 2019 APA, all rights reserved).