Evaluation of implementation facilitation integrated into a national mentoring programme to improve access to evidence-based psychotherapy for post-traumatic stress disorder within the veterans health administration: a quality improvement report.

Despite the resources dedicated to specialised mental healthcare for patients with post-traumatic stress disorder (PTSD) within the US Veterans Health Administration, evidence-based psychotherapies (EBPs) for PTSD have been underutilised, as evidenced by low EBP reach to patients. A research-operation collaboration evaluated whether implementation facilitation delivered by regional PTSD mentors as part of a national mentoring programme improved EBP reach compared with less-intensive quality improvement interventions. We used a non-equivalent comparison-group design that included all PTSD clinics with low EBP reach at baseline (n=51). Clinics were grouped into one of four quality improvement conditions according to self-selection by regional PTSD mentors: facilitation (n=6), learning collaborative (n=15), mentoring as usual in the regions that had facilitation-target clinics (n=15) and mentoring as usual in other regions (n=15). The primary outcome was EBP reach among therapy patients with PTSD at preintervention baseline and postintervention sustainment periods. We used the ratio of odds ratios (ROR) between the two time periods to evaluate the effectiveness of facilitation compared with the other conditions, adjusting for patient-level and clinic-level confounders. 26 126 veterans with PTSD received psychotherapy in one of 51 low-reach PTSD clinics during preintervention baseline and postintervention sustainment periods. The odds of a patient receiving an EBP increased over time across conditions. The adjusted ORs of a patient receiving an EBP from baseline to sustainment were 1.35-1.69 times larger in clinics that received facilitation compared with the three comparison conditions (adjusted RORs of comparison condition versus facilitation ranged from 0.59 (95% CI 0.47 to 0.75) to 0.74 (95% CI 0.58 to 0.94)). Implementation facilitation can be integrated into a national programme for quality improvement for PTSD specialty care and may be particularly useful when less-intensive approaches are not sufficiently effective.

Treatment-related beliefs and reactions among trauma-focused therapy completers and discontinuers: A qualitative examination.

Prolonged exposure (PE) and cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) are effective, but some patients do not respond adequately, and dropout rates are high. Patients' beliefs about treatment and perceptions of treatment components influence treatment outcomes and may be amenable to change through intervention. The present study sought to identify beliefs and reactions to PE and CPT that differentiated completers who screened negative for a PTSD diagnosis after treatment (PTSD-), completers who screened positive for a PTSD diagnosis after treatment (PTSD+), and discontinuers who attended six or fewer sessions. Thematic analysis was used to identify themes in qualitative data collected via retrospective semistructured interviews with 51 completers (19 PTSD- after treatment, 32 PTSD+ after treatment) and 66 discontinuers of PE/CPT. Participants were demographically diverse veterans across service eras. Treatment-related beliefs and reactions differentiating these groups included perceived helpfulness of treatment, self-efficacy in engaging in treatment, anticipatory anxiety and concerns, interpretations of ongoing symptoms, and perceived consequences of treatment on functioning. Further, some patterns seemed to differ in early treatment sessions compared to during the active components of treatment. Findings point to potentially malleable targets that could be intervened upon to improve trauma-focused treatment outcomes. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The Effects of Suicide Exposure on Mental Health Outcomes Among Post-9/11 Veterans: Protocol for an Explanatory, Sequential, Mixed Methods Study.

BACKGROUND: The toll associated with suicide goes well beyond the individual who died. This study focuses on a risk factor for veteran suicide that has received little previous empirical attention-exposure to the suicide death of another person. OBJECTIVE: The study's primary objective is to describe the mental health outcomes associated with suicide exposure among veterans who served on active duty after September 2001 ("post-9/11"). The secondary objective is to elucidate why some veterans develop persistent problems following suicide exposure, whereas others do not. METHODS: This is an explanatory, sequential, mixed methods study of a nationally representative sample of post-9/11 veterans enrolled in Department of Veterans Affairs (VA) health care. Our sampling strategy was designed for adequate representation of female and American Indian and Alaska Native veterans to allow for examination of associations between suicide exposure and outcomes within these groups. Primary outcomes comprise mental health problems associated with trauma and loss (posttraumatic stress disorder and prolonged grief disorder) and suicide precursors (suicidal ideation, attempts, and planning). Data collection will be implemented in 3 waves. During wave 1, we will field a brief survey to a national probability sample to assess exposure history (suicide, other sudden death, or neither) and exposure characteristics (eg, closeness with the decedent) among 11,400 respondents. In wave 2, we will include 39.47% (4500/11,400) of the wave-1 respondents, stratified by exposure history (suicide, other sudden death, or neither), to assess health outcomes and other variables of interest. During wave 3, we will conduct interviews with a purposive subsample of 32 respondents exposed to suicide who differ in mental health outcomes. We will supplement the survey and interview data with VA administrative data identifying diagnoses, reported suicide attempts, and health care use. RESULTS: The study began on July 1, 2022, and will end on June 30, 2026. This is the only national, population-based study of suicide exposure in veterans and the first one designed to study differences based on sex and race. Comparing those exposed to suicide with those exposed to sudden death for reasons other than suicide (eg, combat) and those unexposed to any sudden death may allow for the identification of the common and unique contribution of suicide exposure to outcomes and help seeking. CONCLUSIONS: Integrating survey, qualitative, and VA administrative data to address significant knowledge gaps regarding the effects of suicide exposure in a national sample will lay the foundation for interventions to address the needs of individuals affected by a suicide death, including female and American Indian and Alaska Native veterans. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/51324.

Provider perceptions of their patients' dropout from trauma-focused therapy for PTSD in the U.S. Veterans Health Administration.

OBJECTIVE: Many patients who initiate prolonged exposure (PE) and cognitive processing therapy (CPT) do not complete a full course, although little is known about how providers view PE and CPT dropout among their own patients. METHOD: Semistructured interviews were conducted with providers (n = 29) in the Veterans Health Administration to understand each provider's experience of dropout by a specific patient whom they treated using PE or CPT. Content analysis was used to categorize perceptions of dropout as negative, somewhat negative, or not negative. Themes associated with somewhat or not negative views of dropout were identified via inductive coding. RESULTS: Fourteen percent of providers viewed their patient's dropout from PE or CPT as wholly negative, 38% as somewhat negative, and 48% as not a negative outcome. Themes associated with viewing dropout as something other than wholly negative included belief that the patient would not benefit from treatment if they were not ready, the importance of maintaining the therapeutic relationship, the view that trauma-focused therapy was not what the patient needed or that the patient could benefit from other approaches, the impression that the patient had made some gains, and that patients are responsible for treatment engagement and have the right to disengage. CONCLUSIONS: Providers' perceptions of dropout from PE or CPT for individual patients were rarely viewed as entirely negative. Research is needed to help providers determine when patient dropout is an undesirable outcome and when efforts to reengage patients in trauma-focused treatment are warranted. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Making sense of poor adherence in PTSD treatment from the perspectives of veterans and their therapists.

OBJECTIVE: Dropout rates from trauma-focused PTSD treatments (TFTs) in VA clinics are particularly high. We conducted in-depth qualitative interviews with 29 veterans and their therapists to better understand this phenomenon. METHOD: Participants were part of a multisite, mixed-methods study of TFT adherence in VA clinics. Veterans were eligible for interviews if they exhibited poor TFT adherence and screened positive for PTSD in follow-up surveys. Interviews were analyzed using qualitative dyadic analysis approaches. RESULTS: Therapists relied on stereotypes of poor adherence to understand veterans' experiences and were missing information critical to helping veterans succeed. Veterans misunderstood aspects of the therapy and struggled in ways they inadequately expressed to therapists. Therapist attempts at course corrections were poorly matched to veterans' needs. Many dyads reported difficulties in their therapeutic relationships. Veterans reported invalidating experiences that were not prominent in therapists' interviews. CONCLUSIONS: Future work is needed to test hypotheses generated and find effective ways to help veterans fully engage in TFTs. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Divergent experiences of U.S. veterans who did and did not complete trauma-focused therapies for PTSD: A national qualitative study of treatment dropout.

Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) are first-line treatments for posttraumatic stress disorder (PTSD) and have been disseminated throughout the U.S. Veterans Health Administration. Treatment non-completion is common and lessens clinical effectiveness; however, prior work has failed to identify factors consistently associated with non-completion. Semi-structured interviews were conducted with a national sample of veterans who recently completed (n = 60) or did not complete (n = 66) PE or CPT. Non-completer interviews focused on factors that contributed to veterans' decisions to drop out and efforts undertaken to complete PE/CPT. Completer interviews focused on challenges faced in completing treatment and facilitators of completion. Transcripts were coded using a mixed deductive/inductive approach; constant comparison was used to identify differences between completers and non-completers. Completers and non-completers differed in the extent of treatment-specific therapist support received, therapists' flexibility in treatment delivery, the type of encouragement offered by the care team and social supports, their interpretation of symptom worsening, the perceived impact of treatment on functioning, and the impact of stressors on their treatment engagement. Treatment-specific therapist support, more patient-centered and flexible treatment delivery, leveraging the full care team, and addressing functional concerns are potential targets for PE and CPT engagement interventions.

Can families help veterans get more from PTSD treatment? A randomized clinical trial examining Prolonged Exposure with and without family involvement.

BACKGROUND: Posttraumatic stress disorder occurs in as many as one in five combat veterans and is associated with a host of negative, long-term consequences to the individual, their families, and society at large. Trauma-focused treatments, such as Prolonged Exposure, result in clinically significant symptom relief for many. Adherence to these treatments (i.e., session attendance and homework compliance) is vital to ensuring recovery but can be challenging for patients. Engaging families in veterans' treatment could prove to be an effective strategy for promoting treatment adherence while also addressing long-standing calls for better family inclusion in treatment for posttraumatic stress disorder. This paper describes the methods of a pragmatic randomized controlled trial designed to evaluate if family inclusion in Prolonged Exposure can improve treatment adherence. METHODS: One hundred fifty-six veterans, with clinically significant symptoms of posttraumatic stress disorder, will be randomized to receive either standard Prolonged Exposure or Prolonged Exposure enhanced through family inclusion (Family-Supported Prolonged Exposure) across three different VA facilities. Our primary outcomes are session attendance and homework compliance. Secondary outcomes include posttraumatic stress disorder symptom severity, depression, quality of life, and relationship functioning. The study includes a concurrent process evaluation to identify potential implementation facilitators and barriers to family involvement in Prolonged Exposure within VA. DISCUSSION: While the importance of family involvement in posttraumatic stress disorder treatment is non-controversial, there is no evidence base supporting best practices on how to integrate families into PE or any other individually focused trauma-focused treatments for posttraumatic stress disorder. This study is an important step in addressing this gap, contributing to the literature for both retention and family involvement in trauma-focused treatments. TRIAL REGISTRATION: ClinicalTrials.gov NCT03256227 . Registered on August 21, 2017.

What the public should know about veterans returning from combat deployment to support reintegration: A qualitative analysis.

Consensus reports have called for interventions to educate civilians about the reintegration challenges that veterans experience. The current study describes veterans' perspectives of what the public should know and what the public can do to help veterans reintegrate into civilian life. We conducted thematic analysis of written essays from a stratified random sample of 100 US veterans (half women, half deployed from National Guard or Reserves) from Afghanistan and Iraq military operations who had participated in the control writing condition from a randomized controlled trial of expressive writing to improve reintegration outcomes. Veterans described a military-civilian divide that makes reintegration difficult and recommended that the public help bridge this divide. The divide was attributable to the uniqueness of military culture and bonds, the personal changes associated with deployment, and the time it takes for veterans to reacclimate. Five themes captured what the public can do to foster veteran reintegration: understand deployment hardships; appreciate deployment accomplishments; assist veterans in getting professional help; listen, don't judge; and recognize that employment is critical to reintegration. Themes were present across groupings by gender, type of military service and screening status for posttraumatic stress disorder. Findings can inform interventions that target the public's understanding of and response to returning veteran. Consistent with an ecological model of reintegration, such interventions have the potential to foster successful reintegration. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Evaluation of an Implementation Intervention to Increase Reach of Evidence-Based Psychotherapies for PTSD in US Veterans Health Administration PTSD Clinics.

To evaluate an implementation intervention to increase the uptake, referred to as reach, of two evidence-based psychotherapies (EBP) for posttraumatic stress disorder (PTSD) in Veterans Health Administration (VHA) PTSD specialty clinics. The implementation intervention was external facilitation guided by a toolkit that bundled strategies associated with high EBP reach in prior research. We used a prospective quasi-experimental design. The facilitator worked with local champions at two low-reach PTSD clinics. Each intervention PTSD clinic was matched to three control clinics. We compared the change in EBP reach from 6-months pre- to post-intervention using Difference-in-Difference (DID) effect estimation. To incorporate possible clustering effects and adjust for imbalanced covariates, we used mixed effects logistic regression to model the probability of EBP receipt. Analyses were conducted separately for PTSD and other mental health clinics. 29,446 veterans diagnosed with PTSD received psychotherapy in the two intervention and six control sites in the two 6-month evaluation periods. The proportion of therapy patients with PTSD receiving an EBP increased by 16.98 percentage points in the intervention PTSD clinics compared with .45 percentage points in the control PTSD clinics (DID = 16.53%; SE = 2.26%). The adjusted odd ratio of a patient receiving an EBP from pre to post intervention was almost three times larger in the intervention than in the control PTSD clinics (RoR 2.90; 95% CI 2.22-3.80). EBP reach was largely unchanged in other (not PTSD specialty) mental health clinics within the same medical centers. Toolkit-guided external facilitation is a promising intervention to improve uptake of EBPs in VHA. Toolkits that pre-specify targets for clinic change based on prior research may enhance the efficiency and effectiveness of external facilitation. Trial registration ISRCTN registry identifier: ISRCTN65119065. Available at https://www.isrctn.com/search?q=ISRCTN65119065 .

Online expressive writing intervention for reintegration difficulties among veterans: Who is most likely to benefit?

OBJECTIVE: Some veterans may benefit from psychosocial interventions to facilitate reintegration and prevent chronic impairments following discharge from the service. In a randomized controlled trial, an online expressive writing intervention for Iraq and Afghanistan War veterans with reintegration difficulties reduced distress relative to control conditions, albeit with small between-group effect sizes (Sayer, Noorbaloochi et al., 2015). The aims of this study were to further explore changes in distress severity in the parent study's experimental group by identifying subgroups with similar trajectories and examining predictors of those trajectories. METHOD: We used latent class growth modeling to identify trajectories of change in distress among veterans randomized into expressive writing (N = 508). We also tested six predictors of trajectory membership: baseline probable PTSD, social support, combat exposure, sex, VA user status, and active-duty versus National Guard/Reserve status. The sample was mostly White, middle-aged, Army veterans deployed from active duty, all of whom reported reintegration difficulties. RESULTS: A four-class model, with the following classes, best fit the data: Low Baseline Distress-Moderate Decrease (60%; Cohen's d = -0.69), Moderate Baseline Distress-No Change (25%; Cohen's d = -0.16), Severe Baseline Distress-Small Increase (10%; Cohen's d = 0.23), and Severe Baseline Distress-Very Large Decrease (5%; Cohen's d = -4.80). Veterans without probable PTSD, with less combat exposure, and with higher social support were more likely to be in classes with decreasing distress. CONCLUSION: Analyses revealed several subgroups with unique patterns of change. Non-therapist-assisted expressive writing may be most suitable for veterans with less complex psychosocial problems. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Which patients initiate cognitive processing therapy and prolonged exposure in department of veterans affairs PTSD clinics?

The United States Department of Veterans Affairs (VA) provides Cognitive Processing Therapy (CPT) and Prolonged Exposure therapy (PE) for PTSD at all of its facilities, but little is known about systematic differences between patients who do and do not initiate these treatments. VA administrative data were analyzed for 6,251 veterans receiving psychotherapy over one year in posttraumatic stress disorder (PTSD) specialty clinics at nine VA medical centers. CPT and PE were initiated by 2,173 (35%) patients. Veterans' probability of initiating either CPT or PE (considered together) was 29% lower (adjusted odds ratio = .61) if they had a psychiatric hospitalization within the same year, and 15% lower (AOR = .78) if they had service-connected disability for PTSD. Veterans' probability of starting CPT or PE was 19% lower (AOR = .74) if they were Hispanic or Latino, 10% lower (AOR = .84), if they were male rather than female, and 9% lower (AOR = .87) if they were divorced, separated or widowed rather than currently married. Probability of receiving CPT or PE was also lower if verans had more co-occurring psychiatric diagnoses (AOR per diagnosis = .88), were older (AOR per every five years = .95), or lived further away from the VA clinic (AOR per every ten miles = .98). Nonetheless, most patients initiating CPT or PE had two or more comorbidities and were service-connected for PTSD. Observed gender, age and ethnic differences in initiation of CPT and PE appear unrelated to clinical suitability and warrant further study.

The Influence of Team Functioning and Workload on Sustainability of Trauma-Focused Evidence-Based Psychotherapies.

OBJECTIVE: It has been over a decade since the U.S. Department of Veterans Affairs (VA) began formal dissemination and implementation of two trauma-focused evidence-based psychotherapies (TF-EBPs). The objective of this study was to examine the sustainability of the TF-EBPs and determine whether team functioning and workload were associated with TF-EBP sustainability. METHODS: This observational study used VA administrative data for 6,251 patients with posttraumatic stress disorder (PTSD) and surveys from 78 providers from 10 purposefully selected PTSD clinical teams located in nine VA medical centers. The outcome was sustainability of TF-EBPs, which was based on British National Health System Sustainability Index scores (possible scores range from 0 to 100.90). Primary predictors included team functioning, workload, and TB-EBP reach to patients with PTSD. Multiple linear regression models were used to examine the influence of team functioning and workload on TF-EBP sustainability after adjustment for covariates that were significantly associated with sustainability. RESULTS: Sustainability Index scores ranged from 53.15 to 100.90 across the 10 teams. Regression models showed that after adjustment for patient and facility characteristics, team functioning was positively associated (B=9.16, p<.001) and workload was negatively associated (B=-.28, p<.05) with TF-EBP sustainability. CONCLUSIONS: There was considerable variation across teams in TF-EBP sustainability. The contribution of team functioning and workload to the sustainability of evidence-based mental health care warrants further study.

Context Matters: Team and Organizational Factors Associated with Reach of Evidence-Based Psychotherapies for PTSD in the Veterans Health Administration.

Evidence-based psychotherapies for PTSD are often underused. The objective of this mixed-method study was to identify organizational and clinic factors that promote high levels of reach of evidence-based psychotherapies for PTSD 10 years into their dissemination throughout the Veterans Health Administration. We conducted 96 individual interviews with staff from ten outpatient PTSD teams at nine sites that differed in reach of evidence-based psychotherapies for PTSD. Major themes associated with reach included clinic mission, clinic leader and staff engagement, clinic operations, staff perceptions, and the practice environment. Strategies to improve reach of evidence-based psychotherapies should attend to organizational and team-level factors.

Identity adjustment among Afghanistan and Iraq war veterans with reintegration difficulty.

OBJECTIVE: To examine perceptions of identity adjustment in a diverse, national sample of U.S. veterans of the wars in Afghanistan and Iraq. METHOD: The authors conducted a planned thematic analysis of text written by Afghanistan and Iraq war veterans when they were asked to describe their reintegration difficulties as part of a randomized controlled trial (RCT) of online expressive writing (Sayer et al., 2015). Participants were 100 randomly selected veterans from the larger study (42 women and 58 men, 60 active duty and 38 reserves or National Guard). RESULTS: Nearly 2/3s of participants wrote about their identity adjustment. The 5 interrelated areas of identity adjustment difficulty were (a) feeling like one does not belong in civilian society, (b) missing the military's culture and structured lifestyle, (c) holding negative views of civilian society, (d) feeling left behind compared to civilian counterparts due to military service, and (e) having difficulty finding meaning in the civilian world. The authors did not observe differences by gender. However, those deployed from active duty were particularly likely to feel as if they did not belong in civilian society and that they had not acquired needed skills, whereas those deployed from the reserves or National Guard experienced difficulty in reestablishing former civilian identities. CONCLUSIONS: Identity adjustment is a critical yet understudied aspect of veteran reintegration into community life following combat deployment. (PsycINFO Database Record

Randomized Controlled Trial of Online Expressive Writing to Address Readjustment Difficulties Among U.S. Afghanistan and Iraq War Veterans.

We examined the efficacy of a brief, accessible, nonstigmatizing online intervention-writing expressively about transitioning to civilian life. U.S. Afghanistan and Iraq war veterans with self-reported reintegration difficulty (N = 1,292, 39.3% female, M = 36.87, SD = 9.78 years) were randomly assigned to expressive writing (n = 508), factual control writing (n = 507), or no writing (n = 277). Using intention to treat, generalized linear mixed models demonstrated that 6-months postintervention, veterans who wrote expressively experienced greater reductions in physical complaints, anger, and distress compared with veterans who wrote factually (ds = 0.13 to 0.20; ps < .05) and greater reductions in PTSD symptoms, distress, anger, physical complaints, and reintegration difficulty compared with veterans who did not write at all (ds = 0.22 to 0.35; ps ≤ .001). Veterans who wrote expressively also experienced greater improvement in social support compared to those who did not write (d = 0.17). Relative to both control conditions, expressive writing did not lead to improved life satisfaction. Secondary analyses also found beneficial effects of expressive writing on clinically significant distress, PTSD screening, and employment status. Online expressive writing holds promise for improving health and functioning among veterans experiencing reintegration difficulty, albeit with small effect sizes.

Iraq and Afghanistan War Veterans with Reintegration Problems: Differences by Veterans Affairs Healthcare User Status.

We studied 1,292 Iraq and Afghanistan War veterans who participated in a clinical trial of expressive writing to estimate the prevalence of perceived reintegration difficulty and compare Veterans Affairs (VA) healthcare users to nonusers in terms of demographic and clinical characteristics. About half of participants perceived reintegration difficulty. VA users and nonusers differed in age and military background. Levels of mental and physical problems were higher in VA users. In multivariate analysis, military service variables and probable traumatic brain injury independently predicted VA use. Findings demonstrate the importance of research comparing VA users to nonusers to understand veteran healthcare needs.

Examining gender differences in the relationship between dating violence victimization and anger in college students.

It has been well established that dating violence victimization is associated with various mental health problems. Relatively, little is known about similarities and differences between mental health correlates of dating violence victimization for males and females. We examined the associations between physical and psychological victimization experiences and measures of anger in a sample of 200 male and female undergraduates. Results suggest that men's victimization was more strongly associated with different forms of anger than women's victimization.

Military to civilian questionnaire: a measure of postdeployment community reintegration difficulty among veterans using Department of Veterans Affairs medical care.

The primary objective of this study was to describe the development, reliability, and construct validity of scores on the Military to Civilian Questionnaire (M2C-Q), a 16-item self-report measure of postdeployment community reintegration difficulty. We surveyed a national, stratified sample of 1,226 Iraq and Afghanistan veterans who used U.S. Department of Veterans Affairs (VA) medical care; 745 completed the M2C-Q and validated mental health screening measures. All analyses were based on weighted estimates. The internal consistency of the M2C-Q was .95 in this sample. Factor analyses indicated a single total score was the best-fitting model. Total scores were associated with measures theoretically related to reintegration difficulties including perception of overall difficulty readjusting back into civilian life (R(2) = .49), probable PTSD (d = 1.07), probable problem drug or alcohol use (d = 0.34), and overall mental health (r = -.83). Subgroup analyses revealed a similar pattern of findings in those who screened negative for PTSD. Nonwhite and unemployed veterans reported greater community reintegration difficulty (d = 0.20 and 0.45, respectively). Findings offer preliminary support for the reliability and construct validity of M2C-Q scores.

Examining the link between posttraumatic stress disorder symptoms and dating aggression perpetration.

This study examined the role of posttraumatic stress disorder (PTSD) symptoms with respect to dating aggression perpetration among a sample of 199 undergraduates. Almost one-third of the overall sample reported physical dating aggression perpetration in the past year, and approximately 80% reported engaging in psychological dating aggression. Structural equation modeling (SEM) analyses indicated that the effects of trauma exposure on dating aggression were fully indirect via PTSD symptoms. PTSD symptoms were associated with psychological dating aggression in part through its association with anger, and alcohol problems were also directly related to this outcome. Results generalize findings from other populations suggesting the salience of trauma and PTSD symptoms in intimate relationship aggression and point to possible etiological pathways for these associations.

Psychiatric diagnoses among Iraq and Afghanistan war veterans screened for deployment-related traumatic brain injury.

The authors examined psychiatric diagnoses in administrative records for 13,201 United States military veterans who were screened for traumatic brain injury (TBI) in Department of Veterans Affairs facilities. Over 80% of the veterans with positive TBI screens had psychiatric diagnoses. Compared to veterans with negative TBI screens, those with positive screens, but without confirmed TBI status, were three times more likely to have a posttraumatic stress disorder (PTSD) diagnosis and were two times more likely to have depression and substance-related diagnoses. Among veterans with positive TBI screens, those with clinically confirmed TBI status were more likely than those without confirmed TBI status to have diagnoses for PTSD, anxiety, and adjustment disorders. These findings have implications for health care delivery and provider education.