Suicide-Specific Cognitions and Suicidal Behavior in U.S. Military Veterans.

BACKGROUND: U.S. military veterans may be reluctant to disclose suicidal thoughts and behaviors. Suicide-specific cognitions, which generally avoid direct mention of suicide, may be reliable indicators of risk among those reluctant to disclose such thoughts and behaviors. METHODS: Data from a population-based, cross-sectional study of 2,430 U.S. military veterans were analyzed to examine the associations between the Brief Suicide Cognitions Scale (B-SCS), suicidal ideation, and suicide planning. RESULTS: After adjusting for age, sex, number of adverse childhood experiences, cumulative trauma burden, depressive symptom severity, and lifetime history of suicide attempt, total scores on the B-SCS (excluding the item mentioning suicide) were uniquely associated with suicidal ideation (odds ratio [OR] = 1.23, 95% confidence interval [CI] = 1.15-1.32) and suicide planning (OR = 1.27, 95%CI = 1.18-1.37). Exploratory post-hoc analyses revealed that difficulties with solving and coping with one's problems were uniquely linked to these outcomes. CONCLUSIONS: Assessment of suicide-specific cognitions may help to enhance suicide detection and prevention in veterans, especially in those who may not directly disclose thoughts of suicide. Intervention efforts to bolster perceived deficits in coping and problem-solving may help mitigate suicide risk in this population.

Longitudinal measurement invariance and growth curve modeling of psychological resilience across the deployment cycle.

The concept of resilience is embedded within military culture and professional identity. To date, temporal changes in individuals' perceptions of their own resilience have not been systematically assessed in highstakes occupational contexts, like the military. The current study examined change in selfreported resilience over time by: (1) examining the longitudinal measurement invariance of the Brief Resilience Scale (BRS); (2) assessing the longitudinal pattern of resilience across a combat deployment cycle; and (3) examining predictors of postdeployment resilience and change in resilience scores across time. U.S. Army soldiers assigned to a combat brigade completed a survey at four time points over the course of a deployment cycle: (a) prior to deployment to Afghanistan; (b) during deployment; (c) immediately following return to home station; and (d) approximately 2-3 months thereafter. The longitudinal measurement invariance of the BRS was established. Growth curve modeling indicated that, on average, self-reported resilience decreased across the deployment cycle, but there was considerable individual variation in the rate of change. Of note, loneliness, as measured during deployment, predicted the rate of change in self-reported resilience over time. Results have implications for the longitudinal analysis of resilience and for the development of interventions with military personnel.

Alcohol motivations associated with frequency of alcohol use, binge drinking, and alcohol problems among active duty junior enlisted soldiers and non-commissioned officers.

Problematic alcohol use is a serious threat to the behavioral health of active-duty Service Members (ADSM), resulting in numerous calls from governmental agencies to better understand mechanistic factors contributing to alcohol misuse within the military. Alcohol use motives are reliable predictors of alcohol-related behaviors and are considered malleable targets for prevention and intervention efforts. However, empirical research indicates that drinking motives vary across contextually distinct populations. Although some research has been conducted among veteran and reservist populations, limited work has been specifically focused on ADSM and no research has evaluated motives and alcohol metrics among ADSM based on military rank. Participants for the current study included 682 ADSM recruited from a large military installation in the U.S. Structural equation modeling evaluated associations between four drinking motives (i.e., enhancement, social, conformity, coping) and three alcohol misuse metrics (i.e., alcohol frequency, binge frequency, alcohol problems). Three models were evaluated: one full (combined) model and two separate models based on military rank - junior enlisted (i.e., E1-E4) and non-commissioned officers (NCOs) (i.e., E5-E9). Results for junior enlisted ADSM indicated that coping and enhancement motives were most strongly associated with all alcohol misuse metrics. However, among NCOs, results indicated that alcohol problems were only associated with coping motives. Notably, results also indicated that alcohol use motives accounted for substantively more variance across all alcohol-related metrics among NCOs. Findings generally support extant military-related literature indicating use of alcohol for coping (e.g., with anxiety) as the motivation most consistently associated with increased alcohol misuse. However, novel findings highlight enhancement motives - using alcohol to attain some positive internal reward - as another, often stronger, motivation impacting alcohol use outcomes. Further, findings highlight notable distinctions between alcohol use motives (i.e., coping vs. enhancement) and the impact of alcohol use motives (i.e., effect size) on alcohol metrics between junior enlisted and NCOs.

Measurement validity of the six-factor model of psychological well-being in a military sample: Implications for measuring well-being in service members.

Subjective well-being is a positive psychological construct that has important implications for the U.S. Military's goal to develop service members' strengths and support their overall thriving and downstream resilience. Despite this, the concept of well-being has not been well studied in military populations who have unique work demands, stressors, and autonomy/agency in daily life compared to civilians. To address this shortcoming in the literature, the present study assessed Ryff's measures of psychological well-being (PWB) in 1,333 U.S. service members prior to the deployments in the Middle East. Various methods attempting to validate the theoretical model purported by Ryff were unsuccessful, and exploratory factor analyses did not result in a novel model for this population. Future research should continue to evaluate proposed models of soldier well-being and propose novel theories, as well as measures, to assess this important construct. Implications are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The Impact of Just and Unjust War Events on Mental Health Need and Utilization within U.S. Service Members.

Background: Soldiers are resilient to just war events, such as killing enemy combatants and life-threatening experiences, but these same soldiers appear to struggle with unjust war events, such as killing a noncombatant or being unable to help civilian women and children in need. This study is the first to examine how just and unjust war experiences are associated with clinical health service outcomes. Methods: Two samples of soldiers in different stages of readjustment from deployment were drawn from a longitudinal, survey-based study of a US Army brigade. Measures included items related to combat events, mental health utilization, perceived mental health need, PTSD, depression, and functional impairment. Results: After controlling for other kinds of combat events, just war events (i.e., life-threatening events and killing enemy combatants) predicted outcomes in soldiers who are less than three months post-deployment, but only predicted 2 of 26 outcomes in soldiers one year post deployment. In contrast, unjust war events were found to be robust predictors of short-term and long-term outcomes related to mental health need and utilization, even after controlling for exposure to other combat events. Conclusions: The results extend previous longitudinal research that suggests that exposure to unjust war events carry a heavier long-term mental health burden than other types of events. Additionally, Soldiers exposed to unjust war events had an unmet need for care one year post deployment that was not directly tied to PTSD or depression. The results question the emphasis on life-threat within mental health pathogenesis models.

Order effects in PTSD network analysis: important implications for diagnostic conceptualization, treatment refinement, and research.

BACKGROUND: For decades confirmatory factor analysis (CFA) has been the preeminent method to study the underlying structure of posttraumatic stress disorder (PTSD); however, methodological limitations of CFA have led to the emergence of other analytic approaches. In particular, network analysis has become a gold standard to investigate the structure and relationships between PTSD symptoms. A key methodological limitation, however, which has significant clinical implications, is the lack of data on the potential impact of item order effects on the conclusions reached through network analyses. METHODS: The current study, involving a large sample (N = 5055) of active duty army soldiers following deployment to Iraq, assessed the vulnerability of network analyses and prevalence rate to item order effects. This was done by comparing symptom networks of the DSM-IV PTSD checklist items to these same items distributed in random order. Half of the participants rated their symptoms on traditionally ordered items and half the participants rated the same items, but in random order and interspersed between items from other validated scales. Differences in prevalence rate and network composition were examined. RESULTS: The prevalence rate differed between the ordered and random item samples. Network analyses using the ordered survey closely replicated the conclusions reached in the existing network analyses literature. However, in the random item survey, network composition differed considerably. CONCLUSION: Order effects appear to have a significant impact on conclusions reached from PTSD network analysis. Prevalence rates were also impacted by order effects. These findings have important diagnostic and clinical treatment implications.

Perceptions of purpose, cohesion, and military leadership: A path analysis of potential primary prevention targets to mitigate suicidal ideation.

Rates of suicide in the US Army continue to rise, and by some accounts exceed the general population. This increase has renewed efforts to identify protective factors that may inform novel suicide prevention strategies. Previous research has demonstrated that a sense of purpose in life and perceived cohesion with military peers are related to a reduction in the severity of suicidal ideation (SI). Additionally, research in military samples supports decreased SI in Soldiers who endorse that their leaders convey a sense of purpose and meaning in their shared mission. However, no work has investigated whether these leadership styles relate to a sense of felt purpose and perceived cohesion in Soldiers and thus the indirect effect of these leadership styles on SI. Active duty Army Soldiers (n = 1,160) completed self-report measures of purpose in life (PiL), perceived cohesion, ethical leadership, loneliness, and SI. Indirect effect analyses were conducted to determine how leadership behaviors indirectly relate to SI through PiL and perceived cohesion. Indirect effect analyses revealed that ethical leadership had an indirect effect on reduced SI through increased PiL. In the same parallel indirect effect analysis, ethical leadership was related to less SI through increased perceived cohesion and decreased loneliness sequentially. Enhanced leadership training that effectively increases Soldier purpose may be an important primary prevention tool to mitigate the effect of suicide risk factors. This primary prevention strategy may help augment existing suicide surveillance and clinical prevention efforts to reduce Soldier risk for suicide.

Variability in the stability of personality traits across a single combat deployment.

This study assessed changes in measures of personality traits across a 12-month combat deployment in a sample of conventional US Army soldiers. Results revealed Impulsive Sensation-Seeking (ImpSS) and Sociability (Sy) decreased significantly, whereas Neuroticism-Anxiety (N-Anx) increased. Changes in ImpSS scores were mainly attributed to age, but were inversely related to increases in traumatic stress symptoms. Combat exposure, concussion, age, education, and changes in traumatic stress scores all independently contributed to changes in N-Anx scores. Changes in Sy were not associated with any of the data available from pre-deployment or deployment measures. Changes in Aggression-hostility (Agg-Hos) and Activity (Act) across the deployment were not significant. The findings suggest significant variability in the stability of personality traits when exposed to combat stress and injury while deployed, which may be influenced by factors such as age and education.

Indirect effects of soldier healthy eating and physical activity on suicidal ideation through psychological health symptoms in active-duty military.

The suicide rate within the military continues to rise. New approaches for prevention are needed which capitalize on existing strengths, are scalable at multiple levels, and promote mental fortitude. Healthy eating (HE) and physical activity (PA) represent scalable practices and methods for promoting mental health and protective factors within the military. A cross-sectional sample of N = 1019 active-duty Soldiers completed self-report measures of HE, PA, major depressive disorder (MDD) symptoms, generalized anxiety disorder (GAD) symptoms, and suicidal ideation (SI). Moderated mediation analyses using bootstrapping techniques were used to determine if HE and PA interact to relate to lower SI through reduced psychological health (PH) symptoms. Results indicated an indirect effect of HE on presence versus absence of past month SI through GAD symptoms at moderate-to-high levels of cardiovascular PA. A similar pattern was demonstrated for strength training PA where HE had an indirect effect on past month SI through GAD symptoms at only high levels of strength training PA. HE was indirectly related to lower MDD symptoms at all levels of cardiovascular PA and moderate to high levels of strength training PA. Study limitations and implications for secondary suicide prevention strategies within the military are discussed.

Psychometric properties of the interpersonal needs questionnaire (INQ-15) in Army soldiers: Implications and future directions.

The Interpersonal Theory of Suicide posits that two unmet interpersonal needs, thwarted belongingness and perceived burdensomeness, interact to predict suicide desire. These two constructs are frequently assessed using the 15-item Interpersonal Needs Questionnaire (INQ-15); however, this measure has never been validated in military service members. The current study analyzed the psychometric properties of the INQ-15 in a sample of (N = 1096) military personnel stationed overseas. Results indicated that the two-factor model of the INQ-15 had a poor model fit in this population; however, a bifactor model with two specific factors representing TB and PB demonstrated good fit. As seen in previous research, perceived burdensomeness was more strongly related to suicidal ideation severity than thwarted belongingness. Implications and future directions for research are discussed.

Military suicide prevention: The importance of leadership behaviors as an upstream suicide prevention target.

OBJECTIVE: To evaluate the longitudinal relationships between unit cohesion, Army leader behaviors, and subordinate suicidal/death ideation. Recent cross-sectional research indicates that subordinates who perceive that their leaders instill a sense of purpose regarding military service demonstrate less frequent suicidal ideation. METHOD: Five hundred fifty-nine soldiers completed self-report measures of perceptions of leadership behaviors, unit cohesion, and suicidal/death ideation during deployment as well as one and three months following deployment. Latent change score modeling was conducted to evaluate the course and direction of study variables as well as the relationship between them. RESULTS: Although lower levels of suicidal/death ideation were related to leader-provided purpose, leader-provided meaning, and unit cohesion at baseline, only leader-provided purpose and unit cohesion prospectively predicted changes in suicidal/death ideation. CONCLUSIONS: Consistent with the goal of military leadership to augment effective clinical interventions that reduce suicide risk, prevention programs that reach a broader population of personnel should be considered. Enhanced leadership training may be an important primary prevention tool to reduce suicide risk that warrants further research.

Identifying PTSD symptom typologies: A latent class analysis.

Posttraumatic stress disorder (PTSD) is characterized by re-experiencing, avoidance, negative alterations in cognition and mood, and arousal symptoms per the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). While numerous symptom combinations are possible to meet diagnostic criteria, simplification of this heterogeneity of symptom presentations may have clinical utility. In a nationally representative sample of American adults with lifetime DSM-5 PTSD diagnoses from the third wave of the National Epidemiologic Survey on Alcohol and Related Conditions (n = 2,365), we used Latent Class Analysis (LCA) to identify qualitatively distinct PTSD symptom typologies. Subsequently, we used linear and logistic regressions to identify demographic, trauma-related, and psychiatric characteristics associated with membership in each class. In contrast to prior LCAs with DSM-IV-TR diagnostic criteria, fit indices for the present analyses of DSM-5 PTSD revealed a four-class solution to the data: Dysphoric (23.8%), Threat-Reactivity (26.1%), High Symptom (33.7%), and Low Symptom (16.3%). Exploratory analyses revealed distinctions between classes in socioeconomic impairment, trauma exposure, comorbid diagnoses, and demographic characteristics. Although the study is limited by its cross-sectional design (preventing analysis of temporal associations or causal pathways between covariates and latent classes), findings may support efforts to develop personalized medicine approaches to PTSD diagnosis and treatment.

Leader provided purpose: Military leadership behavior and its association with suicidal ideation.

Suicide in U.S. Army Soldiers is of major concern as it is estimated that over 100 Soldiers die by suicide each year. Examining risk and protective factors is essential to develop both an understanding of Soldier suicide as well as inform systemic interventions to reduce suicide. One potential systemic approach is to embed preventive mechanisms within the structure of the military rather than the typical administration of primary intervention through mandatory training. To examine potential mechanisms of leader-based interventions, several leadership behaviors were assessed in a cross-sectional sample of n = 1,096 active duty Soldiers. Soldiers completed self-report measures of interpersonal predictors of suicide, suicidal ideation (SI), leadership behaviors, and unit cohesion. Logistic regression was used to identify leadership behaviors related to SI. Only the leader behavior attempting to foster a sense of purpose predicted SI. Leader provided purpose (LPP) was then entered into indirect effect analyses to evaluate the mechanisms of this relationship. Analyses revealed that LPP predicted SI through unit cohesion, thwarted belongingness, and perceived burdensomeness. Results demonstrate that specific aspects of military leadership such as fostering Soldier purpose may enhance resilience and reduce risk for SI.

Trauma management therapy with virtual-reality augmented exposure therapy for combat-related PTSD: A randomized controlled trial.

Virtual reality exposure therapy (VRET) realistically incorporates traumatic cues into exposure therapy and holds promise in the treatment of combat-related posttraumatic stress disorder (PTSD). In a randomized controlled trial of 92 Iraq and Afghanistan veterans and active duty military personnel with combat-related PTSD, we compared the efficacy of Trauma Management Therapy (TMT; VRET plus a group treatment for anger, depression, and social isolation) to VRET plus a psychoeducation control condition. Efficacy was evaluated at mid- and post-treatment, and at 3- and 6-month follow-up. Consistent with our hypothesis, VRET resulted in significant decreases on the Clinician Administered PTSD Scale and the PTSD Checklist-Military version for both groups. Also consistent with our hypothesis, significant decreases in social isolation occurred only for those participants who received the TMT group component. There were significant decreases for depression and anger for both groups, although these occurred after VRET and before group treatment. All treatment gains were maintained six-months later. Although not part of the original hypotheses, sleep was not improved by either intervention and remained problematic. The results support the use of VRET as an efficacious treatment for combat-related PTSD, but suggest that VRET alone does not result in optimal treatment outcomes across domains associated with PTSD.

Combat-related guilt and the mechanisms of exposure therapy.

Exposure therapy (EXP) is one of the most widely used and empirically supported treatments for PTSD; however, some researchers have questioned its efficacy with specific populations and in targeting specific symptoms. One such symptom, guilt, has garnered increased attention in the PTSD treatment literature, as it is associated with worse symptomatology and outcomes. The current study examined cognitive changes in guilt in response to Intensive (3-week) and Standard (17-week) Trauma Management Therapy (TMT), and the potential mechanisms underlying TMT treatment. TMT is an exposure based intervention that does not include an emotional processing component after the imaginal exposure session. A portion of the sample completed measures of guilt. As a result, sample size for these analyses ranged from 39 to 102 and varied by the domain and measure. Of the 102 individuals that completed the PTSD Checklist- Military Version, 42 completed the Trauma Related Guilt Inventory, and 39 completed the Clinician Administered PTSD Scale supplemental guilt items. Participants reported significant reductions in trauma-related guilt symptoms over the course of the TMT interventions. Greater reductions in avoidance and prior session general arousal predicted the reduction of guilt symptoms. Exposure therapy may be effective in reducing trauma-related guilt even in the absence of the emotional processing component of treatment.

REACT: A paraprofessional training program for first responders-A pilot study.

The purpose of this study was to evaluate a newly designed peer support training program for first responders titled Recognize, Evaluate, Advocate, Coordinate, and Track (REACT). REACT was developed in partnership with public safety agencies to address the need for promoting psychological health. This resulted in the development of a program that uses train-the-trainer methodology to address primary prevention of stress injuries. REACT was an all-day training that consisted of four modules, each featuring instruction and practice. Six public safety agencies totaling 30 individuals (76.9% from four fire departments, 23.1% from two emergency communication centers) participated in REACT. The primary outcomes were knowledge and training-related self-efficacy; secondary outcomes included general self-efficacy, resilience, and improved attitudes and expectations. A peer-support model, using a train-the-trainer methodology, is a promising approach for addressing the promotion of psychological health.

Transdiagnostic Psychiatric Symptoms and Event-Related Potentials following Rewarding and Aversive Outcomes.

There is a need for a better understanding of transdiagnostic psychiatric symptoms that relate to neurophysiological abnormalities following rewarding and aversive feedback in order to inform development of novel targeted treatments. To address this need, we examined a transdiagnostic sample of 44 adults (mean age: 35.52; 57% female), which consisted of individuals with broadly-defined schizophrenia-spectrum disorders (n = 16), bipolar disorders (n = 10), other mood and anxiety disorders (n = 5), and no history of a psychiatric disorder (n = 13). Participants completed a Pavlovian monetary reward prediction task during 32-channel electroencephalogram recording. We assessed the event-related potentials (ERPs) of feedback-related negativity (FRN), feedback-related positivity (FRP), and the late positive potential (LPP), following better and worse than expected outcomes. Examination of symptom relationships using stepwise regressions across the entire sample revealed that an increase in the clinician-rated Negative Symptoms factor score from the Positive and Negative Syndrome Scale, was related to a decreased LPP amplitude during better than expected (i.e., rewarding) outcomes. We also found that increased self-reported scores on the Schizotypal Personality Questionnaire (Brief-Revised) Disorganized factor related to an increased FRN amplitude during worse than expected (i.e., aversive) outcomes. Across the entire sample, the FRP component amplitudes did not show significant relationships to any of the symptoms examined. Analyses of the three diagnostic groups of schizophrenia-spectrum disorders, bipolar disorders, and nonpsychiatric controls did not reveal any statistically significant differences across the ERP amplitudes and conditions. These findings suggest relationships between specific neurophysiological abnormalities following rewarding and aversive outcomes and particular transdiagnostic psychiatric symptoms.

Heart rate variability and vagal tone in schizophrenia: A review.

Recent heart rate variability (HRV) research has identified diminished levels of parasympathetic activity among schizophrenia patients. Over two dozen empirically-based studies have been published on this topic; primarily over the last decade. However, no theoretical review appears to have been published on this work. Further, only one empirical study has evaluated HRV research findings in the context of documented hypothalamic-pituitary-adrenal axis hyperactivity in schizophrenia. HRV research indicates that no abnormalities exist in the initial sympathetic stress response of schizophrenia patients. However, evidence has consistently demonstrated that patients exhibit a diminished capacity to recover from a stress response as a result of deficits in parasympathetic activity. Moreover, this diminished parasympathetic nervous system (PNS) response, also known as decreased vagal tone, has been found to relate to increased symptom severity. Although these findings may cause speculation that the observed vagal tone disruption merely results from anxiety produced by the presence of positive symptomology, additional studies have identified similar parasympathetic dysfunction among nonpsychotic relatives of individuals with schizophrenia. We posit that the resulting sympathovagal imbalance leads to an overall sympathetic dominance despite the fact that sympathetic nervous system activity is not abnormally elevated among patients. Implications are discussed within the context of the diathesis-stress/vulnerability-stress model, including the potential for identifying a mechanism of action by which environmental stressors may contribute to triggering first-episode psychosis.

Transdiagnostic psychiatric symptoms related to visual evoked potential abnormalities.

Visual processing abnormalities have been reported across a range of psychotic and mood disorders, but are typically examined within a particular disorder. The current study used a novel transdiagnostic approach to examine diagnostic classes, clinician-rated current symptoms, and self-reported personality traits in relation to visual processing abnormalities. We examined transient visual-evoked potentials (VEPs) from 48 adults (56% female), representing a wide range of psychotic and mood disorders, as well as individuals with no history of psychiatric disorder. Stimuli were low contrast check arrays presented on green and red backgrounds. Pairwise comparisons between individuals with schizophrenia-spectrum disorders (SSD), chronic mood disorders (CMD), and nonpsychiatric controls (NC) revealed no overall differences for either P1 or N1 amplitude. However, there was a significant interaction with the color background in which the NC group showed a significant increase in P1 amplitude to the red, vs. green, background, while the SSD group showed no change. This was related to an increase in social anhedonia and general negative symptoms. Stepwise regressions across the entire sample revealed that individuals with greater apathy and/or eccentric behavior had a reduced P1 amplitude. These relationships provide clues for uncovering the underlying causal pathology for these transdiagnostic symptoms.

An event-related potential investigation of error monitoring in adults with a history of psychosis.

OBJECTIVE: Previous research suggests that deficits in error monitoring contribute to psychosis and poor functioning. Consistent with the NIMH Research Domain Criteria initiative, this study examined electrophysiological brain activity, appraisal of self-performance, and personality traits related to psychosis during error monitoring in individuals with and without a history of psychosis across disorders. METHODS: Error-related negativity (ERN), correct response negativity (CRN), error positivity (Pe), and correct response positivity (Pc) were recorded in 14 individuals with a history of psychosis (PSY) and 12 individuals with no history of psychosis (CTR) during a flanker task. Participants continuously rated their performance and completed the Schizotypal Personality Questionnaire-Brief Revised (SPQ-BR). RESULTS: Compared with CTR, PSY exhibited reduced ERN and Pe amplitudes and was also less accurate at evaluating their performance. Group differences were specific to error trials. Across all participants, smaller Pe amplitudes were associated with greater scores on the SPQ-BR Cognitive-Perceptual factor and less accuracy in subjective identification of errors. CONCLUSIONS: Individuals with a history of psychosis, regardless of diagnosis, demonstrated abnormal neural activity and imprecise confidence in response during error monitoring. SIGNIFICANCE: Results suggest that disruptions in neural circuitry may underlie specific clinical symptoms across diagnostic categories.