Development and psychometric evaluation of the mental readiness for military transition scale (MT-Ready).

BACKGROUND: The transition to civilian life following separation from military service is associated with increased risk of mental health disorders, suicide, and poor adjustment. No measure currently enables pre-separation screening to assess mental readiness for transition and identify personnel most at risk of poor outcomes. The Mental Readiness for Military Transition Scale (MT-Ready) was developed to identify psychosocial factors predictive of post-separation psychological adjustment and mental health. METHODS: Phase I was a qualitative study including transitioned veterans (n = 60), partners of transitioned veterans (n = 20) and mental health clinicians (n = 20) which enabled development of candidate items that were subsequently piloted with a current serving Australian Defence Force (ADF) sample (n = 19). Phase II included evaluation of the factor structure, psychometric properties, and scale refinement of the initial pool of 50 items with a convenience sample of transitioning ADF personnel (n = 345). Analyses included exploratory factor analysis, evaluation of test-retest reliability, internal consistency, convergent, divergent, discriminant and predictive validity. Receiver Operating Characteristic Curve Analysis was also conducted to determine an optimal cut-off score. RESULTS: Exploratory factor analysis resulted in a 15-item, three-factor solution that explained 62.2% of the variance: Future focus and optimism; Anger and perceived failure; Civilian connections and social support. Reliability and convergent, divergent, and discriminant validity was established. Receiver Operating Characteristic Curve Analysis determined a cut-off score of 55. MT-Ready scores significantly differentiated those reporting adjusting versus not adjusting to civilian life 3.7 months post-separation, and predicted post-separation outcomes including symptoms of Posttraumatic Stress Disorder, depression, anxiety, psychological adjustment and quality of life. CONCLUSIONS: This evaluation provides promising evidence the MT-Ready is a valid, reliable measure of mental readiness for transition, with predictive capability and considerable potential to assist prevention of poor post-separation outcomes among military personnel.

Posttraumatic sleep disturbances in veterans: A pilot randomized controlled trial of cognitive behavioral therapy for insomnia and imagery rehearsal therapy.

OBJECTIVES: Posttraumatic stress disorder (PTSD) is associated with sleep disturbances including insomnia and nightmares. This study compared cognitive behavioral therapy for insomnia (CBT-I) with CBT-I combined with imagery rehearsal therapy (IRT) for nightmares to evaluate if the combined treatment led to greater reductions in trauma-related sleep disturbances in Australian veterans. METHODS: Veterans with diagnosed PTSD, high insomnia symptom severity, and nightmares (N = 31) were randomized to eight group CBT-I sessions or eight group CBT-I + IRT sessions. Self-reported sleep, nightmare, and psychological measures (primary outcome: Pittsburgh Sleep Quality Index), and objective actigraphy data were collected; the effect of obstructive sleep apnea (OSA) risk on treatment outcomes was also examined. RESULTS: No treatment condition effects were detected for the combined treatment compared to CBT-I alone, and no moderating effect of OSA risk was detected. On average, participants from both groups improved on various self-report measures over time (baseline to 3 months posttreatment). Despite the improvements, mean scores for sleep-specific measures remained indicative of poor sleep quality. There were also no significant differences between the groups on the actigraphy indices. CONCLUSIONS: The findings indicate that there is potential to optimize both treatments for veterans with trauma-related sleep disturbances.

Compassionate mind training for ex-service personnel with PTSD and their partners.

Posttraumatic stress disorder (PTSD) is a significant issue for a substantial proportion of Australian ex-service personnel. In addition to the functional impact on individuals, PTSD can have a significant impact on intimate partner relationships. Research has demonstrated that practicing compassion and self-compassion may be an important component of psychological therapy for survivors of trauma, while also demonstrating benefits to intimate relationships. This pilot study aimed to investigate the utility of a Compassionate Mind Training intervention for ex-service personnel with PTSD and their partners. An uncontrolled, within-subjects, longitudinal design was utilized with assessment at pre-intervention, post-intervention and 3-month follow-up. Twenty-four participants attended 12 biweekly group sessions. Self-report measures of compassion, quality of life and psychological symptoms were administered at each time point. Findings demonstrated a significant reduction in fears of compassion and PTSD symptoms for ex-service personnel at 3-month follow-up and a reduction in depressive symptoms and increase in quality-of-life and social safeness at post-intervention. Additionally, significant reductions in anxiety, stress, external shame and self-criticism at 3-month follow-up were found, and couples reported significant increases in relationship satisfaction. Findings from this pilot study demonstrate promising outcomes, warranting further investigation in a larger randomized controlled trial of Compassionate Mind Training for ex-service personnel and their partners.

Veteran families with complex needs: a qualitative study of the veterans' support system.

BACKGROUND: Families with complex needs face significant challenges accessing and navigating health and social services. For veteran families, these challenges are exacerbated by interactions between military and civilian systems of care, and the density of the veterans' non-profit sector. This qualitative study was designed to gather rich, detailed information on complex needs in veteran families; and explore service providers' and families' experiences of accessing and navigating the veterans' support system. METHODS: The study comprised participant background questionnaires (n = 34), focus groups with frontline service providers (n = 18), and one-on-one interviews with veteran families (n = 16) in Australia. The semi-structured focus groups and interviews were designed to gather rich, detailed information on four study topics: (i) health and wellbeing needs in veteran families; (ii) service-access barriers and facilitators; (iii) unmet needs and gaps in service provision; and (iv) practical solutions for improving service delivery. The study recruited participants who could best address the focus on veteran families with complex needs. The questionnaire data was used to describe relevant characteristics of the participant sample. The focus groups and interviews were audio-recorded, transcribed, and a reflexive thematic analysis was conducted to identify patterns of shared meaning in the qualitative data. RESULTS: Both service providers and families found the veterans' support system difficult to access and navigate. System fragmentation was perceived to impede care coordination, and delay access to holistic care for veteran families with complex needs. The medico-legal aspects of compensation and rehabilitation processes were perceived to harm veteran identity, and undermine health and wellbeing outcomes. Recovery-oriented practice was viewed as a way to promote veteran independence and self-management. Participants expressed a strong preference for family-centred care that was informed by an understanding of military lifestyle and culture. CONCLUSION: The health and wellbeing needs of veteran families intensify during the transition from full-time military service to civilian environments, and service- or reintegration-related difficulties may emerge (or persist) for a significant period of time thereafter. Veteran families with complex needs are unduly burdened by care coordination demands. There is a pressing need for high-quality implementation studies that evaluate initiatives for integrating fragmented systems of care.

Evaluation of mental health first aid training for family members of military veterans with a mental health condition.

BACKGROUND: A concerning proportion of former Australian Defence Force (ADF) members meet criteria for a mental health condition. Mental health difficulties not only affect the individual veteran. They have been found to negatively impact the mental health of family, with an increased likelihood for family members of veterans developing a mental health condition. The aim of this study was to evaluate whether participating in a Mental Health First Aid (MHFA) program improved family members of veterans mental health knowledge, reduced personal and perceived mental health stigma, reduced social distancing attitudes and increased confidence and willingness to engage in MHFA helping behaviours. Additionally, the study measured participant's general mental health and levels of burnout. METHOD: The study utilised an uncontrolled design with assessment at three time points (baseline, post-program and three-month follow-up). Participants (N = 57) were immediate and extended family members of former ADF members with a mental health condition, who took part in a two-day standard adult MHFA program. At each time point, participants completed self-report measures assessing mental health knowledge, personal and perceived mental health stigma, social distancing attitudes, confidence and willingness to engage in MHFA helping behaviours, general mental health and burnout. Cochranes Q and repeated measures ANOVA was computed to measure the impact of time on the outcome variables. RESULTS: Results indicated significant improvements in MHFA knowledge and confidence in providing MHFA assistance. Significant reductions in personal mental health stigma (i.e. an individual's attitude towards mental health) for schizophrenia were observed and maintained at follow up. High levels of perceived mental health stigma (i.e. the belief an individual holds about others attitudes towards mental health) were reported with no significant changes observed following the MHFA program. Results did not indicate any significant benefit in improving general psychological distress or burnout at follow up. The participant sample had high levels of mental health difficulties with over half reporting a lifetime mental health diagnosis. CONCLUSION: The study is an important contribution to the international literature on MHFA. The provision of a MHFA program to family members of military veterans has not previously been evaluated. Implications of the findings are discussed with regards to future directions of MHFA research and implementing MHFA programs in this population.

Assessing psychological adjustment and cultural reintegration after military service: development and psychometric evaluation of the post-separation Military-Civilian Adjustment and Reintegration Measure (M-CARM).

BACKGROUND: The transition out of military service and subsequent reintegration to civilian life has been established as a period associated with an increased risk of psychological adjustment difficulties, psychiatric disorders and suicide risk, yet no tool exists to measure cultural and psychological adjustment following permanent separation from the military. This study describes the two-phase mixed-methods development and validation of the self-report Military-Civilian Adjustment and Reintegration Measure (M-CARM). METHODS: In Phase I, four focus groups (n = 20) and semi-structured one-on-one interviews (n = 80) enabled thematic analysis and generation of 53 initial items that were reviewed by an expert multidisciplinary panel (n = 12) and piloted for clarity and relevance in an Australian service-veteran sample (n = 11). In Phase II, psychometric properties of the 47 items resulting from Phase I were evaluated with online assessment of a convenience sample of transitioned Australian Defence Force veterans (n = 725). Analyses included exploratory and confirmatory factor analyses, as well as evaluation of test-retest reliability, internal consistency, and convergent, divergent and discriminant validity. RESULTS: Exploratory factor analysis on a randomized split-half sample (n = 357), resulted in a 21-item, five-factor solution of Purpose and Connection, Help seeking, Beliefs about civilians, Resentment and regret, and Regimentation, explaining 53.22% of the variance. Confirmatory factor analysis (n = 368) verified this factor structure without modification (χ2 = 304.96, df = 160; CFI = .96, TLI = .94, NFI = .91, RMSEA = .05). Strong convergent, divergent and discriminant validity was demonstrated as M-CARM scores significantly correlated with related constructs assessed by standardised clinical measures as well as differentiated groups based on three binary reintegration items, with large effect sizes (d = > 1). Strong test-retest reliability for the total score (n = 186, r = .93) and excellent internal consistency (n = 725, a = .90) were also found. CONCLUSIONS: Results provide promising evidence the M-CARM is a valid, reliable measure of psychological and cultural reintegration to civilian life, with potential for considerable clinical and research application.

Increased risk of attempted suicide in Australian veterans is associated with total and permanent incapacitation, unemployment and posttraumatic stress disorder severity.

BACKGROUND: Military veterans have higher rates of suicidality and completed suicides compared to the general population. Previous research has demonstrated suicidal behaviour is higher in US combat veterans who are younger, suffer from posttraumatic stress disorder, depression and anxiety and score lower on measures of health. However, research on predictors of suicide for Australian veterans is limited. The aim of this study was to identify significant demographic and psychological differences between veterans with posttraumatic stress disorder who had attempted suicide and those with posttraumatic stress disorder who had not, as well as determine predictors of suicide attempts within an Australian cohort. METHODS: A retrospective analysis was conducted on 229 ex-service personnel diagnosed with posttraumatic stress disorder who had attended a Military Service Trauma Recovery Day Program as outpatients at Toowong Private Hospital from 2007 to 2014. Patients completed a battery of mental health self-report questionnaires assessing symptoms of posttraumatic stress disorder, alcohol use, anger, depression, anxiety and quality of life. Demographic information and self-reported history of suicide attempts were also recorded. RESULTS: Results indicated the average age was significantly lower, and the rates of posttraumatic stress disorder, anger, anxiety and depression symptoms were significantly higher in those veterans with history of a suicide attempt. Multivariate logistic regression analyses indicated posttraumatic stress disorder symptom severity, unemployment or total and permanent incapacity pension status significantly predicted suicide attempt history. CONCLUSION: Among a cohort of Australian veterans with posttraumatic stress disorder, psychopathology severity, unemployment and total and permanent incapacity status are significantly associated with suicidality. This study highlights the importance of early identification of posttraumatic stress disorder and psychopathology, therapeutic and social engagement, and prioritisation of tangible employment options or meaningful and goal-directed activities for veterans deemed unable to work.

Physical comorbidities of post-traumatic stress disorder in Australian Vietnam War veterans.

OBJECTIVE: To determine whether the prevalence of physical comorbidities in Australian Vietnam War veterans with post-traumatic stress disorder (PTSD) is higher than in trauma-exposed veterans without PTSD. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional analysis of the health status (based on self-reported and objective clinical assessments) of 298 Australian Vietnam War veterans enrolled by the Gallipoli Medical Research Institute (Brisbane) during February 2014 - July 2015, of whom 108 were confirmed as having had PTSD and 106 served as trauma-exposed control participants.Main outcomes and measures: Diagnostic psychiatric interview and psychological assessments determined PTSD status, trauma exposure, and comorbid psychological symptoms. Demographic data, and medical and sleep history were collected; comprehensive clinical examination, electrocardiography, spirometry, liver transient elastography, and selected pathology assessments and diagnostic imaging were performed. Outcomes associated with PTSD were identified; regression analysis excluded the effects of potentially confounding demographic and risk factors and comorbid symptoms of depression and anxiety. RESULTS: The mean total number of comorbidities was higher among those with PTSD (17.7; SD, 6.1) than in trauma-exposed controls (14.1; SD, 5.2; P < 0.001). For 24 of 171 assessed clinical outcomes, morbidity was greater in the PTSD group, including for conditions of the gastrointestinal, hepatic, cardiovascular, and respiratory systems, sleep disorders, and laboratory pathology measures. In regression analyses including demographic factors, PTSD remained positively associated with 17 adverse outcomes; after adjusting for the severity of depressive symptoms, it remained significantly associated with ten. CONCLUSION: PTSD in Australian Vietnam veterans is associated with comorbidities in several organ systems, independent of trauma exposure. A comprehensive approach to the health care of veterans with PTSD is needed.

The relationship between chronic PTSD, cortical volumetry and white matter microstructure among Australian combat veterans.

BACKGROUND: Posttraumatic stress disorder (PTSD) has been associated with volumetric and white matter microstructural changes among general and veteran populations. However, regions implicated have greatly varied and often conflict between studies, potentially due to confounding comorbidities within samples. This study compared grey matter volume and white matter microstructure among Australian combat veterans with and without a lifetime diagnosis of PTSD, in a homogenous sample assessed for known confounding comorbidities. METHODS: Sixty-eight male trauma-exposed veterans (16 PTSD-diagnosed; mean age 69 years) completed a battery of psychometric assessments and underwent magnetic resonance and diffusion tensor imaging. Analyses included tract-based spatial statistics, voxel-wise analyses, diffusion connectome-based group-wise analysis, and volumetric analysis. RESULTS: Significantly smaller grey matter volumes were observed in the left prefrontal cortex (P = 0.026), bilateral middle frontal gyrus (P = 0.021), and left anterior insula (P = 0.048) in the PTSD group compared to controls. Significant negative correlations were found between PTSD symptom severity and fractional anisotropy values in the left corticospinal tract (R2 = 0.34, P = 0.024) and left inferior cerebellar peduncle (R2 = 0.62, P = 0.016). No connectome-based differences in white matter properties were observed. CONCLUSIONS: Findings from this study reinforce reports of white matter alterations, as indicated by reduced fractional anisotropy values, in relation to PTSD symptom severity, as well as patterns of reduced volume in the prefrontal cortex. These results contribute to the developing profile of neuroanatomical differences uniquely attributable to veterans who suffer from chronic PTSD.

Evaluation of an equine-assisted therapy program for veterans who identify as 'wounded, injured or ill' and their partners.

The aim of this study was to evaluate outcomes of an equine-assisted therapy program for Defence Force veterans and their partners across the psychological domains of depression, anxiety, stress, posttraumatic stress, happiness, and quality of life, as well as compare the outcomes of an Individual and Couples program. A non-controlled, within-subjects longitudinal design was utilized with assessment at three time points (pre-intervention, post-intervention, and three months follow-up). Between-subjects analysis with two groups was also conducted to compare the outcomes of the Individual and Couples programs. Participants were recruited from ten programs in 2016 with a total of 47 veterans and partners from both an Individual program (n = 25; veterans only) and a Couples program (n = 22). Outcome measures included the Depression Anxiety Stress Scale-21, Posttraumatic Stress Disorder Checklist for DSM-5, Oxford Happiness Questionnaire, and Quality-of-Life Enjoyment and Satisfaction Questionnaire-Short Form. Paired samples t-tests revealed that within both the Individual and Couples programs, there were significantly fewer psychological symptoms and significantly greater levels of happiness and quality of life at post-intervention compared to pre-intervention. Reduced psychological symptoms were maintained at the three months follow-up for participants of the Couples program only. Independent samples t-tests revealed participants in the Couples program reported significantly less symptoms of depression, stress, and posttraumatic stress disorder (PTSD) at follow-up compared to participants in the Individual program. These results indicate there may only be meaningful benefits for equine-assisted therapy in the reduction of depression, stress, and PTSD symptoms for veterans, if partners are integrated into the intervention.

Detailed Polysomnography in Australian Vietnam Veterans With and Without Posttraumatic Stress Disorder.

STUDY OBJECTIVES: Recent results from the PTSD Initiative, a cross-sectional cohort study in Australian Vietnam veterans (VV) with and without posttraumatic stress disorder (PTSD), demonstrated an increased prevalence of self-reported sleep disturbances in those with PTSD. This study aimed to objectively assess the prevalence of sleep disorders in the same cohort using detailed polysomnography (PSG). METHODS: Participants from the PTSD Initiative were recruited to undergo PSG. PTSD status was determined with the Clinician Administered PTSD Scale for DSM-5 (CAPS-5). Subjective sleep information was attained via structured questionnaires. Data from single night PSG were compared between trauma-exposed VV with and without PTSD. RESULTS: A total of 74 trauma-exposed male VV (40 with PTSD) underwent PSG (prospective n = 59, retrospective n = 15). All PSG parameters were similar between groups. No difference was seen in PSG-diagnosed obstructive sleep apnea (OSA) or periodic limb movements of sleep (PLMS). VV with PTSD showed a trend toward increased duration of sleep with oxygen saturations < 90% (10% versus 1.8%; P = .07). VV with PTSD reported increased sleep onset latency (42.4 versus 13.3 minutes; P < .01); were less likely to report sleeping well (32.5% versus 67.5%; P < .01); had higher OSA risk using Berlin Questionnaire (BQ) (70% versus 38.2%; P < .01); and had higher rates of partner-reported limb movements (56.4% versus 17.6%; P < .01). No association between PSG-diagnosed OSA and PTSD severity was evident. CONCLUSIONS: In Australian VV with and without PTSD, no difference was seen across all PSG parameters including the diagnosis and severity of OSA and PLMS. However, VV with PTSD demonstrated an increased perception of sleep disturbances.

University student depression inventory (USDI): confirmatory factor analysis and review of psychometric properties.

BACKGROUND: The 30-item USDI is a self-report measure that assesses depressive symptoms among university students. It consists of three correlated three factors: lethargy, cognitive-emotional and academic motivation. The current research used confirmatory factor analysis to asses construct validity and determine whether the original factor structure would be replicated in a different sample. Psychometric properties were also examined. METHOD: Participants were 1148 students (mean age 22.84 years, SD=6.85) across all faculties from a large Australian metropolitan university. Students completed a questionnaire comprising of the USDI, the depression anxiety stress scale (DASS) and Life Satisfaction Scale (LSS). RESULTS: The three correlated factor model was shown to be an acceptable fit to the data, indicating sound construct validity. Internal consistency of the scale was also demonstrated to be sound, with high Cronbach alpha values. Temporal stability of the scale was also shown to be strong through test-retest analysis. Finally, concurrent and discriminant validity was examined with correlations between the USDI and DASS subscales as well as the LSS, with sound results further supporting the construct validity of the scale. Cut-off points were also developed to aid total score interpretation. LIMITATIONS: Response rates are unclear. In addition, the representativeness of the sample could be improved potentially through targeted recruitment (i.e. reviewing the online sample statistics during data collection, examining the representativeness trends and addressing particular faculties within the university that were underrepresented). CONCLUSIONS: The USDI provides a valid and reliable method of assessing depressive symptoms found among university students.

The impact of school connectedness on violent behavior, transport risk-taking behavior, and associated injuries in adolescence.

Adolescents engage in many risk-taking behaviors that have the potential to lead to injury. The school environment has a significant role in shaping adolescent behavior, and this study aimed to provide additional information about the benefits associated with connectedness to school. Early adolescents aged 13 to 15 years (N=509, 49% boys) were surveyed about school connectedness, engagement in transport and violence risk-taking, and injury experiences. Significant relations were found between school connectedness and reduced engagement in both transport and violence risk-taking, as well as fewer associated injuries. This study has implications for the area of risk-taking and injury prevention, as it suggests the potential for reducing adolescents' injury through school based interventions targeting school connectedness.