A systematic review of lethal means safety counseling interventions: impacts on safety behaviors and self-directed violence.

For lethal means safety counseling (LMSC) interventions to reduce population-level suicide rates, interventions must be deployed across many settings and populations. We conducted a systematic search in 6 databases to review the current state of LMSC interventions across study designs, settings, intervention providers, populations, and injury prevention levels (eg, universal). Eligibility criteria were as follows: any individual or group receiving an LMSC intervention involving a human-to-human component aiming to influence adult behaviors related to lethal suicide methods, and outcome assessment of storage behaviors and/or suicidal self-directed violence (SDV). Risk of bias was assessed using the Effective Public Health Practice Project quality assessment tool. A descriptive synthesis approach was used for analysis. Twenty-two studies were included that reported medication- and/or firearm-storage behaviors and/or SDV after LMSC. Of the 19 studies assessing behavioral change, 14 reported a significant improvement in safe storage behaviors, and all studies measuring acceptability reported that participants found the interventions favorable. The quality of evidence was limited. No studies were rated low risk of bias, and 77% were rated high risk of bias. There was substantial heterogeneity in the settings, populations, injury prevention levels, delivery methods, and intervention elements. Many included studies focused on caregivers of pediatric populations, and few studies assessed SDV outcomes. Higher-quality trials conducted across a variety of settings, particularly those focusing on adults at risk of suicide, are needed. This review was preregistered with the International Prospective Register of Systematic Reviews (no. CRD42021230668).

Longitudinal Influence of Prescribed Antidepressants on Fecal and Oral Microbiomes Among Veterans With Major Depressive Disorder.

OBJECTIVE: The purpose of this study was to evaluate the influence of a new course of antidepressant monotherapy on gut and oral microbiomes and the relationship to depressive symptoms. METHODS: Longitudinal microbiome samples obtained from 10 U.S. veterans were analyzed. Baseline samples were taken before a new course of antidepressant monotherapy (either switching from a previous treatment or starting a new treatment). Targeted genomic sequencing of the microbiome samples was used to analyze changes in taxonomy and diversity across participants, medications, and medication class. Associations between these changes and Patient Health Questionnaire-9 (PHQ-9) scores were analyzed. RESULTS: Taxonomic variability was observed across participants, with the individual being the main microbial community driver. In terms of the fecal microbiome, antidepressants were associated with shifts toward Bacteroides being less abundant and Blautia, Pseudomonas, or Faecalibacterium being more abundant. Likewise, the composition of the oral microbiome was variable, with individual participants being the primary drivers of community composition. In the oral samples, the relative abundance of Haemophilus decreased after antidepressants were started. Increases in Blautia and decreases in Bacteroides were associated with lower PHQ-9 scores. CONCLUSIONS: Antidepressants were found to influence fecal and oral microbiomes such that a new course of antidepressant monotherapy was associated with taxonomic alterations toward healthier states in both fecal and oral microbiomes, which were associated with decreases in depressive symptoms. Additional longitudinal research is required to increase understanding of microbiomes and symptom-based changes, with a particular focus on potential differences between medication classes and underlying mechanisms.

Barriers and Facilitators to the Adoption of Evidence-Based Interventions for Adults Within Occupational and Physical Therapy Practice Settings: A Systematic Review.

OBJECTIVE: Synthesize data regarding barriers and facilitators of adoption (ie, adoption determinants) of evidence-based occupational (OT) and physical therapy (PT) interventions within real-world practice. Whether evidence varied across disciplines, settings, and use of theoretical frameworks was also examined. DATA SOURCES: Literature published from database inception to December 9, 2022, in OVID MEDLINE, EMBASE, OVID PsycINFO, Web of Science Core Collection, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, and Google Scholar. STUDY SELECTION: Original research including: (1) stakeholder insight into adoption determinants; (2) discrete evidence-based interventions delivered/supervised by an OT and/or PT; (3) intervention recipients aged 18 or older; and (4) data regarding adoption determinants. Two reviewers independently screened and evaluated studies for inclusion, with a third resolving discrepancies. Of the 3036 articles identified, 45 articles were included. DATA EXTRACTION: Data were extracted by a primary reviewer, independently evaluated by a second reviewer, and conflicts were resolved via group consensus. DATA SYNTHESIS: A descriptive synthesis approach was used to categorize adoption determinants according to constructs from the Consolidated Framework for Implementation Research. 87% of studies were published after 2014. Many studies: described PT interventions (82%); were within the outpatient setting (44%); had data gathered after implementing the intervention (71%); and did not report use of a theoretical framework to inform data collection (62%). Lack of available resources (64%) and knowledge/beliefs about the intervention (53%) were the most common barrier and facilitator, respectively. Variability in adoption determinants was observed according to discipline, setting, and use of a theoretical framework. CONCLUSIONS: Findings suggest a recent surge of scientific investment in understanding adoption determinants for evidence-based OT and PT interventions. Such knowledge can inform efforts aimed at improving OT and PT quality, thereby enhancing patient outcomes. However, our review highlighted gaps with significant implications for the delivery of evidence-based OT and PT within real-world practice settings.

Developmental Outcomes Following Abusive Head Trauma in Infancy: A Systematic Review.

OBJECTIVE: A systematic review of the literature was conducted to identify measures used to evaluate developmental outcomes after abusive head trauma (AHT), as well as describe outcomes among those with AHT, and explore factors and interventions influencing such outcomes. DESIGN: This systematic review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. The protocol is in PROSPERO, registration number CRD42020179592. On April 17, 2020, OVID Medline, Embase, OVID PsycINFO, Web of Science, CINAHL, Cochrane Library, and Google Scholar were searched (since inception). Inclusion criteria included original, peer-reviewed study data; AHT exposure; infants younger than 24 months at time of AHT; and evaluation of developmental outcomes. Reviewers independently evaluated studies for inclusion and assessed risk of bias using the Effective Public Health Practice Project quality assessment tool for quantitative studies. A descriptive synthesis approach was utilized as variability of study designs, follow-up periods, and outcome assessment tools precluded a meta-analytic approach. RESULTS: Fifty-nine studies were included; 115 assessment tools were used to evaluate developmental outcomes; and 42 studies examined factors influencing outcomes. Two studies evaluated interventions. Five percent of studies ( n = 3) were rated low risk of bias. CONCLUSIONS: Notable variation was observed in terms of case ascertainment criteria. Developmental outcomes after AHT have been assessed in a manner that limits understanding of how AHT impacts development, as well as the efficacy of interventions intended to improve outcomes. Researchers and clinicians are encouraged to adopt consistent diagnostic and assessment approaches.

Suicide among veterans with amyotrophic lateral sclerosis.

BACKGROUND: The purpose of this study was to estimate the risk of death by suicide for those with amyotrophic lateral sclerosis (ALS) seeking care within the Veterans Health Administration (VHA). METHODS: This was a retrospective, cohort study. Extended Cox regression models were used to compare the hazard of suicide between the ALS and the unexposed groups. RESULTS: The hazard of suicide was 3.98 times higher for those with ALS than for those without (95% confidence interval [CI] , 2.64-6.00; P < .0001). After adjusting for covariates, those with ALS remained at increased risk (hazard ratio, 3.48; 95% CI, 2.31-5.24; P < .001). CONCLUSIONS: Among those seeking care in the VHA, individuals with ALS are at increased risk for dying by suicide. Additional suicide prevention efforts, including strategies for reducing access to lethal means, are warranted.

Suicide After Stroke in the United States Veteran Health Administration Population.

OBJECTIVE: To evaluate risk for suicide among veterans with a history of stroke, seeking care within the Veterans Health Administration (VHA), we analyzed existing clinical data. DESIGN: This retrospective cohort study was approved and performed in accordance with the local Institutional Review Board. Veterans were identified via the VHA's Corporate Data Warehouse. Initial eligibility criteria included confirmed veteran status and at least 90 days of VHA utilization between fiscal years 2001-2015. Cox proportional hazards models were used to assess the association between history of stroke and suicide. Among those veterans who died by suicide, the association between history of stroke and method of suicide was also investigated. SETTING: VHA. PARTICIPANTS: Veterans with at least 90 days of VHA utilization between fiscal years 2001-2015 (N=1,647,671). Data from these 1,647,671 veterans were analyzed (1,405,762 without stroke and 241,909 with stroke). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Suicide and method of suicide. RESULTS: The fully adjusted model, which controlled for age, sex, mental health diagnoses, mild traumatic brain injury, and modified Charlson/Deyo Index (stroke-related diagnoses excluded), demonstrated a hazard ratio of 1.13 (95% confidence interval, 1.02-1.25; P=.02). The majority of suicides in both cohorts was by firearm, and a significantly larger proportion of suicides occurred by firearm in the group with stroke than the cohort without (81.2% vs 76.6%). CONCLUSIONS: Findings suggest that veterans with a history of stroke are at increased risk for suicide, specifically by firearm, compared with veterans without a history of stroke. Increased efforts are needed to address the mental health needs and lethal means safety of veterans with a history of stroke, with the goal of improving function and decreasing negative psychiatric outcomes, such as suicide.

Microbial Diversity and Community Structures Among Those With Moderate to Severe TBI: A United States-Veteran Microbiome Project Study.

OBJECTIVE: To evaluate the association between distal moderate/severe traumatic brain injury (TBI) history and the human gut microbiome. SETTING: Veterans Affairs Medical Center. PARTICIPANTS: Veterans from the United States-Veteran Microbiome Project (US-VMP). Veterans with moderate/severe TBI (n = 34) were compared with (1) Veterans with a history of no TBI (n = 79) and (2) Veterans with a history of no TBI or mild TBI only (n = 297). DESIGN: Microbiome analyses from 16S rRNA gene sequencing with gut microbiota function inferred using PICRUSt2. MAIN MEASURES: α-Diversity and ß-diversity of the gut microbiome, as well as taxonomic and functional signatures associated with moderate/severe TBI. RESULTS: There were no significant differences in gut bacterial α- and ß-diversity associated with moderate/severe TBI status. No differentially abundant taxa were identified when comparing samples from moderate/severe TBI to those with no TBI or no TBI/mild TBI. CONCLUSION: Results suggest that moderate/severe TBI-related changes to the gut microbiome do not persist for years postinjury.

Mobile App for Mental Health Monitoring and Clinical Outreach in Veterans: Mixed Methods Feasibility and Acceptability Study.

BACKGROUND: Advances in mobile health (mHealth) technology have made it possible for patients and health care providers to monitor and track behavioral health symptoms in real time. Ideally, mHealth apps include both passive and interactive monitoring and demonstrate high levels of patient engagement. Digital phenotyping, the measurement of individual technology usage, provides insight into individual behaviors associated with mental health. OBJECTIVE: Researchers at a Veterans Affairs Medical Center and Cogito Corporation sought to explore the feasibility and acceptability of an mHealth app, the Cogito Companion. METHODS: A mixed methodological approach was used to investigate the feasibility and acceptability of the app. Veterans completed clinical interviews and self-report measures, at baseline and at a 3-month follow-up. During the data collection period, participants were provided access to the Cogito Companion smartphone app. The mobile app gathered passive and active behavioral health indicators. Data collected (eg, vocal features and digital phenotyping of everyday social signals) are analyzed in real time. Passive data collected include location via global positioning system (GPS), phone calls, and SMS text message metadata. Four primary model scores were identified as being predictive of the presence or absence of depression or posttraumatic stress disorder (PTSD). Veterans Affairs clinicians monitored a provider dashboard and conducted clinical outreach when indicated. RESULTS: Findings suggest that use of the Cogito Companion app was feasible and acceptable. Veterans (n=83) were interested in and used the app; however, active use declined over time. Nonetheless, data were passively collected, and outreach occurred throughout the study period. On the Client Satisfaction Questionnaire-8, 79% (53/67) of the sample reported scores demonstrating acceptability of the app (mean 26.2, SD 4.3). Many veterans reported liking specific app features (day-to-day monitoring) and the sense of connection they felt with the study clinicians who conducted outreach. Only a small percentage (4/67, 6%) reported concerns regarding personal privacy. CONCLUSIONS: Feasibility and acceptability of the Cogito Corporation platform to monitor mental health symptoms, behaviors, and facilitate follow-up in a sample of veterans were supported. Clinically, platforms such as the Cogito Companion system may serve as useful methods to promote monitoring, thereby facilitating early identification of risk and mitigating negative psychiatric outcomes, such as suicide.

Suicide and Traumatic Brain Injury Among Individuals Seeking Veterans Health Administration Services Between Fiscal Years 2006 and 2015.

OBJECTIVE: Examine associations between traumatic brain injury (TBI) and (1) suicide and (2) suicide method among individuals receiving Veterans Health Administration (VHA) care. SETTING: VHA, Fiscal Years 2006-2015. PARTICIPANTS: Veterans with a TBI diagnosis during/prior to the study window (n = 215 610), compared with a 20% random sample of those without TBI (n = 1 187 639). DESIGN: Retrospective, cohort study. Cox proportional hazards models were fit accounting for time-dependent measures, chronic conditions, and demographics for those with TBI compared with those without. Additional models evaluated the impact of TBI severity on the association between TBI and suicide, and method. MAIN OUTCOME MEASURES: Death by and method of suicide. RESULTS: The hazard of suicide was 2.19 times higher for those with TBI than for those without TBI (95% CI = 2.02-2.37), and was still significant after accounting for covariates (hazard ratio [HR] = 1.71; 95% confidence interval [CI] = 1.56-1.87). Considering severity, mild TBI compared with no TBI was significantly associated with an elevated hazard of suicide, after adjusting for covariates (HR = 1.62; 95% CI = 1.47-1.78). There was also a significant difference in death by suicide between moderate/severe TBI when compared with no TBI, after adjusting for covariates (HR = 2.45; 95% CI = 2.02-2.97). Moderate/severe TBI was significantly associated with an increase in the odds of suicide by firearm among decedents (odds ratio = 2.39; 95% CI = 1.48-3.87). CONCLUSION: Traumatic brain injury is associated with an elevated risk for suicide. Particular concern is warranted for those with moderate/severe TBI. Lethal means safety should be explored as an intervention.

The Natural History of Postconcussion Recovery Among High School Athletes.

OBJECTIVE: Evaluate postconcussive symptom reporting and recovery. SETTING: Public high school. PARTICIPANTS: Unmatched controls (n = 760); students who sustained a sports-related concussion (n = 77); matched controls (gender, grade, sport) (n = 77). DESIGN: Prospective longitudinal cohort study. OUTCOME MEASURE: Immediate Postconcussion Assessment and Cognitive Testing. RESULTS: At baseline, athletes who went on to sustain concussions were more likely than unmatched controls to be younger (P = .02), male (P = .001), and participate in different sports (P < .0001) such as football (concussed = 52%, unmatched controls = 20%). Differences were also noted regarding a previous history of concussion (P = .045; concussed athletes = 26%; unmatched control athletes = 16%) and lifetime number of concussions (P = .05). At baseline, those whose sustained concussions during the study period were more likely than matched controls to report numbness (P = .01) and concentration problems (P = .01) and more likely than unmatched controls to report dizziness (P = .02), sensitivity to light (P = .01), sensitivity to noise (P = .002), and numbness (P = .02). However, when data were reanalyzed and those with a previous history of concussion were removed, differences between those who sustained concussions during the study period and matched controls were no longer significant; when compared to unmatched controls, sensitivity to light (P = .01) and vision problems (P = .04) remained significant. Among those who sustained concussions, median time to recovery was 6 days (95% confidence interval: 4-9), and 71 out of 77 (92%) recovered by the fourth postinjury evaluation (median: 20 days postinjury). CONCLUSIONS: Course and time frame of recovery were variable. Data also suggest that a previous history of concussion may be contributing to baseline symptom reporting and highlight the potential enduring impact of history of concussion on sensorimotor function. However, further research as to whether preinjury measures of sensorimotor function may increase understanding regarding concussion risk is warranted.

Persistent Symptoms and Objectively Measured Balance Performance Among OEF/OIF Veterans With Remote Mild Traumatic Brain Injury.

OBJECTIVE: To investigate linear relationships between dizziness, fatigue, and depression and posttraumatic stress disorder (PTSD) and objectively measured balance performance in Veterans with remote mild traumatic brain injury (mTBI). SETTING: Academic laboratory; Veterans Affairs Medical Center. PARTICIPANTS: Thirty Veterans (28 men) who served in Iraq/Afghanistan and whose most recent mTBI was sustained more than 6 months prior to enrollment. DESIGN: Cross-sectional, observational trial. MAIN MEASURES: The Computerized Dynamic Posturography-Sensory Organization Test (CDP-SOT) and the Community Balance and Mobility (CB&M) scale measured balance. Dizziness (Dizziness Handicap Inventory), fatigue (Modified Fatigue Impact Scale), depression-related symptoms (Beck Depression Inventory-II), and PTSD-related symptoms (PTSD Checklist 5) were also measured. RESULTS: Objectively measured balance, CDP-SOT composite, was impaired (mean score of 67.9). CDP-SOT scores correlated with dizziness (r = -0.53; P = .002), fatigue (r = -0.38; P = .03), depression (r = -0.55; P = .001), and PTSD symptoms (r = -0.53; P = .002). Dizziness, time since most recent mTBI, and PTSD symptoms and depression combined explained significant variability in CDP-SOT scores (R = 0.46; P = .003), as did fatigue depression and PTSD symptoms (R = 0.33; P = .01). CONCLUSIONS: Impaired balance was identified among the cohort. Findings suggest that dizziness, fatigue, depression and PTSD, and time since most recent mTBI may influence balance performance. Additional research is needed to identify the potentially interrelated natural histories of these co-occurring symptoms.

Growing literature but limited evidence: A systematic review regarding prebiotic and probiotic interventions for those with traumatic brain injury and/or posttraumatic stress disorder.

Traumatic brain injury (TBI) is highly prevalent among a wide range of populations, including civilians, military personnel, and Veterans. TBI sequelae may be further exacerbated by symptoms associated with frequently occurring comorbid psychiatric conditions, including posttraumatic stress disorder (PTSD). This is particularly true among the population of military personnel from recent conflicts in Iraq and Afghanistan, with a history of mild TBI (mTBI) and PTSD. The need for efficacious treatments for TBI and comorbid PTSD is significant, and evidence-based interventions for these frequently co-occurring conditions are limited. Based on findings suggesting that inflammation may be an underlying mechanism of both conditions, anti-inflammatory/immunoregulatory agents, including probiotics, may represent a novel strategy to treat TBI and/or PTSD-related symptoms. The focus of this systematic review was to identify and evaluate existing research regarding prebiotic and probiotic interventions for the populations of individuals with a history of TBI and/or PTSD. Only 4 studies were identified (3 severe TBI, 1 PTSD, 0 co-occurring TBI and PTSD). Although findings suggested some promise, work in this area is nascent and results to date do not support some claims within the extensive coverage of probiotics in the popular press.

Traumatic brain injury, psychiatric diagnoses, and suicide risk among Veterans seeking services related to homelessness.

OBJECTIVES: To explore the differences in negative psychiatric outcomes (i.e. type and number of psychiatric diagnoses, suicide risk) among Veterans with and without a history of traumatic brain injury (TBI) seeking homeless services. METHODS: Observational design with data collected at one time-point. Veterans seeking homeless services from two Veteran Affairs (VA) Medical Centres completed study measures (n = 309; 282 with a history of TBI and 27 without a history of TBI). Veterans participated in structured clinical interviews regarding psychiatric and TBI histories. RESULTS: Those with a history of TBI met the criteria for significantly more psychiatric diagnoses (p = 0.0003), and were more likely to be at risk for suicide (p = 0.007) than those without a history of TBI. CONCLUSIONS: Even among the high-risk cohort of homeless Veterans, those with a history of TBI were found to be at even greater risk for negative psychiatric outcomes. Further research is required to determine if and how the history of TBI contributes to the inability to maintain stable housing. Moreover, the findings highlight both the importance of assessing for history of TBI among this cohort, and educating providers regarding how to address the needs related to injury sequelae.

Kynurenine and Tryptophan Levels in Patients With Schizophrenia and Elevated Antigliadin Immunoglobulin G Antibodies.

OBJECTIVE: Several studies have reported an association between nonceliac gluten sensitivity and schizophrenia. Immune and kynurenine (KYN) pathways have also been implicated in the pathophysiology of schizophrenia, and certain proinflammatory immune mediators may increase KYN and reduce tryptophan (TRP) levels. METHODS: We measured serum antigliadin immunoglobulin G (IgG), KYN, and TRP in 950 patients with schizophrenia. Patients with antibody level at the 90th percentile or higher of control participants (21.9% of all patients) were classified as having elevated antigliadin IgG. Independent t tests and linear regression models were used to compare TRP, KYN, and KYN-TRP ratio (indicator of TRP metabolism) between patients with and those without elevated antigliadin IgG. The correlation between antigliadin IgG and TRP, KYN, and the ratio was also evaluated in the patients. RESULTS: KYN and KYN-TRP ratio were higher in patients with elevated antigliadin IgG (geometric mean [standard deviation {SD}] = 2.65 [0.25] µmol/L versus 2.25 [0.23] µmol/L [p < .001] and 0.05 [0.26] versus 0.04 [0.25; p = .001] respectively), findings robust to adjustment for potential demographic and clinical confounders. Antigliadin IgG positively correlated with KYN and KYN-TRP ratio (r = 0.12, p < .001; r = 0.11, p = .002). TRP did not differ between the two groups and did not correlate with antigliadin IgG. CONCLUSIONS: Our results connect nonceliac gluten sensitivity with the KYN pathway of TRP metabolism in psychotic illness and hint toward potential individualized treatment targets.

Airborne Exposure to Pollutants and Mental Health: A Review with Implications for United States Veterans.

PURPOSE OF REVIEW: Inhalation of airborne pollutants in the natural and built environment is ubiquitous; yet, exposures are different across a lifespan and unique to individuals. Here, we reviewed the connections between mental health outcomes from airborne pollutant exposures, the biological inflammatory mechanisms, and provide future directions for researchers and policy makers. The current state of knowledge is discussed on associations between mental health outcomes and Clean Air Act criteria pollutants, traffic-related air pollutants, pesticides, heavy metals, jet fuel, and burn pits. RECENT FINDINGS: Although associations between airborne pollutants and negative physical health outcomes have been a topic of previous investigations, work highlighting associations between exposures and psychological health is only starting to emerge. Research on criteria pollutants and mental health outcomes has the most robust results to date, followed by traffic-related air pollutants, and then pesticides. In contrast, scarce mental health research has been conducted on exposure to heavy metals, jet fuel, and burn pits. Specific cohorts of individuals, such as United States military members and in-turn, Veterans, often have unique histories of exposures, including service-related exposures to aircraft (e.g. jet fuels) and burn pits. Research focused on Veterans and other individuals with an increased likelihood of exposure and higher vulnerability to negative mental health outcomes is needed. Future research will facilitate knowledge aimed at both prevention and intervention to improve physical and mental health among military personnel, Veterans, and other at-risk individuals.

Predicting Recovery After Concussion in Pediatric Patients: A Meta-Analysis.

CONTEXT: Prognostic prediction models (PPMs) can help clinicians predict outcomes. OBJECTIVE: To critically examine peer-reviewed PPMs predicting delayed recovery among pediatric patients with concussion. DATA SOURCES: Ovid Medline, Embase, Ovid PsycInfo, Web of Science Core Collection, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Google Scholar. STUDY SELECTION: The study had to report a PPM for pediatric patients to be used within 28 days of injury to estimate risk of delayed recovery at 28 days to 1 year postinjury. Studies had to have at least 30 participants. DATA EXTRACTION: The Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modeling Studies checklist was completed. RESULTS: Six studies of 13 PPMs were included. These studies primarily reflected male patients in late childhood or early adolescence presenting to an emergency department meeting the Concussion in Sport Group concussion criteria. No study authors used the same outcome definition nor evaluated the clinical utility of a model. All studies demonstrated high risk of bias. Quality of evidence was best for the Predicting and Preventing Postconcussive Problems in Pediatrics (5P) clinical risk score. LIMITATIONS: No formal PPM Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) process exists. CONCLUSIONS: The 5P clinical risk score may be considered for clinical use. Rigorous external validations, particularly in other settings, are needed. The remaining PPMs require external validation. Lack of consensus regarding delayed recovery criteria limits these PPMs.

A randomized clinical trial for a self-guided sleep intervention following moderate-severe traumatic brain injury: Study protocol.

BACKGROUND: Individuals with a history of moderate-severe traumatic brain injury (TBI) experience a significantly higher prevalence of insomnia compared to the general population. While individuals living with TBI have been shown to benefit from traditional insomnia interventions (e.g., face-to-face [F2F]), such as Cognitive Behavioral Therapy for Insomnia (CBTI), many barriers exist that limit access to F2F evidence-based treatments. Although computerized CBT-I (CCBT-I) is efficacious in terms of reducing insomnia symptoms, individuals with moderate-severe TBI may require support to engage in such treatment. Here we describe the rationale, design, and methods of a randomized controlled trial (RCT) assessing the efficacy of a guided CCBT-I program for reducing insomnia symptoms for participants with a history of moderate-severe TBI. METHODS: This is an RCT of a guided CCBT-I intervention for individuals with a history of moderate-severe TBI and insomnia. The primary outcome is self-reported insomnia severity, pre- to post-intervention. Exploratory outcomes include changes in sleep misperception following CCBT-I and describing the nature of guidance needed by the Study Clinician during the intervention. CONCLUSION: This study represents an innovative approach to facilitating broader engagement with an evidence-based online treatment for insomnia among those with a history of moderate-severe TBI. Findings will provide evidence for the level and nature of support needed to implement guided CCBT-I. Should findings be positive, this study would provide support for a strategy by which to deliver guided CCBT-I to individuals with a history of moderate-severe TBI.

Study protocol: Identifying transcriptional regulatory alterations of chronic effects of blast and disturbed sleep in United States Veterans.

Injury related to blast exposure dramatically rose during post-911 era military conflicts in Iraq and Afghanistan. Mild traumatic brain injury (mTBI) is among the most common injuries following blast, an exposure that may not result in a definitive physiologic marker (e.g., loss of consciousness). Recent research suggests that exposure to low level blasts and, more specifically repetitive blast exposure (RBE), which may be subconcussive in nature, may also impact long term physiologic and psychological outcomes, though findings have been mixed. For military personnel, blast-related injuries often occur in chaotic settings (e.g., combat), which create challenges in the immediate assessment of related-injuries, as well as acute and post-acute sequelae. As such, alternate means of identifying blast-related injuries are needed. Results from previous work suggest that epigenetic markers, such as DNA methylation, may provide a potential stable biomarker of cumulative blast exposure that can persist over time. However, more research regarding blast exposure and associations with short- and long-term sequelae is needed. Here we present the protocol for an observational study that will be completed in two phases: Phase 1 will address blast exposure among Active Duty Personnel and Phase 2 will focus on long term sequelae and biological signatures among Veterans who served in the recent conflicts and were exposed to repeated blast events as part of their military occupation. Phase 2 will be the focus of this paper. We hypothesize that Veterans will exhibit similar differentially methylated regions (DMRs) associated with changes in sleep and other psychological and physical metrics, as observed with Active Duty Personnel. Additional analyses will be conducted to compare DMRs between Phase 1 and 2 cohorts, as well as self-reported psychological and physical symptoms. This comparison between Service Members and Veterans will allow for exploration regarding the natural history of blast exposure in a quasi-longitudinal manner. Findings from this study are expected to provide additional evidence for repetitive blast-related physiologic changes associated with long-term neurobehavioral symptoms. It is expected that findings will provide foundational data for the development of effective interventions following RBE that could lead to improved long-term physical and psychological health.

Longitudinal invariance of the Patient Health Questionnaire-9 among patients receiving pharmacotherapy for major depressive disorder: A secondary analysis of clinical trial data.

Comparing self-reported symptom scores across time requires longitudinal measurement invariance (LMI), a psychometric property that means the measure is functioning identically across all time points. Despite its prominence as a measure of depression symptom severity in both research and health care, LMI has yet to be firmly established for the Patient Health Questionnaire-9 depression module (PHQ-9), particularly over the course of antidepressant pharmacotherapy. Accordingly, the objective of this study was to assess for LMI of the PHQ-9 during pharmacotherapy for major depressive disorder. This was a secondary analysis of data collected during a randomized controlled trial. A total of 1,944 veterans began antidepressant monotherapy and completed the PHQ-9 six times over 24 weeks of treatment. LMI was assessed using a series of four confirmatory factor analysis models that included all six time points, with estimated parameters increasingly constrained across models to test for different aspects of invariance. Root-mean-square error of approximation of the chi-square difference test values below 0.06 indicated the presence of LMI. Exploratory LMI analyses were also performed for separate sex, age, and race subgroups. Root-mean-square error of approximation of the chi-square difference test showed minimal change in model fits during invariance testing (≤ 0.06 for all steps), supporting full LMI for the PHQ-9. LMI was also supported for all tested veteran subgroups. As such, PHQ-9 sum scores can be compared across extended pharmacotherapy treatment durations. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Association of homelessness and diet on the gut microbiome: a United States-Veteran Microbiome Project (US-VMP) study.

Military veterans account for 8% of homeless individuals living in the United States. To highlight associations between history of homelessness and the gut microbiome, we compared the gut microbiome of veterans who reported having a previous experience of homelessness to those from individuals who reported never having experienced a period of homelessness. Moreover, we examined the impact of the cumulative exposure of prior and current homelessness to understand possible associations between these experiences and the gut microbiome. Microbiome samples underwent genomic sequencing and were analyzed based on alpha diversity, beta diversity, and taxonomic differences. Additionally, demographic information, dietary data, and mental health history were collected. A lifetime history of homelessness was found to be associated with alcohol use disorder, substance use disorder, and healthy eating index compared to those without such a history. In terms of differences in gut microbiota, beta diversity was significantly different between veterans who had experienced homelessness and veterans who had never been homeless (P = 0.047, weighted UniFrac), while alpha diversity was similar. The microbial community differences were, in part, driven by a lower relative abundance of Akkermansia in veterans who had experienced homelessness (mean; range [in percentages], 1.07; 0-33.9) compared to veterans who had never been homeless (2.02; 0-36.8) (P = 0.014, ancom-bc2). Additional research is required to facilitate understanding regarding the complex associations between homelessness, the gut microbiome, and mental and physical health conditions, with a focus on increasing understanding regarding the longitudinal impact of housing instability throughout the lifespan.IMPORTANCEAlthough there are known stressors related to homelessness as well as chronic health conditions experienced by those without stable housing, there has been limited work evaluating the associations between microbial community composition and homelessness. We analyzed, for the first time, bacterial gut microbiome associations among those with experiences of homelessness on alpha diversity, beta diversity, and taxonomic differences. Additionally, we characterized the influences of diet, demographic characteristics, military service history, and mental health conditions on the microbiome of veterans with and without any lifetime history of homelessness. Future longitudinal research to evaluate the complex relationships between homelessness, the gut microbiome, and mental health outcomes is recommended. Ultimately, differences in the gut microbiome of individuals experiencing and not experiencing homelessness could assist in identification of treatment targets to improve health outcomes.