MORBID THOUGHTS AND SUICIDAL IDEATION IN IRAQ WAR VETERANS: THE ROLE OF DIRECT AND INDIRECT KILLING IN COMBAT.

BACKGROUND: Although research has identified numerous risk factors for military suicide, the contribution of combat exposure to suicide risk has not been clearly established. Previous studies finding no association of suicidality with combat exposure have employed overgeneral measures of exposure, which do not differentiate among the varieties of combat experiences. This study disaggregated the forms of combat exposure to assess the contribution of combat-related killing to morbid thoughts and suicidal ideation (MTSI) in National Guard troops deployed to Iraq. METHODS: We conducted parallel analyses of two related samples: a cross-sectional sample (n = 1,665) having postdeployment interview data only and a longitudinal subsample (n = 922) having pre- and postdeployment data. We used multiple logistic regression to examine the role of killing-related exposures, after controlling for general combat and other suicide risks, and examined interactions between killing and other suicide vulnerability factors. RESULTS: Killing-related exposure approximately doubled the risk of MTSI in the cross-sectional multivariate model (Adjusted Odds Ratio [AOR] = 1.87; CI = 1.26-2.78) and the longitudinal model (AOR = 2.02; CI = 1.06-3.85), which also controlled for predeployment risks. Killing exposures further increased the MTSI risk associated with other suicide vulnerability factors, including depression (AOR = 14.89 for depression and killing vs. AOR = 9.92 for depression alone), alcohol dependence (AOR = 5.63 for alcohol and killing vs. 1.91 for alcohol alone), and readjustment stress (AOR = 4.90 for stress and killing vs. 1.48 for stress alone). General combat exposure had no comparable effects. CONCLUSIONS: The findings underscore a need for assessment and treatment protocols that address the psychological effects of killing-related and other potentially "morally injurious" experiences among combat soldiers.

Keeping surveys valid, reliable, and useful: a tutorial.

This tutorial focuses on how to produce reliable and generalizable data from random-digit-dialing (RDD) landline and cell phone surveys. The article notes that RDD response rates have declined and explores the impact of this pronounced decline. The tutorial addresses order, response mode, and many other biases, sample size, cooperation and response rates, weighting, and hybrid designs-all using examples from risk analysis to illustrate the key points. The article ends with a brief review of the advantages and disadvantages of major Internet and paper surveys tools, and how these can be molded and sometimes combined in repeated, longitudinal, and other designs to answer questions about risk preferences and perceptions.

Public support for policies to reduce risk after Hurricane Sandy.

A phone survey was conducted in New Jersey in 2013 four months after the second of two major devastating tropical storms (Sandy in 2012 and Irene in 2011). The objective was to estimate public support for restricting land uses in flood zones, requiring housing to be built to resist storm waters, and otherwise increasing mitigation and resilience. Respondents who supported these mitigation and resilience policies disproportionately were concerned about global climate change, trusted climate scientists and the federal government, and were willing to contribute to a redevelopment program through taxes, bonds, and fees. They also tended to have collectivist and egalitarian worldviews. Half of the respondents supported at least four of the seven risk-reducing policies. How their support translates into public policy remains to be seen. Lack of willingness to personally fund these policies is an obstacle.

An evaluation of transit procurement training.

We evaluated a training course called "Orientation to Transit Procurement", designed and conducted by the National Transit Institute. This course is designed to provide Federal Transit Administration (FTA) grantees an overview of regulations and best practices related to the procurement process. Our objective in conducting the evaluation was to understand how transit agency staff made changes in procurement practices in response to the course training. The evaluation was mixed mode: an Internet survey followed by in-depth interviews with a small group of respondents. Survey respondents were also provided with an open-ended question providing us with additional context for our evaluation. Results show that the training is substantially successful at meeting the goal of improving procurement practices at transit agencies; indeed, most respondents report making changes at their agencies as the proximate result of the training. This was at odds with our exploration of knowledge of procurement topics, as most respondents gave inaccurate answers on multiple-choice "knowledge questions". This may have been due to question structure or, more likely, the nature of online surveys. Suitable training on the procurement of information technology was also a main concern. The lack of training in this area is indicative of the broader challenge facing public transit agencies in how to incorporate new forms of technology into their existing practices and bureaucratic structures.

Randomized controlled trial of a brief Internet-based intervention for families of Veterans with posttraumatic stress disorder.

Veterans with posttraumatic stress disorder (PTSD) and their families require resources to cope with postdeployment readjustment. Responding to this need, the current study examined a brief Internet-based intervention that provided Veterans' families with psychoeducation on postdeployment readjustment. Participants were 103 dyads of Veterans with probable PTSD and a designated family member/partner. Dyads were randomized to an intervention group, in which the family member completed the intervention, or to a control group with no intervention. Each member of the dyad completed surveys at baseline and 2 mo follow-up. Family member surveys focused on perceived empowerment, efficacy to provide support, and communication (perceived criticism and reactivity to criticism). Veteran surveys assessed perceived family support and communication. Results showed that Veterans in the intervention group reported decreases in reactivity to criticism but also decreased perceived family support. No significant differences were observed in outcomes reported by family members. This preliminary study provides an early understanding of this novel outreach program, as well as the challenges inherent with a very brief intervention. Future research can build on the current study by more closely evaluating the communication changes that occur with this form of intervention and whether greater intervention intensity is needed. CLINICAL TRIAL REGISTRATION: Clinical Trials Identifier: NCT01554839.

Rationale and study design of a trial of mindfulness-based cognitive therapy for preventing suicidal behavior (MBCT-S) in military veterans.

BACKGROUND: Although suicide ranks 10th as a cause of death in the United States, and 1st among active military personnel, there are surprisingly few evidence-based therapies addressing suicidality, and development of new treatments is limited. This paper describes a clinical trial testing a novel therapy for reducing suicide risk in military veterans. The intervention, Mindfulness-Based Cognitive Therapy for Preventing Suicide Behavior (MBCT-S), is a 10-week group intervention adapted from an existing treatment for depression (Mindfulness-Based Cognitive Therapy - MBCT). MBCT-S incorporates the Safety Planning Intervention, which is currently implemented throughout the Veterans Health Administration (VHA) for veterans at high suicide risk. METHODS: MBCT-S is being tested in a VHA setting using an intention-to-treat, two-group randomized trial design in which 164 high suicide risk veterans are randomized to either VHA Treatment As Usual (TAU; n=82) or TAU+MBCT-S (n=82). Our primary outcome measure, suicide-related event, defined to include suicide preparatory behaviors, self-harm behavior with suicidal or indeterminate intent, suicide-related hospitalizations and Emergency Department (ED) visits, will be measured through five assessments administered by blinded assessors between baseline and 12months post-baseline. We will measure suicide attempts and suicide deaths as a secondary outcome, because of their anticipated low incidence during the study period. Secondary outcomes also include severity of suicidal ideation, hopelessness and depression. SIGNIFICANCE: This study has the potential to significantly enhance the quality and efficiency of VHA care for veterans at suicide risk and to substantially improve the quality of life for veterans and their families.

Increased risk of alcohol dependency in a cohort of National Guard troops with PTSD: a longitudinal study.

Studies show high rates of co-morbid post-traumatic stress disorder (PTSD) and alcohol use disorder (AUD) but there is no consensus on the causal direction of the relationship. Some theories suggest AUD develops as a coping mechanism to manage PTSD symptoms and others that AUD is a vulnerability factor for PTSD. A third hypothesis posits independent developmental pathways stemming from a shared etiology, such as the trauma exposure itself. We examined these hypotheses using longitudinal data on 922 National Guard soldiers, representing a subsample (56%) of a larger pre- and post-deployment cross-sectional study of New Jersey National Guard soldiers deployed to Iraq. Measures included the PTSD Checklist (PCL), DSM-IV-based measures of alcohol use/misuse from the National Household Survey of Drug Use and Health and other concurrent mental health, military and demographic measures. Results showed no effect of pre-deployment alcohol status on subsequent positive screens for new onset PTSD. However, in multivariate models, baseline PTSD symptoms significantly increased the risk of screening positive for new onset alcohol dependence (AD), which rose 5% with each unit increase in PCL score (AOR = 1.05; 95% CI = 1.02-1.07). Results also supported the shared etiology hypothesis, with the risk of a positive screen for AD increasing by 9% for every unit increase in combat exposure after controlling for baseline PTSD status (AOR = 1.09; 95% CI = 1.03-1.15) and, in a subsample with PCL scores <34, by 17% for each unit increase in exposure (AOR = 1.17; 95% CI = 1.05-1.31). These findings have implications for prevention, treatment and compensation policies governing co-morbidity in military veterans.