Testing the role of aerobic exercise in the treatment of posttraumatic stress disorder (PTSD) symptoms in U.S. active duty military personnel: a pilot study.

The purpose of this pilot study was to determine if the efficacy of imaginal exposure for symptoms of posttraumatic stress disorder (PTSD) could be improved by adding aerobic exercise. We hypothesized that aerobic exercise would enhance the efficacy of exposure therapy. Active duty service members with clinically significant symptoms of posttraumatic stress (PTSD Checklist-Stressor-Specific Version, [PCL-S], ≥25) were randomized into one of four conditions: exercise only; imaginal exposure only; imaginal exposure plus exercise; no exercise/no exposure therapy (control). Participants (N = 72) were primarily male, Army, noncommissioned officers ranging in age from 22 to 52. PTSD symptom severity decreased over time (p < .0001); however, there were no significant differences between the experimental conditions. The prediction that imaginal exposure augmented with aerobic exercise would be superior to either imaginal exposure alone or aerobic exercise alone was not supported, suggesting that engaging in exercise and imaginal exposure simultaneously may not be any better than engaging in either activity alone. A better understanding of individually administered and combined exercise and exposure therapy interventions for PTSD is warranted.

EVALUATING POTENTIAL IATROGENIC SUICIDE RISK IN TRAUMA-FOCUSED GROUP COGNITIVE BEHAVIORAL THERAPY FOR THE TREATMENT OF PTSD IN ACTIVE DUTY MILITARY PERSONNEL.

OBJECTIVE: To determine whether group cognitive processing therapy-cognitive only version (CPT-C) is associated with iatrogenic suicide risk in a sample of active duty US Army personnel diagnosed with posttraumatic stress disorder (PTSD). Possible iatrogenic effects considered include the incidence and severity of suicide ideation, worsening of preexisting suicide ideation, incidence of new-onset suicide ideation, and incidence of suicide attempts among soldiers receiving group CPT-C. Comparison with group present-centered therapy (PCT) was made to contextualize findings. METHOD: One hundred eight soldiers (100 men, eight women) diagnosed with PTSD were randomized to receive either group CPT-C or group PCT. PTSD diagnosis was confirmed via structured clinician interview. Suicide ideation, depression severity, and PTSD severity were assessed at pretreatment, weekly during treatment, and 2 weeks, 6 months, and 12 months posttreatment. RESULTS: Rates of suicide ideation significantly decreased across both treatments. Among soldiers with pretreatment suicide ideation, severity of suicide ideation significantly decreased across both treatments and was maintained for up to 12 months posttreatment. Exacerbation of preexisting suicide ideation was uncommon in both treatments. New-onset suicide ideation was rare and similar across both treatments (<16%). There were no suicide attempts during treatment or follow-up in either group. Change in depression symptoms predicted change in suicide risk. CONCLUSIONS: Suicide-related outcomes were similar across both treatments and primarily associated with comorbid depression. Suicide-related outcomes in group CPT-C were rare and comparable to patterns observed in an active, nontrauma-focused therapy, even among soldiers who entered treatment with suicide ideation. GOV IDENTIFIER: NCT01286415, https://clinicaltrials.gov/ct2/show/NCT01286415.

Loss of consciousness, depression, posttraumatic stress disorder, and suicide risk among deployed military personnel with mild traumatic brain injury.

OBJECTIVE: To identify clinical variables associated with suicidality in military personnel with mild traumatic brain injury (mTBI) while deployed to Iraq. SETTING: Outpatient TBI clinic on a US military base in Iraq. PARTICIPANTS: Military personnel (N = 158) referred to an outpatient TBI clinic for a standardized intake evaluation, 135 (85.4%) who had a diagnosis of mTBI and 23 (14.6%) who did not meet criteria for TBI. MAIN MEASURES: Suicidal Behaviors Questionnaire-Revised, Depression subscale of the Behavioral Health Measure-20, Posttraumatic Stress Disorder Checklist-Military Version, Insomnia Severity Index, self-report questionnaire, and clinical interview addressing TBI-related symptoms. RESULTS: Among patients with mTBI, increased suicidality was significantly associated with depression and the interaction of depression with posttraumatic stress disorder symptoms. Longer duration of loss of consciousness was associated with decreased likelihood for any suicidality. CONCLUSION: Assessment after TBI in a combat zone may assist providers in identifying those at risk for suicidality and making treatment recommendations for service members with mTBI.

Combat exposure and suicide risk in two samples of military personnel.

OBJECTIVE: In light of increased suicidal behaviors among military personnel and veterans since the initiation of combat operations in Afghanistan and Iraq, questions have been raised about the potential causal role of combat. The objective of the current study was to identify any direct or indirect effects of combat exposure on suicide risk through depression symptom severity, posttraumatic stress disorder (PTSD) symptom severity, thwarted belongingness, perceived burdensomeness, and fearlessness about death, consistent with the interpersonal-psychological theory of suicide (Joiner, 2005). METHOD: Structural equation modeling was utilized with two separate samples of deployed military personnel, 1 nonclinical (n = 348; 89.7% male, mean age = 24.50) and 1 clinical (n = 219; 91.8% male, mean age = 27.88), to test the effects of combat exposure on suicide risk. RESULTS: Greater combat exposure was directly associated with fearlessness about death and PTSD symptom severity in both samples, but failed to show either a direct or indirect effect on suicide risk. PTSD symptom severity was strongly associated with depression symptom severity, which in turn was related to suicide risk directly (in the nonclinical sample) or indirectly through low belongingness and perceived burdensomeness (in the clinical sample). CONCLUSIONS: In both samples of deployed active duty military personnel, combat exposure was either unrelated to suicide risk or was too distally related to have a measurable effect. Results do not support the interpersonal-psychological theory's hypothesis that combat exposure should be indirectly related to suicide risk through acquired fearlessness of death.

Using Digital Technology to Build COVID-19 Vaccine Confidence: A Qualitative Study among Latinx Parents of Children Aged 5-11 in Under-Resourced Communities across Los Angeles County.

Background: Latinx school-aged children are more than twice as likely to be infected with and die from COVID-19 as non-Latinx White children in Los Angeles. Although COVID-19 vaccination has the potential to mitigate health disparities exacerbated by the pandemic, vaccination uptake among Latinx children remains limited. MiVacunaLA (MVLA) is a mobile-phone-delivered digital intervention that improved vaccination rates in 12- to 17-year-old Latinx children and parental intention to vaccinate 2- to 11-year-old children. Since piloting MVLA, the COVID-19 vaccine became available to children aged 5-11. We sought to understand parental experiences with the MVLA intervention and their attitudes and beliefs about vaccinating their young children to improve vaccination confidence in the Latinx community. Methods: We conducted six virtual focus groups with 47 parents/caregivers of children aged 5-11 who participated in the MVLA intervention. We used standard qualitative content analysis methods and rigid and accelerated data reduction to identify and analyze major themes discussed in the sessions. Results: Each salient theme from our focus groups was mapped to one of the 5Cs constructs. The themes included the parents' need for more contemplation about vaccinating their children than about vaccinating themselves; the parents' need for trusted sources of vaccine information; the parents' motivations to vaccinate their children against COVID-19; parental concern about short- and long-term effects of the vaccine in children; digital technology and videos as useful engagement tools; and age and health stratification as an approach to parental vaccination decision-making. Conclusions: The results of this study clarify the key factors that influence the decision of Latinx parents and caregivers to vaccinate their children against COVID-19. Our findings can inform efforts to increase COVID-19 vaccination rates among children in underserved Latinx communities, especially regarding the use of digital technologies for promoting vaccine confidence.

Phenotypic predictors of suicide subtypes from pre-to postdeployment in active duty military personnel.

Military service members are at increased risk for suicide, but there are few strategies for detecting those who are at highest risk after a deployment. Using all available data collected from 4119 Military service members before and after their deployment to Iraq for Operation Iraqi Freedom, we tested whether predeployment characteristics clustered together to predict postdeployment suicidal risk. Latent class analysis showed that three classes best characterized the sample at predeployment. Class 1 had significantly higher scores on PTSD severity pre- and postdeployment than Classes 2 and 3 (Ps < .001). At postdeployment, Class 1 also had a greater proportion of endorsement of lifetime and past year suicidal ideation than Classes 2 and 3 (Ps < .05) and a greater proportion of lifetime suicide attempts than Class 3 (P < .001). Class 1 also had a greater proportion of endorsement of past-30-days intention to act on suicidal thoughts than Classes 2 and 3 (Ps < .05) and past-30-days specific plan for suicide than Classes 2 and 3 (Ps < .05). The study showed that based only on predeployment data, it is possible to determine which service members might be at highest risk for suicidal ideation and behavior at postdeployment.

Matched and mismatched cognitive appraisals in patients with breast cancer and their partners: implications for psychological distress.

BACKGROUND: The present study sought to identify couples' cognitive appraisals of breast cancer and the extent to which matched or mismatched appraisals within a couple contribute to distress. METHODS: Women with breast cancer (n = 57) and their partners completed the Cognitive Appraisals of Health Scale along with two self-report measures of distress, the Profile of Mood States and the Impact of Events Scale. Four groups were created based on their cognitive appraisals. Couples where both patient and partner scored highest on challenge or benign appraisals formed the positive outlook group (P+S+); when both scored highest on threat or harm/loss, they formed the negative outlook group (P-S-). In the mismatched groups, the patient had a positive outlook, and their partner had a negative outlook (P+S-), or vice versa (P-S+). RESULTS: In general, lower distress was related to participants' own positive outlook. Higher distress for patients was found in the matched group P-S-; for partners, it was found in the mismatched group P+S-. CONCLUSIONS: These findings suggest partner effects for both patients and partners. When the patient had a negative outlook, a partner negative outlook was associated with the highest psychological distress. When the partner had a negative outlook, a patient positive outlook was associated with the highest psychological distress. There are several possible explanations for these findings, each with different implications for clinical practice. Future research with different groups of cancer patients and longitudinal, mixed methods designs may clarify their meaning.

Magnitudes of decline on Automated Neuropsychological Assessment Metrics subtest scores relative to predeployment baseline performance among service members evaluated for traumatic brain injury in Iraq.

OBJECTIVE: : Identify the proportion of service members demonstrating declines in Automated Neuropsychological Assessment Metrics (ANAM) scores as part of a traumatic brain injury (TBI) evaluation conducted while deployed to Iraq. BACKGROUND: : Although TBI has been associated with poorer performance on cognitive test in the general population and military combatants, little is known about the proportion of service members demonstrating declines in ANAM scores after TBI. METHODS: : Military personnel (N = 116) referred to a combat support hospital for TBI evaluation in Iraq underwent a standardized intake evaluation including computerized neurocognitive testing, psychological and physical health questionnaires, a clinical interview, and a physical examination by a physician. Predeployment and postinjury cognitive performance among service members with and without a TBI diagnosis was compared. RESULTS: : A significantly larger proportion of patients with TBI demonstrated greater declines in speed across all ANAM subtests compared with patients with no TBI. Differences in accuracy scores among patients with TBI relative to patients without TBI were nonsignificant. Patients with TBI also demonstrated greater than minimal declines on throughput Simple Reaction Time, Procedural Reaction Time, Code Substitution-Learning, and Spatial Memory scores, with no significant differences on Code Substitution-Delayed or Mathematical Processing (MATH). A similar pattern was seen among individuals examined within 72 hours of index injury. CONCLUSION: : Assessment of cognitive impairment following TBI in a combat zone may assist providers in making treatment recommendations for service members with mild TBI.

Identifying suicidal subtypes and dynamic indicators of increasing and decreasing suicide risk in active duty military personnel: Study protocol.

OBJECTIVES: Several recent studies have demonstrated that posttraumatic stress disorder (PTSD) and insomnia treatments are associated with significant reductions in suicidal ideation (SI) among service members. However, few investigations have evaluated the manner in which suicide risk changes over time among military personnel receiving PTSD or insomnia treatments. This paper describes the study protocol for a project with these aims: (1) explore potential genetic, clinical, and demographic subtypes of suicide risk in a large cohort of deployed service members; (2) explore subtype change in SI as a result of evidence-based psychotherapies for PTSD and insomnia; (3) evaluate the speed of change in suicide risk; and (4) identify predictors of higher- and lower-risk for suicide. METHODS: Active duty military personnel were recruited for four clinical trials (three for PTSD treatment and one for insomnia treatment) and a large prospective epidemiological study of deployed service members, all conducted through the South Texas Research Organizational Network Guiding Studies on Trauma and Resilience (STRONG STAR Consortium). Participants completed similar measures of demographic and clinical characteristics and subsets provided blood samples for genetic testing. The primary measures that we will analyze are the Beck Scale for Suicide Ideation, Beck Depression Inventory, and the PTSD Checklist for DSM-IV. DISCUSSION: Results from this study will offer new insights into the presence of discrete subtypes of suicide risk among active duty personnel, changes in risk over time among those subtypes, and predictors of subtypes. Findings will inform treatment development for military service members at risk for suicide.

Depression among older Mexican American caregivers.

The authors compared depression levels between older Mexican American caregivers and noncaregivers while controlling for confounds identified but not controlled in past research. Mexican American caregivers and noncaregivers (N = 114) ages 65 and older were matched on age, gender, socioeconomic status, self-reported health, and acculturation. Caregivers reported higher scores on the Center for Epidemiologic Studies Depression scale (CES-D) and were more likely to score in the depressed range than noncaregivers. In a regression model with all participants, group classification (caregiver vs. noncaregiver) and health significantly predicted CES-D scores. A model with only caregivers that included caregiver burden, self-rated health, and gender significantly predicted CES-D scores, with only caregiver burden entering the regression equation. These results suggest that older Mexican American caregivers are more depressed than noncaregivers, as has been found in younger populations.

Social support mediates the relations between role strains and marital satisfaction in husbands of patients with fibromyalgia syndrome.

Husbands of patients with fibromyalgia syndrome (HFMS) report poorer physical and mental health than husbands of women without illness, as well as role strains because of their wives' condition. There are no published reports regarding the impact of fibromyalgia on their marital relationship. In the present study, we used Lazarus and Folkman's (1984) model of stress and coping as a framework to examine marital satisfaction among HFMS. We hypothesized that role strains would be related to marital satisfaction, mediated or moderated by social support and problem and emotion focused coping. HFMS (n=135) and husbands of healthy women (n=153) completed the Locke Wallace Marital Adjustment Test, the Interpersonal Support Evaluation List, and the Ways of Coping Questionnaire. Only HFMS completed the Psychological Adjustment to Illness Scale-Spouse Version. HFMS reported lower marital satisfaction than comparison husbands. Among HFMS, sexual and domestic roles strains and social support were related to marital satisfaction. Social support alone mediated the relationship between role strain and marital satisfaction, and no variable moderated the relationship. These findings support prior research that shows that these husbands are significantly impacted by their wives' condition, and suggest the need to focus more attention on this population, possibly targeting social support for interventions.

The functions of social support as protective factors for suicidal ideation in a sample of air force personnel.

This study examined various functions of social support (i.e., tangible, esteem, belonging, and appraisal) were examined as protective factors for suicidal ideation in a sample of 273 active duty Air Force Security Forces personnel. Generalized linear regression analyses were conducted to determine if various social support functions were differentially associated with the presence and severity of suicidal ideation, both as main effects and as moderators of emotional distress. None of the four social support functions differentiated suicidal from nonsuicidal Airmen, but esteem support (i.e., feeling respected, encouraged, and valued by others) was associated with significantly less severe suicidal ideation (B = -.074, SE = .025, p = .003). A significant interaction of tangible support (i.e., access to material resources) with emotional distress indicated that emotional distress was associated with more severe suicidal ideation only among Airmen reporting low levels of tangible support (B = .006, SE = .003, p = .018). When considered concurrently, both tangible and self-esteem functions of social support are differentially associated with decreased suicidal ideation among Airmen, but belonging (i.e., having someone to do things with) and appraisal (i.e., having someone to talk to about problems) functions were not. Findings suggest that different aspects of social support affect suicidal ideation in different ways.

The associations of physical and sexual assault with suicide risk in nonclinical military and undergraduate samples.

The associations of various forms of sexual and physical assault with a history of suicide attempts and recent suicide ideation were studied in two distinct samples: active duty military and undergraduate students. A total of 273 active duty Air Force personnel and 309 undergraduate students anonymously completed self-report surveys of assault victimization, emotional distress, belongingness, recent suicide ideation, and previous suicide attempts. Among military personnel, rape, robbery, or violent assault was associated with a nonsignificant trend toward increased risk for suicide attempts, whereas physical abuse or battering as an adult was significantly associated with recent suicide ideation. Among undergraduates, unwanted sexual experiences as an adult and physical or sexual abuse as a child were significantly associated with increased risk for suicide attempt, but only unwanted experiences as an adult was significantly associated with increased risk for suicide ideation. Experiencing multiple forms of assault increased risk for suicide attempts and ideation in both groups. Results suggest that different types of assault contribute differentially to suicide risk in military versus undergraduate populations, but experiencing multiple types of assault is associated with increased risk in both groups.

Sleep disturbances in fibromyalgia syndrome: relationship to pain and depression.

OBJECTIVE: This study is an examination of sleep, pain, depression, and physical functioning at baseline and 1-year followup among patients with fibromyalgia syndrome (FMS). Although it is clear that these symptoms are prevalent among FMS patients and that they are related, the direction of the relationship is unclear. We sought to identify and report sleep problems in this population and to examine their relationship to pain, depression, and physical functioning. METHODS: Patients diagnosed with fibromyalgia were recruited from a Southern California health maintenance organization and evaluated according to American College of Rheumatology criteria in the research laboratory. Six hundred patients completed the baseline assessment and 492 completed the 1-year assessment. Measures included the Center for Epidemiologic Studies Depression Scale, the McGill Pain Questionnaire, the Pittsburgh Sleep Quality Index, and the Fibromyalgia Impact Questionnaire. RESULTS: The majority of the sample (96% at baseline and 94.7% at 1 year) scored within the range of problem sleepers. Path analyses examined the impact of baseline values on 1-year values for each of the 4 variables. No variable of interest predicted sleep, sleep predicted pain (beta = 0.13), pain predicted physical functioning (beta = -0.13), and physical functioning predicted depression (beta = -0.10). CONCLUSION: These findings highlight the high prevalence of sleep problems in this population and suggest that they play a critical role in exacerbating FMS symptoms. Furthermore, they support limited existing findings that sleep predicts subsequent pain in this population, but also extend the literature, suggesting that sleep may be related to depression through pain and physical functioning.