Suicide risk among veterans using VHA justice-involved services: a latent class analysis.

BACKGROUND: Justice-involved Veterans experience notable risk for psychosocial stressors (e.g., homelessness) and psychiatric multimorbidity, which can result in complex clinical presentations. However, research examining how such factors coalesce to impact risk for suicide remains limited. METHODS: We conducted a latent class analysis of 180,454 Veterans accessing Veterans Health Administration (VHA) justice-related services from 2005 to 2018. RESULTS: A four-model class membership solution was identified. Among these classes, risk for suicide was highest among Veterans with greater psychiatric burden, with risk most notable among those with high VA service use. Veterans seeking healthcare primarily focused on substance use disorders or with low psychiatric burden and service use had a lower risk for suicide. CONCLUSIONS: Psychiatric multimorbidity is salient as it relates to suicide among Veterans accessing VHA justice-related services. Further evaluation of existing VHA services for this population and methods of augmenting and enhancing care for justice-involved Veterans with histories of co-occurring psychiatric conditions may be beneficial in facilitating suicide prevention efforts.

Personality Disorder Diagnosis Among Justice-Involved Veterans: An Investigation of VA Using Veterans.

ABSTRACT: Justice-involved veterans are more likely to experience myriad mental health sequelae. Nonetheless, examination of personality psychopathology among justice-involved veterans remains limited, with studies focused on males within correctional settings. We examined Department of Veterans Affairs (VA) electronic medical records for 1,534,108 (12.28% justice-involved) male and 127,230 (8.79% justice-involved) female veterans. Male and female veterans accessing VA justice-related services were both approximately three times more likely to have a personality disorder diagnosis relative to those with no history of using justice-related services. This effect persisted after accounting for VA use (both overall and mental health), age, race, and ethnicity. Augmenting and tailoring VA justice-related services to facilitate access to evidence-based psychotherapy for personality psychopathology may promote optimal recovery and rehabilitation among these veterans.

Research Letter: Traumatic Brain Injury Among Veterans Accessing VA Justice-Related Services.

OBJECTIVE: Risk for traumatic brain injury (TBI) within both the Veteran population and among individuals with a history of criminal justice involvement is notably high. Despite this, research examining TBI among Veterans with a history of criminal justice involvement (ie, justice-involved Veterans) remains limited. The sequelae of TBI can impact justice-involved Veterans' engagement in Department of Veterans Affairs (VA) justice-related services (ie, Veterans Justice Outreach and Health Care for Re-entry Veterans), thus potentially increasing risk for recidivism and impacting psychosocial functioning. As such, further understanding of TBI risk among justice-involved Veterans has the potential to inform the need for tailored screening and interventional efforts within VA justice-related service settings. We sought to better understand relative risk for TBI diagnosis among male and female Veteran recipients and nonrecipients of VA justice-related services. SETTING: Electronic medical record data for Veterans accessing VA services from 2005 to 2018. PARTICIPANTS: 1517 447 (12.48% justice-involved) male and 126 237 (8.89% justice-involved) female Veterans. DESIGN: A cross-sectional examination of national VA electronic medical record data. Sex-stratified analyses were conducted to examine relative risk of TBI diagnosis based on use of VA justice-related services. MAIN MEASURES: Documented TBI diagnosis was the main outcome. Covariates included VA service use, age, race, and ethnicity. RESULTS: Both male and female Veterans using VA justice-related services were more likely to have a documented TBI diagnosis in their electronic VA medical record. Associations were attenuated, yet maintained significance, in all adjusted and sensitivity models. CONCLUSIONS: Given potential risk for TBI, enhancing and tailoring care for justice-involved Veterans may be critical to facilitating rehabilitation and reducing recidivism. Examination of existing services within justice-related settings and methods of augmenting care is an important next step.

Relationship of social determinants of health with symptom severity among Veterans and non-Veterans with probable posttraumatic stress disorder or depression.

PURPOSE: Social determinants of health (SDoH) refer to the conditions in the environments in which people live that affect health outcomes and risks. SDoH may provide proximal, actionable targets for interventions. This study examined how SDoH are associated with posttraumatic stress disorder (PTSD) and depression symptoms among Veterans and non-Veterans with probable PTSD or depression. METHODS: Four multiple regressions were conducted. Two multiple regressions with Veterans examined the impact of SDoH on PTSD symptoms and on depression symptoms. Two multiple regressions with non-Veterans examined the impact of SDoH on PTSD symptoms and on depression symptoms. Independent variables included demographic characteristics, adverse experiences (in childhood and adulthood), and SDoH (discrimination, education, employment, economic instability, homelessness, justice involvement, and social support). Correlates that were statistically significant (p < 0.05) and clinically meaningful (rpart >|0.10|) were interpreted. RESULTS: For Veterans, lower social support (rpart = - 0.14) and unemployment (rpart = 0.12) were associated with greater PTSD symptoms. Among non-Veterans, greater economic instability (rpart = 0.19) was associated with greater PTSD symptoms. In the depression models, lower social support (rpart = - 0.23) and greater economic instability (rpart = 0.12) were associated with greater depression for Veterans, while only lower social support was associated with greater depression for non-Veterans (rpart = - 0.14). CONCLUSION: Among Veterans and non-Veterans with probable PTSD or depression, SDoH were associated with PTSD and depression symptoms, particularly social support, economic instability, and employment. Beyond direct treatment of mental health symptoms, addressing social support and economic factors such as instability and employment in the context of PTSD and depression are potential intervention targets that would benefit from future research.

Racial, ethnic, and sex differences in psychiatric diagnosis, mental health sequelae, and VHA service utilization among justice-involved veterans.

OBJECTIVE: Intervening in the cycle of symptom exacerbation and recidivism among justice-involved veterans is critical given elevated rates of psychiatric diagnoses and mental health sequelae. To responsively and effectively address justice-involved veterans' needs, it is essential to examine distinct groups who are at heightened risk (e.g., marginalized communities). Although racial and ethnic disparities within the justice system are well established, veteran-focused research remains limited. HYPOTHESES: We hypothesized that significant differences exist in service utilization, psychiatric diagnoses, and mental health sequelae among Black, Indigenous, and people of color (BIPOC) and White/non-Hispanic justice-involved veterans, for both male and female cohorts. METHOD: We examined a national data set of veterans accessing U.S. Department of Veterans Affairs (VA) justice-related services (i.e., justice-involved veterans) between 2005 and 2018 (N = 183,880; nBIPOC = 73,863, nWhite = 110,017) to elucidate racial and ethnic differences across clinical characteristics documented in the VA electronic medical record. Using linear and logistic analyses, we analyzed male (n = 173,487) and female (n = 10,393) justice-involved veterans separately to capture intersectionality. RESULTS: In general, BIPOC justice-involved veterans were more likely than White/non-Hispanic justice-involved veterans to be diagnosed with schizophrenia and other psychotic disorders and to use homeless services, p < .001. They were less likely to be diagnosed with mood, anxiety, personality, and opioid use disorders, p < .01. Separate examinations of Black and Hispanic justice-involved veterans, compared with their White/non-Hispanic counterparts, demonstrated some divergent trends (e.g., frequency of use of Veterans Health Administration [VHA] services). Our findings also revealed nuanced sex-related differences in terms of service use and diagnoses. Descriptive characteristics for each racial and ethnic category are reported. CONCLUSION: These findings provide support for race and ethnicity as a key social factor of health associated with distinct psychiatric diagnoses and mental health sequelae among justice-involved veterans. We discuss practice and policy implications, including how to adapt existing VHA programming and practices to meet the needs of BIPOC justice-involved veterans. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Prevalence and Correlates of Firearm Access Among Post-9/11 US Women Veterans Using Reproductive Healthcare: a Cross-Sectional Survey.

BACKGROUND: Suicide rates have increased among women Veterans, with increased use of firearms as the method. Addressing suicide risk in this population requires understanding the prevalence and correlates of firearm access in healthcare settings frequented by women Veterans. OBJECTIVES: Characterize the prevalence and correlates of firearm ownership and storage practices among women Veterans using Department of Veterans Affairs (VA) reproductive healthcare (RHC) services. DESIGN: Cross-sectional national survey conducted in 2018-2019 (17.9% response rate). PARTICIPANTS: Post-9/11 women Veterans using RHC (n=350). MAIN MEASURES: VA Military Sexual Trauma Screen, PTSD Checklist for DSM-5, Hurt/Insult/Threaten/Scream, Columbia-Suicide Severity Rating Scale screener, self-reported firearm access. KEY RESULTS: 38.0% (95% confidence interval [95% CI]: 32.9, 43.3) of participants reported personally owning firearms, and 38.9% (95% CI: 33.7, 44.2) reported other household members owned firearms. Among those with firearms in or around their homes, 17.8% (95% CI: 12.3, 24.4) and 21.9% (95% CI: 15.9, 28.9) reported all were unsafely stored (loaded or unlocked, respectively). Women who experienced recent intimate partner violence were less likely to report personally owning firearms (adjusted prevalence ratio [APR]=0.75; 95% CI: 0.57, 0.996). Those who experienced military sexual harassment (APR=1.46; 95% CI=1.09, 1.96), were married (APR=1.74; 95% CI: 1.33, 2.27), or lived with other adult(s) (APR=6.26; 95% CI: 2.87, 13.63) were more likely to report having household firearms owned by someone else. Storing firearms loaded was more prevalent among women with lifetime (APR=1.47; 95% CI=1.03, 2.08) or past-month (APR=1.69; 95% CI=1.15, 2.48) suicidal ideation and less likely among those with other adult(s) in the home (unadjusted PR=0.62; 95% CI=0.43, 0.91). Those with parenting responsibilities (APR=0.61; 95% CI=0.38, 0.97) were less likely to store firearms unlocked. CONCLUSIONS: Firearm access is prevalent among post-9/11 women Veterans using VA RHC. Interpersonal factors may be important determinants of firearm access in this population. Safe firearm storage initiatives are needed among women Veterans using RHC, particularly for those with suicidal ideation.

Addressing co-occurring suicidal thoughts and behaviors and posttraumatic stress disorder in evidence-based psychotherapies for adults: A systematic review.

Posttraumatic stress disorder (PTSD) is a well-established risk factor for suicidal thoughts and behaviors. Historically, guidelines for treating PTSD have recommended against the use of trauma-focused therapies for patients who are at high risk for suicide, likely due to concerns about potential suicide-related iatrogenesis, specifically the "triggering" of suicidal behaviors. This systematic review examined evidence of the impact of treatments specifically designed to treat PTSD or suicide on both PTSD- and suicide-related outcomes. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and a total of 33 articles met the full inclusion criteria: 23 examining PTSD treatments, four examining suicide-focused treatments, and six examining combined treatments. PTSD and combined treatments reduced both PTSD- and suicide-related outcomes, with most studies focusing on cognitive processing therapy or prolonged exposure. Suicide-focused treatments (e.g., cognitive therapies for suicide prevention) also reduced suicide-related outcomes, but the findings were mixed for their impact on PTSD-related outcomes. Overall, PTSD treatments had the most support, primarily due to a larger number of studies examining their outcomes. This supports current clinical guidelines, which suggest utilizing PTSD treatments for individuals who have PTSD and are at risk for suicide. Suicide-focused and combined treatments also appeared to be promising formats, although additional research is needed. Future research should seek to compare the effectiveness of the approaches to the treatment of PTSD and suicidal thoughts and behaviors concurrently as well as to inform guidelines aimed at supporting decisions about the selection of an appropriate treatment approach.

Institutional Betrayal and Closeness Among Women Veteran Survivors of Military Sexual Trauma: Associations with Self-Directed Violence and Mental Health Symptoms.

Institutional betrayal is defined as harm caused by an institution to an individual in the context of trust and dependence. High institutional betrayal is associated with poorer health outcomes, and high levels of trust, dependence, or identification with the institution (institutional closeness) may exacerbate the negative effects of institutional betrayal. While military sexual trauma is prevalent among women Veterans and associated with high rates of institutional betrayal, studies of the impact of military sexual trauma-related institutional betrayal have been limited in size and scope and have not examined the potential role of institutional closeness. We conducted a secondary analysis of national survey data collected from women Veterans who screened positive for military sexual trauma (n = 229). Hierarchical logistic and linear regression were used to examine associations between predictor variables (institutional betrayal, institutional closeness, and their interaction) and outcomes of interest and adjusted for age, education, and military sexual assault history. Institutional betrayal was associated with increased odds of suicidal ideation and suicide attempt during or following military service, as well as more severe symptoms of depression and posttraumatic stress disorder (PTSD). Institutional betrayal was not associated with non-suicidal self-injury or lifetime substance misuse. Counter to hypotheses, institutional closeness did not moderate relationships between institutional betrayal and mental health symptoms or self-directed violence. Results underscore the necessity of preventing and addressing institutional betrayal among women Veterans who experience military sexual trauma.

Female Veterans' Willingness to Seek Veterans Health Administration and Non-Veterans Health Administration Services for Suicidal Thoughts and Mental Health Concerns.

BACKGROUND: The extent to which female veterans are willing to seek Veterans Health Administration (VHA) and non-VHA care when they are suicidal or experiencing mental health (MH) concerns is unknown. OBJECTIVES: The objectives of this study were to: (1) examine whether current, past, and never VHA using female veterans' willingness to seek VHA care differs from their willingness to seek non-VHA care if suicidal or experiencing MH symptoms; (2) examine if VHA use, military sexual trauma, and suicidal ideation and attempt are associated with female veterans' willingness to use VHA and non-VHA care when experiencing suicidal thoughts or MH symptoms. RESEARCH DESIGN: A cross-sectional anonymous survey. SUBJECTS: Four hundred thirty nine female veterans, including current, past, and never VHA users were included. MEASURES: General Help-Seeking Questionnaire, Self-Injurious Thoughts and Behaviors Interview, and the VA Military Sexual Trauma Screening Questions. RESULTS: Current VHA users reported more willingness to use VHA than non-VHA care; conversely, past and never VHA users reported less willingness to use VHA care relative to non-VHA care. Military sexual assault and none or past VHA use were associated with lower willingness to use VHA care if suicidal or experiencing MH symptoms. In contrast, those with none or past VHA use reported greater willingness to use non-VHA care if suicidal or experiencing MH symptoms, while prior suicide attempt was associated with lower willingness. CONCLUSIONS: Ensuring that acceptable and effective suicide prevention services are available to female veterans in both VHA and community settings is critical. Increasing help-seeking intentions among female veterans who have attempted suicide or experienced military sexual assault is also essential.

Interpersonal Violence Throughout the Lifespan: Associations With Suicidal Ideation and Suicide Attempt Among a National Sample of Female Veterans.

BACKGROUND: Female veterans experience interpersonal violence (ie, physical and sexual violence) more often than male veterans and nonveteran females. There is limited knowledge of types of interpersonal violence across the lifespan in relation to suicidal ideation and suicide attempt. Prior research has also focused on those accessing the Veterans Health Administration (VHA) care. OBJECTIVE: This study examined if physical and sexual violence at differing time points (ie, premilitary, during military service) were associated with suicidal ideation and a suicide attempt at subsequent time points. We anticipated that violence would be associated with an increased risk of suicidal ideation and attempt; however, given limited prior research, we were uncertain which types of violence and time points would be associated with risk. RESEARCH DESIGN: Data from a cross-sectional national survey. SUBJECTS: A total of 407 female veterans using, formerly using, or who never used VHA care. MEASURES: Suicidal ideation, suicide attempt, physical violence, and sexual violence were assessed. RESULTS: Premilitary sexual, but not physical, violence was associated with military suicidal ideation. Both premilitary and military sexual and physical violence were associated with postmilitary suicidal ideation. Premilitary and military sexual, but not physical, violence were associated with a postmilitary suicide attempt. These results were maintained after accounting for VHA use. A significant model for military suicide attempt was not generated. CONCLUSIONS: Assessment of premilitary and military sexual violence among female veterans is warranted within the context of suicide risk assessment and prevention. Preventing sexual violence among female veterans may be important for preventing suicidal ideation and attempt.

Clinical Complexity in Women Veterans: A Systematic Review of the Recent Evidence on Mental Health and Physical Health Comorbidities.

A recent evidence map focused on women veterans underscored the limited number of articles published on mental health comorbid with physical health conditions in this population. The quality of this small body of research has yet to be evaluated. The aim of this systematic review was to evaluate and synthesize research published between 2008 and 2015 and identified in the Women Veterans' Health Research Evidence Map as related to mental and physical health comorbidities among women veterans. Following PRISMA guidelines, 23 published studies were identified and 21 were included in the review. In general, significant associations between several mental health conditions (e.g., depression, posttraumatic stress disorder, substance use disorders) and physical health disorders (e.g., cardiovascular disease, diabetes, gastrointestinal disorders, hypertension, obesity, pain, and urinary symptoms) and health behaviors (e.g., preventative care and treatment adherence) were noted. The majority of studies were rated as low risk of bias, with selection and detection bias most frequently observed across studies. Additionally, gaps in the recent literature were observed, including the need for further investigation of the role of medical conditions in complicating mental health symptoms and care provision. Results underscore the importance of healthcare providers attending to women veterans' mental and physical health simultaneously and irrespective of setting. Further, while the Department of Veterans Affairs continues to make sizable gains in its focus on women veterans' health, continued research on several health domains is needed to ensure adequate understanding of the health needs of women veterans.

Firearm Lethal Means Safety with Military Personnel and Veterans: Overcoming Barriers using a Collaborative Approach.

Suicides by firearm have increased over the past decade among United States service members and veterans. As firearm access is a suicide risk factor, firearm-related lethal means safety is critical to suicide prevention. However, identity, occupational, and cultural barriers may deter efforts to promote lethal means safety with service members and veterans. The current manuscript describes a collaborative framework to guide mental health providers' in conducting firearm-related lethal means safety with service members and veterans, including within the context of Safety Planning. In approaching firearm lethal means safety conversations with patients, clinicians must work to overcome their own reticence, address patient concerns directly, and remain culturally sensitive to the values of the military and veteran communities. This approach is illustrated using case vignettes that encompass addressing firearm-related lethal means safety with service members and veterans.

A Factor Analysis of the Suicide Cognitions Scale in Veterans with Military Sexual Trauma-Related Posttraumatic Stress Disorder.

The Suicide Cognitions Scale (SCS) assesses suicide-specific cognitions which may drive suicide risk. Nonetheless, prior work has been mixed regarding optimal factor structure. Additionally, this measure has not been validated for use with veterans with military sexual trauma-related posttraumatic stress disorder (MST-related PTSD), a population that is at elevated risk for suicidal self-directed violence (SDV). This study sought to determine the optimal factor structure of the SCS for use with veterans with MST-related PTSD as well as its psychometric properties. An exploratory factor analysis revealed a four-factor structure, including unlovability, unbearability, unsolvability, and negative urgency. The SCS also demonstrated excellent internal consistency and good convergent validity. This study identified a novel factor, negative urgency, which may explain some of the predictive power of the SCS found in previous research. This paper provides initial support for a four-factor structure of the SCS among those with MST-related PTSD. Additional work remains necessary in evaluating the SCS as a tool for detecting risk for future suicidal SDV among veterans with MST-related PTSD.

"We're Afraid to Say Suicide": Stigma as a Barrier to Implementing a Community-Based Suicide Prevention Program for Rural Veterans.

Suicide is a significant public health concern for veterans residing in rural communities. Although various initiatives have been implemented to prevent suicide among veterans, efforts specific to rural veterans remain limited. To aid such efforts, we examined stigma as a potential barrier to community readiness in the implementation of a community-based suicide prevention program for rural veterans. In this qualitative study, community readiness interviews were conducted with 13 participants in a rural community. Themes included lack of awareness regarding veteran suicide, rare discussions of veteran suicide, and suicide-related stigma within the community. Results suggest that prioritizing destigmatization may be particularly important to implementing community-based suicide prevention programming in rural communities. In particular, addressing community misconceptions regarding veteran suicide, while increasing knowledge of the extent to which veteran suicide occurs locally may facilitate increased awareness and thus community readiness to prevent suicide among rural veterans.

Understanding female veterans' experiences and perspectives of firearms.

OBJECTIVES: Although firearms are the leading suicide means among female veterans, firearm research in this population remains limited. This study explored female veterans' firearm-related experiences and perspectives. METHOD: Sixteen cisgender female veterans (ages 27-69) participated in qualitative interviews. RESULTS: Participants gained initial firearm knowledge and exposure in childhood and adolescence through older male family members. Military service led to broader exposure to firearms, which were perceived as important for survival and protection in a male-dominated environment, predominantly due to the risk for sexual violence. Following military service, the desire for self-protection motivated firearm ownership and storage practices. Participants perceived trust as essential to firearm discussions, preferring for family members to initiate such conversations. CONCLUSIONS: This study provides insight into the context in which female veterans' firearm-related beliefs and practices develop. Interpersonal factors and various lifespan experiences appear to play a vital role in female veterans' firearm access, ownership, and storage practices.

Treating Posttraumatic Stress Disorder in the Presence of Acute Suicide Risk in Veterans and Active Duty Service Members: A Call for Research.

Posttraumatic stress disorder (PTSD) is associated with increased risk for suicide, and clinicians often encounter acute suicide risk during the process of intervening upon PTSD. Although the Department of Veterans Affairs (VA) and the Department of Defense (DoD) have disseminated evidence-based treatments for PTSD, prior clinical trials have used inconsistent definitions and unclear assessment methods of suicide risk. Consequently, translating findings from PTSD treatment research to clinical practice remains challenging. This article describes challenges inherent to the current PTSD interventional research literature related to concurrent acute suicide risk among veterans and active duty service members. We reviewed prior trials and how their assessment methods and nomenclature compare with strategies and definitions mandated within the VA/DoD. Furthermore, we describe methodological recommendations for future research, including consistent use of mandated universal suicide nomenclature, standardization for classifying suicide risk, transparency in reporting assessment means and measures, and examination of current models of PTSD treatment in the context of acute suicide risk.

Patterns and temporal precedence of symptom change during cognitive processing therapy for military sexual trauma-related posttraumatic stress disorder.

BACKGROUND: Cognitive processing therapy (CPT) is an effective treatment for posttraumatic stress disorder (PTSD), including for veterans with military sexual trauma (MST)-related PTSD. Most CPT research to date has focused on pre- to post-treatment change in total PTSD symptoms; however, PTSD symptom criteria may not change equivalently over the course of treatment. For example, changes in re-experiencing symptoms have been shown to precede changes in other PTSD criteria during other PTSD treatments (i.e. virtual reality exposure therapy, venlafaxine ER). An improved understanding of the mechanism of change in PTSD symptoms during CPT may assist in optimizing treatment. AIMS: The purpose of this study was to identify the pattern and temporal precedence of change in PTSD symptom criteria during and after CPT using cross-lagged panel analyses. METHOD: Data from veterans (n = 32) enrolled in a randomized clinical trial investigating the effectiveness of CPT for MST-related PTSD were utilized for this secondary analysis. Using hierarchical linear modelling, each symptom criterion was entered as a predictor of subsequent change in the other PTSD symptom criteria. RESULTS: All symptom criteria followed a logarithmic pattern of change. Hyperarousal symptoms were found to both predict and temporally precede change in avoidance symptoms, but not re-experiencing symptoms. Re-experiencing and avoidance symptoms did not predict change in other PTSD symptom criteria. CONCLUSIONS: These findings provide initial support that targeting and reducing hyperarousal symptoms may be a key component of PTSD intervention with CPT. Additional research is needed to identify factors that predict change in PTSD-related re-experiencing symptoms.

Seeking help for the health sequelae of military sexual trauma: a theory-driven model of the role of institutional betrayal.

Although rates vary, approximately 38.4% of women and 3.9% of men report experiencing military sexual trauma (MST). MST is associated with numerous psychosocial consequences, increased propensity for physical and mental health diagnoses, suicide, and an elevated likelihood of revictimization. Consequently, medical and mental health care for MST-related health sequelae is often warranted for individuals who have experienced MST; however, many MST survivors forgo or delay MST-related care, despite the fact that the Veterans Health Administration (VHA) provides free healthcare for MST-related health conditions. One potential explanation for this phenomenon is that survivors of MST feel betrayed by the military institution that they served when the MST occurred due to the institutional response to MST or perceptions that the institution failed to prevent MST from occurring. Perceptions of institutional betrayal may, in turn, decrease survivors' likelihood of disclosing MST and utilizing necessary treatment through VHA or affiliated institutions. A theoretical model of the role of institutional betrayal on help-seeking is proposed in which institutional betrayal serves as a potential barrier to utilizing MST-related healthcare. Potential mediators of this association (e.g., distrust, beliefs about safety) are also posited. This model offers utility in conceptualizing institutional factors that may influence helping-seeking following MST. By testing and refining such models, institutions and providers may be better-equipped to support MST survivors in obtaining necessary healthcare.

Decreases in Suicide Cognitions After Cognitive Processing Therapy Among Veterans With Posttraumatic Stress Disorder Due to Military Sexual Trauma: A Preliminary Examination.

Posttraumatic stress disorder (PTSD) is associated with suicidal ideation (SI) and suicidal self-directed violence (SDV). Military sexual trauma (MST) is a common precursor to PTSD among veterans. Survivors of MST are more likely to be diagnosed with PTSD and are at greater risk for SI than survivors of other forms of trauma. Suicide-specific beliefs (e.g., unlovability, unbearability, unsolvability) have been shown to be strong predictors of SI and future suicidal SDV. Suicide-specific beliefs were examined over the course of treatment and follow-up in 32 veterans (23 women, 9 men) who received cognitive processing therapy (CPT) for MST-related PTSD. Hierarchical linear models revealed that veterans who received CPT had significant reductions in suicide-specific cognitions regarding unbearability, unlovability, and unsolvability. These preliminary findings warrant replication in a randomized controlled trial with a larger sample that includes participants with more acute suicidal intent.

A preliminary examination of the role of psychotherapist fidelity on outcomes of cognitive processing therapy during an RCT for military sexual trauma-related PTSD.

While cognitive processing therapy (CPT) is an effective evidence-based treatment for many veterans with military-related post-traumatic stress disorder (PTSD), not all veterans experience therapeutic benefit. To account for the discrepancy in outcomes, researchers have investigated patient- and research design-related factors; however, therapist factors (e.g. fidelity) have received less attention. The present study is a preliminary examination of the effect of psychotherapists' fidelity during CPT on clinical outcomes during a randomized clinical trial (RCT) for military sexual trauma-related PTSD. PTSD symptoms, trauma-related negative cognitions (NCs), and depression symptoms were assessed for 72 participants at baseline, and 1-week, 2-month, 4-month, and 6-month posttreatment. Of the four CPT therapists, two were found to have significantly poorer (i.e. "below average") treatment fidelity scores compared to the other two therapists who had "good" treatment fidelity scores. To examine possible therapist effects on outcomes, hierarchical linear modeling was utilized with therapist fidelity entered as a Level 2 predictor. Participants treated by a therapist with "good" treatment fidelity experienced significantly greater reductions in PTSD symptoms, NCs, and depression symptoms than patients treated by a therapist with "below average" treatment fidelity. Our preliminary findings highlight the importance of monitoring, maintaining, and reporting fidelity in psychotherapy treatment RCTs.