Treatment of posttraumatic stress disorder with prolonged exposure for primary care (PE-PC): Effectiveness and patient and therapist factors related to symptom change and retention.

Prolonged exposure (PE) is a first-line treatment for posttraumatic stress disorder (PTSD) available in specialty mental health. PE for primary care (PE-PC) is a brief version of PE adapted for primary care mental health integration, composed of four-eight, 30-min sessions. Using retrospective data of PE-PC training cases from 155 Veterans Health Administration (VHA) providers in 99 VHA clinics who participated in a 4- to 6-month PE-PC training and consultation program, we examined patients' PTSD and depression severity across sessions via mixed effects multilevel linear modeling. Additionally, hierarchical logistic regression analysis was conducted to assess predictors of treatment dropout. Among 737 veterans, medium-to-large reductions in PTSD (intent-to-treat, Cohen's d = 0.63; completers, Cohen's d = 0.79) and small-to-medium reductions in depression (intent-to-treat, Cohen's d = 0.40; completers, Cohen's d = 0.51) were observed. The modal number of PE-PC sessions was five (SD = 1.98). Providers previously trained in both PE and cognitive processing therapy (CPT) were more likely than providers who were not trained in either PE or CPT to have veterans complete PE-PC (OR = 1.54). Veterans with military sexual trauma were less likely to complete PE-PC than veterans with combat trauma (OR = 0.42). Asian American and Pacific Islander veterans were more likely than White veterans to complete treatment (OR = 2.93). Older veterans were more likely than younger veterans to complete treatment (OR = 1.11). (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Testing adaptive interventions to improve PTSD treatment outcomes in Federally Qualified Health Centers: Protocol for a randomized clinical trial.

BACKGROUND: Posttraumatic stress disorder (PTSD) disproportionately affects low-income individuals and is untreated in 70% of those affected. One third of low-income Americans are treated in Federally Qualified Health Centers (FQHCs), which do not have the capacity to provide all patients with first-line treatments such as Prolonged Exposure (PE). To address this problem, FQHCs could use low-intensity interventions (e.g., Clinician-Supported PTSD Coach: CS PTSD Coach) and medium-intensity interventions (e.g., PE for Primary Care: PE-PC) to treat PTSD with fewer resources. However, some patients will still require high-intensity treatments (e.g., full-length PE) for sustained clinical benefit. Thus, there is a critical need to develop stepped-care models for PTSD in FQHCs. METHOD: We are conducting a Sequential, Multiple Assignment, Randomized Trial (SMART) with 430 adults with PTSD in FQHCs. Participants are initially randomized to CS PTSD Coach or PE-PC. After four sessions, early responders step down to lower frequency interaction within their assigned initial treatment strategy. Slow responders are re-randomized to either continue their initial treatment strategy or step up to Full PE for an additional eight weeks. The specific aims are to test the effectiveness of initiating treatment with PE-PC versus CS PTSD Coach in reducing PTSD symptoms and to test the effectiveness of second-stage strategies (continue versus step-up to Full PE) for slow responders. CONCLUSIONS: This project will provide critical evidence to inform the development of an effective stepped-care model for PTSD. Testing scalable, sustainable sequences of PTSD treatments delivered in low-resource community health centers will improve clinical practice for PTSD.

Marriage checkup in integrated primary care: A randomized controlled trial with active-duty military couples.

OBJECTIVE: This study assessed the efficacy of the marriage checkup, as adapted to integrated primary care settings and active-duty military couples, for improving relationship health and depressive symptoms. METHOD: Married couples (N = 244, Mage = 32.4, 67.6% Caucasian) in which at least one member was active-duty Air Force were recruited from bases across the U.S. via online advertisement, emails sent from medical clinics to enrolled beneficiaries, social media posts, and flyers, and randomly assigned to active treatment or waitlist control. Treatment and control couples were linked in pairs sequentially and pairs completed nine sets of questionnaires at baseline, 1-, and 6-month posttreatment. Outcome measures included the Couples Satisfaction Index, Intimate Safety Questionnaire, Responsive Attention Scale, Partner Compassion Scale, Communication Skills Test, and the Center for Epidemiologic Studies Depression Scale. RESULTS: A three-level multilevel model indicated, after adjustment for multiple comparisons, treatment couples experienced statistically significant small-to-moderate improvements compared to the control group (Cohen's d from 0.21 to 0.55) at 1 month that were sustained at 6 months for relationship satisfaction, responsive attention, compassion toward their partners, communication skills, intimate safety, and depressive symptoms. CONCLUSIONS: A longitudinal randomized control trial of the MC supports the hypothesis that the MC significantly improves relationship satisfaction, intimacy, communication, partner compassion, responsive attention, and depressive symptoms. Implications for theory, treatment, and dissemination are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Feasibility and Acceptability of Prolonged Exposure in Primary Care (PE-PC) for Posttraumatic Stress Disorder in Federally Qualified Health Centers: A Pilot Study.

Posttraumatic stress disorder (PTSD) is a debilitating psychiatric disorder that affects 6% of U.S. adults, yet is treated in only 30% of affected individuals and even fewer low-income individuals. One third of the nation's low-income individuals are treated in Federally Qualified Health Centers (FQHCs). Most of these facilities lack capacity to provide their patients with first-line, evidence-based treatments for PTSD such as Prolonged Exposure (PE). To address this problem, PE has been adapted for use in a primary care setting and demonstrated efficacy in a brief model for military service members (PE in Primary Care: PE-PC). The effectiveness of this treatment in civilian, low-resource settings such as FQHCs is unknown. This pilot study tested the feasibility and acceptability of PE-PC in 30 Michigan FQHC patients. High rates of therapy participation suggest that the intervention was feasible and acceptable. Semi-structured interview data from 10 patients and 5 FQHC providers indicated that the intervention was helpful and filled a critical need for effective PTSD treatment in the FQHC setting. Interviews also elucidated barriers such as transportation, provider training, and time commitment for patients and providers. These findings set the stage for a full-scale randomized controlled trial to test the effectiveness of PE-PC on PTSD symptoms in this low-resource, high-need setting.Trial registry ClinicalTrials.gov Identifier: NCT03711266. October 18, 2018.

STRONG STAR and the Consortium to Alleviate PTSD: Shaping the future of combat PTSD and related conditions in military and veteran populations.

The STRONG STAR Consortium (South Texas Research Organizational Network Guiding Studies on Trauma and Resilience) and the Consortium to Alleviate PTSD are interdisciplinary and multi-institutional research consortia focused on the detection, diagnosis, prevention, and treatment of combat-related posttraumatic stress disorder (PTSD) and comorbid conditions in military personnel and veterans. This manuscript outlines the consortia's state-of-the-science collaborative research model and how this can be used as a roadmap for future trauma-related research. STRONG STAR was initially funded for 5 years in 2008 by the U.S. Department of Defense's (DoD) Psychological Health and Traumatic Brain Injury Research Program. Since the initial funding of STRONG STAR, almost 50 additional peer-reviewed STRONG STAR-affiliated projects have been funded through the DoD, the U.S. Department of Veterans Affairs (VA), the National Institutes of Health, and private organizations. In 2013, STRONG STAR investigators partnered with the VA's National Center for PTSD and were selected for joint DoD/VA funding to establish the Consortium to Alleviate PTSD. STRONG STAR and the Consortium to Alleviate PTSD have assembled a critical mass of investigators and institutions with the synergy required to make major scientific and public health advances in the prevention and treatment of combat PTSD and related conditions. This manuscript provides an overview of the establishment of these two research consortia, including their history, vision, mission, goals, and accomplishments. Comprehensive tables provide descriptions of over 70 projects supported by the consortia. Examples are provided of collaborations among over 50 worldwide academic research institutions and over 150 investigators.

Demographic and Occupational Risk Factors Associated With Suicide-Related Aeromedical Evacuation Among Deployed U.S. Military Service Members.

INTRODUCTION: Suicide is a significant problem in the U.S. military, with rates surpassing the U.S. general population as of 2008. Although there have been significant advances regarding suicide risk factors among U.S. military service members and veterans, there is little research about risk factors associated with suicide that could be potentially identified in theater. One salient study group consists of service members who receive a psychiatric aeromedical evacuation out of theater. The primary aims of this study were as follows: (1) determine the incidence of suicide-related aeromedical evacuation in deployed service members, (2) identify demographic and military characteristics associated with suicide-related aeromedical evacuation, and (3) evaluate the relationship between suicide-related aeromedical evacuation from a deployed setting and military separation. MATERIALS AND METHODS: This was an archival analysis of U.S. Transportation Command Regulating and Command and Control Evacuation System and Defense Manpower Data Center electronic records of U.S. military service members (N = 7023) who were deployed to Iraq or Afghanistan and received a psychiatric aeromedical evacuation out of theater between 2001 and 2013. χ2 tests of independence and standardized residuals were used to identify cells with observed frequencies and proportions, respectively, that significantly differed from what would be expected by chance. In addition, odds ratios were calculated to provide context about the nature of any significant relationships. RESULTS: For every 1000 psychiatric aeromedical evacuations that occurred between 2001 and 2013, 34.4 were suicide related. Gender, ethnicity, branch of service, occupation classification, and deployment theater were associated with suicide-related aeromedical evacuation (odds ratios ranged from 1.37 to 3.02). Overall, 53% of all service members who received an aeromedical evacuation for any psychiatric condition had been separated from the military for a variety of reasons (both voluntary and involuntary) upon record review in 2015. Suicide-related aeromedical evacuation was associated with a 37% increased risk of military separation compared to evacuation for another psychiatric condition (P < 0.02). CONCLUSIONS: Findings provide novel information on risk factors associated with suicide-related aeromedical evacuation as well as military separation following a suicide-related aeromedical evacuation. In many cases, the psychiatric aeromedical evacuation of a service member for suicidal ideations and their subsequent separation from active duty is in the best interest of the individual and the military. However, the evacuation and eventual military separation can be costly for the military and the service member. Consequently, the military should focus on indicated prevention interventions for individuals who show sufficient early signs of crisis and functional problems so that specialized interventions can be used in theater to prevent evacuation. Indicated prevention interventions should start with leaders' awareness and mitigation of risk and, when feasible, evidence-based interventions for suicide risk provided by behavioral health (eg, brief cognitive behavioral therapy for suicide). Future research should evaluate the feasibility, safety, and efficacy of delivering suicide-related interventions in theater.

Psychiatric Aeromedical Evacuations of Deployed Active Duty U.S. Military Personnel During Operations Enduring Freedom, Iraqi Freedom, and New Dawn.

Introduction: The primary objective of this study was to describe the demographic, clinical, and attrition characteristics of active duty U.S. military service members who were aeromedically evacuated from Iraq and Afghanistan theaters with a psychiatric condition as the primary diagnosis. The study links the U.S. Transportation Command Regulating and Command and Control Evacuation System (TRAC2ES) data with the Defense Manpower Data Center (DMDC) to conduct an examination of the long-term occupational impact of psychiatric aeromedical evacuations on military separations and discharges. Materials and Methods: Retrospective analyses were conducted on the demographic, clinical, and attrition information of active duty service members (N = 7,023) who received a psychiatric aeromedical evacuation from Iraq or Afghanistan between 2001 and 2013 using TRAC2ES data. Additionally, TRAC2ES database was compared with DMDC data to analyze personal and service demographics, aeromedical evacuation information, and reasons for military separation with the entire 2013 active duty force. Chi-square tests of independence and standardized residuals were used to identify cells with observed frequencies or proportions significantly different than expected by chance. Additionally, OR were calculated to provide context about the nature of any significant relationships. Results: Compared with the active duty comparison sample, those with a psychiatric aeromedical evacuation tended to be younger, female, white, divorced or widowed, and less educated. They were also more likely to be junior enlisted service members in the Army serving in a Combat Arms military occupational specialty. The primary psychiatric conditions related to the aeromedical evacuation were depressive disorders (25%), adjustment disorders (18%), post-traumatic stress disorder (9%), bipolar disorders (6%), and anxiety disorders (6%). Approximately, 3% were evacuated for suicidal ideation and associated behaviors. Individuals who received a psychiatric aeromedical evacuation were almost four times as likely (53%) to have been subsequently separated from active duty at the time of the data analysis compared with other active duty service members (14%). The current study also found that peaks in the number of aeromedical evacuations coincided with significant combat operational events. These peaks almost always preceded or followed a significant operational event. An unexpected finding of the present study was that movement classification code was not predictive of subsequent reasons for separation from the military. Thus, the degree of clinical supervision and restraint of a service member during psychiatric aeromedical evacuation from deployment proved to be unrelated to subsequent service outcome. Conclusions: Psychiatric conditions are one of the leading reasons for the aeromedical evacuation of active duty military personnel from the military combat theater. For many active duty military personnel, a psychiatric aeromedical evacuation from a combat theater is the start of a military career-ending event that results in separation from active duty. This finding has important clinical and operational implications for the evaluation and treatment of psychiatric conditions during military deployments. Whenever possible, deployed military behavioral health providers should attempt to treat psychiatric patients in theater to help them remain in theater to complete their operational deployments. Improved understanding of the factors related to psychiatric aeromedical evacuations will provide important clinical and policy implications for future conflicts.

Moving effective treatment for posttraumatic stress disorder to primary care: A randomized controlled trial with active duty military.

INTRODUCTION: Many military service members with PTSD do not receive evidence-based specialty behavioral health treatment because of perceived barriers and stigma. Behavioral health providers in primary care can deliver brief, effective treatments expanding access and reducing barriers and stigma. The purpose of this randomized clinical trial was to determine if a brief cognitive-behavior therapy delivered in primary care using the Primary Care Behavioral Health model would be effective at reducing PTSD and co-occurring symptoms. METHOD: A total of 67 service members (50 men, 17 women) were randomized to receive a brief, trauma-focused intervention developed for the primary care setting called Prolonged Exposure for Primary Care (PE-PC) or a delayed treatment minimal contact control condition. Inclusion criteria were significant PTSD symptoms following military deployment, medication stability, and interest in receiving treatment for PTSD symptoms in primary care. Exclusion criteria were moderate or greater risk of suicide, severe brain injury, or alcohol/substance use at a level that required immediate treatment. Assessments were completed at baseline, posttreatment/postminimal contact control, and at 8-week and 6-month posttreatment follow-up points. Primary measures were the PTSD Symptom Scale-Interview and the PTSD Checklist-Stressor-Specific. RESULTS: PE-PC resulted in larger reduction in PTSD severity and general distress than the minimal contact control. Delayed treatment evidenced medium to large effects comparable to the immediate intervention group. Treatment benefits persisted through the 6-month follow-up of the study. DISCUSSION: PE-PC delivered in integrated primary care is effective for the treatment of PTSD and co-occurring symptoms and may help reduce barriers and stigma found in specialty care settings. (PsycINFO Database Record

Addressing Relationship Health Needs in Primary Care: Adapting the Marriage Checkup for Use in Medical Settings with Military Couples.

The overall objective of this study was to pilot the Marriage Checkup (MC), a brief intervention for enhancing marital resiliency tailored to a military population, for use by internal behavioral health consultants (IBHCs) working in an integrated primary care clinic. The MC was revised to fit into the fast-paced environment of primary care (e.g., streamlined to fit within three 30-min appointments), and military-relevant material was added to the content. IBHCs working in primary care were then trained to offer the intervention. Thirty participants were enrolled in the study and completed a relationship checkup and one-month follow-up questionnaires. Analysis of post-test and one-month follow-up data showed statistically significant improvements in participants' marital health compared to pre-treatment. The MC intervention appeared to be well received by both couples and IBHCs.

The risk for marital infidelity across a year-long deployment.

Military deployment can create significant relationship strain. Although most couples navigate the challenges of deployment successfully, this period may render some couples more vulnerable to adverse relationship outcomes such as infidelity due to a convergence of factors including geographic separation and reduced emotional and physical intimacy. Despite anecdotal reports of increased rates of infidelity during deployment, empirical findings are lacking. This study used a prospective design to examine the prevalence and risk factors of infidelity across the deployment cycle including a year-long deployment to Iraq. A total of 63 married male Airmen were assessed both pre- and 6-9 months postdeployment. The rate of sexual infidelity prior to deployment (21%) was commensurate with the lifetime rate of sexual involvement outside the marriage in representative community samples of men. Across the deployment period, the prevalence of sexual infidelity was strikingly high (22.6%) compared with annual community estimates (1.5-4%; Allen et al., 2005). Findings demonstrated that service members with a prior history of separation, steps toward divorce, and relationship distress prior to deployment had elevated risk for infidelity over the deployment cycle. Moreover, roughly 75% of Airmen who experienced infidelity over the deployment cycle divorced by 6-9 months postdeployment whereas only 5% of service members without infidelity divorced during this same time period. Considering well-documented adverse impacts of infidelity and divorce, the current findings may assist in identifying military couples at risk for infidelity and informing targeted prevention or early intervention strategies for these couples prior to or immediately following deployment. (PsycINFO Database Record

Help-seeking among airmen in distressed relationships: Promoting relationship well-being.

Although a substantial proportion of service members returning from a combat deployment report individual emotional and behavioral disorders as well as intimate relationship difficulties, previous studies indicate that only a minority actually seek mental health services. Little is known about factors that predict help-seeking in this population. We first review key findings from the literature on help-seeking in military and veteran populations, including mixed findings regarding the role of perceived stigma and attitudes toward mental health treatment. We then present data from a longitudinal study of United States Air Force Security Forces following a year-long high-risk deployment to Iraq-including findings regarding who seeks help, for what problems, and from which providers. We also examine whether these findings differ for Airmen in a married or committed relationship versus nonpartnered Airmen and, for the former group, whether findings differ for those in a distressed versus nondistressed relationship. Finally, we discuss implications of these findings for extending couple-based interventions to service members and veterans, and describe a multitiered "stepped" approach for promoting relationship resiliency.

Treatment of active duty military with PTSD in primary care: A follow-up report.

First-line trauma-focused therapies offered in specialty mental health clinics do not reach many veterans and active duty service members with posttraumatic stress disorder (PTSD). Primary care is an ideal environment to expand access to mental health care. Several promising clinical case series reports of brief PTSD therapies adapted for primary care have shown positive results, but the long-term effectiveness with military members is unknown. The purpose of this study was to determine the long-term outcome of an open trial of a brief cognitive-behavioral primary care-delivered protocol developed specifically for deployment-related PTSD in a sample of 24 active duty military (15 men, 9 women). Measures of PTSD symptom severity showed statistically and clinically significant reductions from baseline to posttreatment that were maintained at the 6-month and 1-year follow-up assessments. Similar reductions were maintained in depressive symptoms and ratings of global mental health functioning.

Coming home: A prospective study of family reintegration following deployment to a war zone.

The consequences of deployment extend beyond the service member to impact the entire family. The current investigation evaluated the unique challenges of family reintegration for partnered service members using a prospective design. In total, 76 partnered service members who deployed on a year-long, high-risk mission to Iraq were assessed across the entirety of the deployment cycle, i.e., pre-, during, and postdeployment. At follow-up, nearly 1 in 5 partnered service members reported moderate to severe difficulties in multiple aspects of family reintegration. Prospective interpersonal indicators such as preparations for deployment as a couple, shared commitment to the military, and predeployment relationship distress predicted postdeployment family reintegration difficulties. Significant interpersonal risk factors were medium to large in their effect sizes. Airmen's willingness to disclose deployment- and combat-related experiences, and postdeployment relationship distress served as concurrent interpersonal correlates of difficulties with family reintegration. Intrapersonal factors, including posttraumatic stress symptoms and alcohol misuse were concurrently related to challenges with family reintegration; predeployment alcohol misuse also predicted subsequent family reintegration difficulties. Additional analyses indicated that pre- and postdeployment relationship distress, combat disclosure, and postdeployment alcohol misuse each contributed to family reintegration when controlling for other intra- and interpersonal risk factors. Implications for prevention and early intervention strategies as well as future research are discussed.

Development of a multilevel prevention program for improved relationship functioning in active duty military members.

The relationships and families of active duty (AD) service members have been tremendously strained by deployments and high operations' tempo. This study involves the first steps in developing a multilevel approach to preventing relationship problems that integrates universal, selective, and indicated prevention/intervention. Such an approach has tremendous empirical support for parenting problems, but no similar program exists for couple problems. We conducted two studies with U.S. Air Force Security Forces members. Study 1 elicited the target population's topics of highest interest. For almost all topics, 70% to 95% of participants who desired information reported being underserved by current prevention offerings (i.e., not receiving needed information). Using the top topics generated in Study 1, we developed prevention information/action planning sheets on 18 relationship issues. In Study 2, we had AD members who gave feedback on the form and content of the sheets. Overall, AD members believed that the sheets were moderately to very useful and were presented well, had pithy but comprehensive information and conveyed the content well. Results imply that a multilevel approach may be a useful complement to formal services in meeting underserved military members' needs and that further research and development of this dissemination vector for evidence-based information is warranted.

Predictors of Suicidal Ideation Across Deployment: A Prospective Study.

OBJECTIVE: Concurrent and prospective predictors of suicidal ideation were examined in a sample of 318 United States Air Force Security Forces across a 1-year deployment in Iraq and 6- to 9-month follow-up. METHOD: Participants included 294 male and 24 female Airmen ranging in age from 18 to 46 years, predominantly (67%) Caucasian. Measures included self-reports of postdeployment suicidal ideation, posttraumatic stress and depressive symptoms, alcohol use, combat experiences, relationship distress, social support, and postdeployment readjustment. RESULTS: Problem drinking before deployment prospectively predicted postdeployment suicidal ideation in univariate analyses. Depressive symptoms and problem drinking were significant independent predictors of postdeployment suicidal ideation. Findings demonstrated a ninefold increase in suicidal ideation among service members with even mild depressive symptoms if moderate problem drinking was also present. CONCLUSIONS: Predeployment problem drinking may serve as a modifiable target for early intervention of suicidal ideation. Findings illuminate the compound risk of comorbid depressive symptoms and moderate problem drinking in predicting suicidal ideation.

Impact of combat deployment on psychological and relationship health: a longitudinal study.

Although previous research has indicated an elevated prevalence of posttraumatic stress disorder (PTSD) and other mental health problems among veterans of Operations Iraqi Freedom and Enduring Freedom following deployment, most of this research has been cross-sectional and has focused on a limited range of military groups and outcome criteria. This investigation was a longitudinal study of U.S. Air Force security forces assigned to a year-long high-threat ground mission in Iraq to determine the degree to which airmen's emotional and behavioral health and committed relationships were adversely impacted by an extended deployment to a warzone. Participants were a cohort of 164 security forces airmen tasked to a 365-day deployment to train Iraqi police. Airmen completed study measures both prior to and 6-9 months following deployment. Rates of deterioration in individual and interpersonal adjustment were both significant and medium to large in magnitude of effect, d = 0.43 to 0.90. Results suggest that the negative effects of deployment are related to levels of traumatic experiences and do not spontaneously remit within the first 6-9 months following return from deployment-particularly among those service members having relatively lower levels of social support.

Intimate partner communication from the war zone: a prospective study of relationship functioning, communication frequency, and combat effectiveness.

This study examined (a) the association between relationship functioning prior to and during deployment, and the frequency of communication during deployment; and (b) the association between relationship functioning and depression during deployment and their influence on service members' ratings of duty performance. Participants were 144 partnered Airmen assessed immediately before and during a one-year high-risk deployment to Iraq. Results showed an overall high frequency of partner communication during deployment. High relationship distress at predeployment predicted lower frequency of communication during deployment. Changes in relationship distress from before deployment to during deployment independently predicted frequency of communication, above and beyond predeployment distress levels. Level of relationship distress and depression during deployment independently predicted service members' ratings of impact on duty performance.

Smokeless tobacco cessation in military personnel: a randomized controlled trial.

INTRODUCTION: Military personnel are twice as likely as civilians to use smokeless tobacco (ST). This study evaluated the efficacy of a minimal-contact ST cessation program in military personnel. METHODS: Participants were recruited from 24 military dental clinics across the United States during annual dental examinations. Participants were 785 active-duty military personnel who were randomly assigned to receive a minimal-contact behavioral treatment (n = 392) or usual care (n = 393). The behavioral treatment included an ST cessation manual, a videotape cessation guide tailored for military personnel, and three 15-min telephone counseling sessions using motivational interviewing methods. Usual care consisted of standard procedures that are part of the annual dental examination, including recommendations to quit using ST and referral to extant local tobacco cessation programs. Participants were assessed at 3 and 6 months after enrollment. RESULTS: Participants in the ST cessation program were significantly more likely to be abstinent from all tobacco, as assessed by repeated point prevalence at both 3 and 6 months (25.0%), and were significantly more likely to be abstinent from ST use for 6 months, as assessed by prolonged abstinence (16.8%), compared with participants in usual care (7.6% and 6.4%, respectively). DISCUSSION: These results indicate that a minimal-contact behavioral treatment can significantly reduce ST use in military personnel and has the potential for widespread dissemination. If ST users were identified in dental visits and routinely referred to telephone counseling, this could have a substantial benefit for the health and well-being of military personnel.

Smokeless tobacco use in military personnel.

Military personnel are more than twice as likely as civilians to use smokeless tobacco (ST), and recent studies indicate that military prevalence rates are rising. However, few studies have examined factors related to ST use in the military. The present study evaluated the characteristics of ST use in 785 active duty military personnel. The results indicated that the average age of initiation was 17.7 years, participants had used ST for 12.3 years, and they used approximately four tins or pouches of tobacco per week. Army personnel were more likely than Air Force personnel to be older, to have used ST longer, and to be heavier users. Officers had used ST longer than enlisted personnel and were more likely to have had a recent quit attempt. Enlisted personnel were more than three times as likely to report concurrent cigarette smoking. These results indicate that there are significant differences in ST use patterns in military personnel, and cessation programs should be tailored to meet these differences.

Behavioral treatment of chronic belching due to aerophagia in a normal adult.

Aerophagia, or excessive air swallowing, is a potential cause of belching, flatulence, bloating, and abdominal pain and may contribute to a worsening of gastrointestinal (GI) disorders. A limited number of published reports of aerophagia treatment indicate that behavioral methods may be of benefit. A case report is presented describing the behavioral treatment of chronic belching due to aerophagia in an adult female. The collaborative application of single-participant design research helped identify open-mouth, diaphragmatic breathing and minimized swallowing as an effective intervention. Belching frequency was reduced from an average rate of 18 per 5-min interval during the baseline period to 3 per 5-min period after treatment. Results were maintained at an 18-month follow-up. Recommendations for the use of a brief treatment protocol with adults referred for chronic belching or other GI complaints attributed to aerophagia are discussed.