Cigarette Smoking Among Veterans at High Risk for Suicide: Challenges and Opportunities for Intervention.

Preventing suicide remains a top clinical priority of the Department of Veterans Affairs (VA). In 2019, U.S. military veterans experienced a suicide rate of 52.3% higher than non-Veteran U.S. adults. Cigarette smoking has been found to be independently associated with an elevated risk of suicidal ideation, attempts, plans, and deaths among veterans and non-veterans. However, tobacco use is frequently overlooked in suicide risk assessment and mitigation and is not yet a target for intervention in VA suicide prevention protocols. In this commentary, we recommend that cigarette smoking be considered in suicide risk assessment protocols and that tobacco cessation interventions be considered as a potential beneficial treatment intervention to reduce the risk of suicide. Given the public health threat of suicide among veterans, it is essential to elucidate promising areas of intervention for those at high risk of suicide. Cigarette smoking is a modifiable target, associated with suicide risk, for which there are evidence-based interventions. Therefore, tobacco use disorder identification and treatment should be considered for inclusion in VA suicide risk protocols.

A Pilot Randomized Controlled Trial of the Insomnia Coach Mobile App to Assess Its Feasibility, Acceptability, and Potential Efficacy.

Insomnia is highly prevalent among military veterans but access to cognitive-behavioral therapy for insomnia (CBT-I) is limited. Thus, this study examined the feasibility, acceptability, and potential efficacy of Insomnia Coach, a CBT-I-based, free, self-management mobile app. Fifty U.S. veterans, who were mostly male (58%) and mean age 44.5 (range = 28-55) years with moderate insomnia symptoms were randomized to Insomnia Coach (n = 25) or a wait-list control condition (n = 25) for 6 weeks. Participants completed self-report measures and sleep diaries at baseline, posttreatment, and follow-up (12 weeks postrandomization), and app participants (n = 15) completed a qualitative interview at posttreatment. Findings suggest that Insomnia Coach is feasible to use, with three quarters of participants using the app through 6 weeks and engaging with active elements. For acceptability, perceptions of Insomnia Coach were very favorable based on both self-report and qualitative interview responses. Finally, for potential efficacy, at posttreatment, a larger proportion of Insomnia Coach (28%) than wait-list control participants (4%) achieved clinically significant improvement (p = .049) and there was a significant treatment effect on daytime sleep-related impairment (d = -0.6, p = .044). Additional treatment effects emerged at follow-up for insomnia severity (d = -1.1, p = .001), sleep onset latency (d = -0.6, p = .021), global sleep quality (d = -0.9, p = .002), and depression symptoms (d = -0.8, p = .012). These findings provide preliminary evidence that among veterans with moderate insomnia symptoms, a CBT-I-based self-management app is feasible, acceptable, and promising for improving insomnia severity and other sleep-related outcomes. Given the vast unmet need for insomnia treatment in the population, Insomnia Coach may provide an easily accessible, convenient public health intervention for individuals not receiving care.

Validating military culture: The factor analysis of a military-related adaptation of acculturation in veterans.

Differences between military and civilian culture can impact a veteran's ability to effectively navigate the transition to the civilian setting after separating from military service. However, systems providing psychological services to veterans lack reliable and valid methods of identifying the extent to which the dissonance between military and civilian cultures is associated with postseparation adjustment (e.g., ability to integrate profound deployment experiences into civilian life) and psychological outcomes. Utilization of a theory-driven, acculturation framework to assess military and civilian cultural affiliation may address this gap. While several quantitative measures exist for evaluating acculturation in reference to different ethnocultural experiences and that evaluate military culture-related adjustment or reintegration, there are no existing validated measures rooted in cultural theory that explicitly assess military-related acculturation. The aim of the present study was to develop and examine the psychometric properties of theoretically grounded, military-related adaptations of validated acculturation measures. Data from 364 veterans were collected with an online survey including four military-related adaptations of acculturation measures. Results suggest that the proposed adaptation of the original ethnocultural measurement model was not a good fit to the data, χ² = 2396.99, p < .001, TLI = .73. An evaluation of localized areas of strain in the confirmatory model and results from an exploratory factor analysis suggest support for the continued development of a military-related model of acculturation after considering further measure restructuring and validation. Opportunities for future research and measure validation are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Military acculturation and readjustment to the civilian context.

OBJECTIVE: Attitudes and beliefs related to immersion in military culture can affect postseparation transition to the civilian setting. The etiology and complexity of these reactions are often overlooked by mental health providers, which can result in negative consequences for treatment. This qualitative study examined veterans' perceptions of military culture and the impact of military service on veterans' values, beliefs, and behaviors. The goal of this research was to identify aspects of military culture that are important for health care providers to consider as they care for veterans and to inform culturally sensitive mental health care for veterans. METHOD: Fifty-two military veterans completed a self-report survey and participated in semistructured focus groups. RESULTS: Participants reported diverse military experiences, and many endorsed a high level of continuing identification with aspects of military culture. Seven broad themes related to military culture emerged from qualitative analyses: (a) military values, beliefs, and behaviors; (b) relationships; (c) occupational habits and practices; (d) acquired skills; (e) communication; (f) affiliation; and (g) psychological health and well-being. CONCLUSION: This thematic analysis elucidated strategies to improve mental health services for veterans, using a nuanced model that encourages providers to better distinguish aspects of cultural transition from psychopathology. Results underscored the importance of training mental health providers to ensure sensitivity to military culture. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Serving Veterans in their Communities: Evaluation of an Online Resource for Behavioral Health Care Providers.

Many veterans receive behavioral health care services from providers in their communities. The Community Provider Toolkit (the Toolkit) is a website developed by the National Center for PTSD and the Department of Veterans Affairs intended to provide community mental health care providers with key veteran-focused educational resources. This mixed-methods study examined the potential impact of the Toolkit on provider knowledge and behaviors. Sixty-four clinicians in the community who currently or plan to provide services to veterans were surveyed. The majority of providers found the website useful and easy to navigate. After visiting the site, many providers found additional online and educational resources that they would add to a hypothetical treatment plan. Forty-five providers completed a 1-month follow-up survey focused on use of the Toolkit. Results indicate that the Toolkit may be a valuable tool for increasing provider knowledge about veteran-specific resources.

A Qualitative Examination of Stay Quit Coach, A Mobile Application for Veteran Smokers With Posttraumatic Stress Disorder.

INTRODUCTION: Smoking is a lethal public health problem that is common in US military veterans, particularly those with posttraumatic stress disorder (PTSD). Mobile applications (apps) to promote smoking cessation are a scalable and low-cost approach that may facilitate treatment engagement. METHODS: This qualitative study examined the acceptability, user experience, and perceptions of a smoking cessation app, Stay Quit Coach (SQC), when incorporated into evidence-based smoking cessation treatment. US military veterans with PTSD who smoked at least five cigarettes per day for 15 of the past 30 days and stated an interested in cessation were eligible to participate. Participants' baseline comfort levels with mobile technology was measured using the Perceptions of Mobile Phone Interventions Questionnaire-Patient version (PMPIQ-P). At treatment end, semi-structured qualitative interviews were conducted. RESULTS: Twenty participants were enrolled and 17 (85.0%) participated in the qualitative interview at treatment end. PMPIQ-P scores at baseline ranged from 4.97 to 5.25 (SDs = 0.73-1.04), reflecting moderately high comfort with mobile technology among participants. Qualitative analyses indicated that most participants: (1) endorsed mobile technology as an appealing format for smoking cessation treatment, due to convenience and instantaneous access; and (2) expressed highest perceived helpfulness for interactive app features. Recommendations to improve SQC clustered into four thematic areas: (1) increasing personalization, (2) including more self-tracking features, (3) increasing visual cues, and (4) sharing progress with peers. CONCLUSIONS: SQC was perceived as an acceptable and useful tool to support smoking cessation in a sample of veteran smokers with PTSD. Qualitative data provided valuable insights that can inform the continued development of SQC and other apps for smoking cessation. IMPLICATIONS: Given the high lethality associated with cigarette smoking, it is crucial to identify scalable, low-risk strategies to promote smoking cessation, particularly in high-risk populations. Mobile technology is a promising approach that can be used to augment evidence-based smoking cessation treatment. Results of this qualitative study support the use of the SQC mobile app when incorporated into evidence-based smoking cessation treatment for veterans with PTSD and provide future directions for refinement of the SQC app. These findings also highlight the importance of using a patient-centered approach in designing apps intended for a clinical population.

A qualitative evaluation of Veterans Health Administration's implementation of measurement-based care in behavioral health.

Measurement-based care (MBC) in behavioral health involves the repeated collection of patient-reported data that is used to track progress, inform care, and engage patients in shared decision making about their treatment. Research suggests that MBC increases the quality and effectiveness of mental health care. However, there can be challenges to implementing MBC, such as time burden, lack of resources to support MBC, and clinician attitudes. The Veterans Health Administration (VHA) is currently undertaking a multiphase MBC roll-out, the first phase of which included 59 sites across the country. The present study examined implementation of this initiative in an effort to learn more about the process of implementation, including best practices, challenges, and innovations. Semistructured interviews were conducted with 20 MBC site champions and 60 staff members from 25 VHA medical centers across the country. Qualitative data analysis was conducted to identify key themes related to MBC implementation. Results were described for 3 components of MBC implementation: preparing for implementation, administering measures, and using and sharing data. Training and staff buy-in were key to the preparation phase. Staff members reported a variety of methods and frequencies for the collection of MBC data, with many staff members identifying a need to streamline the collection process. Staff members reported using data to track progress and adjust treatment with patients. Efforts to use data on a programmatic level were identified as a next step. Innovative solutions across clinics and sites are described in an effort to inform future MBC implementation, both within and outside of VHA. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Predictors of multiple domains of functioning in Veterans with posttraumatic stress disorder: Results from the Mind Your Heart Study.

BACKGROUND: Those with posttraumatic stress disorder (PTSD) have lower overall functioning than healthy controls. However, this population is not homogenous, and those with PTSD have a wide range of functional outcomes. To our knowledge, only one other study has evaluated the predictors of better functioning within patients with PTSD. METHODS: We examined 254 veterans with likely PTSD, using the Clinician-Administered PTSD Scale to assess PTSD symptom severity, and the SF-36 and single-item question to assess aspects of current functioning and quality of life. RESULTS: In fully adjusted models (controlling for age, gender, and PTSD score, and including all significant psychosocial predictors of the outcome of interest), greater sleep quality (p = .03), lower C-reactive protein (p < .01), and lower erythrocyte sedimentation rate (p = 0.04) were associated with greater physical functioning; lower depression (p < .01) and greater perceived social support (p = .05) were associated with greater social functioning; lower depression (p = .02) was associated with greater occupational functioning; and greater combat exposure (p = .04), greater optimism (p < .01) and greater perceived social support (p = .05) were associated with greater quality of life. CONCLUSIONS: These findings highlight the differential impact of psychosocial predictors on multiple functional outcomes. As such, they provide important information for clinicians about aspects of veterans' lives that can be targeted during the treatment to improve specific types of functioning.

Positive impact of IPS supported employment on PTSD-related occupational-psychosocial functional outcomes: Results from a VA randomized-controlled trial.

OBJECTIVE: Posttraumatic stress disorder (PTSD) has significant negative effects on occupational, interpersonal, and social functioning. Supported employment is highly effective in helping people with a diagnosis of PTSD obtain and maintain competitive employment. However, less is known about the impact of supported employment on functioning in work or school, social, and interpersonal areas as specifically related to the symptoms of PTSD. METHOD: The Veterans Individual Placement and Support Toward Advancing Recovery study was a prospective, multisite, randomized, controlled trial that compared Individual Placement and Support (IPS) supported employment with a stepwise vocational rehabilitation involving transitional work (TW) assignments with unemployed veterans with PTSD diagnoses (n = 541) at 12 Veterans Administration (VA) medical centers. This analysis focuses on the PTSD-related functional outcomes over the 18-month follow-up period. RESULTS: Compared with those randomized to TW, the PTSD Related Functioning Inventory (PRFI) total score significantly improved for participants randomized to IPS (LSMeans difference = -3.92, 95% CI [-7.49, -.36]; p = .03) over 18 months. When the Work/School subscale of the PRFI was removed from the analysis, the IPS group continued to show significant improvements compared with the TW group on the PRFI relationship and lifestyle domains (LSMeans difference = -2.37, 95% CI [-4.74, .00]; p = .05), suggesting a positive impact of IPS beyond work/school functioning. CONCLUSION: Compared with the usual-care VA vocational services for veterans with PTSD, IPS supported employment is associated with greater improvement in overall PTSD-related functioning, including occupational, interpersonal, and lifestyle domains. In addition to superior employment outcomes, IPS has a positive impact on occupational-psychosocial functioning outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Factors associated with high functioning despite distress in post-9/11 veterans.

OBJECTIVE: This study aimed to identify modifiable factors associated with perceived functioning among veterans with high symptoms of posttraumatic stress disorder (PTSD). METHOD: Two hundred fifty-one post-9/11 veterans completed a survey of psychosocial symptoms and functioning; a subset participated in a follow-up survey (n = 109). Latent profile analysis (LPA) at baseline identified groups that differed by level of functioning (high/low). Items utilized in the LPA analysis were derived from the World Health Organization Quality of Life-Bref self-report measure. Veterans with high PTSD symptoms in both groups were compared and logistic regression was utilized to predict group membership. RESULTS: Veterans with high functioning/high symptoms (n = 45) had significantly lower alcohol use and sleep problems, and higher postdeployment social support, posttraumatic growth, and optimism than veterans with low functioning/high symptoms (n = 100). Fewer sleep difficulties and higher postdeployment social support and optimism were associated with membership in the high functioning/high symptom group. CONCLUSIONS: These findings support the importance of identifying factors that can facilitate higher social, occupational, and general functional capacity for those with high levels of PTSD symptomatology. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Student veterans with posttraumatic stress symptoms: Perceived preferences for on-campus psychoeducation.

OBJECTIVE: This investigation aimed to better understand perceived barriers to academic success and preferences for a veteran-specific psychosocial course among veterans with symptoms of posttraumatic stress (PTS). METHOD: Ninety-three veterans participated in this investigation as part of a larger study examining psychosocial functioning among veterans with PTS symptoms. Participants completed a self-report survey focused on perceived barriers to academic success and psychoeducational preferences related to health and well-being. RESULTS: Perceived barriers to academic success reported as most problematic were sleep difficulties, stress, depression, and financial concerns. Results indicated that veterans would be interested in attending an on-campus course focusing on these areas. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: These findings contribute to the understanding of student veterans with PTS symptoms' perceived needs and inform the development of campus programs for this population. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Deployment Anxiety Reduction Training: A Pilot Study of Acceptability and Feasibility in Current or Recent Active Duty Service Members.

Objectives: The Deployment Anxiety Reduction Training (DART) is a manualized tool that was developed and piloted with active duty service members and recently deployed veterans regarding their response to potential and experienced acute combat stress reactions. DART is low risk and has high potential to be beneficial. It is a brief, one-session, non-pharmacological approach designed to reduce symptoms of peritraumatic panic and increase resilience in the face of a potentially traumatic stressor. Methods: This study was a mixed-methods pilot study to assess the utility and acceptability of DART during deployment. Results: Self-report and interview responses indicated that participants generally found the DART techniques acceptable and easy to understand. Overall, the techniques were perceived as likely to be helpful with high utility, although there was variation in perceived helpfulness among the different techniques. Participants overwhelmingly positively endorsed delivery of the DART protocol through use of smartphone technology. Conclusions: Results indicate that the DART components were considered highly acceptable and feasible for use in the deployed environment.

Mobile Technology for Treatment Augmentation in Veteran Smokers With Posttraumatic Stress Disorder.

INTRODUCTION: The purpose of this study is to examine the feasibility and acceptability of incorporating a mobile application, Stay Quit Coach, into an integrated care smoking-cessation treatment protocol for veterans with posttraumatic stress disorder (PTSD). METHODS: Participants included veteran smokers aged 18-69 years with PTSD. The integrated care protocol includes eight weekly PTSD-informed cognitive behavioral therapy sessions for smoking cessation, followed by monthly booster sessions and a prescription for standard smoking-cessation medications if desired. Participants used Stay Quit Coach as desired. Outcome measures at 3-month follow-up included: adherence (sessions attended), 30-day point-prevalence abstinence bioverified with carbon monoxide <6 parts per million, past-30 day mean daily cigarette use, exhaled carbon monoxide, nicotine dependence, and PTSD symptom severity. Repeated outcomes were analyzed with random-intercept linear mixed models. Data were collected in 2015-2016 and analyses were conducted in 2016-2017. RESULTS: Participants (n=20) were 95% male and 5% female; mean age 41.4 (SD=16.2) years. Thirteen participants (65%) attended all scheduled sessions, four (20%) did not adhere to the protocol on schedule, and three (15%) were lost to follow-up. At 3-month follow-up, six of 17 completers (35.3%) had bioverified 30-day point-prevalence abstinence. Nicotine dependence, carbon monoxide levels, and past 30-day cigarette use significantly decreased and PTSD symptoms were unchanged from baseline to follow-up. Participants self-reported using Stay Quit Coach 2.5 (SD=2.2) days/week; 15 of 17 (88.2%) reported using Stay Quit Coach <30 minutes/week; two of 17 (11.8%) reported using Stay Quit Coach 30-60 minutes/week. CONCLUSIONS: Although results must be interpreted with caution given the lack of control group and small sample size, findings indicate that integrating Stay Quit Coach into integrated care was feasible and acceptable.

Impact of Engagement in Exercise on Sleep Quality Among Veterans With Posttraumatic Stress Disorder Symptoms.

BACKGROUND: Exercise has beneficial effects for physical health outcomes and has also been shown to reduce the severity of psychological health symptoms. Recent studies have shown a potentially positive impact of exercise on posttraumatic stress disorder (PTSD). Prominent among those with PTSD, sleep disturbance and nightmares are among the top three PTSD symptoms commonly reported by treatment-seeking Veterans. Regular physical exercise has been consistently associated with better sleep. This study utilized a longitudinal design to explore the relationship between exercise and sleep among Veterans with PTSD symptoms at baseline and one-year follow-up. MATERIALS AND METHODS: Veterans (n = 76) who served in support of Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn were recruited for this study. Correlations were assessed between PTSD symptoms, sleep, and engagement in exercise at each time point (baseline, one-year follow-up). Regression analyses were conducted to examine the relationship between engagement in exercise at baseline and PTSD symptoms at one-year follow-up, as well as sleep quality at one-year follow-up. Regression models controlled for demographic variables (age and gender), alcohol use, baseline PTSD symptoms, and baseline sleep quality. RESULTS: Multiple regression analyses demonstrated that engagement in exercise at baseline was significantly associated with better sleep quality at one-year follow-up while controlling for age, gender, alcohol use, baseline PTSD symptoms, and baseline sleep quality (ß = -0.128, p < 0.05). Multiple regression analyses examining the relationship between engagement in exercise at baseline and PTSD symptoms at one-year follow-up (controlling for age, gender, alcohol use, baseline PTSD symptoms, and baseline sleep quality) did not yield statistically significant results (ß = 0.053, p = 0.57). CONCLUSION: Results from the present study found that engagement in exercise at baseline was associated with better sleep quality at one-year follow-up. These findings were consistent with the current literature suggesting exercise can have a positive impact on sleep quality. Furthermore, our findings suggest that exercise could be considered as an adjunctive intervention for individuals with PTSD-particularly for those patients whose difficulties with sleep are predominant. Given that exercise is highly accessible and is embedded in the military culture, future research should examine the way in which exercise can be leveraged in PTSD treatment, specifically in ameliorating sleep difficulties. Exercise may also reap demonstrable public health benefits in multiple psychological and physical domains and reduce the psychiatric and medical morbidity and mortality associated with PTSD.

Assessing posttraumatic stress related impairment and well-being: The Posttraumatic Stress Related Functioning Inventory (PRFI).

Posttraumatic stress symptoms are associated with poorer social and occupational functioning and quality of life. However, general assessments of functioning do not determine the extent to which these difficulties are directly related to PTSD symptoms. This study examines the psychometric properties of a self-report measure, the 27-item Posttraumatic Stress Related Functioning Inventory (PRFI), which was developed to provide a self-report tool for clinicians and researchers to better understand the perceived impact of PTSD symptoms on functioning. The psychometric properties of the PRFI were examined utilizing data collected within a larger study examining quality of life and functioning in 251 veterans who had served in OEF/OIF/OND and endorsed the presence of subsyndromal or greater levels of PTSD symptoms at screening. One-year test-retest reliability of the measure was examined in a subset of the baseline sample who received a second administration of the PRFI (n = 109). Higher levels of PTSD symptoms were associated with poorer functioning in all domains. The PRFI demonstrated convergent validity with a measure of PTSD symptoms and was less correlated with measures of alcohol and drug use, good internal consistency and test-retest reliability from baseline to one-year follow-up. The PRFI provides self-report information regarding several domains of functioning. This initial examination of psychometric properties of the scale indicated that it may be useful for efficiently eliciting information about the ways in which PTSD symptoms in veterans impact everyday functioning.

Prospective study of police officer spouse/partners: a new pathway to secondary trauma and relationship violence?

INTRODUCTION: It has been reported that posttraumatic stress disorder (PTSD) is associated with secondary spouse/partner (S/P) emotional distress and relationship violence. OBJECTIVE: To investigate the relationships between PTSD, S/P emotional distress and relationship violence among police recruits using a prospective design. METHODS: Two hypotheses were tested in 71 S/Ps: (1) Police officer reports of greater PTSD symptoms after 12 months of police service will be associated with greater secondary trauma symptoms among S/Ps; (2) Greater secondary trauma symptoms among S/Ps at 12 months will be associated with S/P reports of greater relationship violence. METHODS: 71 police recruits and their S/Ps were assessed at baseline and 12 months after the start of police officer duty. Using linear and logistic regression, we analyzed explanatory variables for 12 month S/P secondary traumatic stress symptoms and couple violence, including baseline S/P variables and couple violence, as well as exposure and PTSD reports from both S/P and officer. RESULTS: S/P perception of officer PTSD symptoms predicted S/P secondary traumatic stress. OS/P secondary trauma was significantly associated with both total couple violence (.34, p = .004) and S/P to officer violence (.35, p = .003). CONCLUSIONS: Although results from this relatively small study of young police officers and their S/Ps must be confirmed by larger studies in general populations, findings suggest that S/P perception of PTSD symptoms may play a key role in the spread of traumatic stress symptoms across intimate partner relationships and intimate partner violence in the context of PTSD.

Cognitive behavioral therapy for insomnia in posttraumatic stress disorder: a randomized controlled trial.

STUDY OBJECTIVES: Examine whether cognitive behavioral therapy for insomnia (CBT-I) improves sleep in posttraumatic stress disorder (PTSD) as well as nightmares, nonsleep PTSD symptoms, depression symptoms, and psychosocial functioning. DESIGN: RANDOMIZED CONTROLLED TRIAL WITH TWO ARMS: CBT-I and monitor-only waitlist control. SETTING: Department of Veterans Affairs (VA) Medical Center. PARTICIPANTS: Forty-five adults (31 females: [mean age 37 y (22-59 y)] with PTSD meeting research diagnostic criteria for insomnia, randomly assigned to CBT-I (n = 29; 22 females) or monitor-only waitlist control (n = 16; nine females). INTERVENTIONS: Eight-session weekly individual CBT-I delivered by a licensed clinical psychologist or a board-certified psychiatrist. MEASUREMENTS AND RESULTS: Measures included continuous monitoring of sleep with diary and actigraphy; prepolysomnography and postpolysomnography and Clinician-Administered PTSD Scale (CAPS); and pre, mid, and post self-report questionnaires, with follow-up of CBT-I participants 6 mo later. CBT-I was superior to the waitlist control condition in all sleep diary outcomes and in polysomnography-measured total sleep time. Compared to waitlist participants, CBT-I participants reported improved subjective sleep (41% full remission versus 0%), disruptive nocturnal behaviors (based on the Pittsburgh Sleep Quality Index-Addendum), and overall work and interpersonal functioning. These effects were maintained at 6-mo follow-up. Both CBT-I and waitlist control participants reported reductions in PTSD symptoms and CAPS-measured nightmares. CONCLUSIONS: Cognitive behavioral therapy for insomnia (CBT-I) improved sleep in individuals with posttraumatic stress disorder, with durable gains at 6 mo. Overall psychosocial functioning improved following CBT-I. The initial evidence regarding CBT-I and nightmares is promising but further research is needed. Results suggest that a comprehensive approach to treatment of posttraumatic stress disorder should include behavioral sleep medicine. CLINICAL TRIAL INFORMATION: TRIAL NAME: Cognitive Behavioral Treatment Of Insomnia In Posttraumatic Stress Disorder. URL: http://clinicaltrials.gov/ct2/show/NCT00881647. REGISTRATION NUMBER: NCT00881647.

Social support may protect against development of posttraumatic stress disorder: findings from the Heart and Soul Study.

PURPOSE: No prospective studies have examined the association of poor social support and development of posttraumatic stress disorder (PTSD) in patients with chronic illness. This study addresses this knowledge gap. DESIGN: This prospective study examines the relationship of social support to the subsequent development of PTSD during a 5-year period. SETTING: San Francisco Veterans Affairs Medical Center. SUBJECTS: A total of 579 participants with cardiovascular disease did not have PTSD at baseline and returned for the 5-year follow-up examination. MEASURES: PTSD measured by Computerized Diagnostic Interview Schedule for DSM-IV. Social support measured by Interpersonal Support Evaluation List (ISEL). ANALYSIS: Unconditional ordered logistic regression analyses were performed to yield the odds ratio of developing PTSD for a one-standard-deviation change in ISEL score. RESULTS: Of 579 participants who did not have PTSD at baseline, approximately 6.4% (n = 37) developed PTSD. Higher baseline perceived social support was strongly protective against development of PTSD (OR = .60, p = .001). Results remained significant after adjustment for age, sex, race, income, and depression (OR = .69, p = .04). Of social support types examined, the "tangible" and "belonging" domains were most strongly associated with future PTSD status. CONCLUSION: Social support may impact development of PTSD. Interventions that optimize social support may be part of a PTSD prevention program designed to help individuals at risk of developing PTSD.