Predictors of non-fatal suicide attempts among Veterans Health Administration (VHA) patients who experienced military sexual trauma.

OBJECTIVE: Military sexual trauma (MST) has been identified as a risk factor for suicidal behavior. To inform suicide prevention efforts within the Veterans Health Administration (VHA), this study evaluates predictors of non-fatal suicide attempts (NFSAs) among VHA patients who experienced MST. METHODS: For VHA patients in fiscal year (FY) 2019 who previously screened positive for a history of MST, documented NFSAs were assessed. Using multivariable logistic regression, demographic, clinical, and VHA care utilization predictors of NFSAs were assessed. RESULTS: Of the 212,215 VHA patients who screened positive for MST prior to FY 2019 and for whom complete race, service connection, and rurality information was available, 1742 (0.8%) had a documented NFSA in FY 2019. In multivariable logistic regression analyses, total physical and mental health morbidities were not associated with NFSA risk. Predictors of a documented NFSA included specific mental health diagnoses [adjusted odds ratio (aOR) range: 1.28-1.94], receipt of psychotropic medication prescriptions (aOR range: 1.23-2.69) and having a prior year emergency department visit (aOR = 1.32) or inpatient psychiatric admission (aOR = 2.15). CONCLUSIONS: Among VHA patients who experienced MST, specific mental health conditions may increase risk of NFSAs, even after adjustment for overall mental health morbidity. Additionally, indicators of severity of mental health difficulties such as receipt of psychotropic medication prescriptions and inpatient psychiatric admissions are also associated with increased risk above and beyond risk associated with diagnoses. Findings highlight targets for suicide prevention initiatives among this vulnerable group within VHA and may help identify patients who would benefit from additional support.

Engagement in posttraumatic stress disorder treatment for veterans who experienced military sexual trauma and are diagnosed with serious mental illness.

It is important to ensure that veterans who have experienced military sexual trauma (MST) and have posttraumatic stress disorder (PTSD) have access to trauma-focused treatment. For veterans with serious mental illness (SMI), prior work documents decreased likelihood to receive trauma-focused care. This study focused on evaluating the engagement of Veterans Health Administration (VHA) patients diagnosed with PTSD and who have experienced MST in PTSD specialty care, as well as how this differs for veterans with SMI. Using VHA administrative data, all VHA patients who screened positive for MST prior to fiscal year 2019 (FY2019) were identified (N = 84,503). Based on information from FY2019, measures of psychiatric diagnosis status and VHA treatment participation were generated for all cohort members. Logistic regressions assessed whether there were differences in the likelihood to initiate PTSD care (1+ VHA PTSD specialty clinic encounter) or receive guideline-concordant levels of PTSD specialty care (8+ VHA PTSD specialty clinic encounter) during FY2019. Several other patient characteristics associated with decreased likelihood to receive VHA PTSD specialty servies were identified, including White race and older age. Patient SMI status was not significantly associated with likelihood to initiate or receive guideline-concordant levels of PTSD specialty care. Overall, PTSD treatment initiation was low (11% of veterans with SMI initiated PTSD specialty treatment, as opposed to 10% of veterans without SMI). Additional work is merited to identify ways that VHA is able to overcome barriers to trauma care participation experienced by persons who have experienced MST and been diagnosed with PTSD. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Posttraumatic Stress Disorder and Conduct Problems: The Role of Self-Control Demands.

We tested within- and between-person effects of posttraumatic stress disorder (PTSD) symptoms on conduct problems and alcohol intoxication via self-control demands using multilevel structural equation modeling in a longitudinal burst-design study of 251 U.S. veterans who participated in the recent wars in Iraq and Afghanistan. We theorized that experiencing PTSD symptoms engenders efforts to regulate mood, control thoughts, and inhibit or control behavior that is taxing to the individual (i.e., it places demands on self-control) and hypothesized that this process results in subsequent deficits in regulatory control that manifest in heightened intoxication and conduct problems associated with PTSD. At the within-person level, daytime PTSD symptoms, IRR = 1.09, and self-control demands, IRR = 1.12, exhibited within-person associations with nighttime conduct problems over and above nighttime intoxication. Consistent with our hypothesis, daytime increases in self-control demands mediated the associations between daytime PTSD symptoms and subsequent nighttime conduct problems. The indirect effect between daytime PTSD symptoms and nighttime intoxication via self-control demands was nonsignificant. At the between-person level, self-control demands mediated the associations between PTSD symptoms and conduct problems; however, the expected between-person associations with intoxication were nonsignificant. Drinking behavior is related to but cannot fully account for various difficulties in psychosocial functioning associated with PTSD. The present results suggest that dysregulated behavior may, ironically, stem from individuals' concerted efforts to control and manage overwhelming symptoms. Self-control demands may be a common factor that accounts for a broad range of functional impairments associated with PTSD.

Affective dynamics among veterans: Associations with distress tolerance and posttraumatic stress symptoms.

We tested a dynamic structural equation model (DSEM; Asparouhov, Hamaker, & Muthén, 2018) of positive and negative affect in 254 veterans with approximately 1.5 years of experience sampling data. The analysis provided estimates of several aspects of veteran's emotional experience including "trait" positive and negative affect (i.e., mean levels), inertia (i.e., tendency for emotions to self-perpetuate), innovation variance (conceptualized as lability, reactivity, or exposure to stressors), and cross-lagged associations between positive and negative affect. Veterans with higher trait negative affect had more negative affect inertia and innovation variance. This suggests a pattern whereby the veteran has more negative reactions, and negative emotions, in turn, tend to maintain themselves, contributing to higher trait negative affect. In contrast, veterans with higher trait positive affect exhibited more positive affect innovation variance (e.g., positive reactivity). Although veterans showed some consistency in dynamics across emotions (e.g., positive and negative reactivity were positively correlated), trait positive and negative affect were not significantly associated. Veterans with higher posttraumatic stress symptoms (PTSS) at baseline exhibited higher reactivity to negative events, less positive affect, and more negative affect during the follow-up. Veterans with higher distress tolerance reported not only lower PTSS but also a more adaptive pattern of affective experience characterized by lower inertia and reactivity in negative affect and more positive lagged associations between negative affect and subsequent positive affect. The results demonstrated that distress tolerance and PTSS in veterans were associated with dynamics of positive and negative emotion over time, suggesting specific differences in affect regulation processes. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Trauma-Informed Telehealth in the COVID-19 Era and Beyond.

BACKGROUND: The Veterans Health Administration (VHA) entered the COVID-19 pandemic crisis with an existing and robust telehealth program, but it still faces a fundamental paradigm shift as most routine outpatient in-person care was converted to telehealth visits. Veterans are a highly trauma-exposed population, and VHA has long offered effective telemental health services. Natural disasters and pandemics like COVID-19 are known to be traumatic. Those with preexisting trauma exposure and mental health conditions are often at greater risk than the general population for long-term adverse health sequelae. Application of trauma-informed principles to telehealth care is critical and timely. OBSERVATIONS: Trauma-focused care (including telemental health) refers to evidence-based treatment models that directly facilitate recovery from trauma-related conditions like posttraumatic stress disorder. Despite the widespread availability of trauma-focused treatment in VHA, not all veterans chose to engage in it. In contrast, trauma-informed care (TIC) is a global, "universal precautions" approach to providing strengths-based, collaborative quality medical care in any discipline or location. In this article the authors, all primary care and mental health clinicians at VHA, advocate for the application of the 6 Substance Abuse and Mental Health Services Administration principles of trauma-informed care to telehealth. Using examples from telehealth research conducted in trauma-exposed patient populations, we illustrate the characteristics of telehealth that are well suited to delivery of trauma-informed care and suggest readily applicable strategies that can be used across disciplines including primary care and medical/surgical specialties. A primary care patient case scenario is included to illustrate how telehealth visits can be trauma-informed. CONCLUSIONS: Telehealth expansion has occurred nationally out of necessity during the COVID-19 pandemic. Trauma-informed virtual care has the potential to ensure and even expand continuity of medical care by fostering safe and collaborative interactions between patients and the health care team.

Evaluating Bystander Intervention Training to Address Patient Harassment at the Veterans Health Administration.

PURPOSE: One in four women veteran patients report experiencing sexual and gender harassment when attending the Veterans Health Administration (VA) for health care. Bystander intervention-training community members how to intervene when witnessing inappropriate behaviors-is a common approach for addressing harassment in school and military settings. We evaluated implementation of a VA harassment awareness and bystander intervention training that teaches health care staff how to identify and intervene in the harassment of women veteran patients. METHODS: Participants included 180 VA staff, including both providers and administrative staff from one VA state health care system, who participated in harassment training during the first year of implementation. Pretest and post-test evaluation surveys included questions on acceptability of training length and relevance, staff experiences with harassment, perceptions of the training, and four short-term attitudinal outcomes: awareness of harassment, barriers to intervening, self-efficacy for intervening, and intentions to intervene. RESULTS: At pretest, most staff reported witnessing harassment, yet fewer than one-half had intervened. By post-test, staff reported significantly decreased barriers to intervening and increased awareness, self-efficacy, and intentions to intervene. Belief that harassment is a problem increased from 42.4% to 75.0%. The majority of staff found the training relevant and appropriate in length. Staff felt the most useful aspects of the training were learning how to intervene, group discussion, effective facilitation, and information on harassment. CONCLUSIONS: We found that a bystander approach was acceptable to health care staff and efficacious on short-term outcomes. Bystander intervention may be a promising strategy to address harassment among patients in medical facilities.

Nexus of despair: A network analysis of suicidal ideation among veterans.

The objective of this study was to estimate a network model of risk and resilience factors of suicidal ideation among veterans. Two network models of suicidal ideation among Operation Iraqi Freedom/Operation Enduring Freedom/Operation New Dawn veterans (N = 276) incorporated key disorders, traumatic stress, and resilience constructs to contextualize suicidal ideation. Childhood trauma was positively connected with suicidal ideation and harassment and inversely connected with social support and distress tolerance. This exemplifies long-lasting associations between childhood trauma and re-victimization, emotion regulation, and ability to form supportive social relationships. A subsequent model including lower-order facets indicated that combat trauma was predominantly associated with posttraumatic stress disorder-intrusion symptoms. This study highlights the importance of addressing both risk and resilience to reduce suicide risk among veterans and increases understanding of factors that contribute to suicidal ideation.

The Importance of Adolescent Self-Report in Autism Spectrum Disorder: Integration of Questionnaire and Autonomic Measures.

Anxiety and sensory symptoms are highly prevalent and meaningful in the daily lives of individuals with autism spectrum disorder (ASD). Despite the importance of carefully measuring, researching, and treating these symptoms, current methods in ASD seldom include self-report. This study investigated the consistency of adolescent and parent reports of anxiety and auditory sensitivity in individuals with ASD, and examined their validity via comparisons with sympathetic arousal at baseline and in response to an auditory challenge. Fifty adolescent-parent dyads (n = 26 ASD, n = 24 typically developing; 12-16 years old; IQ>80) completed parallel versions of both anxiety and auditory hypersensitivity scales, which were compared to heart rate collected at rest and during an aversive noise task. Adolescents with ASD exhibited greater anxiety and auditory hypersensitivity than their peers, based on both self and parent report. Across groups, self-report was higher than parent report. In individuals with ASD, a significant relationship was found between self-reported anxiety and autonomic arousal at rest, and between self-reported auditory sensitivity and autonomic reactivity during the noise task. These relationships were not significant for parent-report. These findings extend past work by demonstrating greater self-reported (than parent-reported) anxiety and sensory symptoms. Furthermore, the presence of significant correlations between self-reported symptoms and sympathetic arousal supports the validity of self-report in adolescents with ASD with average or above average cognitive abilities. This indicates that adolescents with ASD have a unique perspective on their internal experience, which can complement parent reports and provide a more comprehensive assessment of symptoms in research and clinical settings.

The Influence of Noise on Autonomic Arousal and Cognitive Performance in Adolescents with Autism Spectrum Disorder.

This study examined the impact of noise on cognitive performance in autism spectrum disorder (ASD), while concurrently measuring sympathetic responses. Adolescents with and without ASD completed visually presented span tasks in a 2 × 2 experimental manipulation of noise (quiet vs. 75 dB gated broadband noise) and task difficulty (easier vs. harder). Analyses revealed a significant noise × difficulty interaction on performance, and a significant group × noise × difficulty interaction on sympathetic arousal. Correlational analyses indicated an adaptive effect of noise and increased arousal on performance in the easier condition for the control group and a detrimental effect of noise and increased arousal in the harder condition for the ASD group. Implications for sensory processing research and intervention development are discussed.

PTSD symptoms and alcohol-related problems among veterans: Temporal associations and vulnerability.

Posttraumatic stress disorder (PTSD) is associated with elevated risk of both alcohol use disorder (AUD) and related conduct problems, which are associated with behavioral and emotional dysregulation. We conducted an intensive longitudinal burst design study with 10 weeks of experience sampling over the course of 1.5 years with 250 veterans of recent conflicts. We tested time-series models of daily associations between posttraumatic stress symptoms (PTSS), alcohol dependence syndrome, and conduct problems. Exacerbations of PTSS predicted higher dependence syndrome and conduct problems the next day. This effect was significant after controlling for both concurrent (i.e., same-day) associations between drinking and the outcomes as well as the strength of associations between the outcomes from one day to the next (i.e., autoregression). Affect lability and disinhibition were hypothesized vulnerability factors increasing the strength of within-person predictors of dependence syndrome and conduct problems. Lability and disinhibition were associated with greater dependence syndrome symptoms and conduct problems over the follow-up period. Consistent with expectation, lability rather than disinhibition increased the association between drinking and dependence syndrome as well as the strength of association between dependence syndrome symptoms from one day to the next. Moderating effects of disinhibition in the conduct problems model were not significant. Importantly, results indicated reciprocal associations over time. Lability potentiated the association between dependence syndrome symptoms and next day PTSS, whereas disinhibition potentiated the association between conduct problems and next day PTSS. Results demonstrate complex dynamic associations between PTSS, AUD symptoms, and conduct problems over time indicative of broad regulatory impairments. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Children with autism spectrum disorder have reduced otoacoustic emissions at the 1 kHz mid-frequency region.

Autism spectrum disorder (ASD) is a behaviorally diagnosed disorder of early onset characterized by impairment in social communication and restricted and repetitive behaviors. Some of the earliest signs of ASD involve auditory processing, and a recent study found that hearing thresholds in children with ASD in the mid-range frequencies were significantly related to receptive and expressive language measures. In addition, otoacoustic emissions have been used to detect reduced cochlear function in the presence of normal audiometric thresholds. We were interested then to know if otoacoustic emissions in children with normal audiometric thresholds would also reveal differences between children with ASD and typical developing (TD) controls in mid-frequency regions. Our objective was to specifically measure baseline afferent otoacoustic emissions (distortion-product otoacoustic emissions [DPOAEs]), transient-evoked otoacoustic emissions (TrOAEs), and efferent suppression, in 35 children with high-functioning ASD compared with 42 aged-matched TD controls. All participants were males 6-17 years old, with normal audiometry, and rigorously characterized via Autism Diagnostic Interview-Revised and Autism Diagnostic Observation Schedule. Children with ASD had greatly reduced DPOAE responses in the 1 kHz frequency range, yet had comparable DPOAE responses at 0.5 and 4-8 kHz regions. Furthermore, analysis of the spectral features of TrOAEs revealed significantly decreased emissions in ASD in similar frequencies. No significant differences were noted in DPOAE or TrOAE noise floors, middle ear muscle reflex activity, or efferent suppression between children with ASD and TD controls. In conclusion, attention to specific-frequency deficits using non-invasive measures of cochlear function may be important in auditory processing impairments found in ASD. Autism Res 2017, 10: 337-345. © 2016 International Society for Autism Research, Wiley Periodicals, Inc.

PTSD, alcohol dependence, and conduct problems: Distinct pathways via lability and disinhibition.

This study tested the role of affect lability and disinhibition in mediating associations between PTSD symptoms and two forms of alcohol-related problems, dependence syndrome symptoms (e.g., impaired control over consumption) and conduct problems (e.g., assault, risk behaviors). Genotype at the serotonin transporter linked polymorphic region (5-HTTLPR) was hypothesized to moderate associations between traumatic stress and PTSD symptoms. In addition, the study tested whether childhood traumatic stress moderated associations between combat trauma and PTSD symptoms. Participants were 270 OIF/OEF/OND veterans. The hypothesized model was largely supported. Participants with the low expression alleles of 5-HTTLPR (S or LG) exhibited stronger associations between childhood (but not combat) traumatic stress and PTSD symptoms. Affect lability mediated the associations between PTSD symptoms and alcohol dependence symptoms. Behavioral disinhibition mediated associations between PTSD symptoms and conduct related problems. Conditional indirect effects indicated stronger associations between childhood traumatic stress and lability, behavioral disinhibition, alcohol consumption, AUD symptoms, and associated conduct problems via PTSD symptoms among those with the low expression 5-HTTLPR alleles. However, interactions between combat trauma and either childhood trauma or genotype were not significant. The results support the hypothesis that affect lability and behavioral disinhibition are potential intermediate traits with distinct associations with AUD and associated externalizing problems.

Don't tell: Military culture and male rape.

The issue of sexual assault that occurs during military service has been a focus of attention over the past several years. Although approximately 50% of survivors of military sexual assault are men, virtually all of the literature focuses on the assault of female service members. Research has demonstrated that cultural variables are robust correlates of the sexual assault of women. This paper proposes that cultural variables are equally important when examining the rape of men, especially when this assault occurs in military contexts. We discuss male rape myths and related constructs as they are expressed within military culture. The results of data analysis from a treatment sample of veterans with military sexual trauma (MST)-related posttraumatic stress disorder (PTSD) and clinical case examples are presented to further explore the concepts. We conclude that male rape myths and related beliefs that arise from cultural norms and are further amplified and modified by military culture impact male MST survivors and delay or obstruct their recovery. Suggestions for clinical application and future research are offered to encourage further efforts in this important area of practice.

The relationship between contact and attitudes: Reducing prejudice toward individuals with intellectual and developmental disabilities.

Increases in intellectual and developmental disability (IDD) diagnoses coupled with higher rates of inclusion in school and community settings, has created more opportunities for exposure and integration between those with IDD and the mainstream population. Previous research has found that increased contact can lead to more positive attitudes toward those with IDD. The current study further investigated this impact of contact on attitudes by examining the influence of the quality and quantity of contact on both explicit and implicit levels of prejudice, while also considering potential mediation via intergroup anxiety and implicit attitudes. Based on past research and theory, we predicted that contact (especially quality contact) would have a strong relationship with explicit and implicit positive attitudes toward individuals with IDD. In the present study, 550 people completed a survey and short task that measured their level of contact with individuals with IDD across their lifetime, their current attitudes toward these individuals, and other constructs that are thought to influence this relationship. Multiple regression analyses suggested consistent links between higher quality of contact and lower levels of prejudice toward individuals with IDD at both the explicit and implicit levels. After controlling for quality of contact, higher quantity of contact was either not significantly associated with our measures of prejudice or was, importantly, associated with higher levels of prejudice. Additional analyses support intergroup anxiety and implicit positive attitudes as significant mediators in the associations between quality of contact and the various dimensions of explicit prejudice. Thus, it would seem that it is the quality of interpersonal interactions that is most strongly related to positive attitudes toward individuals with IDD, making it crucial to take care when developing inclusion opportunities in community settings.

Correlates of cognitive flexibility in veterans seeking treatment for posttraumatic stress disorder.

This study examined the association between cognitive flexibility and variables that may be associated with treatment outcome for 579 veterans seeking Veterans Health Administration treatment for posttraumatic stress disorder (PTSD) secondary to combat or sexual trauma. Factors associated with severity of PTSD (level of PTSD symptoms and guilt cognitions) and with PTSD prognosis (posttraumatic growth and optimistic expectations for the future) were examined. Regression analyses revealed that cognitive flexibility was associated with lower levels of PTSD symptoms and fewer guilt cognitions. Cognitive flexibility was positively associated with posttraumatic growth and optimistic expectations for the future, even when controlling for PTSD severity. These results suggest that interventions designed to increase cognitive flexibility in veterans may be a worthwhile adjunct to treatment for PTSD as we continue efforts to improve treatment outcomes.

Preliminary open trial of interpersonal counseling for subsyndromal depression following miscarriage.

Miscarriage occurs in 10-20% of clinically recognized pregnancies and is associated with two- to fourfold increases in depressive symptoms. No counseling programs for depressed miscarrying women have been manualized or evaluated for safety and efficacy. We investigated whether depressive symptoms decline substantially among miscarrying women receiving one to six weekly sessions of manualized, telephone-administered interpersonal counseling (IPC), a variant of interpersonal psychotherapy (IPT) in an open trial. Depressive symptom levels were measured with the Center for Epidemiologic Studies-Depression (CES-D) scale. Of 65 women evaluated, 24 were study eligible; 17 consented to participate. Change in symptom levels was evaluated by comparing baseline to postintervention CES-D scores in an intention to treat (ITT) sample (n=17) and a completer subsample (n=9). The latter sample comprised women reevaluated postintervention. In the ITT sample, the CES-D mean score declined from 25.4 to 18.8 [mean within-subject change=6.6, 95% confidence interval (CI)=1.4-11.6]; in the completer subsample, it declined from 23.6 to 11.2 (mean within-subject change=12.3, 95% CI=4.0-20.7). Findings from this small open trial suggest that IPC decreases depressive symptoms after miscarriage. A randomized, controlled trial of IPC's safety and efficacy with depressed miscarrying women is warranted.

Pilot randomized controlled trial of interpersonal counseling for subsyndromal depression following miscarriage.

OBJECTIVE: Miscarriage, which occurs in 10% to 20% of clinically recognized pregnancies, is associated with an increased risk for subsyndromal depression. We examined whether Interpersonal Counseling (IPC) was superior to treatment as usual (TAU) in reducing subsyndromal depression among miscarrying women and, secondarily, superior to TAU in improving role functioning. METHOD: Nineteen of 20 eligible women participated in a randomized controlled trial of 1 to 6 weekly telephone sessions of IPC versus TAU, which consisted of whatever lay counseling or professional care women sought on their own initiative, from October 2001 to April 2002. The 2 trial arms were compared on mean within-subject change in Hamilton Rating Scale for Depression-17-item (HAM-D-17) scores and in role functioning scale scores (a 5-item modification of the 36-item Medical Outcomes Study questionnaire) from baseline to post-intervention. RESULTS: In the primary intent-to-treat analysis, the baseline mean HAM-D-17 scores were 18.0 (SD +/- 8.4) and 14.8 (SD +/- 6.6) in the IPC (N = 10) and TAU (N = 9) arms, respectively; post-intervention, the corresponding means were 11.6 (SD +/- 8.2) and 12.9 (SD +/- 8.3). The mean within-subject decline in HAM-D-17 scores was significantly greater in the IPC (6.4) than in the TAU (1.9) arm (difference in mean within-subject score decline, adjusted for design features, baseline HAM-D-17 scores and for baseline ethnic imbalance between study arms, 6.2 [95% CI = 0.4 to 12.0]). In a subordinate completers' analysis (N = 15), the corresponding mean decline and difference in adjusted mean decline were 8.0, 2.4, and 6.7 (95% CI = 0.4 to 13.1), respectively. Treatment was unrelated to improved role functioning. CONCLUSION: The efficacy of telephone-administered IPC for subsyndromal depression after miscarriage warrants testing in a full-scale randomized controlled trial.