Partnership building for scale-up in the Veteran Sponsorship Initiative: Strategies for harnessing collaboration to accelerate impact in suicide prevention.

OBJECTIVE: To evaluate the implementation and trust-building strategies associated with successful partnership formation in scale-up of the Veteran Sponsorship Initiative (VSI), an evidence-based suicide prevention intervention enhancing connection to U.S. Department of Veterans Affairs (VA) and other resources during the military-to-civilian transition period. DATA SOURCES AND STUDY SETTING: Scaling VSI nationally required establishing partnerships across VA, the U.S. Department of Defense (DoD), and diverse public and private Veteran-serving organizations. We assessed partnerships formalized with a signed memorandum during pre- and early implementation periods (October 2020-October 2022). To capture implementation activities, we conducted 39 periodic reflections with implementation team members over the same period. STUDY DESIGN: We conducted a qualitative case study evaluating the number of formalized VSI partnerships alongside directed qualitative content analysis of periodic reflections data using Atlas.ti 22.0. DATA COLLECTION/EXTRACTION METHODS: We first independently coded reflections for implementation strategies, following the Expert Recommendations for Implementing Change (ERIC) taxonomy, and for trust-building strategies, following the Theoretical Model for Trusting Relationships and Implementation; a second round of inductive coding explored emergent themes associated with partnership formation. PRINCIPAL FINDINGS: During this period, VSI established 12 active partnerships with public and non-profit agencies. The VSI team reported using 35 ERIC implementation strategies, including building a coalition and developing educational and procedural documents, and trust-building strategies including demonstrating competence and credibility, frequent interactions, and responsiveness. Cultural competence in navigating DoD and VA and accepting and persisting through conflict also appeared to support scale-up. CONCLUSIONS: VSI's partnership-formation efforts leveraged a variety of implementation strategies, particularly around strengthening stakeholder interrelationships and refining procedures for coordination and communication. VSI implementation activities were further characterized by an intentional focus on trust-building over time. VSI's rapid scale-up highlights the value of partnership formation for achieving coordinated interventions to address complex problems.

Leveraging available metadata in VA PTSD clinics and generating benchmarks for clinically significant change.

OBJECTIVE: Measurement-based care is designed to track symptom levels during treatment and leverage clinically significant change benchmarks to improve quality and outcomes. Though the Veterans Health Administration promotes monitoring progress within posttraumatic stress disorder (PTSD) clinical teams, actionability of data is diminished by a lack of population-based benchmarks for clinically significant change. We reported the state of repeated measurement within PTSD clinical teams, generated benchmarks, and examined outcomes based on these benchmarks. METHOD: PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition data were culled from the Corporate Data Warehouse from the pre-COVID-19 year for Veterans who received at least eight sessions in 14 weeks (episode of care [EOC] cohort) and those who received sporadic care (modal cohort). We used the Jacobson and Truax (1991) approach to generate clinically significant change benchmarks at clinic, regional, and national levels and calculated the frequency of cases that deteriorated, were unchanged, improved, or probably recovered, using our generated benchmarks and benchmarks from a recent study, for both cohorts. RESULTS: Both the number of repeated measurements and the cases who had multisession care in the Corporate Data Warehouse were very low. Clinically significant change benchmarks were similar across locality levels. The modal cohort had worse outcomes than the EOC cohort. CONCLUSIONS: National benchmarks for clinically significant change could improve the actionability of assessment data for measurement-based care. Benchmarks created using data from Veterans who received multisession care had better outcomes than those receiving sporadic care. Measurement-based care in PTSD clinical teams is hampered by low rates of repeated assessments of outcome. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Exploring the longitudinal clustering of lifestyle behaviors, social determinants of health, and depression.

Lifestyle behaviors such as exercise, sleep, smoking, diet, and social interaction are associated with depression. This study aimed to model the complex relationships between lifestyle behaviors and depression and among the lifestyle behaviors. Data from three waves of the Midlife in the United States study were used, involving 6898 adults. Network models revealed associations between the lifestyle behaviors and depression, with smoker status being strongly associated with depression. Depression, smoker status, age, time, and exercise were some of the most central components of the networks. Future lifestyle intervention research might prioritize specific behaviors based on these associations and centrality indices.

Social Interaction Within a Trauma-Exposed Population During the Early Phase of COVID-19.

The novel coronavirus (COVID-19) has led to significant stressors and shifts in social life, yet social interactions experienced by people with trauma exposure during the COVID pandemic is largely unknown. This study assessed frequency of interactions, social support given and received, and prosocial behavior using online survey methods (N=1049). We examined differences in experiences across three groups: no trauma exposure, trauma-exposed with low PTSD symptoms, and trauma-exposed with high PTSD symptoms. We also explored correlations between social interactions and PTSD symptom clusters. Results indicated significant differences across groups and the high PTSD group reported stronger associations between social interaction variables and symptom clusters, on average.

Low Incidence of Death and Renal Failure in United States Military Service Members Hospitalized with Exertional Heat Stroke: A Retrospective Cohort Study.

INTRODUCTION: The goal of the current study was to characterize the rate and estimate associated mortality and morbidity of exertional heat stroke (EHS) in U.S. military service members. MATERIALS AND METHODS: The current study was a retrospective cohort medical chart review study of all active-duty U.S. military service members, hospitalized with EHS at any MTF in the world between January1, 2007 and July 1, 2014. Enrolled patients were identified by altered mental status and elevated temperatures associated with physical exercise. RESULTS: Out of 607 service members with an International Classification of Disease code indicating any type of heat injury, 48 service members met inclusion criteria for EHS. Core temperature was M = 105.8°F (41°C), standard deviation = 1.43, 90% were diagnosed with EHS prior to hospitalization, and 71% received prehospital cooling. Meantime to normothermia post-hospitalization was 56 minutes (standard deviation = 79.28). Acute kidney injury was diagnosed in 40% of patients although none developed hyperkalemia or required dialysis. Disseminated intravascular coagulation was rare (4%, n = 2) and overall observed mortality was very low (2%, n = 1). CONCLUSION: EHS is aggressively identified and treated in U.S. Military Treatment Facilities. Mortality and morbidity were strikingly low.

Pre- to Posttreatment Changes in Trauma-Cued Negative Emotion Mediate Improvement in Posttraumatic Stress Disorder, Depression, and Impulsivity.

Posttraumatic stress disorder (PTSD) is characterized by strong negative emotions, often in response to trauma cues or reminders. Subsequent emotion regulation strategies impact the maintenance of PTSD symptoms and other trauma-related outcomes (depression, substance use). This study aimed to examine a range of trauma-cued emotions to enhance our understanding of changes following treatment and their potential role in improving relevant outcomes. Participants included 67 veterans diagnosed with PTSD and a substance use disorder who completed a dual diagnosis residential program that used cognitive processing therapy. At pre- and posttreatment, we measured 8 negative emotions following a trauma recall and PTSD symptoms, depressive symptoms, and negative urgency (impulsivity following negative emotions) as treatment outcomes. We used t-tests to assess changes at posttreatment and a within-subjects mediational analysis to test whether changes in trauma-cued emotions mediated treatment outcomes. Participants reported moderate, significant decreases for 5 emotions at posttreatment: anger at self, disgust at self, fear, guilt, and sadness (d ≥ 0.50), whereas nonsignificant changes were found for anger at others, disgust at others, and shame. Mediation analyses indicated greater reductions in trauma-cued sadness had a significant indirect effect on improvement in PTSD symptoms, depressive symptoms, and negative urgency. Reductions in disgust at self and fear also demonstrated a significant indirect effect on depressive symptom improvement. In this dual diagnosis program, veterans reported a significant reduction in some, but not all, trauma-cued emotions, and improvements in only select emotions accounted for a significant portion of improvement in relevant treatment outcomes.

SOCIAL ENGAGEMENT EARLY IN THE U.S. COVID-19 CRISIS: EXPLORING SOCIAL SUPPORT AND PROSOCIAL BEHAVIOR BETWEEN THOSE WITH AND WITHOUT DEPRESSION OR ANXIETY IN AN ONLINE SAMPLE.

INTRODUCTION: Social distancing and sheltering-in-place mitigate the physical health risks of the novel coronavirus (COVID-19); however, there are concerns about the impact on mental health and social engagement. METHODS: We used data from a U.S.-based online survey (March 2020) to examine patterns of social support and prosocial behavior, explore differences between people with and without depression or anxiety, and explore correlates of social engagement in both groups, including symptom severity in the clinical group. RESULTS: The clinical group reported greater social engagement. In both groups, social engagement was positively associated with COVID-19-related worry and trait moral elevation; mindfulness was positively associated with all outcomes for the clinical group only. Social interaction frequency had little influence on outcomes. Depressive symptom severity was positively associated with all outcomes, whereas anxiety was negatively associated with prosocial behavior. DISCUSSION: These findings highlight how social engagement was experienced early in the U.S. COVID-19 crisis.

Bringing Philosophy to Bear on Moral Injury and Posttraumatic Stress Disorder Construct Validation: Commentary on Farnsworth (2019).

Farnsworth (2019) proposed that posttraumatic stress disorder (PTSD) and moral injury (MI) can be differentiated using DSM-5 PTSD's Criteria D. It was suggested that PTSD cognitions are descriptions about what the world is like whose accuracy can be targeted by cognitive therapies, whereas MI cognitions are prescriptions about what the world should be like, which cannot be assessed for truth or falsehood and so are unsuitable for cognitive therapies. We believe that this appeal to the is/ought distinction distorts the therapeutic challenge, and misconceptualizes moral thinking as manifested only in thin terms such as "ought/should." In practical usage, it is unlikely that when people express cognitions they are only describing the world and not evaluating it as well. In this commentary, we will critique the prescriptivist view of trauma, suggest the importance of "thick terms," and reconsider the purported differences between MI and PTSD. MI might be meaningfully different from PTSD, but it is premature to differentiate these constructs based on DSM-5's Criteria D. A trauma theory that accounts for the interwoven descriptive and evaluative, cognitive as well as affective, elements of traumatic experiences will clarify both the PTSD diagnosis and MI model and improve treatment development and clinical care.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Aportando la filosofía sobre el daño moral y la validación de construcciones de TEPT: Comentario sobre Farnsworth (2019) COMENTARIO SOBRE FARNSWORTH (2019) Farnsworth (2019) propuso que el Trastorno de Estrés Postraumático (TEPT) y el daño moral (DM) se pueden diferenciar utilizando los Criterios D del TEPT del DSM-5. Se sugiere que las cogniciones del TEPT son descripciones sobre cómo es el mundo cuya precisión puede ser abordada por las terapias cognitivas, mientras que las cogniciones de DM son prescripciones sobre cómo debería ser el mundo, que no pueden ser evaluadas por la verdad o la falsedad y, por lo tanto, no son adecuadas para las terapias cognitivas. Creemos que esta apelación a la distinción es/debería distorsiona el desafío terapéutico, y malinterpreta el pensamiento moral como se manifiesta solo en términos ligeros como "debe / debería". En el uso práctico, es poco probable que cuando las personas expresan cogniciones solo sean describiendo el mundo y no evaluándolo también. En este comentario, criticaremos la visión prescriptivista del trauma, sugeriremos la importancia de los términos contundentes y reconsideraremos las supuestas diferencias entre el DM y el TEPT. El DM podría ser significativamente diferente del TEPT, pero es prematuro diferenciar estas construcciones basados en los Criterios D del DSM-5. Una teoría del trauma que considera los elementos entrelazados descriptivos y evaluativos, cognitivos y afectivos de las experiencias traumáticas aclararán tanto el diagnóstico de TEPT como el modelo de DM y mejorarán el desarrollo del tratamiento y la atención clínica.

Predictors of recovery from post-deployment posttraumatic stress disorder symptoms in war veterans: The contributions of psychological flexibility, mindfulness, and self-compassion.

Posttraumatic stress disorder (PTSD) is a major challenge among war veterans. This study assessed the contribution of several interrelated, modifiable psychosocial factors to changes in PTSD symptom severity among combat-deployed post-9/11 Veterans. Data were drawn from a longitudinal study of predictors of mental health and functional outcomes among U.S. Iraq and Afghanistan war Veterans (N = 117). This study assessed the unique contribution of psychological flexibility, mindfulness, and self-compassion to PTSD recovery, after accounting for established predictors of PTSD chronicity, including combat exposure, alcohol use problems, and traumatic brain injury. PTSD symptom severity was assessed using a clinician-administered interview, and PTSD recovery was defined as the change in symptom severity from lifetime worst severity, measured at baseline, to current severity at one-year follow-up. A mindful awareness latent factor comprised of all three variables measured at baseline predicted PTSD recovery beyond the other predictors of PTSD chronicity (f2 = 0.30, large effect). Each construct predicted PTSD recovery when tested individually. When tested simultaneously, self-compassion, but not mindfulness or psychological flexibility, predicted PTSD recovery. These findings suggest that mindful awareness of emotional distress predicts recovery from PTSD symptoms in war veterans, which supports the utility mindfulness-based interventions in promoting post-trauma recovery.

Mechanisms of Moral Injury Following Military Sexual Trauma and Combat in Post-9/11 U.S. War Veterans.

Objective: Moral injury may result from perpetration-based and betrayal-based acts that violate deeply held norms; however, researchers and clinicians have little guidance about the moral injury syndrome's specific developmental pathways following morally injurious events. The present study's objective was to examine the direct and indirect pathways proposed in a frequently cited model of moral injury (1) in relation to two types of military-related traumas [experiencing military sexual trauma (MST) and combat exposure]. Methods: Secondary analyses were conducted within a sample of post-9/11 veterans at a Southwestern Veterans Health Care System (N = 310) across two time-points. Structural equation modeling tested the direct and indirect pathways from MST and combat to a PTSD-depression factor via betrayal, perpetration, guilt, and shame. Results: Betrayal accounted for the association between MST and PTSD-depression (ß = 0.10, p < 0.01, 95% CI = 0.01 - 0.11) and perpetration accounted for the association between combat and PTSD-depression (ß = 0.07, p < 0.05, 95% CI = 0.02 - 0.14). The indirect path from combat to shame to PTSD-depression was significant (ß = 0.16, p < 0.01, 95% CI = 0.07 - 0.28) but the path through guilt was not. The specific indirect paths through perpetration or betrayal to shame or guilt were non-significant. Conclusions: Betrayal and perpetration are associated with PTSD-depression following MST and combat. Results suggest multiple pathways of moral injury development following different military traumas and morally injurious events. Implications for moral injury conceptualization and treatment are discussed.

The influence of mindfulness, self-compassion, psychological flexibility, and posttraumatic stress disorder on disability and quality of life over time in war veterans.

OBJECTIVES: Posttraumatic stress disorder (PTSD) strongly predicts greater disability and lower quality of life (QOL). Mindfulness-based and other third-wave behavior therapy interventions improve well-being by enhancing mindfulness, self-compassion, and psychological flexibility. We hypothesized that these mechanisms of therapeutic change would comprise a single latent factor that would predict disability and QOL after accounting for PTSD symptom severity. METHOD: Iraq and Afghanistan war veterans (N = 117) completed a study of predictors of successful reintegration. Principal axis factor analysis tested whether mindfulness, self-compassion, and psychological flexibility comprised a single latent factor. Hierarchical regression tested whether this factor predicted disability and QOL 1 year later. RESULTS: Mindfulness, self-compassion, and psychological flexibility comprised a single factor that predicted disability and QOL after accounting for PTSD symptom severity. PTSD symptoms remained a significant predictor of disability but not QOL. CONCLUSIONS: Targeting these mechanisms may help veterans achieve functional recovery, even in the presence of PTSD symptoms.

Indirect Relations Between Transgressive Acts and General Combat Exposure and Moral Injury.

INTRODUCTION: Moral injury describes the deleterious effects of acts of commission (e.g., killing noncombatants), omission (e.g., failing to prevent a massacre), or betrayal (i.e., by a trusted authority figure) during military service that transgress accepted behavioral boundaries and norms. Transgressive acts are proposed to lead to a guilt- and shame-based syndrome consisting of post-traumatic stress disorder (PTSD) symptoms, demoralization, self-handicapping, and self-injury. In this study, we tested a frequently cited model of moral injury and assessed the associations between potentially transgressive acts, moral injury outcomes, and guilt and fear. Additionally, we sought to clarify the relative contribution of transgressive and nontransgressive/general combat exposure to moral injury. On the basis of previous research and theory, we anticipated that the transgressive acts would be related to outcomes through guilt and that nontransgressive combat exposure would be related to outcomes through fear. MATERIALS AND METHODS: Secondary analysis was conducted on data from a sample of combat-exposed male veterans at a Midwestern Veterans Affairs (VA) medical center (N = 190) who participated in a larger parent study on postdeployment readjustment. Structural equation modeling was used to test the pathways from transgressive and nontransgressive combat exposure to PTSD symptoms and suicidality through combat-related guilt and combat-related fear. The institutional review boards of the Midwestern VA medical center and the university of the affiliated researchers approved the study. RESULTS: In total, 38% (n = 72) of the sample reported a potentially transgressive act as one of their three worst traumatic events. The most common potentially transgressive act was killing an enemy combatant (17%; n = 32). In structural equation modeling analyses. potentially transgressive acts were indirectly related to both suicidality (ß = 0.09, p < 0.01) and PTSD symptoms (ß = 0.06, p < 0.05) through guilt. General combat exposure was indirectly related to PTSD through fear, ß = 0.19, p < 0.01. Combat exposure was not directly or indirectly related to suicidality. CONCLUSION: Overall, these findings suggest that veterans with a history of potentially transgressive acts may present to the VA with a constellation of symptoms that are associated with combat-related guilt. Transgressive acts were identified using a qualitative approach, allowing a broader sampling of this domain. Results were limited by the use of self-report data and by gathering data from participants who were Veterans seeking compensation and pension evaluations for PTSD. The clinical implications suggest that focusing on fear-related outcomes and ignoring guilt- and shame-based reactions may lead to an incomplete case conceptualization. Clinicians working with veterans with moral injury are encouraged to prepare themselves for the discomfiting therapeutic experiences of bearing witness to and empathizing with clients' memories of their actions, which may include atrocities. Effective and empathic treatments that address the guilt and shame associated with transgressive acts are needed to adequately care for returning veterans.

Latent-level relations between DSM-5 PTSD symptom clusters and problematic smartphone use.

Common mental health consequences following the experience of potentially traumatic events include Posttraumatic Stress Disorder (PTSD) and addictive behaviors. Problematic smartphone use is a newer manifestation of addictive behaviors. People with anxiety severity (such as PTSD) may be at risk for problematic smartphone use as a means of coping with their symptoms. Unique to our knowledge, we assessed relations between PTSD symptom clusters and problematic smartphone use. Participants (N = 347), recruited through Amazon's Mechanical Turk (MTurk), completed measures of PTSD and smartphone addiction. Results of the Wald tests of parameter constraints indicated that problematic smartphone use was more related to PTSD's negative alterations in cognitions and mood (NACM) than to PTSD's avoidance factor, Wald χ2(1, N = 347) = 12.51, p = 0.0004; and more to PTSD's arousal compared to PTSD's avoidance factor, Wald χ2(1, N = 347) = 14.89, p = 0.0001. Results indicate that problematic smartphone use is most associated with negative affect and arousal among trauma-exposed individuals. Implications include the need to clinically assess problematic smartphone use among trauma-exposed individuals presenting with higher NACM and arousal severity; and targeting NACM and arousal symptoms to mitigate the effects of problematic smartphone use.

Do gender and directness of trauma exposure moderate PTSD's latent structure?

The PTSD diagnosis and latent structure were substantially revised in the transition from DSM-IV to DSM-5. However, three alternative models (i.e., anhedonia model, externalizing behavior model, and hybrid model) of PTSD fit the DSM-5 symptom criteria better than the DSM-5 factor model. Thus, the psychometric performance of the DSM-5 and alternative models' PTSD factor structure needs to be critically evaluated. The current study examined whether gender or trauma directness (i.e., direct or indirect trauma exposure) moderates the PTSD latent structure when using the DSM-5 or alternative models. Model performance was evaluated with measurement invariance testing procedures on a large undergraduate sample (n=455). Gender and trauma directness moderated the DSM-5 PTSD and externalizing behavior model and did not moderate the anhedonia and hybrid models' latent structure. Clinical implications and directions for future research are discussed.

Variations in Criterion A and PTSD rates in a community sample of women.

We assessed PTSD prevalence and symptoms as a function of whether participants' worst lifetime event met Criterion A1 for PTSD (DSM-IV-TR; APA, 2000) and whether the event was directly or indirectly experienced in a community sample of adult women (N=884). Exposure to both non-Criterion A1 and Criterion A1 events was systematically assessed. PTSD was assessed with regard to participants' self-nominated worst event using the PTSD module of the SCID-I/NP (First, Spitzer, Gibbon, & Williams, 1997). There were no differences in PTSD prevalence rates between Criterion A1 and non-A1 events; however, directly experienced worst events were significantly more likely to meet PTSD criteria than were indirectly experienced worst events. Non-Criterion A1 and directly experienced worst events were associated with significantly more PTSD symptoms than were Criterion A1 or indirectly experienced events, respectively. Criterion A2 (experiencing fear, helplessness, or horror) had little effect on PTSD rates.