The Impact of Resilience on Employment Among Post-9/11 Veterans With and Without Military Sexual Trauma Exposure.

INTRODUCTION: Successful employment is a functional outcome of high importance for veterans after military discharge. There is a significant rising concern regarding exposure to military sexual trauma (MST) and related mental health outcomes that can impair functional outcomes, such as employment. Although resilience training is a key component of preparing for military service, to date the impact of resilience on employment outcomes for veterans with exposure to MST has yet to be examined. We sought to examine the relationship between resilience and employment in a national sample of post-9/11 veterans with and without MST exposure. MATERIALS AND METHODS: A national survey was conducted between October 2021 and January 2022 to respond to the 2021 National Defense Authorization Act mandate to identify factors affecting post-9/11 women veteran's unemployment. Of veterans, 1,185 completed the survey. Of these, 565 (47.6%) were post-9/11 veterans. The survey collected data on demographics and employment; MST, adult sexual trauma (AST, outside of military), and childhood sexual trauma (CST) exposure; resilience (Response to Stressful Experiences Scale); Post Traumatic Stress Disorder (PTSD) Checklist (PCL-5); and depression (Patient Health Questionnaire-2). Multivariable logistic regression models identified gender-specific associations of resilience with employment among those exposed and not exposed to MST, adjusting for AST, CST, PTSD, and depression. Significance was set at P < .05. RESULTS: Of 322 women and 243 men post-9/11 veterans, 86.5% were employed. MST exposure (MST[+]) was reported by 31.4% (n = 101) of women and 16.9% (n = 41) of men. MST(+) women veterans were more likely to report CST (35.6% vs. 14.5%; P < .001), AST (68.3% vs. 17.2%; P < .001), and both CST and AST (19.8% vs. 7.2%; P < .001) than MST(-) women. MST(+) men were more likely to report AST (65.9% vs. 7.9%; P < .001), and both CST and AST (14.6% vs. 1.0%; P < .001) than MST(-) men. Levels of self-reported resilience were similar for MST(+) women and men and their MST(-) counterparts (women: 11.1 vs. 11.0; men: 11.5 vs. 12.0). For MST(+) women, each unit increase in resilience was associated with a 36% increase in odds of employment (OR: 1.36, 95% CI, 1.08-1.71); resilience was not associated with increased odds of employment among MST(-) women. Among MST(+) men veterans, each unit increase in resilience was associated with an 83% increase in odds of employment (aOR: 1.83, 95% CI, 1.13-2.98), and like women veterans, resilience was not associated with employment among MST(-) men. CONCLUSIONS: Among MST(+) women and men post-9/11 veterans, higher resilience was associated with increased odds of employment, whereas resilience was not associated with employment in MST(-) veterans. These findings suggest that resiliency during and after military service is a key component for potentially improving long-term outcomes. Improving resilience using evidence-based approaches among post-9/11 veterans exposed to MST may be an important avenue for increasing successful functional outcomes such as employment. Moreover, MST(+) women and men veterans may benefit from trauma-informed care as a substantial proportion of these individuals also report exposure to CST, AST, PTSD, and depression.

COVID-19 pandemic experiences among people with epilepsy: Effect on symptoms of co-occurring health conditions and fear of seizure.

OBJECTIVE: The Coronavirus disease 2019 (COVID-19) pandemic profoundly affected people worldwide, but little is known about how it impacted people with epilepsy (PWE). We examined the associations between COVID-19 stressors and health outcomes including increases in other health symptoms and fear of seizure among PWE. METHODS: This cross-sectional study used data from an online survey that asked about demographic characteristics, health conditions, and potential life stressors during COVID-19. Data were collected from October 30 to December 8, 2020. COVID-19 stressors were anger, anxiety, stress, healthcare access, fear of seeking healthcare, social isolation, sense of control over their lives, and alcohol consumption. A binary variable was created for each of these measures to indicate whether PWEs experienced a negative change versus a neutral or positive change. We used multivariable logistic regression to assess the associations of COVID-19 stressors with primary outcomes: exacerbated co-occurring health conditions and increasing fear of seizure during the pandemic. RESULTS: Of the 260 PWE included in the study, 165 (63.5%) were women; the average age was 38.7 years. During the survey administration period, 79 (30.3%) of the respondents reported exacerbated co-occurring health conditions, and 94 (36.2%) reported an increased fear of seizures. Regression results indicated that the fear of seeking healthcare during COVID-19 was associated with both exacerbated co-occurring health conditions (aOR 1.12; 95%CI 1.01-1.26) and increasing fear of seizure (aOR 2.31; 95%CI 1.14-4.68). Social isolation was associated with exacerbated co-occurring health conditions during COVID-19 (aOR 1.14; 95%CI 1.01-1.29). Reduced access to physical healthcare was associated with increasing fear of seizure (aOR 2.58; 95%CI 1.15-5.78). CONCLUSION: A considerable number of PWE experienced more symptoms of existing health conditions and fear of seizure during the initial year of the pandemic (2020). Fear of seeking healthcare services was associated with both negative outcomes. Assuring access to health care and reducing social isolation could potentially reduce negative outcomes for PWE. It is necessary to provide adequate support for PWE to reduce risks as COVID-19 continues to be a health concern.

Factors That Impact the Long-Term Outcome of Postconcussive Dizziness Among Post-9/11 Veterans.

PURPOSE: The primary aim of this study was to examine the factors associated with long-term outcomes of postconcussive disruptive dizziness in Veterans of the post-9/11 wars. METHOD: For this observational cohort study, the Neurobehavioral Symptom Inventory-Vestibular subscale (NSI-V) score was used as an outcome measure for dizziness in 987 post-9/11 Veterans who indicated disruptive dizziness at an initial Veterans Health Administration Comprehensive Traumatic Brain Injury Evaluation (CTBIE). An NSI-V change score was calculated as the difference in the scores obtained at the initial CTBIE and on a subsequent survey. Differences in the NSI-V change scores were examined for demographics, injury characteristics, comorbidities, and vestibular and balance function variables, and multiple linear regression analyses were used to explore associations among the variables and the NSI-V change score. RESULTS: The majority of Veterans (61%) demonstrated a decrease in the NSI-V score, suggesting less dizziness on the survey compared with the CTBIE; 16% showed no change; and 22% had a higher score. Significant differences in the NSI-V change score were observed for traumatic brain injury (TBI) status, diagnoses of post-traumatic stress disorder (PTSD), headache and insomnia, and vestibular function. Multivariate regressions revealed significant associations between the NSI-V change score and the initial CTBIE NSI-V score, education level, race/ethnicity, TBI status, diagnoses of PTSD or hearing loss, and vestibular function. CONCLUSIONS: Postconcussive dizziness can continue for years following an injury. Factors associated with poor prognosis include TBI, diagnoses of PTSD or hearing loss, abnormal vestibular function, increased age, identification as a Black Veteran, and high school education level.

Caregiver burden and COVID-19: How epilepsy caregivers experienced the pandemic.

INTRODUCTION: Caregivers of adults with epilepsy face unique challenges, yet most studies focus on the impact of epilepsy on those living with the condition, rather than the impact on caregivers. Our objective was to evaluate whether caregivers' pandemic-related changes and experiences - namely those related to their health, healthcare access, and well-being - were associated with their caregiving burden. METHODS: Caregivers of adults with epilepsy (n = 261) were recruited through Qualtrics Panels to participate in an online survey examining health, well-being, COVID-19 experiences, and caregiver burden from October-December, 2020. The burden was measured using the Zarit 12-item measure; the clinically significant burden was defined as a score greater than 16. Adjustments were made to account for burden scores related to exposures of interest. Chi-square tests, t-tests, and generalized linear regression models were used to compare cross-sectional associations between COVID-19 experiences and burden. RESULTS: Over half (57.9%) of caregivers had clinically significant caregiver burden. Most reported increased anxiety (65%), stress (64%), and sense of social isolation (58%) during the pandemic. Many caregivers reported that their sense of control over their life (44%) and their use of healthcare changed (88%) due to COVID-19. In adjusted models, caregivers who reported increased anger, increased anxiety, decreased sense of control, or changes in healthcare utilization during COVID-19 had about twice the odds of having clinically significant caregiver burden compared to caregivers who did not report changes. DISCUSSION: Changes experienced by caregivers of adults with epilepsy during the pandemic were strongly associated with clinically significant levels of caregiver burden. These findings demonstrate the link between mass-level events, such as a pandemic, the burden caregivers of adults with epilepsy may carry, and subsequent psychological outcomes. CONCLUSION: Caregivers of adults with epilepsy may need support to reduce the negative impact of COVID-19-related experiences and should be connected to healthcare and resources that can help alleviate their burden.

Post-9/11 veterans perceptions of the pandemic: Areas of greatest impact on health and well-being.

Objective: Assess potential impacts of the COVID-19 pandemic on a subset of Post-9/11 U.S. Veterans included in a study of post-traumatic epilepsy (PTE). Methods: Two measures were added to a structured health interview for Veterans during temporary pandemic research shutdown: a validated health questionnaire [1] previously completed by survey, and a semi-structured instrument developed to assess whether pandemic conditions affected responses to the health questionnaire and identify unique impacts. Interviews were conducted between August 2020 - February 2021. Scaled items were calculated and t-tests used to compare results. Open-ended items were coded using thematic analyses. Results: Veterans identified eight major areas of impact with negative and positive impacts: mental health, family, social, work/employment, access to resources, physical health, finances, and education. Innovation: The temporary shut-down of a large health study for Post-9/11 Veterans provided an opportunity to devise an instrument to assess COVID-19's impact on health and well-being. The instrument was accepted as of the first Veteran instrument in a pandemic SDOH research repository [2], and is being used in other studies. Conclusion: This study highlights the need to assess and understand interrelated relationships of factors impacting health and well-being, especially as COVID-19 moves from pandemic to endemic with reverberating effects across multiple social determinants of health (SDOH).

Leveraging anthropological expertise to respond to the COVID-19 global mental health syndemic.

This commentary asks anthropologists to work within communities to actively address the global mental health impact of COVID-19 and contribute to the pandemic response. Multiple social and physical losses, worsened by numerous factors, have produced syndemic traumatic stress and suffering across populations, highlighting persistent inequalities further amplified by the effects of COVID-19. Specifically, anthropologists can work to contribute to the development of mental health programs; confront the racialization of COVID-19 alongside marginalized communities; support real-time policy making with community responses; and innovate transparent collaborative research methods through open science. This pandemic can serve as an opportunity to prioritize research endeavors, public service, and teaching to better align with societal needs while providing new opportunities for synergy and collaborations between anthropologists in and outside the academy. Anthropologists collaborating directly with mental health clinicians and the public can contribute to knowledge specifically through direct program development and implementation of interventions designed to improve mental well-being. Innovating to find impactful solutions in response to the unprecedented mental health challenges exacerbated by the COVID-19 pandemic has the potential to promote more equitable recovery around the world.

Analysis of a national response to a White House directive for ending veteran suicide.

OBJECTIVE: Analyze responses to a national request for information (RFI) to uncover gaps in policy, practice, and understanding of veteran suicide to inform federal research strategy. DATA SOURCE: An RFI with 21 open-ended questions generated from Presidential Executive Order #1386, administered nationally from July 3 to August 5, 2019. STUDY DESIGN: Semi-structured, open-ended responses analyzed using a collaborative qualitative and text-mining data process. DATA EXTRACTION METHODS: We aligned traditional qualitative methods with natural language processing (NLP) text-mining techniques to analyze 9040 open-ended question responses from 722 respondents to provide results within 3 months. Narrative inquiry and the medical explanatory model guided the data extraction and analytic process. RESULTS: Five major themes were identified: risk factors, risk assessment, prevention and intervention, barriers to care, and data/research. Individuals and organizations mentioned different concepts within the same themes. In responses about risk factors, individuals frequently mentioned generic terms like "illness" while organizations mentioned specific terms like "traumatic brain injury." Organizations and individuals described unique barriers to care and emphasized ways to integrate data and research to improve points of care. Organizations often identified lack of funding as barriers while individuals often identified key moments for prevention such as military transitions and ensuring care providers have military cultural understanding. CONCLUSIONS: This study provides an example of a rapid, adaptive analysis of a large body of qualitative, public response data about veteran suicide to support a federal strategy for an important public health topic. Combining qualitative and text-mining methods allowed a representation of voices and perspectives including the lived experiences of individuals who described stories of military transition, treatments that worked or did not, and the perspective of organizations treating veterans for suicide. The results supported the development of a national strategy to reduce suicide risks for veterans as well as civilians.

Disruptive Dizziness Among Post-9/11 Veterans With Deployment-Related Traumatic Brain Injury.

OBJECTIVE: To identify disruption due to dizziness symptoms following deployment-related traumatic brain injury (TBI) and factors associated with receiving diagnoses for these symptoms. SETTING: Administrative medical record data from the Department of Veterans Affairs (VA). PARTICIPANTS: Post-9/11 veterans with at least 3 years of VA care who reported at least occasional disruption due to dizziness symptoms on the comprehensive TBI evaluation. DESIGN: A cross-sectional, retrospective, observational study. MAIN MEASURES: International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes of dizziness, vestibular dysfunction, and other postconcussive conditions; neurobehavioral Symptom Inventory. RESULTS: Increased access to or utilization of specialty care at the VA was significant predictors of dizziness and/or vestibular dysfunction diagnoses in the fully adjusted model. Veterans who identified as Black non-Hispanic and those with substance use disorder diagnoses or care were substantially less likely to receive dizziness and vestibular dysfunction diagnoses. CONCLUSIONS: Access to specialty care was the single best predictor of dizziness and vestibular dysfunction diagnoses, underscoring the importance of facilitating referrals to and utilization of specialized, comprehensive clinical facilities or experts for veterans who report disruptive dizziness following deployment-related TBI. There is a clear need for an evidence-based pathway to address disruptive symptoms of dizziness, given the substantial variation in audiovestibular tests utilized by US providers by region and clinical specialty. Further, the dearth of diagnoses among Black veterans and those in more rural areas underscores the potential for enhanced cultural competency among providers, telemedicine, and patient education to bridge existing gaps in the care of dizziness.

Effect of multimorbidity and psychosocial factors on posttraumatic stress symptoms among post-9/11 veterans.

OBJECTIVES: Examine the association of multimorbidity and psychosocial functioning with posttraumatic stress disorder (PTSD) symptom severity reported among post-9/11 veterans. METHOD: This was a secondary analysis of survey data collected from a national sample of post-9/11 veterans with at least 3 years of Department of Veterans Affairs care, stratified by comorbidity trajectory and sex (N = 1,989). Comorbidity trajectories were derived by latent class analysis to develop probabilistic combinations of physical and mental health conditions in a previous effort (Pugh et al., 2016). In this study, linear models analyzed symptom severity reported on the PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition by psychosocial factors (i.e., resilience, self-efficacy, and postdeployment social support) while controlling for sociodemographic characteristics and deployment experiences. RESULTS: Veterans in the mental health, pain, and polytrauma clinical triad comorbidity trajectories reported more severe PTSD symptoms than the healthy comorbidity trajectory (p < .01). All psychosocial factors were significantly associated with PTSD symptom severity, accounting for nearly 43% of variability in follow-up analyses. Confidence in self-efficacy demonstrated the strongest association among them (p < .01). CONCLUSION: Veterans experiencing multimorbidity, particularly mental health distress, reported greater PTSD symptom severity after controlling for psychosocial factors, sociodemographics, and deployment experiences. The salience of psychosocial factors in reported PTSD symptom severity underscores resilience, self-efficacy and social support as potential facilitators of functional reintegration following military service. Our analyses underscore the need to address the systemic barriers in health care access and delivery for minority patient populations in future investigations. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The Military Injuries: Understanding Post-Traumatic Epilepsy Study: Understanding Relationships among Lifetime Traumatic Brain Injury History, Epilepsy, and Quality of Life.

Understanding risk for epilepsy among persons who sustain a mild (mTBI) traumatic brain injury (TBI) is crucial for effective intervention and prevention. However, mTBI is frequently undocumented or poorly documented in health records. Further, health records are non-continuous, such as when persons move through health systems (e.g., from Department of Defense to Veterans Affairs [VA] or between jobs in the civilian sector), making population-based assessments of this relationship challenging. Here, we introduce the MINUTE (Military INjuries-Understanding post-Traumatic Epilepsy) study, which integrates data from the Veterans Health Administration with self-report survey data for post-9/11 veterans (n = 2603) with histories of TBI, epilepsy and controls without a history of TBI or epilepsy. This article describes the MINUTE study design, implementation, hypotheses, and initial results across four groups of interest for neurotrauma: 1) control; 2) epilepsy; 3) TBI; and 4) post-traumatic epilepsy (PTE). Using combined survey and health record data, we test hypotheses examining lifetime history of TBI and the differential impacts of TBI, epilepsy, and PTE on quality of life. The MINUTE study revealed high rates of undocumented lifetime TBIs among veterans with epilepsy who had no evidence of TBI in VA medical records. Further, worse physical functioning and health-related quality of life were found for persons with epilepsy + TBI compared to those with either epilepsy or TBI alone. This effect was not fully explained by TBI severity. These insights provide valuable opportunities to optimize the resilience, delivery of health services, and community reintegration of veterans with TBI and complex comorbidity.