Trajectory of adjustment difficulties following disaster: 10-year longitudinal cohort study.

BACKGROUND: Although much is known about psychopathology such as post-traumatic stress disorder (PTSD) and depression following bushfire (also known as wildfire), little is known about prevalence, trajectory and impacts for those experiencing general adjustment difficulties following exposure to these now-common events. AIMS: This was an exploratory analysis of a large cohort study that examined the prevalence, trajectory and risk factors of probable adjustment disorder over a 10-year period following bushfire exposure. METHOD: The Beyond Bushfires study assessed individuals exposed to a large and deadly bushfire across three time points spanning 10 years. Self-report survey data from participants from areas with moderate and high levels of fire-affectedness were analysed: n = 802 participants at Wave 1 (3-4 years post-fires), n = 596 at Wave 2 (5 years post-fires) and n = 436 at Wave 3 (10 years post-fires). Surveys indexed fire-related experiences and post-fire stressors, and comprised the six-item Kessler Psychological Distress Scale (probable adjustment disorder index), four-item Posttraumatic Stress Disorder Checklist (probable fire-related PTSD) and nine-item Patient Health Questionnaire (probable major depressive episode). RESULTS: Prevalence of probable adjustment disorder was 16% (Wave 1), 15% (Wave 2) and 19% (Wave 3). Probable adjustment disorder at 3-4 years post-fires predicted a five-fold increase in risk for escalating to severe psychiatric disorder (i.e. probable fire-related PTSD/major depressive episode) at 10 years post-fires, and was associated with post-fire income and relationship stressors. CONCLUSIONS: Adjustment difficulties are prevalent post-disaster, many of which are maintained and exacerbated over time, resulting in increased risk for later disorder and adaptation difficulties. Psychosocial interventions supporting survivors with adjustment difficulties may prevent progression to more severe disorder.

Exploring Women's Religious Coping Strategies and Psychological Impact After the 2023 Earthquake in Syria.

This paper examined gender (N = 1406;77.7% women) patterns of religious coping and psychological impact following the devastating 2023 Syrian earthquakes. Measures in this nation-wide convenience sample study included positive religious coping (PRC) and negative religious coping (NRC) using the Brief Religious Coping Scale (RCOPE), and probable PTSD, depression, and anxiety, using the PCL-5, PHQ-9, and GAD-7, respectively. Women reported higher endorsement of PRC items while men higher endorsement of NRC items. Within the women only sample, lower education and lower income, education and younger age predicted PRC and NRC, respectively. NRC was strongly positively associated with PTSD, depression and anxiety; while, PRC was positively associated only with PTSD. These vulnerable women require targeted support to adopt more adaptive religious coping strategies.

Three-Item Dimensions of Anger Reactions Scale.

Importance: Problematic anger is prevalent and associated with adjustment difficulties in military populations. To facilitate measurement of problematic anger, a very brief valid measure is needed. Objective: To reduce the Dimensions of Anger Reactions 5-item (DAR-5) scale to a very brief measure. Design, Setting, and Participants: This cross-sectional study used survey data collected between 2014 and 2016 in the Australian Transition and Well-Being Research Programme and US Millennium Cohort Study. Participants were service members who were actively serving or had transitioned out of the military (separated). Statistical analyses were performed from September 2021 to June 2023. Main Outcomes and Measures: The DAR-5 was reduced to the 3 experiential items: frequency, intensity, and duration (the DAR-3). Psychometrics for the DAR-3 and DAR-5 were compared in terms of standardized Cronbach α, positive screening result, mean, and SD. Analyses were stratified by Australian and US military service status cohorts (active duty and separated). Results: A total of 71 010 participants were included from Australia and the US. Of 10 900 Australian participants (8145 active duty participants [74.7%]; 2755 separated participants [25.3%]), 5893 (55.2%) were aged 40 years or older and 8774 (80.5%) were male; of 60 110 US participants (24 706 active duty participants [41.1%]; 35 404 separated participants [58.9%]), 28 804 (47.9%) were aged 30 to 39 years and 43 475 (72.3%) were male. The DAR-3 demonstrated good internal consistency in the active duty (Australia: mean [SD] score, 4.97 [2.5]; α = 0.90; US: mean [SD] score, 5.04 [2.6]; α = 0.87) and separated (Australia: mean [SD] score, 6.53 [3.4]; α = 0.92; US: mean [SD] score, 6.05 [3.2]; α = 0.91) samples. The cutoff score of 8 or greater on the DAR-3 had optimal sensitivity and specificity across all samples. DAR-3 and DAR-5 were associated with posttraumatic stress disorder (PTSD), depression, aggression, and relationship conflict. While the scales did not significantly differ in their associations with PTSD, depression, and relationship conflict, the magnitude of association for aggression was significantly lower in US samples using the DAR-3 (eg, US active duty sample: DAR-5 OR, 9.96; 95% CI, 9.01-11.00; DAR-3 OR, 8.36; 95% CI, 7.58-9.22). Conclusions and Relevance: In this cross-sectional study of a very brief measure of anger, each item contributed to the overall strength of the measure without losing psychometric strength compared with the DAR-5. The consistency of these findings across military and veteran samples in Australian and US populations demonstrated the psychometric robustness of the DAR-3.

Cumulative trauma load and timing of trauma prior to military deployment differentially influences inhibitory control processing across deployment.

Military personnel experience high trauma load that can change brain circuitry leading to impaired inhibitory control and posttraumatic stress disorder (PTSD). Inhibitory control processing may be particularly vulnerable to developmental and interpersonal trauma. This study examines the differential role of cumulative pre-deployment trauma and timing of trauma on inhibitory control using the Go/NoGo paradigm in a military population. The Go/NoGo paradigm was administered to 166 predominately male army combat personnel at pre- and post-deployment. Linear mixed models analyze cumulative trauma, trauma onset, and post-deployment PTSD symptoms on NoGo-N2 and NoGo-P3 amplitude and latency across deployment. Here we report, NoGo-N2 amplitude increases and NoGo-P3 amplitude and latency decreases in those with high prior interpersonal trauma across deployment. Increases in NoGo-P3 amplitude following adolescent-onset trauma and NoGo-P3 latency following childhood-onset and adolescent-onset trauma are seen across deployment. Arousal symptoms positively correlated with conflict monitoring. Our findings support the cumulative trauma load and sensitive period of trauma exposure models for inhibitory control processing in a military population. High cumulative interpersonal trauma impacts conflict monitoring and response suppression and increases PTSD symptoms whereas developmental trauma differentially impacts response suppression. This research highlights the need for tailored strategies for strengthening inhibitory control, and that consider timing and type of trauma in military personnel.

The mental health impact of the 2023 earthquakes on the Syrian population: cross-sectional study.

BACKGROUND: Natural disasters have a significant impact on the mental health of affected populations. The February 2023 earthquakes in Syria and Turkey caused widespread devastation. AIMS: To explore the mental health impact of the earthquakes in Syria on the population across areas differentially damaged by the disaster. METHOD: This cross-sectional study conducted in Syria included 1406 adults recruited via social media platforms 1 month after the February 2023 earthquakes. Demographic information, earthquake exposure questions, the PTSD Checklist for DSM-5 (PCL-5: for probable post-traumatic stress disorder, PTSD), the Patient Health Questionnaire-9 (PHQ-9: for probable depression) and the seven-item Generalized Anxiety Disorder scale (GAD-7: for probable anxiety) were included to compare outcomes across areas severely, moderately and slightly damaged by the earthquakes. RESULTS: Probable PTSD and GAD rates were higher in the severely (57.9 and 57.3% respectively) and moderately damaged regions (55.4 and 56.3% respectively) than in the slightly damaged regions (44.6 and 48.3% respectively) (PTSD: P < 0.001, GAD: P = 0.005). More participants in severely damaged regions (60.6%) reported symptoms of depression compared with moderately (53.1%) and slightly damaged (50.8%) regions (P = 0.003). Poorer mental health outcomes were associated with being female, single, younger, having a damaged or destroyed house, seeing something tragic in person and hearing tragic stories. Seeing something tragic on social media was not statistically significant. CONCLUSIONS: This study highlights the higher prevalence of probable mental disorders in areas with more severe earthquake damage, with over 50% of the population reporting probable PTSD, depression or anxiety. The study also suggests a significant cumulative effect of these earthquakes on an already trauma- and disaster-affected population.

Towards a Holistic Model of Care for Moral Injury: An Australian and New Zealand Investigation into the Role of Police Chaplains in Supporting Police Members following exposure to Moral Transgression.

Police members can be exposed to morally transgressive events with potential for lasting psychosocial and spiritual harm. Through interviews with police members and police chaplains across Australia and New Zealand, this qualitative study explores the current role that police chaplains play in supporting members exposed to morally transgressive events. The availability of chaplains across police services and the close alignment between the support they offer, and the support sought by police, indicates they have an important role. However, a holistic approach should also consider organizational factors, the role of leaders, and access to evidence-based treatment in collaboration with mental health practitioners.

The Lingering Impact of Resolved PTSD on Subsequent Functioning.

This study investigated whether impairment persists after posttraumatic stress disorder (PTSD) has resolved. Traumatically injured patients (N = 1,035) were assessed during hospital admission and at 3 (85%) and 12 months (73%). Quality of life prior to traumatic injury was measured with the World Health Organization Quality of Life-BREF during hospitalization and at each subsequent assessment. PTSD was assessed using the Clinician-Administered PTSD Scale at 3 and 12 months. After controlling for preinjury functioning, current pain, and comorbid depression, patients whose PTSD symptoms had resolved by 12 months were more likely to have poorer quality of life in psychological (OR = 3.51), physical (OR = 10.17), social (OR = 4.54), and environmental (OR = 8.83) domains than those who never developed PTSD. These data provide initial evidence that PTSD can result in lingering effects on functional capacity even after remission of symptoms. Reprinted from Clin Psychol Sci 2016; 4:493-498, with permission from Sage. Copyright © 2016.

Airway changes in patients with unilateral cleft lip/palate (UCL/P) after maxillary advancement.

OBJECTIVES: To assess the effect on the retropalatal airway (RPA), retroglossal airway (RGA), and total airway (TA) volumes and cephalometrics (SNA, SNB, ANB, PP-SN, Occl-SN, N-A, A-TVL, B-TVL) after maxillary advancement orthognathic surgery in patients with unilateral cleft lip/palate (UCL/P) using cone-beam computed tomography (CBCT). MATERIALS AND METHODS: The CBCT scans of 30 patients (13 males and 17 females, 17-20 years old) with UCL/P were evaluated at two time points: preoperative (T1) and postoperative (T2). The interval between T1 and T2 ranged from 9-14 weeks, except for two patients in whom the interval was 24 weeks. Intraexaminer reliability was measured with an intraclass correlation coefficient test. A paired t-test was used to compare the airway and cephalometric measurements between T1 and T2, with a P value of .05 being considered significant. RESULTS: From T1 to T2, significant increases were found in the volumes of RPA (from 9574 ± 4573 to 10,472 ± 4767, P = .019), RGA (from 9736 ± 5314 to 11,358 ± 6588, P = .019), and TA (from 19,121 ± 8480 to 21,750 ± 10,078, P = .002). In addition, the RGA (from 385 ± 134 to 427 ± 165, P = .020) and TA (from 730 ± 213 to 772 ± 238, P = .016) sagittal area increased significantly. For minimal cross-sectional area (MCA), only the RPA increased significantly (from 173 ± 115 to 272 ± 129, P = .002). All cephalometric changes were statistically significant between T1 and T2 except for SNB. CONCLUSIONS: Maxillary advancement in patients with UCL/P produces statistically significant increases in the retropalatal (volumetric and MCA), retroglossal (volumetric and sagittal), and total (volumetric and sagittal) airways based on data from CBCT imaging.

Gambling problems predict suicidality in recently transitioned military veterans.

OBJECTIVE: This study investigated associations between gambling problems and suicidality in Australian veterans. METHODS: Data drawn from n = 3,511 Australian Defence Force veterans who had recently transitioned to civilian life. Gambling problems were assessed using the Problem Gambling Severity Index (PGSI) and suicidal ideation and behaviour were assessed using items adapted from the National Survey of Mental Health and Wellbeing. RESULTS: At-risk gambling and problem gambling were associated with increased odds of suicidal ideation [at-risk gambling: odds ratio (OR), 1.93; 95% confidence interval (CI), 1.47‒2.53; problem gambling: OR, 2.75; 95% CI 1.86‒4.06] and suicide planning or attempts (at-risk gambling: OR, 2.07; 95% CI, 1.39‒3.06; problem gambling: OR 4.22, 95% CI, 2.61‒6.81). The association with total scores on the PGSI and any suicidality was substantially reduced and became non-significant when controlling for the effects of depressive symptoms, but not financial hardship or social support. CONCLUSIONS: Gambling problems and harms are important risk factors for suicide in veterans, and should be recognised in veteran-specific suicide prevention policies and programs, along with co-occurring mental health problems. IMPLICATIONS FOR PUBLIC HEALTH: A comprehensive public health approach to reducing gambling harm should feature in suicide prevention efforts in veteran and military populations.

Understanding the temporal dynamics of problem anger using sequence analysis.

Problem anger is a common, and potentially destructive mental health issue in trauma-affected populations, affecting up to 30% of veteran and military populations. Problem anger is associated with a range of psychosocial and functional difficulties and elevated risk of harm to self and others. Increasingly, ecological momentary assessment (EMA) is being used to understand the microlevel dynamics of emotions, and this information is valuable to inform treatment approaches. Using a data-driven approach, we used sequence analysis to determine whether heterogeneity exists amongst veterans with problem anger using EMA-recorded experiences of anger intensity. Veterans with problem anger (N = 60; Mage = 40.28) completed 10 days of EMA with four prompts per day. We identified four subtypes of veterans within the data, whose anger intensity dynamics differed significantly, and the subtypes mapped onto macrolevel indicators of anger and well-being. Taken together, these results highlight the importance of microlevel investigations of mood states in clinical populations, and in some instances, the novel use of sequence analysis may be appropriate. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Massed v. standard prolonged exposure therapy for PTSD in military personnel and veterans: 12-month follow-up of a non-inferiority randomised controlled trial.

BACKGROUND: The utilisation of massed therapy for treating posttraumatic stress disorder (PTSD) is gaining strength, especially prolonged exposure. However, it is unknown whether massed prolonged exposure (MPE) is non-inferior to standard prolonged exposure (SPE) protocols in the long term. The current study aimed to assess whether MPE was non-inferior to SPE at 12 months post-treatment, and to ascertain changes in secondary measure outcomes. METHODS: A multi-site non-inferiority randomised controlled trial (RCT) compared SPE with MPE in 12 clinics. The primary outcome was PTSD symptom severity (CAPS-5) at 12 months post-treatment commencement. Secondary outcome measures included symptoms of depression, anxiety, anger, disability, and quality of life at 12 weeks and 12 months post-treatment commencement. Outcome assessors were blinded to treatment allocation. The intention-to-treat sample included 138 Australian military members and veterans and data were analysed for 134 participants (SPE = 71, MPE = 63). RESULTS: Reductions in PTSD severity were maintained at 12 months and MPE remained non-inferior to SPE. Both treatment groups experienced a reduction in depression, anxiety, anger, and improvements in quality of life at 12 weeks and 12 months post-treatment commencement. Treatment effects for self-reported disability in the SPE group at 12 weeks were not maintained, with neither group registering significant effects at 12 months. CONCLUSIONS: The emergence of massed protocols for PTSD is an important advancement. The current study provides RCT evidence for the longevity of MPE treatment gains at 12 months post-treatment commencement and demonstrated non-inferiority to SPE. Promisingly, both treatments also significantly reduced the severity of comorbid symptoms commonly occurring alongside PTSD.

Mental health across the early years in the military.

BACKGROUND: The mental health impact of the initial years of military service is an under-researched area. This study is the first to explore mental health trajectories and associated predictors in military members across the first 3-4 years of their career to provide evidence to inform early interventions. METHODS: This prospective cohort study surveyed Australian Defence personnel (n = 5329) at four time-points across their early military career. Core outcomes were psychological distress (K10+) and posttraumatic stress symptoms [four-item PTSD Checklist (PCL-4)] with intra-individual, organizational and event-related trajectory predictors. Latent class growth analyses (LCGAs) identified subgroups within the sample that followed similar longitudinal trajectories for these outcomes, while conditional LCGAs examined the variables that influenced patterns of mental health. RESULTS: Three clear trajectories emerged for psychological distress: resilient (84.0%), worsening (9.6%) and recovery (6.5%). Four trajectories emerged for post-traumatic stress, including resilient (82.5%), recovery (9.6%), worsening (5.8%) and chronic subthreshold (2.3%) trajectories. Across both outcomes, prior trauma exposure alongside modifiable factors, such as maladaptive coping styles, and increased anger and sleep difficulties were associated with the worsening and chronic subthreshold trajectories, whilst members in the resilient trajectories were more likely to be male, report increased social support from family/friends and Australian Defence Force (ADF) sources, and use adaptive coping styles. CONCLUSIONS: The emergence of symptoms of mental health problems occurs early in the military lifecycle for a significant proportion of individuals. Modifiable factors associated with wellbeing identified in this study are ideal targets for intervention, and should be embedded and consolidated throughout the military career.

Effect of massed v. standard prolonged exposure therapy on PTSD in military personnel and veterans: a non-inferiority randomised controlled trial.

BACKGROUND: A short, effective therapy for posttraumatic stress disorder (PTSD) could decrease barriers to implementation and uptake, reduce dropout, and ameliorate distressing symptoms in military personnel and veterans. This non-inferiority RCT evaluated the efficacy of 2-week massed prolonged exposure (MPE) therapy compared to standard 10-week prolonged exposure (SPE), the current gold standard treatment, in reducing PTSD severity in both active serving and veterans in a real-world health service system. METHODS: This single-blinded multi-site non-inferiority RCT took place in 12 health clinics across Australia. The primary outcome was PTSD symptom severity measured by the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) at 12 weeks. 138 military personnel and veterans with PTSD were randomised. 71 participants were allocated to SPE, with 63 allocated to MPE. RESULTS: The intention-to-treat sample included 138 participants, data were analysed for 134 participants (88.1% male, M = 46 years). The difference between the mean MPE and SPE group PTSD scores from baseline to 12 weeks-post therapy was 0.94 [95% confidence interval (CI) -4.19 to +6.07]. The upper endpoint of the 95% CI was below +7, indicating MPE was non-inferior to SPE. Significant rates of loss of PTSD diagnosis were found for both groups (MPE 53.8%, SPE 54.1%). Dropout rates were 4.8% (MPE) and 16.9% (SPE). CONCLUSIONS: MPE was non-inferior to SPE in significantly reducing symptoms of PTSD. Significant reductions in symptom severity, low dropout rates, and loss of diagnosis indicate MPE is a feasible, accessible, and effective treatment. Findings demonstrate novel methods to deliver gold-standard treatments for PTSD should be routinely considered.

Suicide among emergency service workers: a retrospective mortality study of national coronial data, 2001-2017.

BACKGROUND: Emergency service workers (ESW) are known to be at increased risk of mental disorders but population-level and longitudinal data regarding their risk of suicide are lacking. METHOD: Suicide data for 2001-2017 were extracted from the Australian National Coronial Information Service (NCIS) for two occupational groups: ESW (ambulance personnel, fire-fighters and emergency workers, police officers) and individuals employed in all other occupations. Age-standardised suicide rates were calculated and risk of suicide compared using negative binomial regression modelling. RESULTS: 13 800 suicide cases were identified among employed adults (20-69 years) over the study period. The age-standardised suicide rate across all ESW was 14.3 per 100 000 (95% CI 11.0-17.7) compared to 9.8 per 100 000 (95% CI 9.6-9.9) for other occupations. Significant occupational differences in the method of suicide were identified (p < 0.001). There was no evidence for increased risk of suicide among ESW compared to other occupations once age, gender and year of death were accounted for (RR = 0.99, 95% CI 0.84-1.17; p = 0.95). In contrast, there was a trend for ambulance personnel to be at elevated risk of suicide (RR = 1.41, 95% CI 1.00-2.00, p = 0.053). CONCLUSION: Whilst age-standardised suicide rates among ESW are higher than other occupations, emergency service work was not independently associated with an increased risk of suicide, with the exception of an observed trend in ambulance personnel. Despite an increased focus on ESW mental health and wellbeing over the last two decades, there was no evidence that rates of suicide among ESW are changing over time.

Ambulatory assessment to predict problem anger in trauma-affected adults: Study protocol.

BACKGROUND: Problem anger is common after experiencing a traumatic event. Current evidence-driven treatment options are limited, and problem anger negatively affects an individual's capacity to engage with traditional psychological treatments. Smartphone interventions hold significant potential in mental health because of their ability to deliver low-intensity, precision support for individuals at the time and place they need it most. While wearable technology has the capacity to augment smartphone-delivered interventions, there is a dearth of evidence relating to several key areas, including feasibility of compliance in mental health populations; validity of in vivo anger assessment; ability to predict future mood states; and delivery of timely and appropriate interventions. METHODS: This protocol describes a cohort study that leverages 10 days of ambulatory assessment in the form of ecological momentary assessment and a wearable. Approximately 100 adults with problem anger will complete four-hourly in vivo mobile application-delivered micro-surveys on anger intensity, frequency, and verbal and physical aggression, as well as other self-reported mental health and wellbeing measures. Concurrently, a commercial wearable device will continuously record indicators of physiological arousal. The aims are to test the feasibility and acceptability of ambulatory assessment in a trauma-affected population, and determine whether a continuously measured physiological indicator of stress predicts self-reported anger intensity. DISCUSSION: This study will contribute new data around the ability of physiological indicators to predict mood state in individuals with psychopathology. This will have important implications for the design of smartphone-delivered interventions for trauma-affected individuals, as well as for the digital mental health field more broadly.

Problematic Anger in the Military: Focusing on the Forgotten Emotion.

PURPOSE OF REVIEW: Problematic anger is common in veteran and military populations, yet understudied relative to other mental health difficulties. However, in recent years, more clinical and research attention has been turned to problematic anger. This paper highlights important new findings in the epidemiology, course, and neurobiology of anger, the associations of anger with other mental health problems and risk, and next steps for research and practice. RECENT FINDINGS: In longitudinal research, findings show that problematic anger changes over the life course of military members and veterans, and that deployment increases the likelihood of problematic levels of anger. Problematic anger is related to a range of mental health issues, most perniciously aggression and suicidality. Promising new assessment and treatment approaches are emerging, including innovations that leverage digital technology. Key areas of research include advancing assessment of problematic anger to identify patterns of heterogeneity, as well as advancing the evidence base for anger treatments. Recommended progress in clinical practice include conducting routine assessment of problematic anger in veteran and military populations, developing prevention and early intervention for at risk individuals, and optimizing the timing of interventions throughout the military lifecycle.

A Qualitative Study of the Expectations, Experiences, and Perceptions That Underpin Decisions Regarding PTSD Treatment in Help-seeking Veterans.

INTRODUCTION: A range of evidence-based treatments are available for PTSD. However, many veterans with PTSD do not engage in these treatments. Concurrently, various novel PTSD treatments with little or no evidence based are increasingly popular among veterans. This qualitative study explored the expectations, experiences, and perceptions of help-seeking veterans with PTSD to improve understanding of how these veterans make treatment decisions. MATERIALS AND METHODS: Fifteen treatment-seeking veterans with PTSD participated in the study. Participants took part in semi-structured interviews. Data were analyzed using interpretative phenomenological analysis. RESULTS: A number of themes and subthemes emerged from the data, providing a detailed account of the factors that influenced participants' treatment decisions. Most participants were in an acute crisis when they made the initial decision to seek treatment for their PTSD. In choosing a specific treatment, they tended to follow recommendations made by other veterans or health professionals or orders or directions from their superiors, health providers, or employers. Few participants actively considered the scientific evidence supporting different treatments. Participants had a strong preference for treatment provided by or involving other veterans. They reported finding PTSD treatments helpful, although some were not convinced of the value of evidence-based treatments specifically. Many participants reported negative experiences with treatment providers. CONCLUSIONS: These findings will inform strategies to improve engagement of veterans in evidence-based PTSD treatments and advance progress toward veteran-centered care.

Mental Health Reform: Design and Implementation of a System to Optimize Outcomes for Veterans and Their Families.

The social, health, and economic burden of mental health problems in the veteran community is heavy. Internationally, the array of services and support available to veterans and their families are extensive but vary in quality, are often disconnected, complex to navigate, and lack clear coordination. This paper describes a conceptual framework to guide the design and implementation of a system of services and supports to optimize the mental health and wellbeing of all veterans and their families. The framework recognizes the diversity of veterans across intersecting identities that uniquely shape experiences of posttraumatic mental health and wellbeing. It brings together several strands of research: the values and principles that should underpin the system; the needs of diverse veterans and their families; challenges in the current services and supports; evidence-based interventions; and principles of effective implementation. Central to the future system design is a next generation stepped model of care that organizes best and next practice interventions in a coherent system, matches service provision to level of need and addresses access and navigation. Practical guidance on implementation provides an aspirational and flexible structure for system evolution, and a template for all stakeholders-individuals, groups, agencies and organizations-to effect system change.