Comparison of telehealth and in-person mental health care in military veterans and active-duty service members.

Telehealth services are increasingly utilized to improve mental health care access for active-duty service members (ADSM) and military veterans. This article examines mental health outcomes for veterans (n = 4,536) and ADSMs (n = 378) who met Diagnostic and Statistical Manual of Mental Disorders, fifth edition diagnostic criteria for depression, posttraumatic stress disorder, or generalized anxiety disorder (N = 4,914) and were treated at Cohen Veterans Network Clinics using either telehealth or in-person treatment modalities. Results demonstrate small but statistically significant advantages for telehealth in terms of discharge scores, rates of clinically significant change, and efficiency of treatment. For depression and posttraumatic stress disorder, veterans reported greater changes than ADSMs, but there was no interaction between treatment modality and client type. These findings support the use of telehealth as a viable option for mental health care in these populations, while suggesting several areas requiring further study. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Evaluating Suicide Risk Stratification in Outpatient Settings: A Vignette-Based Approach.

Suicide risk assessment and stratification are a key suicide prevention strategy in mental health care systems that treat military service members and veterans. The aim of the current mixed-method project was to address a gap in our knowledge as to how therapists make these important clinical decisions. This manuscript reports the results of a project during which six vignettes were developed reflecting varying levels of risk according to the Rocky Mountain MIRECC Risk Stratification Table. Mental health therapists were asked to evaluate the risk level of each vignette, determine a treatment disposition, and provide justification for their ratings. The results of the study indicate that therapists can reliably evaluate risk, but that treatment planning tended to be based more on vignette-specific factors than essential features of the risk model. The qualitative findings revealed variations in the definition and perception of foundational concepts, suggesting a need for further research and training in these domains. Overall, the results support the use of vignettes as a method to assess clinical decision-making and provide several areas for further training and research.

Treatment outcomes after screening positive for suicidal ideation in United States military veterans.

Suicidal ideation is a significant risk factor for suicidal behaviors, precipitating increased levels of clinical assessment and concern. The purpose of the current study was to determine if screening positive for ideation significantly predicted treatment outcomes in a non-VHA veteran population. Participants were military veterans seen at a Cohen Veterans Network clinic between January 1, 2016, and December 31, 2021. Of 12,178 episodes of care, 673 (5.5%) were positive screens (moderate or high risk on the C-SSRS) and 234 (1.9%) were high risk. Overall, a positive screen was not a significant predictor of the reason for discharge or whether it was planned or unplanned. However, meeting the criteria for being high risk was associated with negative treatment outcomes in terms of the reason for discharge and the planned or unplanned nature of the discharge. These findings emphasize the significance of stratifying suicide risk as well as the advantages of routinely gathering data on reasons for client discharge.

Prevention System Implementation and Reach: Attitudes and Environmental Predictors in a Randomized Controlled Trial of the NORTH STAR Prevention System.

Although many evidence-based interventions are well-established, our understanding of how to effectively implement and sustain those interventions in real-world settings is less well understood. We investigated predictors of implementation and reach in a randomized controlled trial of the NORTH STAR prevention system. One-third of U.S. Air Force (AF) bases worldwide were randomly assigned to NORTH STAR (n = 12) or an assessment-and-feedback-only condition (n = 12). Process data regarding implementation factors were collected from Community Action Team (CAT) members and observations of CAT processes. Results from a series of regression analyses indicated that change in leadership and community support, action planning processes, and perceived approach effectiveness from pre-action planning to follow-up predicted community action plan (CAP) implementation and that changes in barriers to implementation predicted CAP reach. Pre-action planning reports of CAT member self-efficacy and perceived approach effectiveness also predicted CAP implementation at 1-year follow-up. Future directions and practice recommendations are provided.

High sensitivity and specificity screening for clinically significant intimate partner violence.

The U.S. Preventive Services Task Force has recommended that clinicians screen patients for intimate partner violence (IPV). This article aims to develop and test the first screeners for clinically significant physical and psychological IPV (i.e., acts meeting criteria in the International Classification of Diseases (11th ed.; ICD-11; World Health Organization, 2019) and the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013). The goal was to derive screeners that (1) are maximally brief, while still achieving high sensitivity and specificity; (2) assess perpetration and victimization when either men or women are reporting; and (3) use ICD-11/DSM-5 criteria as the reference standard. Random samples of active duty service members at 82 installations worldwide were obtained via e-mail invitation (2006: N = 54,543; 2008: N = 48,909); their response rates were excellent for long general population surveys with no payment (2006: 44.7%, 2008: 49.0%). The population of spouses at the participating installation was invited by mailed postcard (2006: N = 19,722; 2008: N = 12,127; response rates-2006: 12.3%, 2008: 10.8%). Clinically significant physical intimate partner violence can be effectively screened with as few as four items, with sensitivities > 90% and specificities > 95%; clinically significant psychological intimate partner violence can be screened with two items. Men and women can be screened with equivalent accuracy, as can those committing the violence and those victimized by it. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The Impact of NORTH STAR on Suicidality, Substance Problems, Intimate Partner Violence, and Child Abuse.

INTRODUCTION: We evaluated the effectiveness of New Orientation for Reducing Threats to Health from Secretive-problems That Affect Readiness (NORTH STAR), a community assessment, planning, and action framework to reduce the prevalence of suicidality, substance problems, intimate partner violence, and child abuse. MATERIALS AND METHODS: One-third of U.S. Air Force bases worldwide were randomly assigned to NORTH STAR (n = 12) or an assessment-and-feedback-only condition (n = 12). Two Air Force-wide, cross-sectional, anonymous, web-based surveys were conducted of randomly selected samples assessing risk/protective factors and outcomes. This study was reviewed and approved by the institutional review board at the investigators' university and by the institutional review board at Fort Detrick. RESULTS: NORTH STAR, relative to control, bases experienced a 33% absolute risk reduction in hazardous drinking rates and cumulative risk, although, given the small number of bases, these effects were not statistically significant. CONCLUSIONS: Given its relatively low cost, use of empirically supported light-touch interventions, and emphasis on sustainability with existing resources, NORTH STAR may be a useful system for prevention of a range of adult behavioral health problems that are difficult to impact.

Effect of the Wingman-Connect Upstream Suicide Prevention Program for Air Force Personnel in Training: A Cluster Randomized Clinical Trial.

Importance: Suicide has been a leading manner of death for US Air Force personnel in recent years. Universal prevention programs that reduce suicidal thoughts and behaviors in military populations have not been identified. Objectives: To determine whether the Wingman-Connect program for Airmen-in-training reduces suicidal ideation, depression, and occupational problems compared with a stress management program and to test the underlying network health model positing that cohesive, healthy units are protective against suicidal ideation. Design, Setting, and Participants: This cluster randomized clinical trial was conducted from October 2017 to October 2019 and compared classes of personnel followed up for 6 months. The setting was a US Air Force technical training school, with participants studied to their first base assignment, whether US or international. Participants in 216 classes were randomized, with an 84% retention rate. Data analysis was performed from November 2019 to May 2020. Interventions: The Wingman-Connect program used group skill building for cohesion, shared purpose, and managing career and personal stressors (3 blocks of 2 hours each). Stress management training covered cognitive and behavioral strategies (2 hours). Both conditions had a 1-hour booster session, plus text messages. Main Outcomes and Measures: The primary outcomes were scores on the suicidal ideation and depression scales of the Computerized Adaptive Test for Mental Health and self-reports of military occupational impairment. Class network protective factors hypothesized to mediate the effect of Wingman-Connect were assessed with 4 measures: cohesion assessed perceptions that classmates cooperate, work well together, and support each other; morale was measured with a single item used in other studies with military samples; healthy class norms assessed perceptions of behaviors supported by classmates; and bonds to classmates were assessed by asking each participant to name classmates whom they respect and would choose to spend time with. Results: A total of 215 classes including 1485 individuals (1222 men [82.3%]; mean [SD] age, 20.9 [3.1] years) participated; 748 individuals were enrolled in the Wingman-Connect program and 737 individuals were enrolled in the stress management program. At 1 month, the Wingman-Connect group reported lower suicidal ideation severity (effect size [ES], -0.23; 95% CI, -0.39 to -0.09; P = .001) and depression symptoms (ES, -0.24; 95% CI, -0.41 to -0.08; P = .002) and fewer occupational problems (ES, -0.14; 95% CI, -0.31 to -0.02; P = .02). At 6 months, the Wingman-Connect group reported lower depression symptoms (ES, -0.16; 95% CI, -0.34 to -0.02; P = .03), whereas the difference in suicidal ideation severity was not significant (ES, -0.13; 95% CI, -0.29 to 0.01; P = .06). The number needed to treat to produce 1 fewer participant with elevated depression at either follow-up point was 21. The benefits of the training on occupational problems did not extend past 1 month. The Wingman-Connect program strengthened cohesive, healthy class units, which helped reduce suicidal ideation severity (estimate, -0.035; 95% CI, -0.07 to -0.01; P = .02) and depression symptom scores (estimate, -0.039; 95% CI, -0.07 to -0.01; P = .02) at 1 month. Conclusions and Relevance: Wingman-Connect is the first universal prevention program to reduce suicidal ideation and depression symptoms in a general Air Force population. Group training that builds cohesive, healthy military units is promising for upstream suicide prevention and may be essential for ecological validity. Extension of the program to the operational Air Force is recommended for maintaining continuity and testing the prevention impact on suicidal behavior. Trial Registration: ClinicalTrials.gov Identifier: NCT04067401.

Evaluating the Effectiveness of NORTH STAR: a Community-Based Framework to Reduce Adult Substance Misuse, Intimate Partner Violence, Child Abuse, Suicidality, and Cumulative Risk.

We evaluated the effectiveness of NORTH STAR, a community assessment, planning, and action framework to reduce the prevalence of several secretive adult problems (hazardous drinking, controlled prescription drug misuse, suicidality, and clinically significant intimate partner violence and child abuse [both emotional and physical]) as well as cumulative risk. One-third of US Air Force (AF) bases worldwide were randomly assigned to NORTH STAR (n = 12) or an assessment-and-feedback-only condition (n = 12). Two AF-wide, cross-sectional, anonymous, web-based surveys were conducted of randomly selected samples assessing risk/protective factors and outcomes. Process data regarding attitudes, context, and implementation factors were also collected from Community Action Team members. Analyzed at the level of individuals, NORTH STAR significantly reduced intimate partner emotional abuse, child physical abuse, and suicidality, at sites with supportive conditions for community prevention (i.e., moderation effects). Given its relatively low cost, use of empirically supported light-touch interventions, and emphasis on sustainability with existing resources, NORTH STAR may be a useful framework for the prevention of a range of adult behavioral health problems that are difficult to impact.

Self-reporting DSM-5/ICD-11 clinically significant intimate partner violence and child abuse: Convergent and response process validity.

Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5) and International Classification of Diseases-11th Revision (ICD-11; proposed) now include criteria for clinically significant (a) intimate partner violence (IPV) and neglect and (b) child abuse and neglect. However, existing measures of IPV and child abuse do not allow for assessment of established criteria. The current study examines the convergent and response process validity of the Family Maltreatment (FM) measure of clinically significant physical and psychological IPV and child abuse. Participants (N = 126) completed the FM via computer and measures of IPV (Revised Conflict Tactics Scale; Straus, Hamby, Boney-McCoy, & Sugarman, 1996) and child abuse (Parent-Child Conflict Tactics Scale; Straus, Hamby, Finkelhor, Moore, & Runyan, 1998) via paper-and-pencil. Participants who endorsed acts of aggression on the FM completed an audio-recorded computerized interview recounting the 2 most severe incidents. Verbalized incidents (n = 138) were coded for clinically significant family maltreatment. Results largely supported the convergent validity of the FM. Agreement of acts endorsed on the FM with those endorsed on convergent measures was excellent for IPV and physical child abuse, yet poor for psychological child abuse. Further, in support of the response process validity of the FM, comparison with observer ratings of interviews indicated few "false positives" and no "false negatives" on the FM across the examined types of clinically significant IPV and child abuse. In summary, the FM is a promising measure for the assessment of clinically significant physical and psychological abuse as defined in the DSM-5 and ICD-11 (proposed). (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Child emotional aggression and abuse: definitions and prevalence.

OBJECTIVE: Research on and intervention for child emotional abuse and emotional aggression toward children have been severely hampered because there have been no agreed-upon, clinically usable definitions. METHODS: We have (a) proposed and field-tested a set of criteria to operationally define child emotional abuse for clinical settings and (b) used these criteria to design a parent-report measure of parental emotional aggression and child emotional abuse that could be used in research. In this paper, we review the development and field trials of these criteria for making substantiation decisions. RESULTS: Agreement between master reviewers and field decisions was extremely high in a 5-site development trial (96% agreement, κ=.89) and a 41-site dissemination trial (90% agreement, κ=.73). We compare these criteria to other research criteria in the literature. We then present data collected using a self-report measure designed to parallel these criteria from an anonymous online survey of US Air Force personnel and their spouses. The final sample (N=52,780) was weighted to be representative of the United States civilian population. The prevalence of parents' emotionally aggressive acts was much higher than the prevalence of emotional abuse (acts plus impact), but rates of parents' acts of emotional aggression were lower than those typically reported in the literature. Additional analyses tested for differential effects due to gender of perpetrator (i.e., mothers or fathers), age of victim, and clustering within families. These factors did not drive rates of aggression or abuse. CONCLUSIONS: In sum, the criteria developed and proposed appear to support reliable clinical decision making regarding child emotional abuse and can be translated to research survey tools that better capture the continuum of parents' emotional aggression and child emotional abuse than the measures that are currently available, advancing the state of the science with respect to child emotional abuse.

Substantiation of spouse and child maltreatment reports as a function of referral source and maltreatment type.

Substantiation rates for alleged incidents of spouse (N = 33,787) and child (N = 31,986) maltreatment reported to the U.S. Air Force (AF) Family Advocacy Program between 2000 and 2007 were examined. For spouse maltreatment, physical abuse and multiple forms of maltreatment were most likely to be substantiated and neglect was least likely to be substantiated. For child maltreatment, emotional abuse was most likely to be substantiated and physical abuse was least likely to be substantiated. Substantiation rates were higher for referrals by military professionals than for referrals by civilian professionals or nonprofessionals; considerable variation in substantiation rates within each of these categories also was observed. Overall, AF substantiation rates were higher for spouse than for child maltreatment, and substantiation rates for child maltreatment were higher in the AF than in the general U.S. population. Substantiation rates have declined over time in both the AF and the United States.

Suspected child and spouse maltreatment referral sources: who reports child and spouse maltreatment to the Air Force Family Advocacy Program?

The present study describes the sources of Air Force (AF) Family Advocacy Program referrals (N = 42,389) for child and spouse maltreatment between 2000 and 2004. Sources of referrals were stable over time, with military sources accounting for the majority of both child and spouse referrals. Most (85%) of spouse maltreatment referrals came from AF law enforcement, medical and psychological staff, command, and victim self-referrals. For child maltreatment, most referrals (71%) were from law enforcement, medical and psychological staff, command, social services, and friends or relatives. Differences in the sources of referrals across different types of maltreatment were greater for child than for spouse maltreatment. Comparison of the sources of child maltreatment referrals in the AF and U.S. samples revealed substantial similarity. However, self-referrals by the victim or offender were more common in the Air Force, whereas referrals by friends and relatives or by school or child care staff were more common in the U.S. sample.

An application of cognitive-behavioral anger management training in a military/occupational setting: efficacy and demographic factors.

OBJECTIVE: This treatment outcome study evaluated the efficacy of a cognitive-behavioral psychoeducational anger management training application offered in a military/occupational setting. Additionally, demographic factors were analyzed to identify any relationship among age, gender, occupational/educational status, and anger subscale scores or treatment effects. METHOD: The State-Trait Anger Expression Inventory was used as a pretest/post-test measure for 91 total participants in a series of four-session cognitive behavioral anger management training groups conducted through Francis E. Warren Air Force Base mental health clinic over an 18-month period. RESULTS: Significant improvements (p < 0.05) on all State-Trait Anger Expression Inventory anger scales were noted for the 46 participants who completed the program. Post hoc comparisons of demographic factors yielded no significant differences. CONCLUSIONS: The results are consistent with previously published findings insofar as the intervention was effective in reducing self-reported anger as measured by the State-Trait Anger Expression Inventory. The present study affirms the efficacy of a brief cognitive-behavioral psychoeducational approach to treat problem anger in a noncontrolled community/occupational sample.