Differences in quality-of-life scores across injury categories by mental health status among injured U.S. military service members and veterans.

PURPOSE: Posttraumatic stress disorder (PTSD) and depression are strong predictors of poor health-related quality of life (HRQOL) among injured U.S. military service members (SMs). Patterns of HRQOL between injury categories and injury categories stratified by mental health (MH) symptoms have not been examined. Among deployment-injured SMs and veterans (n = 4353), we examined HRQOL and screening data for PTSD and/or depression within specific injury categories. METHODS: Participants included those enrolled in the Wounded Warrior Recovery Project with complete data for HRQOL (SF-36) from June 2017 to May 2020. Injuries were categorized using the Barell Injury Diagnosis Matrix (Barell Matrix). Mean physical component summary (PCS) and mental component summary (MCS) scores were calculated for each injury category and stratified by the presence or absence of probable PTSD and/or depression. RESULTS: The average follow-up time that participants were surveyed after injury was 10.7 years. Most participants were male, non-Hispanic White, served in the Army, and enlisted rank. Mechanism of injury for 77% was blast-related. Mean PCS and MCS scores across the entire sample were 43.6 (SD = 10.3) and 39.5 (SD = 13.3), respectively; 50% screened positive for depression and/or PTSD. PCS and MCS scores were significantly lower within each injury category among individuals with probable PTSD and/or depression than those without. CONCLUSION: Among deployment-injured SMs, those with probable PTSD and/or depression reported significantly lower HRQOL within injury categories and HRQOL component (i.e., physical or mental) than those without. Findings are consistent with prior reports showing mental health symptoms to be strongly associated with lower HRQOL and suggest integration of mental health treatment into standard care practices to improve long-term HRQOL.

Deployment-related concussion and long-term health-related quality of life among US military personnel.

PURPOSE: To examine the relationship between deployment-related concussion and long-term health-related quality of life (HRQoL) among injured US military personnel. METHODS: The study sample included 810 service members with deployment-related injuries between 2008 and 2012 who responded to a web-based longitudinal health survey. Participants were categorized into three injury groups: concussion with loss of consciousness (LOC; n = 247), concussion without LOC (n = 317), or no concussion (n = 246). HRQoL was measured using the 36-Item Short Form Health Survey physical and mental component summary (PCS and MCS) scores. Current post-traumatic stress disorder (PTSD) and depression symptoms were examined. Multivariable linear regression models assessed the effects of concussion on PCS and MCS scores, while controlling for covariates. RESULTS: A lower PCS score was observed in participants with concussion with LOC (B = - 2.65, p = 0.003) compared with those with no history of concussion. Symptoms of PTSD (PCS: B = - 4.84, p < 0.001; MCS: B = - 10.53, p < 0.001) and depression (PCS: B = - 2.85, p < 0.001; MCS: B = - 10.24, p < 0.001) were the strongest statistically significant predictors of lower HRQoL. CONCLUSION: Concussion with LOC was significantly associated with lower HRQoL in the physical domain. These findings affirm that concussion management should integrate physical and psychological care to improve long-term HRQoL and warrant a more detailed examination of causal and mediating mechanisms. Future research should continue to incorporate patient-reported outcomes and long-term follow-up of military service members to further define the lifelong impact of deployment-related concussion.

Baseline executive functioning moderates treatment-related changes in quality of life in veterans with posttraumatic stress disorder and comorbid traumatic brain injury.

Posttraumatic stress disorder (PTSD) treatment has been associated with improvement in quality of life (QOL); however, little is known about factors that moderate treatment-related changes in QOL, particularly cognitive factors. Executive functioning (EF) is important for success across all aspects of everyday life and predicts better psychological and physical health. EF is important to QOL, but more work is needed to better understand the association between EF and QOL improvements following interventions. We hypothesized that poorer baseline EF would be associated with less improvement in overall life satisfaction and satisfaction with health following PTSD treatment. U.S. veterans who served after the September 11, 2001 terrorist attacks (post 9-11; N = 80) with PTSD and a history of mild-to-moderate traumatic brain injury were randomized to standard cognitive processing therapy (CPT) or CPT combined with cognitive rehabilitation (SMART-CPT). Multilevel modeling was used to examine whether baseline EF performance was associated with changes in QOL scores from pretreatment to follow-up across both groups. Results indicated that poorer baseline performance on EF tests of working memory and inhibition were associated with less treatment-related improvements in general life satisfaction and satisfaction with health, rs = .26-.36. Treatment condition did not moderate any results. Future research should examine whether implementing EF-focused techniques before and/or concurrently with CPT for individuals with poorer baseline working memory and inhibition enhances QOL treatment gains, particularly in terms of general life and health-related satisfaction.

Prevalence and correlates of self-reported cognitive difficulties in deployment-injured U.S. military personnel.

Cognitive difficulties typically resolve within days to weeks following mild traumatic brain injury (mTBI); however, a sizable proportion of individuals continue to report cognitive symptoms months to years later that are often associated with posttraumatic stress disorder (PTSD) and depression to a greater degree than a history of mTBI. The current study sought to evaluate the prevalence of self-reported cognitive difficulties as well as the relative contributions of demographic, injury-related, and mental health variables in a large study of U.S. military personnel injured during deployment since 2001. Slightly fewer than half (42.0%) of participants reported elevated cognitive difficulties compared with a normative population; however, this was driven primarily by those who screened positive for PTSD or depression. Hierarchical linear regression revealed that various demographic and injury factors, including lower educational attainment, retired or separated military status, enlisted rank, and a history of deployment-related mTBI, were associated with more self-reported cognitive difficulties, f2 = 0.07. Screening positive for PTSD or depression accounted for 32.1% of the variance in self-reported cognitive symptoms, f2 = 0.63, whereas injury variables, including a history of deployment-related mTBI, albeit significant in the model, accounted for 1.6%. The current findings add to the growing body of literature underscoring the importance of screening for and treating mental health conditions in injured military personnel.

Sleep Insufficiency and Baseline Preseason Concussion-Like Symptom Reporting in Youth Athletes.

OBJECTIVE: To examine the association between insufficient sleep and baseline symptom reporting in healthy student athletes. DESIGN: Cross-sectional cohort study. SETTING: Preseason testing for student athletes. PARTICIPANTS: Student athletes (n = 19 529) aged 13 to 19 years who completed the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), including the number of hours slept the night before, and denied having developmental/health conditions, a concussion in the past 6 months, and a previous history of 2 or more concussions. INDEPENDENT VARIABLES: Total hours of sleep the night before testing (grouped by ≤5, 5.5-6.5, 7-8.5, and ≥9 hours), gender, and concussion history. MAIN OUTCOME MEASURES: Symptom burden on the Post-Concussion Symptom Scale (modified to exclude sleep-related items), cognitive composite scores, and prevalence of athletes who reported a symptom burden resembling the International Classification of Diseases, 10th Revision (ICD-10) diagnosis of postconcussional syndrome (PCS). RESULTS: Fewer hours of sleep, gender (ie, girls), and 1 previous concussion (vs 0) were each significantly associated with higher total symptom scores in a multivariable model (F = 142.01, P < 0.001, R2 = 0.04). When a gender-by-sleep interaction term was included, the relationship between sleep and symptoms was stronger for girls compared with boys. In healthy athletes who slept ≤5 hours, 46% of girls and 31% of boys met the criteria for ICD-10 PCS compared with 16% of girls and 11% of boys who slept ≥9 hours. Sleep duration was not meaningfully associated with neurocognitive performance. CONCLUSIONS: Insufficient sleep the night before testing is an important factor to consider when interpreting symptom reporting, especially for girls. It will be helpful for clinicians to take this into account when interpreting both baseline and postinjury symptom reporting.

Independent and Synergistic Associations Between TBI Characteristics and PTSD Symptom Clusters on Cognitive Performance and Postconcussive Symptoms in Iraq and Afghanistan Veterans.

OBJECTIVE: The investigators sought to evaluate the independent and interactive associations between mild traumatic brain injury (mTBI) characteristics and posttraumatic stress disorder (PTSD) symptoms with regard to postconcussive symptoms and cognition among treatment-seeking veterans of the U.S. conflicts in Iraq and Afghanistan. METHODS: Sixty-seven Iraq and Afghanistan veterans who had a history of mTBI and comorbid PTSD were grouped based on injury mechanism (blast versus nonblast) and number of lifetime mTBIs (one to two versus three or more). Independent associations between mTBI characteristics and PTSD symptom clusters were evaluated with regard to cognition and postconcussive symptoms. Follow-up analyses were conducted to determine any interactive associations between TBI characteristics and PTSD symptom clusters. RESULTS: Higher PTSD symptoms, particularly hyperarousal, were associated with poorer executive functioning and higher postconcussive symptoms. No direct relationships were observed between PTSD symptom clusters and memory or processing speed. The relationship between hyperarousal and processing speed was moderated by lifetime mTBIs, such that those with a history of at least three mTBIs demonstrated a negative association between hyperarousal and processing speed. Blast-related mTBI history was associated with reduced processing speed, compared with non-blast-related mTBI. However, an interaction was observed such that among those with blast-related mTBI history, higher re-experiencing symptoms were associated with poorer processing speed, whereas veterans without history of blast-related mTBI did not demonstrate an association between processing speed and re-experiencing symptoms. CONCLUSIONS: Higher hyperarousal and re-experiencing symptoms were associated with reduced processing speed among veterans with repetitive and blast-related mTBI history, respectively. PTSD symptoms, specifically hyperarousal, were associated with poorer executive functioning and higher postconcussive symptoms. Limited associations were found between injury characteristics and cognition chronically following mTBI. However, these results support synergistic effects of specific PTSD symptom clusters and TBI characteristics.

Self-efficacy and coping style in Iraq and Afghanistan-era veterans with and without mild traumatic brain injury and posttraumatic stress disorder.

OBJECTIVE: To examine self-efficacy and coping style in combat-exposed Veterans with and without mild traumatic brain injury (mTBI) history and posttraumatic stress disorder (PTSD). METHODS: Veterans (N = 81) were categorized into four groups: comorbid mTBI and PTSD (n = 23), PTSD-only (n = 16), mTBI-only (n = 25), and combat-exposed controls (n = 17). Outcomes included the Self-Efficacy for Symptom Management Scale and the Brief Coping Orientation to Problems Experienced. RESULTS: Significant group effects were found on self-efficacy and coping style, even when adjusting for total mTBIs and psychiatric comorbidities. Post-hoc analyses revealed that the comorbid and PTSD-only groups generally had lower self-efficacy than the mTBI-only and control groups and that the PTSD-only group used less action-focused coping than the mTBI-only and control groups. CONCLUSION: Our results suggest that self-efficacy and coping style vary as a function of mTBI history and PTSD status and that it may be important to integrate these malleable factors into interventions for this population.

Psychological Symptoms and Rates of Performance Validity Improve Following Trauma-Focused Treatment in Veterans with PTSD and History of Mild-to-Moderate TBI.

OBJECTIVE: Iraq and Afghanistan Veterans with posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) history have high rates of performance validity test (PVT) failure. The study aimed to determine whether those with scores in the invalid versus valid range on PVTs show similar benefit from psychotherapy and if psychotherapy improves PVT performance. METHOD: Veterans (N = 100) with PTSD, mild-to-moderate TBI history, and cognitive complaints underwent neuropsychological testing at baseline, post-treatment, and 3-month post-treatment. Veterans were randomly assigned to cognitive processing therapy (CPT) or a novel hybrid intervention integrating CPT with TBI psychoeducation and cognitive rehabilitation strategies from Cognitive Symptom Management and Rehabilitation Therapy (CogSMART). Performance below standard cutoffs on any PVT trial across three different PVT measures was considered invalid (PVT-Fail), whereas performance above cutoffs on all measures was considered valid (PVT-Pass). RESULTS: Although both PVT groups exhibited clinically significant improvement in PTSD symptoms, the PVT-Pass group demonstrated greater symptom reduction than the PVT-Fail group. Measures of post-concussive and depressive symptoms improved to a similar degree across groups. Treatment condition did not moderate these results. Rate of valid test performance increased from baseline to follow-up across conditions, with a stronger effect in the SMART-CPT compared to CPT condition. CONCLUSION: Both PVT groups experienced improved psychological symptoms following treatment. Veterans who failed PVTs at baseline demonstrated better test engagement following treatment, resulting in higher rates of valid PVTs at follow-up. Veterans with invalid PVTs should be enrolled in trauma-focused treatment and may benefit from neuropsychological assessment after, rather than before, treatment.

SMART-CPT for veterans with comorbid post-traumatic stress disorder and history of traumatic brain injury: a randomised controlled trial.

OBJECTIVE: To better concurrently address emotional and neuropsychological symptoms common in veterans with comorbid post-traumatic stress disorder (PTSD) and history of traumatic brain injury (TBI), we integrated components of compensatory cognitive training from the Cognitive Symptom Management and Rehabilitation Therapy (CogSMART) programme into cognitive processing therapy (CPT) for PTSD to create a hybrid treatment, SMART-CPT (CogSMART+CPT). This study compared the efficacy of standard CPT with SMART-CPT for treatment of veterans with comorbid PTSD and history of TBI reporting cognitive symptoms. METHODS: One hundred veterans with PTSD, a history of mild to moderate TBI and current cognitive complaints were randomised and received individually delivered CPT or SMART-CPT for 12 weeks. Participants underwent psychological, neurobehavioural and neuropsychological assessments at baseline, on completion of treatment and 3 months after treatment. RESULTS: Both CPT and SMART-CPT resulted in clinically significant reductions in PTSD and postconcussive symptomatology and improvements in quality of life. SMART-CPT resulted in additional improvements in the neuropsychological domains of attention/working memory, verbal learning/memory and novel problem solving. CONCLUSION: SMART-CPT, a mental health intervention for PTSD, combined with compensatory cognitive training strategies, reduces PTSD and neurobehavioural symptoms and also provides added value by improving cognitive functioning.

Mild Traumatic Brain Injury Burden Moderates the Relationship Between Cognitive Functioning and Suicidality in Iraq/Afghanistan-Era Veterans.

OBJECTIVES: Suicidal ideation (SI) is highly prevalent in Iraq/Afghanistan-era veterans with a history of mild traumatic brain injury (mTBI), and multiple mTBIs impart even greater risk for poorer neuropsychological functioning and suicidality. However, little is known about the cognitive mechanisms that may confer increased risk of suicidality in this population. Thus, we examined relationships between neuropsychological functioning and suicidality and specifically whether lifetime mTBI burden would moderate relationships between cognitive functioning and suicidal ideation. METHODS: Iraq/Afghanistan-era Veterans with a history of mTBI seeking outpatient services (N = 282) completed a clinical neuropsychological assessment and psychiatric and postconcussive symptom questionnaires. RESULTS: Individuals who endorsed SI reported more severe post-traumatic stress disorder (PTSD), depression, and postconcussive symptoms and exhibited significantly worse memory performance compared to those who denied SI. Furthermore, mTBI burden interacted with both attention/processing speed and memory, such that poorer performance in these domains was associated with greater likelihood of SI in individuals with a history of three or more mTBIs. The pattern of results remained consistent when controlling for PTSD, depression, and postconcussive symptoms. CONCLUSIONS: Slowed processing speed and/or memory difficulties may make it challenging to access and use past experiences to solve current problems and imagine future outcomes, leading to increases in hopelessness and SI in veterans with three or more mTBIs. Results have the potential to better inform treatment decisions for veterans with history of multiple mTBIs. (JINS, 2019, 25, 79-89).

The Role of Pain Catastrophizing in Cognitive Functioning Among Veterans With a History of Mild Traumatic Brain Injury.

OBJECTIVE: To determine the role of pain catastrophizing (PC) in neuropsychological functioning in veterans with a history of mild traumatic brain injury (TBI). PARTICIPANTS: Thirty-nine Iraq and Afghanistan combat veterans evaluated in the post-acute phase following mild TBI. METHODS: Participants underwent psychiatric and TBI clinical interviews, neuropsychological tests, and self-report assessments of PC, pain intensity, depression, and posttraumatic stress disorder symptoms. Cognitive functioning composite scores of executive functioning, processing speed, and learning and memory were created. Composites were entered as dependent variables into separate linear regressions to examine relations with PC. RESULTS: Greater PC was associated with worse executive functioning and processing speed even when controlling for confounding variables. CONCLUSIONS: One's interpretation of pain, in addition to pain intensity, has implications for cognitive functioning. Future research is encouraged to determine whether adaptive pain coping mechanisms improve cognitive functioning or, alternatively, whether cognitive rehabilitation strategies reduce PC.

Contributions to Executive Dysfunction in Operation Enduring Freedom/Operation Iraqi Freedom Veterans With Posttraumatic Stress Disorder and History of Mild Traumatic Brain Injury.

OBJECTIVE: Posttraumatic stress disorder (PTSD), history of mild traumatic brain injury (mTBI), and executive function (EF) difficulties are prevalent in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. We evaluated the contributions of injury variables, lower-order cognitive component processes (processing speed/attention), and psychological symptoms to EF. PARTICIPANTS: OEF/OIF Veterans (N = 65) with PTSD and history of mTBI were administered neuropsychological tests of EF and self-report assessments of PTSD and depression. RESULTS: Those impaired on one or more EF measures had higher PTSD and depression symptoms and lower processing speed/attention performance than those with intact performance on all EF measures. Across participants, poorer attention/processing speed performance and higher psychological symptoms were associated with worse performance on specific aspects of EF (eg, inhibition and switching) even after accounting for injury variables. Although direct relationships between EF and injury variables were equivocal, there was an interaction between measures of injury burden and processing speed/attention such that those with greater injury burden exhibited significant and positive relationships between processing speed/attention and inhibition/switching, whereas those with lower injury burden did not. CONCLUSION: Psychological symptoms as well as lower-order component processes of EF (attention and processing speed) contribute significantly to executive dysfunction in OEF/OIF Veterans with PTSD and history of mTBI. However, there may be equivocal relationships between injury variables and EF that warrant further study. Results provide groundwork for more fully understanding cognitive symptoms in OEF/OIF Veterans with PTSD and history of mTBI that can inform psychological and cognitive interventions in this population.

Pilot investigation of a novel white matter imaging technique in Veterans with and without history of mild traumatic brain injury.

OBJECTIVE: The objective of this study is to assess utility of in vivo myelin imaging in combat Veterans with and without history of mild traumatic brain injury (mTBI). We hypothesized that those with history of mTBI would have lower myelin water fraction (MWF), a marker of myelin integrity and content, than those without, and lower MWF would be associated with worse speeded attention/processing speed. RESEARCH DESIGN: Combat Veterans (N = 70) with (n = 42) and without history of mTBI (n = 28) underwent neuroimaging including a novel myelin-sensitive magnetic resonance imaging technique (multicomponent-driven equilibrium single-pulse observation of T1/T2; mcDESPOT) and comprehensive neuropsychological assessment. RESULTS: There were no group differences in MWF using a region-of-interest approach. An exploratory analysis applying limited spatial constraints, however, revealed significantly more 'potholes' (clusters of low MWF) in Veterans with history of mTBI compared to those without. Lower MWF across several ROIs was associated with worse performance on a speeded attention task across groups. CONCLUSION: Veterans in the post-acute period following mTBI showed limited and spatially heterogeneous MWF changes and myelin integrity was significantly related to processing speed. This preliminary evidence for usefulness of mcDESPOT in combat Veterans with history of mTBI warrants future research to determine mcDESPOT's relative utility compared to techniques such as diffusion tensor imaging.

Crosswords to computers: a critical review of popular approaches to cognitive enhancement.

Cognitive enhancement strategies have gained recent popularity and have the potential to benefit clinical and non-clinical populations. As technology advances and the number of cognitively healthy adults seeking methods of improving or preserving cognitive functioning grows, the role of electronic (e.g., computer and video game based) cognitive training becomes more relevant and warrants greater scientific scrutiny. This paper serves as a critical review of empirical evaluations of publically available electronic cognitive training programs. Many studies have found that electronic training approaches result in significant improvements in trained cognitive tasks. Fewer studies have demonstrated improvements in untrained tasks within the trained cognitive domain, non-trained cognitive domains, or on measures of everyday function. Successful cognitive training programs will elicit effects that generalize to untrained, practical tasks for extended periods of time. Unfortunately, many studies of electronic cognitive training programs are hindered by methodological limitations such as lack of an adequate control group, long-term follow-up and ecologically valid outcome measures. Despite these limitations, evidence suggests that computerized cognitive training has the potential to positively impact one's sense of social connectivity and self-efficacy.

Associations between health-related behaviors and self-reported cognitive symptoms in U.S. military personnel injured on deployment.

Health behaviors may be core contributors to cognition and mental health following mild traumatic brain injury (TBI). The aims of the present study examined: (1) whether health behaviors including sleep duration, alcohol use, and physical activity differed in injured military personnel with and without deployment-related mild TBI history and (2) the relative contributions of health behaviors and deployment-related mild TBI history to self-reported cognitive, posttraumatic stress disorder (PTSD), and depressive symptoms. Participants included 3076 military personnel injured on deployment participating in the Wounded Warrior Recovery Project, an ongoing web-based study. Military personnel with deployment-related mild TBI history reported similar rates of physical activity and levels of alcohol problems as those without, but were less likely to report receiving the recommended duration of sleep. When adjusting for demographic and injury variables, all three health behaviors were associated with cognitive, PTSD, and depressive symptoms. Alcohol problems demonstrated significant but small effects across all outcomes measures (ηp2=.01) whereas physical activity was associated with slightly larger effects albeit still within the small range (ηp2=.02-0.04). Duration of sleep bordered a medium effect for cognitive symptoms (ηp2=.05) and was in the medium range for PTSD and depressive symptoms (ηp2=.06). Although deployment-related mild TBI history was significant in all models, effect sizes were small (ηp2=.01). Findings from the present study provide support that health behaviors have stronger effects with regard to cognitive, PTSD, and depressive symptoms compared to deployment-related mild TBI history in military personnel and, given their modifiable nature, may represent treatment targets in this population.

Mechanisms through which executive dysfunction influences suicidal ideation in combat-exposed Iraq and Afghanistan veterans.

OBJECTIVE: Executive dysfunction has previously been associated with suicidality, but it remains unclear how deficits in executive functioning contribute to increased suicidal thoughts and behaviors. Although it has been proposed that poorer executive functioning leads to difficulty generating and implementing appropriate coping strategies to regulate distress and inhibit suicidal thoughts and behaviors, studies have not systematically examined these relationships. Therefore, the present study examined various hypotheses to elucidate the mechanisms through which executive dysfunction influences suicidal ideation (SI) in combat-exposed Iraq/Afghanistan veterans. METHOD: Veterans who endorsed SI were compared to those who denied SI on demographic and diagnostic variables and measures of neuropsychological functioning, psychological symptoms, coping styles, and combat experiences. Serial mediation models were tested to examine mechanistic relationships among executive functioning, psychological distress, coping, and SI. RESULTS: Those who endorsed SI had worse executive functioning, greater psychological distress, and greater avoidant coping relative to those who denied SI. Serial mediation model testing indicated a significant indirect path, such that executive dysfunction increased psychological distress, which in turn increased avoidant coping, leading to SI. CONCLUSIONS: Findings support and extend previous hypotheses regarding how executive functioning contributes to increased risk of suicidality via increased distress and avoidant coping. Intervention efforts focused on reducing suicidality may benefit from techniques that enhance executive functioning (e.g. computerized training, cognitive rehabilitation) and in turn reduce distress prior to targeting coping strategies.

White matter integrity, suicidal ideation, and cognitive dysfunction in combat-exposed Iraq and Afghanistan Veterans.

White matter alterations in frontolimbic circuits and poorer cognitive functioning have been observed in individuals endorsing suicidality across numerous psychiatric conditions. However, relationships between white matter integrity, cognition, and suicidality in Veterans are poorly understood, particularly for those at increased risk for suicide due to mental health conditions (e.g., posttraumatic stress disorder, depression) and traumatic brain injury history. We (1) examined white matter alterations in combat-exposed Iraq/Afghanistan Veterans with and without suicidal ideation (SI) and (2) investigated relationships between white matter integrity and neuropsychological functioning in regions that differed between SI groups. No group differences were found regarding psychiatric diagnoses. Participants with SI had lower fractional anisotropy (FA) in the posterior corona radiata, superior corona radiata, and superior longitudinal fasciculus relative to those without SI. Worse processing speed/attention performance was associated with lower FA in the superior longitudinal fasciculus, while worse executive functioning performance was associated with lower FA in the superior corona radiata and superior longitudinal fasciculus. Memory performance was not associated with FA. These findings suggest that white matter integrity may be involved in cognitive dysfunction and increased risk for SI. Interventions that target cognitive dysfunction may ameliorate SI, and in turn, reduce risk for suicide among Veterans.

Baseline sleep quality moderates symptom improvement in veterans with comorbid PTSD and TBI receiving trauma-focused treatment.

Poor sleep quality is common among Veterans with posttraumatic stress disorder (PTSD) and history of traumatic brain injury (TBI). However, the relationship between sleep quality and treatment outcomes following trauma-focused interventions is less well-understood in this population. We sought to better understand whether 1) sleep quality changed as a result of trauma-focused treatment and 2) if baseline sleep quality moderated psychological and neurobehavioral treatment outcomes. Our sample consisted of 100 Iraq/Afghanistan era Veterans with PTSD and history of mild to moderate TBI who were randomized to one of two trauma-focused treatments: 1) Cognitive Processing Therapy (CPT) or 2) combined CPT and Cognitive Symptom Management and Rehabilitation Therapy (SMART-CPT). Self-reported sleep quality, psychiatric symptoms (PTSD and depression), and neurobehavioral concerns were assessed at multiple timepoints throughout the study. Multilevel modeling showed sleep quality did not improve, regardless of treatment condition. However, worse baseline sleep quality was associated with less improvement in PTSD symptoms and cognitive complaints. There was no effect of baseline sleep quality on change in depression symptoms. These findings suggest that more targeted treatments to address sleep quality either prior to or in conjunction with trauma-focused therapy may help to improve treatment outcomes for Veterans with comorbid PTSD and TBI history.

Factors associated with employment and work perception in combat-exposed veterans.

PURPOSE/OBJECTIVE: The purpose of this study was 2-fold: (a) to evaluate whether perception of work ability is associated with employment status in a sample of combat-exposed veterans, and (b) to determine whether the same sets of variables that are associated with employment status are also associated with perception of work ability. Research Method/Design: In this cross-sectional study, veterans (N = 83) underwent a neuropsychological assessment and completed questionnaires assessing demographic characteristics, combat-related experiences, and psychiatric and neurobehavioral/health-related symptoms. Primary outcomes of interest were employment status (unemployed vs. employed) and veterans' perception of whether their ability to work has declined due to an ongoing condition (yes vs. no). RESULTS: A chi-square analysis revealed a significant relationship between perception of work ability and employment status. Additionally, psychiatric and neurobehavioral/health-related symptoms were associated with employment status and perception of work ability, whereas demographic characteristics (i.e., service-connected disability rating) and combat-related experiences (i.e., mTBI history) were only associated with perception of work ability. Objective cognitive functioning was not associated with employment status or perception of work ability. CONCLUSIONS/IMPLICATIONS: Although preliminary, results suggest that perception of work ability is an important factor to consider when evaluating employment-related outcomes in veterans. Moreover, results indicate that while there is some overlap among the variables associated with employment status and perception of work ability, additional variables are linked with perception of work ability. Taken together, these findings suggest that perception of one's ability to work and factors that influence it may be particularly important treatment targets in the veteran population. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Utility of the D-KEFS Color Word Interference Test as an embedded measure of performance validity.

Objective: The D-KEFS Color Word Interference Test (CWIT) is among the most commonly administered measures of verbally mediated processing speed and executive functioning. Previous research suggests that this test may also be sensitive to performance invalidity. We sought to develop new embedded measures of performance invalidity based on multi-condition performance on the CWIT and to evaluate previously proposed embedded measures for performance invalidity on this test.Method: Newly developed and previously proposed embedded measures were evaluated in three samples: a traumatic brain injury (TBI) sample (N = 224) classified into psychometrically-defined performance-valid and performance-invalid subgroups; the D-KEFS normative sample (N = 1,735); and a Parkinson's disease sample (N = 166). To explore the resilience of CWIT cutoffs to the effects of age and neurocognitive impairment, the D-KEFS normative sample was stratified into age groups of 8-19, 20-69, and 70-89 and the Parkinson's disease sample into normal cognition, mild cognitive impairment, and dementia groups.Results: Our newly developed embedded measures derived from within the TBI sample were largely resilient to the effects of age and neurocognitive impairment other than dementia. Overall, a cutoff of ≤18 on the sum of age-corrected scaled scores on all four conditions exhibited the strongest classification accuracy. In contrast, previously proposed cutoffs (Erdodi et al., 2018) produced unacceptable false-positive rates within the TBI sample and generally a high rate of potential false positives in the normative age and clinical groups.Conclusion: Scoring ≤18 on the sum of all conditions on the CWIT appears to be an optimal cutoff for performance invalidity detection in non-demented samples.