Quantifying relational change in community organisations participating in a Veteran suicide prevention learning collaborative: a social network analysis.

BACKGROUND: Veteran suicide remains a significant issue, as 17.5 Veterans die by suicide each day. The US Department of Veteran Affairs (VA) has implemented a robust suicide prevention program within its integrated behavioural health system. Further, the VA has increasingly contributed to suicide prevention in community settings, where a large proportion of Veterans receive health care and social services. One component integral to preventing suicide among Veterans receiving community services is ensuring that organisations are equipped with the latest evidence-based Veteran-specific suicide prevention strategies. METHODS: The Patient Safety Center of Inquiry-Suicide Prevention Collaborative piloted a Veteran suicide prevention learning collaborative in the Denver/Colorado Springs, CO region, spanning 16 months as a multimodal initiative to integrate community organisations and assist them in implementing Veteran suicide prevention strategies used within VA. Agencies completed social network analysis surveys at baseline (T1), year 1 (T2) and 16 months (T3) to examine social networks, partnerships and collaborations among community organisations and the VA over time. RESULTS: The quantity of learning collaborative relationships increased from 30 at T1 to 41 at T3 while the quality of relationships deepened over time from awareness and cooperative to more coordinated and integrated. CONCLUSION: Improvement in relationship quantity and quality facilitates community organisation engagement in collaborating to strengthen their Veteran suicide prevention programming. Learning collaboratives work with the individual organisation for intraorganisational facilitation of implementing suicide prevention strategies and engage and enhance interorganisational partnerships. This multimodal intervention can engage community organisations and provide a stronger safety net for Veterans at risk for suicide.

Mission Alliance Community Engagement Project: Exploring the Impact of COVID-19 on Social Isolation, Loneliness, Mental Health and Wellbeing in Veterans.

During the Coronavirus disease pandemic, many U.S. veterans with posttraumatic stress disorder (PTSD) experienced increased symptomology and worsened mental health and well-being due in part to social isolation and loneliness. The Mission Alliance project explored these ramifications and prioritized critical issues expressed by U.S. veterans and stakeholders (N = 182) during virtual regional meetings (N = 32). Field notes created specifically for this project were recorded and thematically analyzed. Emerging themes included: (1) social isolation: missed opportunities, collapsed social circles, work-life balance, fostering relationships, and evolving health care delivery; (2) loneliness: deteriorated mental health, suffered with PTSD together but alone, looked out for each other, ambivalence toward technology, and strained and broken systems; (3) mental health: sense of chaos, increased demand and decreased access, aggravation, implementation of tools, innovative solutions, fear and loss, and availability of resources; (4) wellbeing: sense of purpose, holistic perspective on well-being, recognition of balance, persisting stigma, redefined pressures, freedom to direct treatment, and reconnection and disconnection. A PTSD-related patient centered outcomes research (PCOR)/comparative effectiveness research (CER) agenda was developed from these themes. Establishment of a veteran and stakeholder network is suggested to support, facilitate, and promote the PTSD-related PCOR/CER agenda. Furthermore, enhancement of opportunities for veterans with PTSD and stakeholders to partner in PCOR/CER is required to develop and conduct projects that lead to PTSD-related comprehensive care of veterans affected by traumatic events with the potential to translate findings to other populations.

Contextual Triggers and Tic Severity Across Life Periods: A Retrospective Analysis in Adults with Tic Disorders.

In tic disorders (TD), tic expression varies across the lifespan and as a function of contextual factors. This study explored connections between tic expression and contextual triggers across life periods in 74 adults (Mage = 23.2) with TDs. The Tic History and Coping Strategies form assessed retrospective self-reports of contextual antecedents, consequences, and tic severity during four life periods (middle school; 9th/10th grade; 11th/12th grade; college/work) and past month. Tics reportedly worsened during and after school in school-aged years and worsened in the evening during college/work years. Stress and anxiety were reported to consistently trigger tics across time. The impact of activities, places, and emotions did not differ across life periods. Attention-based consequences, most prevalent during middle school, were more common than escape- or avoidance-related consequences across all periods. Findings illuminate how contextual factors may influence tics across life periods and underscore the consistent impact of tic-triggering emotions and attention-related consequences.

Mechanisms of change in posttraumatic headache-related disability: A mediation model.

OBJECTIVE: To explore whether the association between change in headache management self-efficacy and posttraumatic headache-related disability is partially mediated by a change in anxiety symptom severity. BACKGROUND: Many cognitive-behavioral therapy treatments for headache emphasize stress management, which includes anxiety management strategies; however, little is currently known about mechanisms of change in posttraumatic headache-related disability. Increasing our understanding of mechanisms could lead to improvements in treatments for these debilitating headaches. METHODS: This study is a secondary analysis of veterans (N = 193) recruited to participate in a randomized clinical trial of cognitive-behavioral therapy, cognitive processing therapy, or treatment as usual for persistent posttraumatic headache. The direct relationship between headache management self-efficacy and headache-related disability, along with partial mediation through change in anxiety symptoms was tested. RESULTS: The mediated latent change direct, mediated, and total pathways were statistically significant. The path analysis supported a significant direct pathway between headache management self-efficacy and headache-related disability (b = -0.45, p < 0.001; 95% confidence interval [CI: -0.58, -0.33]). The total effect of change of headache management self-efficacy scores on change in Headache Impact Test-6 scores was significant with a moderate-to-strong effect (b = -0.57, p = 0.001; 95% CI [-0.73, -0.41]). There was also an indirect effect through anxiety symptom severity change (b = -0.12, p = 0.003; 95% CI [-0.20, -0.04]). CONCLUSIONS: In this study, most of the improvements in headache-related disability were related to increased headache management self-efficacy with mediation occurring through change in anxiety. This indicates that headache management self-efficacy is a likely mechanism of change of posttraumatic headache-related disability with decreases in anxiety explaining part of the improvement in headache-related disability.

The interactions between patient preferences, expectancies, and stigma contribute to posttraumatic stress disorder treatment outcomes.

Cognitive processing therapy (CPT) is an effective treatment for posttraumatic stress disorder (PTSD); however, some patients do not improve to the same extent as others. It is important to understand potential factors that can be modified for better patient outcomes. This clinical trial implemented a three-arm, equipoise-stratified randomization design to allow for the accommodation of patient preference before randomization to one of three CPT treatment modalities: in-home, in-office, or telehealth. This study examined whether satisfaction with the modality, perceived stigma, expectations of therapy, and credibility of the therapist differed between modalities and whether these factors impacted treatment outcomes. We hypothesized that the contributions of these variables would depend upon whether participants opted out of any treatment arms and that these factors would predict treatment outcomes. Participants who endorsed less perceived stigma demonstrated larger reductions in PTSD symptom severity than those with similar levels of perceived stigma in the telehealth and in-office conditions, η2 = .12-.18. Participants who endorsed lower satisfaction with their treatment modality and were assigned to the in-home condition experienced larger PTSD symptom reductions than those with similar dissatisfaction in the telehealth and in-office conditions, η2 = .20. The results show the robustness of evidence-based therapies for PTSD given that dissatisfaction did not impede treatment success. In addition, they demonstrate that it is important for clinicians to address stigma before initiating evidence-based therapies for PTSD. Strategies to address these factors are discussed.

Treatment of comorbid sleep disorders and posttraumatic stress disorder in U.S. active duty military personnel: A pilot randomized clinical trial.

Insomnia and nightmares are common in patients with posttraumatic stress disorder (PTSD). They are associated with worse psychological and physical health and worse PTSD treatment outcomes. In addition, they are resistant to PTSD treatments, which do not typically address sleep disorders. Cognitive behavioral therapy for insomnia and nightmares (CBT-I&N) and cognitive processing therapy (CPT) for PTSD are first-line treatments, but limited evidence exists guiding the treatment of individuals with all three disorders. The current study randomized U.S. military personnel (N = 93) to one of three conditions: CBT-I&N delivered before CPT, CBT-I&N delivered after CPT, or CPT alone; all groups received 18 sessions. Across groups, participants demonstrated significantly improved PTSD symptoms. Because the study was terminated prematurely due to challenges with recruitment and retention, it was underpowered to answer the initially intended research questions. Nonetheless, statistical findings and relevant clinically meaningful changes were observed. Compared to participants who received CPT alone, those who received CBT-I&N and CPT, regardless of sequencing, demonstrated larger improvements in PTSD symptoms, d = -0.36; insomnia, d = -0.77; sleep efficiency, d = 0.62; and nightmares, d = -.53. Compared to participants who received CBT-I&N delivered before CPT, those who received CBT-I&N delivered after CPT demonstrated larger improvements in PTSD symptoms, d = 0.48, and sleep efficiency, d = -0.44. This pilot study suggests that treating comorbid insomnia, nightmares, and PTSD symptoms results in clinically meaningful advantages in improvement for all three concerns compared to treating PTSD alone.

Transcriptional regulators of the Golli/myelin basic protein locus integrate additive and stealth activities.

Myelin is composed of plasma membrane spirally wrapped around axons and compacted into dense sheaths by myelin-associated proteins. Myelin is elaborated by neuroepithelial derived oligodendrocytes in the central nervous system (CNS) and by neural crest derived Schwann cells in the peripheral nervous system (PNS). While some myelin proteins accumulate in only one lineage, myelin basic protein (Mbp) is expressed in both. Overlapping the Mbp gene is Golli, a transcriptional unit that is expressed widely both within and beyond the nervous system. A super-enhancer domain within the Golli/Mbp locus contains multiple enhancers shown previously to drive reporter construct expression specifically in oligodendrocytes or Schwann cells. In order to determine the contribution of each enhancer to the Golli/Mbp expression program, and to reveal if functional interactions occur among them, we derived mouse lines in which they were deleted, either singly or in different combinations, and relative mRNA accumulation was measured at key stages of early development and at maturity. Although super-enhancers have been shown previously to facilitate interaction among their component enhancers, the enhancers investigated here demonstrated largely additive relationships. However, enhancers demonstrating autonomous activity strictly in one lineage, when missing, were found to significantly reduce output in the other, thus revealing cryptic "stealth" activity. Further, in the absence of a key oligodendrocyte enhancer, Golli accumulation was markedly and uniformly attenuated in all cell types investigated. Our observations suggest a model in which enhancer-mediated DNA-looping and potential super-enhancer properties underlie Golli/Mbp regulatory organization.

Self-labelled encoder-decoder (SLED) for multi-echo gradient echo-based myelin water imaging.

PURPOSE: Reconstruction of high quality myelin water imaging (MWI) maps is challenging, particularly for data acquired using multi-echo gradient echo (mGRE) sequences. A non-linear least squares fitting (NLLS) approach has often been applied for MWI. However, this approach may produce maps with limited detail and, in some cases, sub-optimal signal to noise ratio (SNR), due to the nature of the voxel-wise fitting. In this study, we developed a novel, unsupervised learning method called self-labelled encoder-decoder (SLED) to improve gradient echo-based MWI data fitting. METHODS: Ultra-high resolution, MWI data was collected from five mouse brains with variable levels of myelination, using a mGRE sequence. Imaging data was acquired using a 7T preclinical MRI system. A self-labelled, encoder-decoder network was implemented in TensorFlow for calculation of myelin water fraction (MWF) based on the mGRE signal decay. A simulated MWI phantom was also created to evaluate the performance of MWF estimation. RESULTS: Compared to NLLS, SLED demonstrated improved MWF estimation, in terms of both stability and accuracy in phantom tests. In addition, SLED produced less noisy MWF maps from high resolution MR microscopy images of mouse brain tissue. It specifically resulted in lower noise amplification for all mouse genotypes that were imaged and yielded mean MWF values in white matter ROIs that were highly correlated with those derived from standard NLLS fitting. Lastly, SLED also exhibited higher tolerance to low SNR data. CONCLUSION: Due to its unsupervised and self-labeling nature, SLED offers a unique alternative to analyze gradient echo-based MWI data, providing accurate and stable MWF estimations.

In-office, in-home, and telehealth cognitive processing therapy for posttraumatic stress disorder in veterans: a randomized clinical trial.

BACKGROUND: Trauma-focused psychotherapies for combat-related posttraumatic stress disorder (PTSD) in military veterans are efficacious, but there are many barriers to receiving treatment. The objective of this study was to determine if cognitive processing therapy (CPT) for PTSD among active duty military personnel and veterans would result in increased acceptability, fewer dropouts, and better outcomes when delivered In-Home or by Telehealth as compared to In-Office treatment. METHODS: The trial used an equipoise-stratified randomization design in which participants (N = 120) could decline none or any 1 arm of the study and were then randomized equally to 1 of the remaining arms. Therapists delivered CPT in 12 sessions lasting 60-min each. Self-reported PTSD symptoms on the PTSD Checklist for DSM-5 (PCL-5) served as the primary outcome. RESULTS: Over half of the participants (57%) declined 1 treatment arm. Telehealth was the most acceptable and least often refused delivery format (17%), followed by In-Office (29%), and In-Home (54%); these differences were significant (p = 0.0008). Significant reductions in PTSD symptoms occurred with all treatment formats (p < .0001). Improvement on the PCL-5 was about twice as large in the In-Home (d = 2.1) and Telehealth (d = 2.0) formats than In-Office (d = 1.3); those differences were statistically large and significant (d = 0.8, 0.7 and p = 0.009, 0.014, respectively). There were no significant differences between In-Home and Telehealth outcomes (p = 0.77, d = -.08). Dropout from treatment was numerically lowest when therapy was delivered In-Home (25%) compared to Telehealth (34%) and In-Office (43%), but these differences were not statistically significant. CONCLUSIONS: CPT delivered by telehealth is an efficient and effective treatment modality for PTSD, especially considering in-person restrictions resulting from COVID-19. TRIAL REGISTRATION: ClinicalTrials.gov ID NCT02290847 (Registered 13/08/2014; First Posted Date 14/11/2014).

Mindfulness-Based Interdisciplinary Pain Management Program for Complex Polymorbid Pain in Veterans: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the effects of interdisciplinary pain management on pain-related disability and opioid reduction in polymorbid pain patients with 2 or more comorbid psychiatric conditions. DESIGN: Two-arm randomized controlled trial testing a 3-week intervention with assessments at pre-treatment, post-treatment, 6-month, and 12-month follow-up. SETTING: Department of Veterans Affairs medical facility. PARTICIPANTS: 103 military veterans (N=103) with moderate (or worse) levels of pain-related disability, depression, anxiety, and/or posttraumatic stress disorder randomly assigned to usual care (n=53) and interdisciplinary pain management (n=50). All participants reported recent persistent opioid use. Trial participants had high levels of comorbid medical and mental health conditions. INTERVENTIONS: Experimental arm-a 3-week, interdisciplinary pain management program guided by a structured manual; comparison arm-usual care in a large Department of Veterans Affairs medical facility. MAIN OUTCOME MEASURES: Oswestry Disability Index (pain disability); Timeline Followback Interview and Medication Event Monitoring System (opioid use). Analysis used generalized linear mixed model with all posttreatment observations (posttreatment, 6-month follow-up, 12-month follow-up) entered simultaneously to create a single posttreatment effect. RESULTS: Veterans with polymorbid pain randomized to the interdisciplinary pain program reported significantly greater decreases in pain-related disability compared to veterans randomized to treatment as usual (TAU) at posttreatment, 6-month, and 12-month follow-up. Aggregated mean pain disability scores (ie, a summary effect of all posttreatment observations) for the interdisciplinary pain program were -9.1 (95% CI: -14.4, -3.7, P=.001) points lower than TAU. There was no difference between groups in the proportion of participants who resumed opioid use during trial participation (32% in both arms). CONCLUSION: These findings offer the first evidence of short- and long-term interdisciplinary pain management efficacy in polymorbid pain patients, but more work is needed to examine how to effectively decrease opioid use in this population.

Natural recovery from posttraumatic stress in injured military service members: A commentary on Soumoff et al. (2021).

Soumoff et al. (2021) reported on a sample of 2,217 injured military service members and found that somatic symptom severity was more predictive of the development of probable posttraumatic stress disorder (PTSD) symptoms than injury severity. PTSD has been described as one of the invisible wounds of war, suggesting that many military service members with PTSD may suffer in silence because some symptoms-such as psychological and somatic symptoms-are often not observable by others. In contrast, friends, family, fellow service members, and health care providers often ask military service members with visible, physical wounds what happened, prompting a discussion of their injury and the events that contributed to it. I posit that the findings reported by Soumoff et al. may be an example of the differences that can occur in the course of natural recovery in military service members suffering from visible versus invisible wounds of war and further hypothesize that the repeated conversations that often occur after physical injuries in military service members may foster natural recovery from the co-occurring invisible, psychological wounds of war.

The associations between posttraumatic stress disorder and delay discounting, future orientation, and reward availability: A behavioral economic model.

The theoretical framework of behavioral economics, a metatheory that integrates operant learning and economic theory, has only recently been applied to posttraumatic stress disorder (PTSD). A behavioral economic theory of PTSD reflects an expansion of prior behavioral conceptualization of PTSD, which described PTSD in terms of respondent and operant conditioning. In the behavioral economic framework of PTSD, negatively reinforced avoidance behavior is overvalued, in part due to deficits in environmental reward, and may be conceptualized as a form of reinforcer pathology (i.e., excessive preference for and valuation of an immediate reinforcer). We investigated cross-sectional relationships between PTSD severity and several constructs rooted in this behavioral economic framework, including future orientation, reward availability, and delay discounting in a sample of 110 military personnel/veterans (87.2% male) who had served combat deployments following September 11, 2001. Total PTSD severity was inversely related to environmental reward availability, ß = -.49, ΔR2 = 0.24, p < .001; hedonic reward availability, ß = -.32, ΔR2 = 0.10, p = .001; and future orientation, ß = -.20, ΔR2 = 0.04, p = .032, but not delay discounting, r = -.05, p = .633. An examination of individual symptom clusters did not suggest that avoidance symptoms were uniquely associated with these behavioral economic constructs. The findings offer support for a behavioral economic model of PTSD in which there is a lack of positive reinforcement as well as a myopic focus on the present.

Combining a stellate ganglion block with prolonged exposure therapy for posttraumatic stress disorder: A nonrandomized clinical trial.

Prolonged exposure therapy (PE) is an efficacious treatment for active duty service members and veterans with posttraumatic stress disorder (PTSD). However, PE is sometimes associated with high dropout rates, limited tolerability, and temporary symptom exacerbation during treatment. Stellate ganglion blocks (SGBs) are an emerging treatment that has the potential to enhance outcomes for PTSD when combined with trauma-focused psychotherapy. To date, no study of which we are aware has examined the potential additive benefits of SGB injections when administered in conjunction with trauma-focused behavioral treatment for PTSD. Thus, we conducted a nonrandomized clinical trial to evaluate the use of an SGB combined with massed PE therapy for combat-related PTSD. Participants (N = 12) were treated with 10 daily 90-min PE sessions delivered over 2 weeks and received a single SGB injection between Sessions 1 and 2. PE sessions lasted 90 min each. Participants reported a mean posttreatment PTSD symptom reduction of 32 points on the PTSD Checklist for DSM-5 (PCL-5), Hedges' gs = 1.28-2.80. Most participants (90.9%) demonstrated clinically significant change on the PCL-5 (i.e., ≥10 points) by the final treatment session and 50.0% no longer met the diagnostic criteria for PTSD per the Clinician-Administered PTSD Scale for DSM-5 at 1-month follow-up. Adverse events for the combined treatment were consistent with those previously reported for standalone SGB and PE. This combined treatment approach provides promising results for improving the tolerability of trauma-focused therapies, reducing symptom severity, and increasing PTSD remission rates.

Secondary individual outcomes following multicouple group therapy for posttraumatic stress disorder: An uncontrolled pilot study with military dyads.

Cognitive-behavioral conjoint therapy (CBCT) for posttraumatic stress disorder (PTSD) has demonstrated efficacy for improving PTSD and comorbid symptoms and relationship adjustment. To enhance treatment efficiency and scalability, we developed a 2-day, abbreviated, intensive, multicouple group version of CBCT for PTSD (AIM-CBCT for PTSD). Prior work demonstrated that AIM-CBCT for PTSD wasassociated with reductions in PTSD and comorbid symptoms in a sample of 24 post-9/11 active duty military or veteran couples who received the treatment in a retreat format over a single weekend. The current study investigated secondary outcomes regarding trauma-related cognitions, psychosocial impairment, and insomnia. For trauma-related cognitions, reductions were nonsignificant and small at 1-month follow-up, ds = -0.14 to -0.32. However, by 3-month follow-up, there were significant, medium effect size reductions in total trauma-related cognitions, d = -0.68, and negative views of self and others, ds = -0.64 and -0.57, respectively, relative to baseline. There was also a nonsignificant, small-to-medium effect-size reduction in self-blame, d = -0.43, p = .053, by 3-month follow-up. For psychosocial impairment, there were significant and medium-to-large and large effect size reductions by 1- and 3-month follow-ups, ds = -0.73 and -0.81, respectively. There were nonsignificant, small effect size reductions in insomnia at both 1- and 3-month follow-ups relative to baseline, ds = -0.30 and -0.34, respectively. These findings suggest that AIM-CBCT for PTSD is associated with reductions in maladaptive posttraumatic cognitions and psychosocial impairment but that adjunctive interventions may be needed to address insomnia.

The impact of prior head injury on outcomes following group and individual cognitive processing therapy among military personnel.

This study examined the impact of a history of head injury (HHI) on posttraumatic stress disorder (PTSD) and depression symptoms in active duty military personnel following group and individual cognitive processing therapy (CPT). Data for these secondary analyses were drawn from a clinical trial comparing group and individual CPT. Service members (N = 268, 91.0% male) were randomized to 12 sessions of group (n = 133) or individual (n = 135) CPT. Most participants (57.1%) endorsed a deployment-related HHI, 92.8% of whom reported currently experiencing symptoms (CES) related to the head injury (i.e., HHI/CES). Patients classified as non-HHI/CES demonstrated large, significant improvements in PTSD symptom severity in both individual and group therapy, ds = 1.1, p < .001. Patients with HHI/CES status showed similar significant improvements when randomized to individual CPT, d = 1.4, p < .001, but did not demonstrate significant improvements when randomized to group CPT, d = 0.4, p = .060. For participants classified as HHI/CES, individual CPT was significantly superior to group CPT, d = 0.98, p = .003. Symptoms of depression improved following treatment, with no significant differences by treatment delivery format or HHI/CES status. The findings of this clinical trial subgroup study demonstrate evidence that group CPT is less effective than individual CPT for service members classified as HHI/CES. The results suggest that HHI/CES status may be important to consider in selecting patients for group or individual CPT; additional research is needed to confirm the clinical implications of these findings.

Testing the role of aerobic exercise in the treatment of posttraumatic stress disorder (PTSD) symptoms in U.S. active duty military personnel: a pilot study.

The purpose of this pilot study was to determine if the efficacy of imaginal exposure for symptoms of posttraumatic stress disorder (PTSD) could be improved by adding aerobic exercise. We hypothesized that aerobic exercise would enhance the efficacy of exposure therapy. Active duty service members with clinically significant symptoms of posttraumatic stress (PTSD Checklist-Stressor-Specific Version, [PCL-S], ≥25) were randomized into one of four conditions: exercise only; imaginal exposure only; imaginal exposure plus exercise; no exercise/no exposure therapy (control). Participants (N = 72) were primarily male, Army, noncommissioned officers ranging in age from 22 to 52. PTSD symptom severity decreased over time (p < .0001); however, there were no significant differences between the experimental conditions. The prediction that imaginal exposure augmented with aerobic exercise would be superior to either imaginal exposure alone or aerobic exercise alone was not supported, suggesting that engaging in exercise and imaginal exposure simultaneously may not be any better than engaging in either activity alone. A better understanding of individually administered and combined exercise and exposure therapy interventions for PTSD is warranted.

Development and psychometric validation of the Dispositional Recovery and Dysfunction Inventory: a tool to assess for positive and negative cognitions following trauma exposure.

BACKGROUND: Recovery from trauma can be naturally occurring or facilitated through psychotherapy. Few brief measures exist to provide clinicians with dispositional, empirical assessments of patient's sentiments during psychotherapy. AIMS: This manuscript presents the Dispositional Recovery and Dysfunction Inventory (DRDI), a measure created to assist clinicians in evaluating patient's treatment progress during psychotherapy, as well as evaluate its factor structure, reliability estimates, measurement invariance, and correlates. METHOD: The DRDI was created based on feedback from experts with experience treating posttraumatic stress disorder (PTSD) and was structurally validated in two distinct populations. Exploratory factor analysis was conducted in sample 1 consisting of (n=401) university students. Confirmatory factor analysis, measure validity and structure validation were then conducted in sample 2 (n=249) composed of 49% individuals with clinically significant PTSD symptoms. RESULTS: Exploratory and confirmatory factor analysis revealed that the DRDI was best represented by a two-factor correlated traits model representing sentiments related to dispositional recovery and dysfunctional cognitions. The recovery subscale exhibited relationships with convergent measures including authenticity and psychological hardiness (r values of .30 to .60). The dysfunctional beliefs subscale exhibited relationships with convergent measures: PTSD, depression, suicidality and stress (r values of .55 to 80). Measurement invariance across gender and PTSD status was observed. CONCLUSION: Initial findings indicate that the DRDI has the potential to be a useful tool to assess individuals' beliefs about their propensity to recover from and thrive through adversity.

Conducting a Pragmatic Trial in Integrated Primary Care: Key Decision Points and Considerations.

Pragmatic trials testing the effectiveness of interventions under "real world" conditions help bridge the research-to-practice gap. Such trial designs are optimal for studying the impact of implementation efforts, such as the effectiveness of integrated behavioral health clinicians in primary care settings. Formal pragmatic trials conducted in integrated primary care settings are uncommon, making it difficult for researchers to anticipate the potential pitfalls associated with balancing scientific rigor with the demands of routine clinical practice. This paper is based on our experience conducting the first phase of a large, multisite, pragmatic clinical trial evaluating the implementation and effectiveness of behavioral health consultants treating patients with chronic pain using a manualized intervention, brief cognitive behavioral therapy for chronic pain (BCBT-CP). The paper highlights key choice points using the PRagmatic-Explanatory Continuum Indicator Summary (PRECIS-2) tool. We discuss the dilemmas of pragmatic research that we faced and offer recommendations for aspiring integrated primary care pragmatic trialists.

Persistent posttraumatic headaches and functioning in veterans: Injury type can matter.

OBJECTIVE: To characterize the relationship between head trauma types (blast injury, blunt injury, combined blast+blunt injury) with subsequent headache presentations and functioning. BACKGROUND: Posttraumatic headaches (PTHs), the most common sequelae of traumatic brain injury (TBI), are painful and disabling. More than 400,000 veterans report having experienced a TBI, and understanding the predictors of PTHs may guide treatment developments. METHODS: This study used a nested-cohort design analyzing baseline data from a randomized clinical trial of cognitive behavioral therapy for PTH (N = 190). Participants had PTH (from blast and/or blunt head trauma) and symptoms of posttraumatic stress disorder (PTSD). The Structured Diagnostic Interview for Headache-Revised and Ohio State University Traumatic Brain Injury Identification Method were used to phenotype headaches and head injury histories, respectively. RESULTS: Individuals with persistent PTHs after a combined blast and blunt head trauma were more likely (OR =3.45; 95% CI [1.41, 8.4]) to experience chronic (vs. episodic) PTHs compared with the blunt trauma only group (23/33, 70% vs. 26/65, 40%, respectively); and they were more likely (OR =2.51; 95% CI [1.07, 5.9]) to experience chronic PTH compared with the blast trauma only group (44/92, 48%). There were no differences between head injury type on headache-related disability, depression symptoms, or severity of PTSD symptoms. CONCLUSION: The combination of blast and blunt injuries was associated with headache chronicity, but not headache disability. Considering the refractory nature of chronic headaches, the potential added and synergistic effects of distinct head injuries warrant further study.

Examination of the Factor Structure and Correlates of the Perceived Military Healthcare Stressors Scale.

The current study evaluated the factor structure, reliability estimates, correlates, and predictive utility of the Perceived Military Healthcare Stressor Scale (PMHSS) in a sample of active duty military medical personnel (N = 1,131) deployed to Joint Base Balad in Iraq. The sample was composed of an approximately even split of male (51.2%) and female (48.8%) participants who ranged in age from 18 to 60 years. The PMHSS is a 21-item measure that was designed to assess the impact of specific medical stressors that military healthcare providers may encounter while deployed. An exploratory factor analysis of the PMHSS revealed the presence of two distinct factors: trainable and futility stressors. Confirmatory factor analysis showed that a bifactor model best represented the data, with all items loading higher on the general factor relative to their specific subscale factors. Evidence of partial scalar invariance by gender was found. The PMHSS was significantly correlated with several convergent measures, including assessments of posttraumatic stress disorder (PTSD), depression severity, distress due to both combat exposure and general deployment-related concerns, and positive affect, rs = .30-.59. PMHSS scores were more strongly correlated with PTSD and depression in women than in men, and they provided incremental validity in predicting convergent measures over and above other related constructs. Healthcare-specific stressors are an understudied area, and this study provides new insights into how deployment-related caregiving stress may impact deployed military medical personnel independently of the impact of combat experiences.