Suicide risk communication and intervention preferences for veterans and service members.

Despite the investment of public resources to fight staggering suicide rates among veterans, we know little about how veterans and service members in crisis communicate suicidal ideations, and what interventions they are willing to receive. We aim to identify communication and suicide intervention preferences of veterans and service members in times of crisis. Descriptive statistics were used to explore veterans communication of suicidal ideations. While 89.9% of participants indicated they were willing to speak to someone when having thoughts of suicide, less than 26% of participants indicated they were willing to bring up their thoughts with a crisis line or veterans organization. Rather, they indicate that family members (62.2%) and military friends (51.1%) would be their primary outreach. Logistic regression was used to determine whether or not preferred interventions varied by participant demographic characteristics. While the majority of participants indicated they were willing to allow intervention (88.6%), no one method was accepted by the majority of the population. The most accepted means of communication was to proactively contact a friend or family member about general life struggles (32.6%) or suicide-specific concerns (27.5%). Many participants were open to receiving resources (42.0%), suicide-specific mental health treatment (36.3%), and some sort of lethal means safety intervention (19.1%-26.4%). The age, marital status, and veterans status of participants significantly impacted what interventions they were willing to allow. We discuss the implications of these findings and the need for evidence-based, multimodal interventions in order to assist veterans in need.

Acceptance and Commitment Therapy for Co-Occurring Posttraumatic Stress Disorder and Alcohol Use Disorders in Veterans: Pilot Treatment Outcomes.

Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) frequently co-occur and are associated with worse outcomes together than either disorder alone. A lack of consensus regarding recommendations for treating PTSD-AUD exists, and treatment dropout is a persistent problem. Acceptance and Commitment Therapy (ACT), a transdiagnostic, mindfulness- and acceptance-based form of behavior therapy, has potential as a treatment option for PTSD-AUD. In this uncontrolled pilot study, we examined ACT for PTSD-AUD in 43 veterans; 29 (67%) completed the outpatient individual therapy protocol (i.e., ≥ 10 of 12 sessions). Clinician-assessed and self-reported PTSD symptoms were reduced at posttreatment, ds = 0.79 and 0.96, respectively. Self-reported symptoms of PTSD remained lower at 3-month follow-up, d = 0.88. There were reductions on all alcohol-related outcomes (clinician-assessed and self-reported symptoms, total drinks, and heavy drinking days) at posttreatment and 3-month follow-up, dmean = 0.91 (d range: 0.65-1.30). Quality of life increased at posttreatment and follow-up, ds = 0.55-0.56. Functional disability improved marginally at posttreatment, d = 0.35; this effect became significant by follow-up, d = 0.52. Fewer depressive symptoms were reported at posttreatment, d = 0.50, and follow-up, d = 0.44. Individuals experiencing suicidal ideation reported significant reductions by follow-up. Consistent with the ACT theoretical model, these improvements were associated with more between-session mindfulness practice and reductions in experiential avoidance and psychological inflexibility. Recommendations for adapting ACT to address PTSD-AUD include assigning frequent between-session mindfulness practice and initiating values clarification work and values-based behavior assignments early in treatment.

Promoting Help Seeking to Veterans.

BACKGROUND: Few studies have considered different messaging strategies that may augment campaign efficacy to generate help-seeking behaviors among populations at increased risk for suicide, mainly US military veterans. AIMS: Findings are presented from the pilot evaluation of the It's Your Call campaign implemented by the Department of Veterans Affairs (VA). Three messaging strategies (with varying intensity and mix of messages) were compared to explore which best promote use of the Veterans Crisis Line (VCL) among veteran populations. METHOD: Daily VCL call data were obtained for 10 US cities during 2011-2012 where the campaign was active, and modeled using Poisson regression to identify changes in utilization patterns associated with the implementation of different messaging strategies. RESULTS: Significant increases in call rates were only evident during the campaign in communities where mixed messages were disseminated. Further, use of mixed messages yielded greater increases in call rates when compared with the other tested strategies. This was an observational study where identification of causal relationships between variables was limited. CONCLUSION: Findings are encouraging as messaging was associated with help seeking, and they provide insights into strategies that may rapidly promote crisis line use. Results also underscore the need for further research on suicide prevention campaigns and dissemination practices.

Military Sexual Trauma Among Recent Veterans: Correlates of Sexual Assault and Sexual Harassment.

INTRODUCTION: Military sexual trauma (MST) includes sexual harassment or sexual assault that occurs during military service and is of increasing public health concern. The population prevalence of MST among female and male veterans who served during Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) has not been estimated to our knowledge. The purpose of this study is to assess the population prevalence and identify military correlates of MST, sexual harassment, and sexual assault among OEF/OIF veterans. METHODS: MST was assessed in the 2009-2011 National Health Study for a New Generation of U.S. Veterans, a survey of 60,000 veterans who served during the OEF/OIF eras (response rate, 34%, n=20,563). Weighted prevalence estimates and AORs of MST, sexual harassment, and sexual assault among women and men were calculated. Gender-stratified logistic regression models controlled for military and demographic characteristics. Data analyses were conducted in 2013-2014. RESULTS: Approximately 41% of women and 4% of men reported experiencing MST. Deployed men had lower risk for MST compared with non-deployed men, though no difference was found among women. However, veterans reporting combat exposure during deployment had increased risk for MST compared with those without, while controlling for OEF/OIF deployment. Among women, Marines and Navy veterans had increased risk for MST compared with Air Force veterans. MST was significantly higher among veterans who reported using Veterans Affairs healthcare services. CONCLUSIONS: These prevalence estimates underscore the importance of public awareness and continued investigation of the public health impact of MST.

Collaborating across the Departments of Veterans Affairs and Defense to integrate mental health and chaplaincy services.

BACKGROUND: Recognizing that clergy and spiritual care providers are a key part of mental health care systems, the Department of Veterans Affairs (VA) and Department of Defense (DoD) jointly examined chaplains' current and potential roles in caring for veterans and service members with mental health needs. OBJECTIVE: Our aim was to evaluate the intersection of chaplain and mental health care practices in VA and DoD in order to determine if improvement is needed, and if so, to develop actionable recommendations as indicated by evaluation findings. DESIGN: A 38-member multidisciplinary task group partnered with researchers in designing, implementing, and interpreting a mixed methods study that included: 1) a quantitative survey of VA and DoD chaplains; and 2) qualitative interviews with mental health providers and chaplains. PARTICIPANTS: Quantitative: the survey included all full-time VA chaplains and all active duty military chaplains (n = 2,163 completed of 3,464 invited; 62 % response rate). Qualitative: a total of 291 interviews were conducted with mental health providers and chaplains during site visits to 33 VA and DoD facilities. MAIN MEASURES: Quantitative: the online survey assessed intersections between chaplaincy and mental health care and took an average of 37 min to complete. Qualitative: the interviews assessed current integration of mental health and chaplain services and took an average of 1 h to complete. KEY RESULTS: When included on interdisciplinary mental health care teams, chaplains feel understood and valued (82.8-100 % of chaplains indicated this, depending on the team). However, findings from the survey and site visits suggest that integration of services is often lacking and can be improved. CONCLUSIONS: Closely coordinating with a multidisciplinary task group in conducting a mixed method evaluation of chaplain-mental health integration in VA and DoD helped to ensure that researchers assessed relevant domains and that findings could be rapidly translated into actionable recommendations.

Disparities in adverse childhood experiences among individuals with a history of military service.

IMPORTANCE: Adverse childhood experiences (ACEs) are associated with several adulthood health problems, such as self-directed violence. For some individuals, enlistment in the military may be an instrumental act to escape adverse household environments; however, to our knowledge prevalence of ACEs among persons with a history of military service has not been documented in the United States using population-based data. OBJECTIVE: To compare the prevalence of ACEs among individuals with and without a history of military service. DESIGN, SETTING, AND PARTICIPANTS: Data are from the 2010 Behavioral Risk Factor Surveillance System. Computer-assisted telephone interviews were conducted with population-based samples of noninstitutionalized US adults from January 1 through December 31, 2010. Analyses were limited to respondents who received the ACE module (n = 60,598). Participants were categorized by history of military service and whether a respondent was 18 years of age in 1973. MAIN OUTCOMES AND MEASURES: History of military service was defined by active duty service, veteran status, or training for the Reserves or National Guard. The ACE inventory assessed 11 negative experiences before the age of 18 years. Weighted χ2 tests and multiple logistic regression analyses were used to examine differences in ACEs by history of military service, era of service, and sex. RESULTS: Those with military experience had greater odds of any difference in prevalence of ACEs. In the all-volunteer era, men with military service had a higher prevalence of ACEs in all 11 categories than men without military service. Notably, in the all-volunteer era, men with military service had twice the odds of reporting forced sex before the age of 18 years (odds ratio, 2.19; 95% CI, 1.34-3.57) compared with men without military service. In the draft era, the only difference among men was household drug use, in which men with a history of military service had a significantly lower prevalence than men without a history of military service (2.1% vs. 3.3%; P = .003). Fewer differences were observed among women in the all-volunteer and draft eras. CONCLUSIONS AND RELEVANCE: Differences in ACEs by era and sex lend preliminary support that enlistment may serve as an escape from adversity for some individuals, at least among men. Further research is needed to understand how best to support service members and veterans who may have experienced ACEs.

Sexual trauma disclosure in clinical settings: addressing diversity.

Although sexual trauma is an experience with wide prevalence, it remains difficult for many individuals to discuss this trauma openly with others. Disclosure of a sexual trauma history to a receptive individual can lead to both emotional and instrumental support. However, a myriad of factors related not only to current circumstances but also to cultural and individual differences determine whether an individual will choose to share his or her trauma history with someone else. Mental health clinicians may be more likely than many other people to be the recipients of a disclosure of sexual trauma. Thus, ensuring that clinicians show sensitivity to the role that diverse demographic and cultural factors can play in the process of disclosure is important to facilitating a thoughtful and productive response to such an event. The current article reviews a segment of the literature on disclosure of sexual assault and focuses on selected diversity domains (i.e., nonheterosexual orientation, age, gender, and race) that may impact the disclosure of sexual assault. Practical suggestions are proposed to assist clinicians in assessing sexual trauma and facilitating disclosure in a culturally competent manner.

Measuring avoidance in medical rehabilitation.

OBJECTIVE: To establish psychometric properties of the Acceptance and Action Questionnaire (AAQ), a measure of avoidance, in medical rehabilitation populations. STUDY DESIGN: Cross-sectional and longitudinal. SETTING: Three acute, inpatient rehabilitation units. PARTICIPANTS: One hundred thirty-nine adults with spinal cord dysfunction, stroke, amputation, or orthopedic surgery. MEASURES: AAQ, Hope Scale, Spiritual Well-Being Scale, Positive and Negative Affect Scale, Brief Symptom Inventory, Hopkins Rehabilitation Engagement Rating Scale, Functional Independence Measure, Craig Handicap Assessment and Reporting Technique, Satisfaction with Life Scale. RESULTS: The AAQ has adequate internal consistency (alpha = .70), is best understood with a two-factor solution, is positively correlated with depression (r = .36, p < .01) and negative affect (r = .41, p < .001), and is negatively correlated with hope (r = -.51, p < .001), positive affect (r = -.33, p < .001), and spiritual well-being (r = -.32, p < .001). Predictive relationships with life satisfaction (beta = -.40, p < .001) and level of handicap (beta = -.20, p < .014) were found at 3-month follow-up. CONCLUSIONS: Findings provide preliminary support that the AAQ is reliable and valid in medical populations and that avoidance plays an important role in rehabilitation outcomes.

Veteran interest in family involvement in PTSD treatment.

[Correction Notice: An erratum for this article was reported in Vol 7(3) of Psychological Services (see record 2010-17074-004). The copyright for the article was listed incorrectly. This article is in the Public Domain. The online version has been corrected.] The present study examined interest in family involvement in treatment and preferences concerning the focus of family oriented treatment for veterans (N = 114) participating in an outpatient Veterans Affairs outpatient posttraumatic stress disorder (PTSD) program. Most veterans viewed PTSD as a source of family stress (86%) and expressed interest in greater family involvement in their treatment (79%). These results suggest the need to consider increasing family participation in the clinical care of individuals with PTSD and to develop specialized family educational and support services for this population. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

Psychological services for returning veterans and their families: evolving conceptualizations of the sequelae of war-zone experiences.

The provision of effective and timely behavioral health care for veterans returning from the conflicts in Iraq and Afghanistan has become the focus of national attention. In this special issue, attempts to provide psychological care for service members and their families are examined in light of three key constructs. First, it is contended that at no other time in history has more attention been paid to the psychological consequences of engaging in combat. Second, for the first time in recorded warfare, psychological morbidity is likely to far outstrip physical injury associated with combat. Finally, although posttraumatic stress disorder and traumatic brain injury are serious concerns, most service members return without significant physical or psychological injury and will be able to return to functioning without notable problems. Accurate diagnosis, a focus on resilience, and the expectation of readjustment are essential precepts that should guide clinical efforts and resource allocation.

Integrative outpatient treatment for returning service members.

Veterans returning from Operations Enduring and Iraqi Freedom (OEF/OIF) frequently present with multiple psychological and physical symptoms. The authors propose an innovative approach in which primary care providers, polytrauma specialists, vocational rehabilitation specialists, and mental health clinicians work together to provide care that is not simply concurrent, but truly integrated. All members of this interdisciplinary team must provide a consistent message that supports treatment engagement and progress. The authors illustrate this approach with a case report of a soldier deployed to both OEF and OIF, requiring subsequent treatment for joint pain, headaches, mild traumatic brain injury, posttraumatic stress disorder, depression, and substance abuse. Despite the emphasis on early intervention, treatment engagement and retention remain challenges in this population.

Post-traumatic stress reactions before the advent of post-traumatic stress disorder: potential effects on the lives and legacies of Alexander the Great, Captain James Cook, Emily Dickinson, and Florence Nightingale.

Evidence is presented that Alexander the Great, Captain James Cook, Emily Dickinson, and Florence Nightingale each developed symptoms consistent with post-traumatic stress disorder in the aftermath of repeated potentially traumatizing events of differing character. Their case histories also varied with respect to background, premorbid personality style, risk factors, clinical presentation, and course of the illness, illustrating the pleomorphic character of the disorder, as well as the special problems in diagnosing it in historical figures.

Chronic avoidance helps explain the relationship between severity of childhood sexual abuse and psychological distress in adulthood.

Recent studies have found that chronic avoidance of unpleasant internal experiences (e.g., thoughts, emotions, memories) is a maladaptive means of affect regulation often adopted by women with a history of sexual victimization in childhood. The primary aim of this study was to replicate and extend previous findings suggesting that higher levels of experiential avoidance may account for the relationship between childhood sexual abuse (CSA) and psychological distress in adulthood. It was hypothesized that, in a sample of undergraduate females (n = 151), the relationship between severity of CSA (e.g., frequency, nature of victimization) and trauma-related psychological distress would be mediated by avoidance. Results supported this hypothesis. Findings are consistent with previous studies, and further suggest that the general tendency to avoid or escape from unpleasant internal experiences may be a specific factor that exacerbates psychological distress among women with a history of sexual victimization in childhood.

Acceptance and commitment therapy in the treatment of posttraumatic stress disorder.

The current article describes the application of a behavioral psychotherapy, acceptance and commitment therapy (ACT), to the treatment of post-traumatic stress disorder (PTSD). It is argued that PTSD can be conceptualized as a disorder that is developed and maintained in traumatized individuals as a result of excessive, ineffective attempts to control unwanted thoughts, feelings, and memories, especially those related to the traumatic event(s). As ACT is a therapeutic method designed specifically to reduce experiential avoidance, it may be a treatment that is particularly suited for individuals with PTSD. The application of ACT to PTSD is described, and a case example is used to demonstrate how this therapy can be successfully used with individuals presenting for life problems related to a traumatic event.

An experimental study of emotional responding in women with posttraumatic stress disorder related to interpersonal violence.

Although posttraumatic stress disorder (PTSD) is defined by the experience of intense negative emotions and emotional numbing (American Psychiatric Association, 1994), empirical study of emotional responding in PTSD has been limited. This study examined emotional responding among women with and without PTSD to positive and negative film stimuli across self-reported experience, facial expression, and written expression. Consistent with previous findings, no evidence for generalized numbing was found. In general, women with PTSD exhibited higher levels of negative activation and expressed more negative emotion words to both positive and negative film stimuli, whereas no group differences emerged in facial expressivity. Results are interpreted within the context of the current literature on emotional deficits associated with PTSD.

Childhood maltreatment as a risk factor for adult cardiovascular disease and depression.

BACKGROUND: Traumatic experiences in childhood are linked to adult depression and cardiovascular disease. Depression is twice as common in women than men, and depression after cardiovascular events is more common in women than men. However, sex differences in these relationships have not been comprehensively investigated using a nationally representative sample in which demographic factors related to these illnesses can be controlled. METHOD: Data come from the Part 2 sample of the U.S. National Comorbidity Survey, a nationally representative sample containing over 5000 adults. Relationships between childhood maltreatment (sexual abuse, physical abuse, neglect), adult depression (DSM-III-R), and cardiovascular disease were examined using multiple logistic regression models with a specific emphasis on the evaluation of sex differences. RESULTS: Childhood maltreatment was associated with a significant increase in cardiovascular disease for women only and with a significant increase in lifetime depression for both genders. A history of childhood maltreatment removed the natural protection against cardiovascular disease for women and depression for men. Although depression and cardiovascular disease were correlated, depression did not contribute to the prediction of cardiovascular disease in women when controlling for history of childhood maltreatment. CONCLUSIONS: Gender is important in evaluating potential psychiatric and physical correlates of childhood maltreatment. Maltreatment is a potent risk factor for cardiovascular disease in women and for depression in both women and men. Effective clinical assessment should recognize the role of childhood abuse or neglect in adult health and disease. Research on the consequences of childhood maltreatment should focus on both psychiatric and physical outcomes.

Implications of biological findings for psychological treatments of post-traumatic stress disorder.

The goal of this article is to initiate dialogue among those conducting research on the biological aspects of post-traumatic stress disorder (PTSD) and clinicians and researchers concerned with developing effective psychological treatments for PTSD. Important biological findings in PTSD are reviewed, paying special attention to the clinical implications of these findings. A discussion of the psychological treatments effective for PTSD follows, focusing on how these empirically supported treatments may address some of the issues raised by the biological findings. Finally, suggestions are made for future directions for psychological treatment development for this disabling condition, examining how these innovative treatment approaches may be relevant to the reviewed biological findings.