Bidirectional Associations Between Pain and Perceived Stress Among Veterans: Depressive Disorder as a Predisposing Factor.

OBJECTIVE: Military veterans who were injured in combat very often report pain along with co-occurring perceived stress and preexisting depressive disorder. The systems model of pain is a theoretical model suggesting that pain and perceived stress are bidirectionally associated at the within-person level, and associations are heightened among those with depressive disorder. However, the systems model of pain has not been adequately tested. Testing the systems model of pain could illuminate salient treatment targets for combat-injured veterans with pain and co-occurring psychological problems. METHODS: The present study empirically tests the systems model of pain among a sample of combat-injured veterans ( N = 902) surveyed five times during an 18-month period. We used a multigroup, autoregressive latent trajectory with structured residual statistical model to test the within-person associations between pain and perceived stress and determine whether associations differ between veterans with and without a positive screen for depressive disorder. RESULTS: In line with the systems model of pain, pain and perceived stress were bidirectionally associated only among combat-injured veterans with depressive disorder. Among such veterans, perceived stress was positively associated with subsequent pain ( b = 0.12; 95% confidence interval = 0.06-0.17), and pain was positively associated with subsequent perceived stress ( b = 0.44; 95% CI = 0.11-0.77). CONCLUSIONS: Our work highlights the interplay between pain and its psychological correlates among a particularly at-risk population. Clinicians addressing pain and perceived stress among combat-injured veterans should be prepared to identify and address depressive disorder.

Moral injury events and behavioral health outcomes among American veterans.

Among American veterans, the behavioral health impact of potentially morally injurious experiences (PMIEs) has recently garnered attention. There is heterogeneity in the types of experiences that are classified as PMIEs, and different PMIEs may be differentially associated with various outcomes. We aimed to explore heterogeneity in PMIEs among veterans, and whether PMIE classes are differentially associated with several behavioral health outcomes (i.e., symptoms of posttraumatic stress disorder, depression, anxiety, and anger). Data were from a survey study of veteran health attitudes and behavior (N=1004). We employed a Latent Class Analysis approach to identify sub-groups of participants with similar PMIE response patterns on the Moral Injury Events Scale and to determine the relationship between class membership and behavioral health outcomes. A 4-class solution best fit our data, with classes including (1) high all, (2) witnessed transgressions, (3) troubled by failure to act, and (4) moderate all. There was a link between class membership and behavioral health, with the high all class and moderate all classes consistently reporting especially poor outcomes. Our results are in line with cumulative stress models suggesting exposure to multiple forms of adversity may place individuals at particular risk of poor health and functioning. Clinicians working with veterans should screen for exposure to the full range of PMIE types and be prepared to address the multitude of behavioral health impacts.

Health and Service-related Impact of Sexual and Stalking Victimization During United States Military Service on LGBT Service Members.

Prior research among military personnel has indicated that sexual harassment, stalking, and sexual assault during military service are related to negative health sequelae. However, research specific to LGBT U.S. service members is limited. The current study aimed to explore the health, service utilization, and service-related impact of stalking and sexual victimization experiences in a sample of active-duty LGBT U.S. service members (N = 248). Respondent-driven sampling was used to recruit study participants. U.S. service members were eligible to participate if they were 18 years or older and active-duty members of the U.S. Army, U.S. Navy, U.S. Marine Corps, or U.S. Air Force. This study included a sizeable portion of transgender service members (N = 58, 23.4%). Sociodemographic characteristics, characteristics of military service, health, and sexual and stalking victimization in the military were assessed. Regression was used to examine relationships between health and service outcomes and sexual and stalking victimization during military service. Final adjusted models showed that experiencing multiple forms of victimization in the military increased the odds of visiting a mental health clinician and having elevated somatic symptoms, posttraumatic stress disorder symptomatology, anxiety, and suicidality. Sexual and stalking victimization during U.S. military service was statistically significantly related to the mental and physical health of LGBT U.S. service members. Interventions to reduce victimization experiences and support LGBT U.S. service members who experience these types of violence are indicated. Research that examines the role of LGBT individuals' experiences and organizational and peer factors, including social support, leadership characteristics, and institutional policies in the United States military is needed.

Support for Transgender Military Service from Active Duty United States Military Personnel.

INTRODUCTION: Most transgender individuals are banned from serving in and joining the U.S. military. Historically, exclusions and limits have been placed on women, people of color, and sexual minority people seeking to serve and advance within the U.S. military. However, both history and prior research demonstrate that diversity contributes to social and institutional advancement within both U.S. and international militaries. METHODS: We used an adapted respondent-driven sampling (RDS) approach to recruit transgender and cisgender heterosexual and LGB active duty military members in a first-of-its-kind study funded by the Department of Defense. We recruited 540 active duty service members serving one of the four major branches of the U.S. military between August 2017 and March 2018. We examined data from 486 heterosexual cisgender and LGB cisgender service members to understand their support for transgender people serving in the U.S. military. RESULTS: Findings indicate broad support for transgender military service across all four branches of the military and military ranks, with some statistically significant differences in support emerging by gender, sexual orientation, and race/ethnicity. DISCUSSION: Results suggest that the ban, in part, based on a belief that transgender service members degrade unit readiness, contradicts our findings of broad support for transgender service among active duty service members. POLICY IMPLICATIONS: Policies limiting transgender service in the U.S. military should be lifted given these data.

Associations between symptoms of posttraumatic stress disorder, pain, and alcohol use disorder among OEF/OIF/OND veterans.

BACKGROUND: Alcohol use disorder (AUD) is prevalent among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND) veterans. Pain and posttraumatic stress disorder (PTSD) are highly comorbid and increase risk of AUD. Prior studies linking pain or PTSD to AUD have not explored interactions between pain and PTSD symptoms. METHODS: OEF/OIF/OND veterans (N = 1230) were recruited from social media websites for a cross-sectional study of health behavior. Pain was assessed using the Pain Outcomes Questionnaire. PTSD symptoms and PTSD symptom clusters were assessed using the Posttraumatic Stress Disorder Checklist for DSM-5. AUD symptoms were assessed with the AUD Identification Test. Linear regression models were used to test for main and interaction effects in the full sample and separately by sex. RESULTS: Both pain and PTSD symptoms were associated with increased AUD symptomology, though the relationship between pain and AUD was heighted at relatively low PTSD symptoms. With respect to PTSD symptom clusters, re-experiencing and negative cognitions and mood were associated with increased AUD symptomology. Interactions between pain and re-experiencing as well as pain and avoidance were revealed. Results for men mirrored the full sample, while an interaction between pain and negative cognitions and mood was associated with AUD in women. CONCLUSIONS: Results highlight associations between AUD, PTSD symptoms, and pain among veterans. While the relationship between pain and AUD appeared stronger in the context of low PTSD symptoms, both pain and PTSD symptoms were associated with increased AUD. Clinicians treating veterans with AUD should address the range of potential comorbidities.

An Examination of Stalking Experiences During Military Service Among Female and Male Veterans and Associations With PTSD and Depression.

Stalking is associated with mental health concerns, although little is known about the influence of stalking and mental health concerns among veterans. This study evaluated stalking experienced during military service in two community-based, nonclinical samples of veterans (N = 1,980). Models explored (a) types of stalking, (b) characteristics of veterans who experienced stalking, and (c) the associations between stalking with posttraumatic stress disorder (PTSD) and depression. Types of stalking varied by sex; female veterans were significantly more likely to experience stalking than male veterans (58.5% vs. 34.6%, p < .001, respectively). Female veterans reported unwanted messages, emails, or phone calls (37.2%), and male veterans experienced someone showing up unannounced or uninvited (23.5%) most frequently. Stalking experiences also differed by age with female and male veterans 18 to 39 years old significantly more likely to have experienced stalking (p < .001 and p < .001, respectively) than veterans over age 40. Associations between prior stalking experiences and mental distress were found for both female and male veterans. Both female and male veterans who experienced stalking were significantly more likely to have probable PTSD (odds ratio [OR] = 1.88, 95% confidence interval [CI] = [1.04, 3.39] and OR = 3.08, 95% CI = [2.27, 4.18], respectively) and depression (OR = 2.54, 95% CI = [1.38, 4.58] and OR = 2.78, 95% CI = [2.05, 3.79], respectively). These findings highlight (a) the rates of stalking experienced during military service, (b) the need for assessment of stalking to inform treatment, and (c) lay the foundation for the Department of Defense (DoD) to further evaluate stalking among military populations.

Experiences of Sexual Harassment, Stalking, and Sexual Assault During Military Service Among LGBT and Non-LGBT Service Members.

Sexual victimization, including sexual harassment and assault, remains a persistent problem in the U.S. military. Service members identifying as lesbian, gay, bisexual, or transgender (LGBT) may face enhanced risk, but existing research is limited. We examined experiences of sexual harassment, stalking, and sexual assault victimization during service in a sample of LGBT and non-LGBT active duty service members. Service members who identified as LGBT (n = 227 LGB, n = 56 transgender) or non-LGBT (n = 276) were recruited using respondent-driven sampling for an online survey. Logistic regression models examined the correlates of sexual and stalking victimization. Victimization was common among LGBT service members, including sexual harassment (80.7% LGB, 83.9% transgender), stalking (38.6% LGB, 30.4% transgender), and sexual assault (25.7% LGB, 30.4% transgender). In multivariable models, LGB identity remained a significant predictor of sexual harassment, OR = 4.14, 95% CI [2.21, 7.78]; stalking, OR = 1.98, 95% CI [1.27, 3.11]; and assault, OR = 2.07, 95% CI [1.25, 3.41]. A significant interaction between LGB identity and sex at birth, OR = 0.34, 95% CI [0.13, 0.88], suggests an elevated sexual harassment risk among male, but not female, LGB service members. Transgender identity predicted sexual harassment and assault at the bivariate level only. These findings suggest that LGBT service members remain at an elevated risk of sexual and/or stalking victimization. As the military works toward more integration and acceptance of LGBT service members, insight into victimization experiences can inform tailored research and intervention approaches aimed at prevention and care for victims.

Moving Beyond Housing: Service Implications for Veterans Entering Permanent Supportive Housing.

As a result of efforts to end homelessness among U.S. veterans, more former service members are entering permanent supportive housing (PSH). While PSH has been successfully used to house homeless veterans, more research is needed about services beyond housing placement and retention. This study uses the Gelberg-Andersen behavioral model for vulnerable populations to determine associations between predisposing, enabling, and need characteristics and recent service use (i.e., services to satisfy basic needs, occupational development, financial, healthcare, mental health) among unaccompanied homeless veterans (N=126) entering PSH in Los Angeles. Among the significant findings, as indicated using univariable logistic regression models, were veterans who had incarceration histories were more likely to utilize basic needs services, compared to those without incarceration histories. Veterans who received an honorable discharge were more likely to utilize occupational development services, compared to veterans with other discharge statuses. Veterans who had a case manager were more likely to utilize mental health services than those without a case manager, while those who received social security were less likely to utilize mental health services compared to veterans who did not receive social security. Veterans who met criteria for a psychological disability and veterans who met criteria for probable PTSD were more likely to use basic needs services and mental health services than veterans who fell below these thresholds. Clinical implications for social workers including "equal access to services," "enhancing economic stability," "providing safe and affordable housing with trauma-informed services," and "training service social workers to deliver well-informed linkages and services" are discussed.

Military Sexual Assault as a Mediator of the Association Between Posttraumatic Stress Disorder and Depression Among Lesbian, Gay, and Bisexual Veterans.

Lesbian, gay, and bisexual (LGB) civilians report higher rates of sexual assault, posttraumatic stress disorder (PTSD), and depression compared to their heterosexual counterparts. In this study, we compared military sexual assault (MSA), PTSD, and depression in LGB individuals and their non-LGB peers in two community samples of veterans (N = 2,583). Participants were selected for inclusion if they identified as LGB (n = 110) and were matched 1 to 3 on gender and age with non-LGB veterans (n = 330). Chi-square analyses showed significant differences for LGB veterans compared to non-LGB veterans for experiencing MSA (32.7% vs. 16.4%, respectively), p < .001; probable PTSD (41.2% vs. 29.8%, respectively), p = .039; and probable depression (47.9% vs. 36.0%, respectively), p = .039. Multivariable logistic regression analyses showed LGB veterans were 1.93 times more likely to have experienced MSA compared to non-LGB veterans, 95% CI [1.30, 2.88], p = .001. The experience of MSA significantly mediated associations with probable PTSD, odds ratio (OR) = 1.43, 95% CI [1.13, 1.80], p = .003, and probable depression, OR = 1.32, 95% CI [1.07, 1.64], p = .009. As the experience of MSA fully mediates the presence of PTSD and depression among LGB veterans, we highly recommend health providers assess for MSA among LGB veterans, especially those who meet clinical thresholds for PTSD and depression.

Expanding the Understanding of Risk Behavior Associated With Homelessness Among Veterans.

INTRODUCTION: To advance large-scale efforts to end veteran homelessness, an understanding of factors that contribute to housing insecurity is necessary. Common risk behaviors (e.g., substance use and risky sexual practices) are associated with lengthier experiences of homelessness among the general homeless population, but less understood among homeless veterans. Additionally, whether emerging risk behaviors among veterans (e.g., sensation seeking and aggression) are associated with lengthy homeless experiences is unknown. MATERIALS AND METHODS: Data were drawn from a sample of Los Angeles County veterans surveyed using a mixed nonprobability sampling strategy, which included recruiting veterans via national and local veterans service organizations, college organizations, and social media campaigns. Measures aligning with factors of sensation seeking (reckless driving, gambling, suicidal ideation); substance use (alcohol misuse, tobacco use, driving while intoxicated); risky sexual practices (risking getting a sexually transmitted disease); and aggression (looking to start a fight) were tested in multivariate, multinomial logistic regression analyses to determine their association with varying lengths of homelessness in the past year (less than 1 month, 2-6 months, 6 months to 1 year). RESULTS: Risking getting a sexually transmitted disease, gambling, suicidal ideation, alcohol misuse, tobacco use, driving while intoxicated, and looking to start a fight were associated with 6 or more months of homelessness. Several indicators of risk were associated with brief periods of homelessness, including gambling and looking to start a fight. Although a clear exposure-response effect was not detected with risk behaviors, results suggested there may be some wavering of engagement in risk behaviors over time. CONCLUSION: Findings suggest sensation seeking and aggression risk behaviors should be included in risk assessments and prevention efforts along with substance use and risky sexual practices to reduce veterans' risk of becoming homeless and reducing risk of chronic homelessness. Further research is needed to understand the trajectory of these risk behaviors and the mechanisms that underlie the association between these risk behaviors and homelessness for veterans.

Lesbian, Gay, Bisexual, and Transgender (LGBT) Service Members: Life After Don't Ask, Don't Tell.

Lesbian, gay, and bisexual service members can serve openly in the military with the repeal of the Don't Ask, Don't Tell policy. The fate of transgender service members remains uncertain as the policy preventing them from serving in the military remains under review. The health care needs of these populations remain for the most part unknown, with total acceptance and integration in the military yet to be achieved. In this paper, we review the literature on the health care needs of lesbian, gay, bisexual, and transgender (LGBT) service members, relying heavily on what is known about LGBT civilian and veteran populations. Significant research gaps about the health care needs of LGBT service members are identified, along with recommendations for closing those gaps. In addition, recommendations for improving LGBT acceptance and integration within the military are provided.

Sexual assault in the military.

Military sexual assault is a pervasive problem throughout the military services, despite numerous initiatives to end it. No doubt the military's lack of progress stems from the complexity of sexual assaults, yet in order to develop effective strategies and programs to end sexual assault, deep understanding and appreciation of these complexities are needed. In this paper, we describe the root causes and numerous myths surrounding sexual assault, the military cultural factors that may unintentionally contribute to sexual assault, and the uncomfortable issues surrounding sexual assault that are often ignored (such as the prevalence of male sexual assault within the military). We conclude by offering a broad, yet comprehensive set of recommendations that considers all of these factors for developing effective strategies and programs for ending sexual assault within in the military.

The US framework for understanding, preventing, and caring for the mental health needs of service members who served in combat in Afghanistan and Iraq: a brief review of the issues and the research.

This paper reviews the psychological health research conducted in the United States in support of combat veterans from Iraq and Afghanistan, using the Military Psychological Health Research Continuum, which includes foundational science, epidemiology, etiology, prevention and screening, treatment, follow-up care, and services research. The review is limited to those studies involving combat veterans and military families. This review discusses perplexing issues regarding the impact of combat on the mental health of service members such as risk and resilience factors of mental health, biomarkers of posttraumatic stress syndrome (PTSD), mental health training, psychological screening, psychological debriefing, third location decompression, combat and suicide, the usefulness of psychotherapy and drug therapy for treating PTSD, role of advanced technology, telemedicine and virtual reality, methods to reduce stigma and barriers to care, and best approaches to the dissemination of evidence-based interventions. The mental health research of special populations such as women, National Guardsmen and reservists, and military families is also presented. The review concludes by identifying future areas of research.

Suicides in the military: the post-modern combat veteran and the Hemingway effect.

Suicides in the military have increased over the last ten years. Much effort has been focused on suicide prevention and treatment, as well as understanding the reasons for the sharp increase in military suicides. Despite this effort, the definitive causes of military suicides remain elusive. Further, highly effective suicide prevention and treatment approaches have not yet been developed. The purpose of this article is to present a short review of the current state of suicide prevention interventions within the context of the military. The root causes of suicidal behavior and the role of combat in the military are each discussed. Interpersonal-psychological theory of suicide and the military transition theory are introduced as guiding frameworks for understanding suicides and suicidal behavior amongst active military personnel and military veterans. The article concludes with a set of recommendations for moving forward in understanding and addressing suicides in the military.

NATO survey of mental health training in army recruits.

To-date, there has been no international review of mental health resilience training during Basic Training nor an assessment of what service members perceive as useful from their perspective. In response to this knowledge gap, the North Atlantic Treaty Organization (NATO) Human Factors & Medicine Research & Technology Task Group "Mental Health Training" initiated a survey and interview with seven to twenty recruits from nine nations to inform the development of such training (N = 121). All nations provided data from soldiers joining the military as volunteers, whereas two nations also provided data from conscripts. Results from the volunteer data showed relatively consistent ranking in terms of perceived demands, coping strategies, and preferences for resilience skill training across the nations. Analysis of data from conscripts identified a select number of differences compared to volunteers. Subjects also provided examples of coping with stress during Basic Training that can be used in future training; themes are presented here. Results are designed to show the kinds of demands facing new recruits and coping methods used to overcome these demands to develop relevant resilience training for NATO nations.

Postdeployment military mental health training: cross-national evaluations.

Deployments increase risk for adjustment problems in service members. To mitigate this increased risk, mental health training programs have been developed and implemented in several nations. As part of a coordinated effort, three nations adapted a U.S. mental health training program that had been validated by a series of group randomized trials demonstrating improvement in postdeployment adjustment. Implementation of evidence-based programs in a new context is challenging: How much of the original program needs to remain intact in order to retain its utility? User satisfaction rates can provide essential data to assess how well a program is accepted. This article summarizes service member ratings of postdeployment mental health training and compares ratings from service members across four nations. The participating nations (Canada, New Zealand, United Kingdom, and the United States) administered mental health training to active duty military personnel in their respective nations. Following the training, military personnel completed an evaluation of the training. Overall, across the four nations, more than 70% of military personnel agreed or strongly agreed that they were satisfied with the mental health training. Although some differences in evaluations were observed across nations, components of training that were most important to overall satisfaction with the training were strikingly similar across nations. Fundamentally, it appears feasible that despite cultural and organizational differences, a mental health training program developed in one nation can be successfully adapted for use in other nations.

Mental health training with soldiers four months after returning from Iraq: randomization by platoon.

Military personnel report significant and increasing mental health problems in the months following return from combat. Nevertheless, studies have not assessed the impact of mental health training with this at-risk population. The present study evaluated the efficacy of a prototype mental health training module designed for U.S. soldiers 3-6 months after returning from combat; the module was a component of the Battlemind Training system. Soldiers (N = 1,645) were randomly assigned by platoon to 1 hour of training or a survey-only control group. Baseline surveys were conducted immediately before training; a training satisfaction survey was administered immediately after training, and a follow-up survey was administered 6 months later. Immediate postsession surveys were conducted with 681 subjects, and follow-up surveys were conducted with 542 soldiers. The Battlemind Training module received positive ratings from participants, and those who received it reported significantly better adjustment in terms of posttraumatic stress disorder symptoms, depression, and life satisfaction at follow-up compared to those in the survey-only control group. Changes in attitudes about the stigma of seeking mental health care were found immediately posttraining, but not at follow-up. The findings demonstrate that brief mental health training can be effective in reducing mental health systems with at-risk occupational groups.

Effect of transition home from combat on risk-taking and health-related behaviors.

Transition home following a combat deployment involves a period of adjustment. Exploratory and confirmatory factor analyses of a new 16-item transition scale were conducted with 2 samples and resulted in 4 factors (Benefit, Appreciation, Anger/Alienation, and Guilt/Remorse). In Study 1 (N = 1,651), the number of combat events was positively related to Anger/Alienation 4 months later even after controlling for posttraumatic stress disorder (PTSD) symptoms, partial r = .18, p < .001. In Study 2 (N = 647), after controlling for PTSD symptoms, Anger/Alienation assessed at 4 months postdeployment predicted more risk-taking behaviors 4 months later, partial r = .10, p = .01. Appreciation predicted fewer unhealthy habits, partial r = -.13, p = .001, whereas Anger/Alienation predicted more unhealthy habits, partial r = .09, p = .024. Results demonstrate the importance of broadening the conceptualization of adjustment in combat veterans.

Battlemind debriefing and battlemind training as early interventions with soldiers returning from iraq: Randomization by platoon.

Researchers have found that there is an increase in mental heath problems as a result of military-related traumatic events, and such problems increase in the months following return from combat. Nevertheless, researchers have not assessed the impact of early intervention efforts with this at-risk population. In the present study, the authors compared different early interventions with 2,297 U.S. soldiers following a year-long deployment to Iraq. Platoons were randomly assigned to standard postdeployment stress education, Battlemind debriefing, and small and large group Battlemind training. Results from a 4-month follow-up with 1,060 participants showed those with high levels of combat exposure who received Battlemind debriefing reported fewer posttraumatic stress symptoms, depression symptoms, and sleep problems than those in stress education. Small group Battlemind training participants with high combat exposure reported fewer posttraumatic stress symptoms and sleep problems than stress education participants. Compared to stress education participants, large group Battlemind training participants with high combat exposure reported fewer posttraumatic stress symptoms and lower levels of stigma and, regardless of combat exposure, reported fewer depression symptoms. Findings demonstrate that brief early interventions have the potential to be effective with at-risk occupational groups.

Time-driven battlemind psychological debriefing: a group-level early intervention in combat.

Military personnel who experience combat-related events are more likely to report mental health problems yet few early interventions have been designed to do more than assess those with problems or treat those with diagnoses. Psychological debriefing is one early intervention technique that has been used with military populations to reduce symptoms across entire groups. Although there are several different kinds of debriefings, this article describes time-driven Battlemind Psychological Debriefing procedures for use during a combat deployment. The five phases include: Introduction, Event, Reactions, Self and Buddy Aid, and Battlemind Focus. The paper reviews implementation guidelines, scientific support for Battlemind Psychological Debriefing, and feedback from military behavioral health providers in Iraq. Comparisons with other military debriefing models identify unique features and how Battlemind Psychological Debriefing is integrated into the larger Battlemind Training system.