Divergent trends in accidental deaths since return from an Afghanistan/Iraq deployment among army soldiers.

PURPOSE: Accidental death is a leading cause of mortality among military members and Veterans; however, knowledge is limited regarding time-dependent risk following deployment and if there are differences by type of accidental death. METHODS: Longitudinal cohort study (N = 860,930) of soldiers returning from Afghanistan/Iraq deployments in fiscal years 2008-2014. Accidental deaths (i.e., motor vehicle accidents [MVA], accidental overdose, other accidental deaths), were identified through 2018. Crude and age-adjusted mortality rates, rate ratios, time-dependent hazard rates and trends postdeployment were compared across demographic and military characteristics. RESULTS: During the postdeployment observation period, over one-third of deaths were accidental; most were MVA (46.0 %) or overdoses (37.9 %). Across accidental mortality categories (all, MVA, overdose), younger soldiers (18-24, 25-29) were at higher risk compared to older soldiers (40+), and females at lower risk than males. MVA death rates were highest immediately postdeployment, with a significant decreasing hazard rate over time (annual percent change [APC]: -6.5 %). Conversely, accidental overdose death rates were lowest immediately following deployment, with a significant increasing hazard rate over time (APC: 9.9 %). CONCLUSIONS: Observed divergent trends in risk for the most common types of accidental deaths provide essential information to inform prevention and intervention planning for the immediate postdeployment transition and long-term.

Efficacy of an Internet-Delivered Intervention for Improving Insomnia Severity and Functioning in Veterans: Randomized Controlled Trial.

BACKGROUND: Despite a growing evidence base that internet-delivered cognitive behavioral therapy for insomnia (iCBT-I) is associated with decreased insomnia severity, its efficacy has been minimally examined in veterans. OBJECTIVE: The objective of this study was to evaluate the efficacy of an unguided iCBT-I (Sleep Healthy Using the Internet [SHUTi]) among veterans. METHODS: We conducted a single-blind, randomized controlled trial in Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans eligible for Veterans Health Administration care. Participants were randomly assigned (1:1) to receive SHUTi (a self-guided and interactive program) or an Insomnia Education Website (IEW) that provided nontailored and fixed insomnia information. Web-based assessments were administered at baseline, postintervention, 6 months postintervention, and 1 year postintervention. The primary outcome was self-reported insomnia severity (Insomnia Severity Index [ISI]). Secondary outcomes were self-reported mental and physical health functioning (Veterans RAND 36-item Health Survey). Exploratory outcomes comprised sleep diary parameters. RESULTS: Of the 231 randomized participants (mean age 39.3, SD 7.8 years; 170/231, 73.5% male sex; 26/231, 11.3% Black; 172/231, 74.5% White; 10/231, 4.3% multiracial; and 17/231, 7.4% other; 36/231, 15.6% Hispanic) randomized between April 2018 and January 2019, a total of 116 (50.2%) were randomly assigned to SHUTi and 115 (49.8%) to the IEW. In intent-to-treat analyses, SHUTi participants experienced significantly larger ISI decreases compared with IEW participants at all time points (generalized η2 values of 0.13, 0.12, and 0.10, respectively; all P<.0001). These corresponded to estimated larger differences in changes of -3.47 (95% CI -4.78 to -2.16), -3.80 (95% CI -5.34 to -2.27), and -3.42 (95% CI -4.97 to 1.88) points on the ISI for the SHUTi group. SHUTi participants experienced significant improvements in physical (6-month generalized η2=0.04; P=.004) and mental health functioning (6-month and 1-year generalized η2=0.04; P=.009 and P=.005, respectively). Significant sleep parameter improvements were noted for SHUTi (all P<.05), though the pattern and magnitude of these reductions varied by parameter. No adverse events were reported. CONCLUSIONS: Self-administered iCBT-I was associated with immediate and long-term improvements in insomnia severity. Findings suggest that leveraging technology to meet insomnia treatment demands among veterans may be a promising approach. TRIAL REGISTRATION: ClinicalTrials.gov NCT03366870; https://clinicaltrials.gov/ct2/show/NCT03366870.

Associations of Military-Related Traumatic Brain Injury With New-Onset Mental Health Conditions and Suicide Risk.

Importance: Research to identify the direct and indirect associations of military-related traumatic brain injury (TBI) with suicide has been complicated by a range of data-related challenges. Objective: To identify differences in rates of new-onset mental health conditions (ie, anxiety, mood, posttraumatic stress, adjustment, alcohol use, and substance use disorders) among soldiers with and without a history of military-related TBI and to explore the direct and indirect (through new-onset mental health disorders) associations of TBI with suicide. Design, Setting, and Participants: This retrospective cohort study used data from the Substance Use and Psychological Injury Combat Study (SUPIC) database. Demographic, military, and health data from the Department of Defense within SUPIC were compiled and linked with National Death Index records to identify deaths by suicide. Participants included US Army soldiers who returned from an Afghanistan or Iraq deployment. Data were analyzed from September to December 2022. Exposures: Military-related TBI. Main Outcomes and Measures: The outcome of interest was suicide. Secondary outcomes were incidence of new-onset mental health conditions. Mediation analyses consisted of accelerated failure time (AFT) models in conjunction with the product of coefficients method. The 6 new-onset mental health diagnosis categories and the 2 or more categories variable were each considered separately as potential mediators; therefore, a total of 14 models plus the overall AFT model estimating the total effect associated with TBI in suicide risk were fit. Results: The study included 860 892 soldiers (320 539 soldiers [37.2%] aged 18-24 at end of index deployment; 766 454 [89.0%] male), with 108 785 soldiers (12.6%) with at least 1 documented TBI on their military health record. Larger increases in mental health diagnoses were observed for all conditions from before to after documented TBI, compared with the matched dates for those without a history of TBI, with increases observed for mood (67.7% vs 37.5%) and substance use (100% vs 14.5%). Time-to-suicide direct effect estimates for soldiers with a history of TBI were similar across mediators. For example, considering new-onset adjustment disorders, time-to-suicide was 16.7% faster (deceleration factor, 0.833; 95% CI, 0.756-0.912) than for soldiers without a history of TBI. Indirect effect estimates of associations with TBI were substantial and varied across mediators. The largest indirect effect estimate was observed through the association with new-onset substance use disorder, with a time to suicide 63.8% faster (deceleration factor, 0.372; 95% CI, 0.322-0.433) for soldiers with a history of TBI. Conclusions and Relevance: In this longitudinal cohort study of soldiers, rates of new-onset mental health conditions were higher among individuals with a history of TBI compared with those without. Moreover, risk for suicide was both directly and indirectly associated with history of TBI. These findings suggest that increased efforts are needed to conceptualize the accumulation of risk associated with multiple military-related exposures and identify evidence-based interventions that address mechanisms associated with frequently co-occurring conditions.

Trends in suicide rates by race and ethnicity among members of the United States Army.

Efforts were focused on identifying differences in suicide rates and time-dependent hazard rate trends, overall and within age groups, by race and ethnicity among United States Army members who returned from an index deployment (October 2007 to September 2014). This retrospective cohort study was conducted using an existing longitudinal database, the Substance Use and Psychological Injury Combat Study (SUPIC). Demographic (e.g., race and ethnicity) and military data from the Department of Defense compiled within SUPIC, as well as Department of Veterans Affairs data were linked with National Death Index records (through 2018) to identify deaths by suicide including those that occurred after military service. The cohort included 860,930 Army Service members (Active Duty, National Guard, and Reserve). Age-adjusted (using the direct standardization method) and age-specific suicide rates per 100,000 person years were calculated and rate ratios (RR) were used for comparisons. Trends were evaluated using hazard rates over time since the end of individuals' index deployments. Among those aged 18-29 at the end of their index deployment, the suicide rate for American Indian/Alaskan Native (AI/AN) individuals was 1.51 times higher (95% confidence interval [CI]: 1.03, 2.14) compared to White non-Hispanic individuals (WNH), and lower for Hispanic and Black non-Hispanic (BNH) than for WNH individuals (RR = 0.65 [95% CI: 0.55, 0.77] and RR = 0.71 [95% CI: 0.61, 0.82], respectively). However, analyses revealed increasing trends in hazard rates post-deployment (≤ 6.5 years) within groups of Hispanic and BNH individuals (Average Annual Percent Change [APC]: 12.1% [95% CI: 1.3%, 24.1%] and 11.4% [95% CI: 6.9%, 16.0%], respectively) with a smaller, increase for WNH individuals (APC: 3.1%; 95% CI: 0.1%, 6.1%). Findings highlight key subgroups at risk for post-deployment suicide (i.e., WNH, AI/AN and younger individuals), as well as heterogeneous trends overtime, with rates and trends varying within race and ethnic groups by age groups. Post-deployment suicide prevention efforts that address culturally relevant factors and social determinants of health associated with health inequities are needed.

The association among insomnia symptom severity, comorbid symptoms, and suicidal ideation in two veteran cohorts meeting diagnostic criteria for insomnia disorder.

OBJECTIVE: Examine the association between insomnia symptom severity and suicidal ideation (SI), after adjusting for clinical comorbidity in veterans meeting diagnostic criteria for insomnia disorder. METHODS: Secondary data analyses of psychometrically validated baseline assessments of depression, posttraumatic stress disorder (PTSD), and anxiety symptoms from two online insomnia intervention randomized clinical trials (n = 232; n = 80) were conducted. Multiple linear regression was used to determine the association between insomnia symptom severity and SI, after controlling for clinical comorbidity and demographics. RESULTS: Insomnia symptom severity was significantly correlated with comorbid depression, PTSD, and anxiety symptoms in both cohorts and significantly correlated with SI in one. After controlling for demographics and clinical comorbidity, insomnia symptom severity was not significantly associated with SI in linear regression models. CONCLUSION: Findings extend insomnia-suicide research by providing evidence that insomnia symptom severity may not confer a unique risk for SI above comorbid mental health symptoms in veterans meeting diagnostic criteria for insomnia disorder.

Morally injurious combat events as an indirect risk factor for postconcussive symptoms among veterans: The mediating role of posttraumatic stress.

OBJECTIVE: Psychosocial factors, including combat-related distress (e.g., posttraumatic stress disorder [PTSD]), contribute to postconcussive symptoms (PCS) among veterans with mild traumatic brain injury (mTBI). However, research on risk factors for PCS has focused solely on life-threatening combat experiences, neglecting the morally injurious dimension of combat-related trauma and associated implications for treatment. Morally injurious events (MIEs) are associated with PTSD symptoms among veterans, a robust risk factor of PCS. Nonetheless, the interplay between MIEs, PTSD symptoms, and PCS remains poorly understood. We sought to investigate MIEs as an indirect risk factor for PCS among Veterans with mTBI. METHOD: This cross-sectional study of 145 veterans with mTBI used path analysis to investigate whether PTSD symptoms mediated the relationship between MIEs (transgressions and betrayals) and PCS (mood-behavioral, vestibular-sensory, and cognitive domains) among 145 veterans with mTBI. We used the Moral Injury Event Scale, PTSD Checklist-Civilian Version, and Neurobehavioral Symptom Inventory to measure MIEs, PTSD, and PCS, respectively. RESULTS: Perceived transgressions were indirectly associated with mood-behavioral (ß = .21, p = .005), vestibular-sensory (ß = .17, p = .005), and cognitive PCS (ß = .20, p = .005), as mediated by PTSD. Greater transgressions were associated with more severe PTSD (ß = .27, p = .003), and greater PTSD was associated with more severe mood-behavioral (ß = .79, p < .001), vestibular-sensory (ß = .64, p < .001), and cognitive PCS (ß = .73, p < .001). Betrayals were not indirectly associated with PCS. CONCLUSIONS: Findings offer preliminary support for responses to MIEs being a modifiable risk factor for PCS among veterans. Interventions designed to foster veterans' recovery by targeting the unique emotions and beliefs associated with MIEs may be indicated. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Time-dependent suicide rates among Army soldiers returning from an Afghanistan/Iraq deployment, by military rank and component.

BACKGROUND: To date, knowledge is limited regarding time-dependent suicide risk in the years following return from deployment and whether such rates vary by military rank (i.e., enlisted, officer) or component (i.e., active duty, National Guard, reserve). To address these gaps in knowledge, the objectives of this study were to determine and compare postdeployment suicide rates and trends (percent change over time), and hazard rates for Army soldiers, by rank and component (measured at the end of the deployment). METHODS: Longitudinal cohort study of 860,930 Army soldiers returning from Afghanistan/Iraq deployment in fiscal years 2008-2014 from the Substance Use and Psychological Injury Combat study. Death by suicide was observed from the end of the first deployment in the study period through 2018 (i.e., the most recently available mortality data) for up to 11 years of follow-up. Analyses were conducted in 2021-2022. RESULTS: Adjusting for age, lowest-ranking Junior Enlisted (E1-E4) soldiers had a suicide rate 1.58 times higher than Senior Enlisted (E5-E9)/Warrant Officers (95% CI [1.24, 2.01]) and 2.41 times higher than Officers (95% CI [1.78, 3.29]). Suicide rates among lower-ranking enlisted soldiers remained elevated for 11 years postdeployment. Overall and annual postdeployment suicide rates did not differ significantly across components. Comparisons across rank and component for females were generally consistent with the full cohort results. CONCLUSIONS: Lower-ranking enlisted soldiers had the highest rate of suicide, underscoring the importance of understanding rank as it relates to social determinants of health. For over a decade following Afghanistan/Iraq deployment, lower-enlisted rank during deployment was associated with an elevated rate of suicide; thereby suggesting that postdeployment prevention interventions targeting lower-ranking military members are warranted.

Parkinson's disease and suicide among individuals seeking care within the United States Veterans Health Administration.

BACKGROUND: Independently, veterans and individuals with Parkinson's Disease (PD) are at increased risk for suicide. To our knowledge, the risk of suicide among veterans with PD has yet to be evaluated. This study aimed to examine the associations between PD and risk of suicide, as well as suicide means among those using Veteran Health Administration (VHA) services. METHODS: Retrospective cohort study of individuals who used VHA services between 1/1/2001-12/31/2019. Cox proportional hazard models were used to estimate the hazard of suicide for those with PD relative to those without. A nested-case control study was carried out among the suicide decedents where logistic regression was used to assess the relationship between PD and suicide by firearms versus suicide by any other means. RESULTS: The unadjusted hazard of death by suicide for those with a PD diagnosis, relative to those without, was 1.51 (95% CI: 1.32-1.72, p < 0.0001), and was still significant after controlling for age/gender, and psychiatric/chronic physical health diagnoses (HR: 1.50; 95% CI: 1.32-1.72, p < 0.0001; HR:1.21, 95% CI:1.06-1.38, p = 0.006, respectively). Compared to the non-PD cohort, the PD group also had higher rates of mood, anxiety, and psychotic disorders. There was no significant difference between the method of suicide for those with PD versus those without PD (p = 0.60). Most suicide deaths among both cohorts were firearm-related (PD = 78.9%, No-PD = 80.3%). CONCLUSIONS: PD is associated with an elevated risk for suicide. Based on the high rate of deaths by firearm, increased efforts to facilitate lethal means safety among veterans is warranted.

Suicide After Stroke in the United States Veteran Health Administration Population.

OBJECTIVE: To evaluate risk for suicide among veterans with a history of stroke, seeking care within the Veterans Health Administration (VHA), we analyzed existing clinical data. DESIGN: This retrospective cohort study was approved and performed in accordance with the local Institutional Review Board. Veterans were identified via the VHA's Corporate Data Warehouse. Initial eligibility criteria included confirmed veteran status and at least 90 days of VHA utilization between fiscal years 2001-2015. Cox proportional hazards models were used to assess the association between history of stroke and suicide. Among those veterans who died by suicide, the association between history of stroke and method of suicide was also investigated. SETTING: VHA. PARTICIPANTS: Veterans with at least 90 days of VHA utilization between fiscal years 2001-2015 (N=1,647,671). Data from these 1,647,671 veterans were analyzed (1,405,762 without stroke and 241,909 with stroke). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Suicide and method of suicide. RESULTS: The fully adjusted model, which controlled for age, sex, mental health diagnoses, mild traumatic brain injury, and modified Charlson/Deyo Index (stroke-related diagnoses excluded), demonstrated a hazard ratio of 1.13 (95% confidence interval, 1.02-1.25; P=.02). The majority of suicides in both cohorts was by firearm, and a significantly larger proportion of suicides occurred by firearm in the group with stroke than the cohort without (81.2% vs 76.6%). CONCLUSIONS: Findings suggest that veterans with a history of stroke are at increased risk for suicide, specifically by firearm, compared with veterans without a history of stroke. Increased efforts are needed to address the mental health needs and lethal means safety of veterans with a history of stroke, with the goal of improving function and decreasing negative psychiatric outcomes, such as suicide.

Suicide among veterans with amyotrophic lateral sclerosis.

BACKGROUND: The purpose of this study was to estimate the risk of death by suicide for those with amyotrophic lateral sclerosis (ALS) seeking care within the Veterans Health Administration (VHA). METHODS: This was a retrospective, cohort study. Extended Cox regression models were used to compare the hazard of suicide between the ALS and the unexposed groups. RESULTS: The hazard of suicide was 3.98 times higher for those with ALS than for those without (95% confidence interval [CI] , 2.64-6.00; P < .0001). After adjusting for covariates, those with ALS remained at increased risk (hazard ratio, 3.48; 95% CI, 2.31-5.24; P < .001). CONCLUSIONS: Among those seeking care in the VHA, individuals with ALS are at increased risk for dying by suicide. Additional suicide prevention efforts, including strategies for reducing access to lethal means, are warranted.

Risk Factors for Suicide in a National Sample of Veterans With Multiple Sclerosis.

OBJECTIVES: To examine risk factors in the year before suicide in a national sample of United States veterans with multiple sclerosis (MS), as well as means of suicide and receipt of mental health services prior to death. DESIGN: Case control study. Individuals in the Veterans Affairs MS National Data Repository were linked to the National Death Index Plus to obtain death records, including specific causes of death. Participants were veterans with MS who died by suicide and randomly selected nonsuicide MS controls (5 per participant) who were alive at the time of the index suicide. Mental health disorders and medical comorbidities were identified in the year before death for suicides and during the identical time period for controls. SETTING: Veterans Health Administration. PARTICIPANTS: Veterans (N=426) who received treatment for MS in the United States Veterans Health Administration between 1999 and 2011. There were 71 deaths by suicide and 355 randomly selected controls. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Suicide. RESULTS: Results from the adjusted multivariable model suggest that the following factors were associated with an increased risk for suicide: male sex (odds ratio [OR], 3.60; 95% confidence interval [CI], 1.35-9.42), depression (OR, 1.82; 95% CI, 1.03-3.23), and alcohol use disorder (OR, 3.10; 95% CI, 1.38-6.96). Half (50.7%) had a mental health appointment in the year before suicide. The primary means of suicide was by firearm (62.0%). CONCLUSIONS: Routine assessment of suicide risk in individuals with MS is warranted, particularly for those with recent history of depression or alcohol use disorder.

Efficacy of the Home-Based Mental Health Evaluation (HOME) Program for Engaging Patients in Care After Hospitalization.

OBJECTIVE: The risk of suicide is elevated in the days and weeks after discharge from a psychiatric hospitalization, and lack of treatment engagement posthospitalization is also associated with suicide. The authors sought to determine whether the Home-Based Mental Health Evaluation [HOME] Program is efficacious in helping patients engage in care after psychiatric hospitalization. METHODS: This study was a nonrandomized, controlled, two-arm (HOME Program versus enhanced care as usual [E-CARE]) trial that took place at four Department of Veterans Affairs medical centers. Participants (N=302) were patients admitted to a psychiatric inpatient unit. The HOME Program consists of phone- and home-based contacts that include suicide risk assessment, safety planning, and problem-solving around barriers to care. The primary outcome was treatment engagement, as documented in the electronic medical record. RESULTS: Veterans in the HOME Program group were 1.33 (95% confidence interval [CI]=1.29-1.37) times more likely to engage in treatment, compared with veterans in the E-CARE group (p<0.001). HOME Program participants were estimated to have attended 55% more individual appointments (95% CI=12%-113%, p=0.02), compared with those in the E-CARE group. The adjusted difference in median time to treatment engagement was 15 days (95% CI=3.5-27.0) such that HOME Program participants engaged in treatment more quickly than participants at the E-CARE sites. CONCLUSIONS: Findings suggest that participation in the HOME Program can help individuals at high risk of suicide engage in care after psychiatric hospitalization.

Characterization of lifetime TBIs in a cohort of recently deployed soldiers: The warrior strong study.

OBJECTIVE: To describe and characterize the lifetime history of traumatic brain injury (TBI) among active duty soldiers returning from deployment to Afghanistan or Iraq. METHOD: Data were extracted from a larger parent study that was conducted at two large United States Army bases between 2009 and 2014 during Post-Deployment Health Assessment. The sample included 1,060 soldiers who sustained at least one TBI during their lifetime. RESULTS: The Ohio State University TBI-Identification Method interview was administered to characterize individuals' total lifetime history of TBI. Soldiers reported sustaining a median of 2 lifetime TBIs. Slightly more than half of the sample without a most recent deployment-related TBI still reported a history of a lifetime TBI (some of which occurred during previous deployments). Most lifetime injuries reported were of mild severity; however, 6% of individuals reported a history of moderate/severe TBI. Blast was the most frequent mechanism associated with recent deployment-related mild TBIs. CONCLUSION: Findings suggest that soldiers who screened positive, as well as those who screened negative, for a history of TBI during their recent deployment still endorsed a lifetime history of TBI. Future research is needed to explore the functional impact of multiple TBIs over one's lifetime to help inform screening, assessment, and treatment among military personnel. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Suicide and Traumatic Brain Injury Among Individuals Seeking Veterans Health Administration Services Between Fiscal Years 2006 and 2015.

OBJECTIVE: Examine associations between traumatic brain injury (TBI) and (1) suicide and (2) suicide method among individuals receiving Veterans Health Administration (VHA) care. SETTING: VHA, Fiscal Years 2006-2015. PARTICIPANTS: Veterans with a TBI diagnosis during/prior to the study window (n = 215 610), compared with a 20% random sample of those without TBI (n = 1 187 639). DESIGN: Retrospective, cohort study. Cox proportional hazards models were fit accounting for time-dependent measures, chronic conditions, and demographics for those with TBI compared with those without. Additional models evaluated the impact of TBI severity on the association between TBI and suicide, and method. MAIN OUTCOME MEASURES: Death by and method of suicide. RESULTS: The hazard of suicide was 2.19 times higher for those with TBI than for those without TBI (95% CI = 2.02-2.37), and was still significant after accounting for covariates (hazard ratio [HR] = 1.71; 95% confidence interval [CI] = 1.56-1.87). Considering severity, mild TBI compared with no TBI was significantly associated with an elevated hazard of suicide, after adjusting for covariates (HR = 1.62; 95% CI = 1.47-1.78). There was also a significant difference in death by suicide between moderate/severe TBI when compared with no TBI, after adjusting for covariates (HR = 2.45; 95% CI = 2.02-2.97). Moderate/severe TBI was significantly associated with an increase in the odds of suicide by firearm among decedents (odds ratio = 2.39; 95% CI = 1.48-3.87). CONCLUSION: Traumatic brain injury is associated with an elevated risk for suicide. Particular concern is warranted for those with moderate/severe TBI. Lethal means safety should be explored as an intervention.

Veteran Participation in Intensive Suicide Research Protocols: No Evidence of Iatrogenic Effects.

Suicide research remains fraught with ethical and methodological issues, including researchers' reservations about conducting intensive suicide research protocols due to potential iatrogenic effects and liability concerns. Such issues significantly impede scientific inquiry related to suicide. To date, no research has explored potential iatrogenic effects of intensive, nontreatment suicide research among Veterans. This study aimed to fill this gap. It was hypothesized that participation in suicide-specific protocols would not significantly increase risk among Veterans. Veterans completed self-reports, structured interviews, and rigorous suicide-specific tasks (Study A, N = 34; Study B, N = 18; Study C, N = 119). Findings indicated there were no significant differences in pre- and postassessment suicide risk variables (all ps > .05). Estimated mean change for "urge to harm self" was -0.24 (95% confidence interval [CI]: -0.60, 0.13), -0.28 (CI: -0.56, 0.01), and -0.01 (CI: -0.09, 0.07) and "intent to harm self" was -0.18 (95% CI: -0.45, 0.10), 0 (CI: -0.17, 0.17), and 0.01 (CI: -0.04, 0.06) for Studies A, B, and C, respectively. Results indicated the respective protocols did not produce iatrogenic effects. The current findings are discussed with attention to safety-monitoring techniques that may reduce iatrogenic effects and considerations for future researchers.

Relationship between traumatic brain injury history and recent suicidal ideation in Iraq/Afghanistan-era veterans.

This study evaluated whether a history of traumatic brain injury (TBI) was associated with increased risk for recent suicidal ideation (SI) after accounting for demographics, depression, posttraumatic stress disorder (PTSD), and sleep quality. In terms of increased risk, we hypothesized that a history of lifetime TBI would be associated with increased recent SI when compared with no history of TBI; multiple injuries were also evaluated. The sample included Iraq and Afghanistan war-era veterans (n = 838) who served in the United States military since 9/2001 and completed a structured TBI interview. Approximately 50% reported a lifetime history of at least 1 TBI, and 17.9% met criteria for current major depressive disorder (MDD). SI over the past week per the Beck Scale for Suicide Ideation was the primary outcome. Demographics, current MDD and posttraumatic stress disorder (PTSD) per Structured Clinical Interview of DSM-IV Axis I Disorders, sleep quality per Pittsburgh Sleep Quality Index, and TBI history per structured interview were included in all statistical models. Current depression and poor sleep quality were consistently associated with recent SI. A history of any TBI history across the life span was not associated with increased recent SI (OR = 1.35, 95% CI [0.83, 2.19]). However, a history of multiple TBIs compared with no history of TBI was associated with increased recent SI (OR = 1.76, 95% CI [1.01, 3.06]). Results support the assertion than an accumulation of injuries amplifies risk. Severity of injury and deployment injuries were not significant factors. Among those with a history of 1 TBI, sleep, and depression, which may also be injury sequelae, may be salient treatment targets. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A Rasch analysis of the Neurobehavioral Symptom Inventory in a national cohort of Operation Enduring and Iraqi Freedom veterans with mild traumatic brain injury.

This study investigated the dimensionality and measurement properties of the Neurobehavioral Symptom Inventory (NSI), a 22-item questionnaire of postconcussive symptoms, in a national sample of 9,679 Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) Veterans with mild traumatic brain injury. Dimensionality of the NSI was examined using exploratory factor analysis (EFA) and Rasch analysis. Rasch measurement properties, including overall fit, unidimensionality, item level statistics, and category functioning were examined for individual NSI symptom domains identified through EFA. Differential item functioning (DIF) analyses of subgroups based on gender and Posttraumatic Stress Disorder (PTSD) diagnosis were also conducted. Results showed that the NSI items are multidimensional and responses can be differentiated into 3 unidimensional domains reflecting Cognitive, Mood-Behavioral, and Vestibular-Sensory symptoms. All items in each of the 3 subscales demonstrated adequate fit to the Rasch model. In each domain, the item hierarchy was consistent with expectations regarding the theoretical ordering of symptoms. Some problems were observed regarding test targeting for all 3 subscales, such that items were generally concentrated around the mean ability level of the population. As such there were fewer items that differentiated between those at the upper and lower extremes of the scale. Differential item functioning (DIF) based on gender was noted for hearing difficulty. This item on average reflected a higher degree of severity for women than for men. There was no DIF based on PTSD status. Implications for using the NSI as an outcome measure are discussed. (PsycINFO Database Record

The Association Between Posttraumatic Stress Disorder and Perceptions of Deployment-Related Injury in Veterans With and Without Mild Traumatic Brain Injury.

OBJECTIVES: To examine whether the association between posttraumatic stress disorder (PTSD) and injury perceptions (ie, consequences, emotional representations, and coherence) differs for Veterans with mild traumatic brain injury (mTBI) compared with Veterans with non-TBI (ie, orthopedic). PARTICIPANTS: Eighty Veterans injured during post-9/11 deployments. DESIGN: Observational, 2×2 factorial design. MAIN MEASURES: Injury histories ascertained using the Ohio State University TBI-Identification Method and Deployment Injury Questionnaire; Injury Perception Questionnaire-Revised (injury perceptions); Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (PTSD diagnosis); and PTSD Symptom Checklist-Civilian Version (PTSD symptoms). RESULTS: The association between PTSD diagnosis and injury perceptions did not differ between Veterans with mTBI and those with non-TBIs, adjusting for age, subjective pain, and depressive symptoms. PTSD symptom severity was significantly associated with injury consequences (P < .0001) and emotional representations (P < .0001), irrespective of injury type (mTBI vs non-TBI). Only injury coherence was associated with a significant interaction between PTSD symptom severity and mTBI (P = .04). CONCLUSION: PTSD symptom severity influences perceptions about mTBI and non-TBIs sustained during deployment. Altering injury perceptions may be an important treatment target for Veterans with co-occurring PTSD and deployment-related injuries.

Window to Hope: A Randomized Controlled Trial of a Psychological Intervention for the Treatment of Hopelessness Among Veterans With Moderate to Severe Traumatic Brain Injury.

OBJECTIVE: To evaluate the efficacy of a psychological intervention to reduce moderate to severe hopelessness among Veterans with moderate to severe traumatic brain injury (TBI). DESIGN: Two-arm parallel group, controlled, randomized crossover trial, with 3-month follow-up for those initially allocated to treatment. Participants were randomly allocated in blocks of 4 on a 1:1 ratio to treatment (n = 15) or waitlist (n = 20) groups. SETTING: A Veterans Affairs Medical Center. PARTICIPANTS: Veterans between the ages of 26 and 65 years, with a history of moderate to severe TBI, and moderate to severe hopelessness. INTERVENTIONS: A 20-hour manualized small group cognitive-behavioral intervention. MAIN OUTCOME MEASURES: Beck Hopelessness Scale (primary), Beck Depression Inventory, and Beck Scale for Suicide Ideation. RESULTS: A significant difference between groups was found for postintervention scores on the Beck Hopelessness Scale (P = .03). Significant decreases were maintained at follow-up. For those initially allocated to the waitlist group who completed the intervention, treatment gains were noted in decreased hopelessness (P = .01) and depression (P = .003). CONCLUSIONS: Findings from this trial provide additional support for the efficacy of this method of psychological treatment of hopelessness among individuals with moderate to severe TBI.