Posttraumatic stress disorder and insomnia in US military veterans: Prevalence, correlates, and psychiatric and functional burden.

Military veterans have high rates of psychiatric conditions such as posttraumatic stress disorder, which can complicate the clinical management of insomnia. Population-based data are lacking on the prevalence, characteristics and mental health burden of veterans with co-occurring posttraumatic stress disorder and insomnia. The current cross-sectional study analysed data from a nationally representative sample of 4069 US veterans examining the prevalence and comorbidity between posttraumatic stress disorder and insomnia, and their associations with psychiatric and medical comorbidities, suicidality, and psychosocial functioning. Results revealed that 4.0% of US veterans screened positive for posttraumatic stress disorder + insomnia, 7.4% for insomnia only, and 3.2% for posttraumatic stress disorder only. Compared with controls, higher odds of major depressive disorder and generalized anxiety disorder were observed in the posttraumatic stress disorder + insomnia and posttraumatic stress disorder only groups. Moreover, compared with the control group, posttraumatic stress disorder + insomnia and posttraumatic stress disorder only groups had higher odds of current suicidal ideation, while the posttraumatic stress disorder + insomnia group had also higher odds of attempting suicide. Relative to the posttraumatic stress disorder only group, the posttraumatic stress disorder + insomnia group scored substantially lower on measures of cognitive, emotional and social functioning (d = 1.05, 1.04 and 0.87, respectively). This study provides contemporary data regarding current prevalence, correlates, and psychiatric and functional burden of posttraumatic stress disorder + insomnia among US veterans. The results underscore the importance of assessing, monitoring and treating posttraumatic stress disorder and insomnia as part of the efforts to mitigate suicide risk and promote multi-domain functioning in this population.

Suicide-Specific Cognitions and Suicidal Behavior in U.S. Military Veterans.

BACKGROUND: U.S. military veterans may be reluctant to disclose suicidal thoughts and behaviors. Suicide-specific cognitions, which generally avoid direct mention of suicide, may be reliable indicators of risk among those reluctant to disclose such thoughts and behaviors. METHODS: Data from a population-based, cross-sectional study of 2,430 U.S. military veterans were analyzed to examine the associations between the Brief Suicide Cognitions Scale (B-SCS), suicidal ideation, and suicide planning. RESULTS: After adjusting for age, sex, number of adverse childhood experiences, cumulative trauma burden, depressive symptom severity, and lifetime history of suicide attempt, total scores on the B-SCS (excluding the item mentioning suicide) were uniquely associated with suicidal ideation (odds ratio [OR] = 1.23, 95% confidence interval [CI] = 1.15-1.32) and suicide planning (OR = 1.27, 95%CI = 1.18-1.37). Exploratory post-hoc analyses revealed that difficulties with solving and coping with one's problems were uniquely linked to these outcomes. CONCLUSIONS: Assessment of suicide-specific cognitions may help to enhance suicide detection and prevention in veterans, especially in those who may not directly disclose thoughts of suicide. Intervention efforts to bolster perceived deficits in coping and problem-solving may help mitigate suicide risk in this population.

Helping the Helpers: Mental Health Challenges of Psychosocial Support Workers During the Russian-Ukrainian War.

OBJECTIVE: The ongoing Russian-Ukrainian war has been linked to mental health problems in the Ukrainian general population. To date, however, scarce research has examined the mental health of psychosocial support workers (PSWs) in Ukraine who have a burdensome workload in the context of ongoing conflict. This study aimed to examine the prevalence and correlates of burnout, posttraumatic stress disorder (PTSD), and suicidal ideation (SI) in PSWs in Ukraine during the Russian-Ukrainian war. METHODS: One hundred seventy-eight PSWs in Ukraine completed a survey assessing war exposure, mental health, and psychosocial characteristics. RESULTS: A total 59.6% of PSWs screened positive for burnout, 38.2% for PTSD, and 10.7% for current SI. Lower optimism was associated with greater odds of burnout. Greater distress from witnessing war-related destruction, lower optimism, lower presence of meaning in life, and lower levels of close social relationships were associated with greater odds of burnout. Lower presence of meaning in life was associated with greater odds of SI. CONCLUSIONS: Results of this study highlight the mental health challenges faced by PSWs in Ukraine during the ongoing Russian-Ukrainian war. They further suggest that interventions to foster meaning in life and promote social connectedness may "help the helpers" during this ongoing conflict.

Health correlates of experiential and behavioral avoidance among trauma-exposed veterans.

INTRODUCTION: Avoidance is a well-documented risk factor for poor mental and physical health outcomes. However, limited research has explored this relationship specifically among trauma-exposed veterans, a population known to be particularly prone to avoidance behavior. Conceptually, avoidance is often divided into two distinct but overlapping constructs - experiential avoidance (resisting distressing internal states) and behavioral avoidance (avoiding or changing experiences that elicit distress). In this exploratory survey study, we examined associations between behavioral and experiential avoidance and mental, physical, and cognitive functioning, as well as quality of life. METHODS: Veterans with a trauma history (N = 89) completed a 121-item survey containing validated assessments to examine several mental and physical health and wellness-related variables. Correlations between experiential avoidance and outcome measures, and behavioral avoidance and outcome measures, were explored. Multivariable linear regression analyses were conducted to explore the association between experiential and behavioral avoidance on mental health outcomes. In addition, we conducted exploratory analyses in which we investigated these correlations in those who screened positive for PTSD versus those who did not, and between different types of behavioral avoidance and major outcomes. RESULTS: Experiential avoidance was moderately correlated with distress from depressive symptoms, distress related to past trauma, and health-related and cognitive dysfunction. Experiential Avoidance was weakly correlated with distress from anxiety symptoms and poorer quality of life. Behavioral avoidance was moderately correlated with distress from depressive and anxiety symptoms, distress related to past trauma, and cognitive dysfunction, and was weakly correlated with health-related dysfunction and poorer quality of life. Results from multivariable analyses revealed that experiential avoidance was associated with greater distress related to depressive symptoms and past trauma, and behavioral avoidance was associated with greater distress related to anxiety symptoms, depressive symptoms, and past trauma. CONCLUSIONS: Results suggest that avoidance negatively influences major domains of mental and physical health as well as functioning and health-related quality of life in trauma-exposed veterans. They further indicate that behavioral and experiential avoidance may be differentially linked to mental health outcomes. The results support the idea that avoidance may be an important marker for psychosocial functioning and may serve as a treatment target in trauma-exposed veterans.

Obstructive respiratory disease in U.S. veterans: Prevalence, characteristics, and health burden.

OBJECTIVE: To examine the psychiatric and physical health burden of obstructive respiratory disease in a nationally representative sample of U.S. Veterans. METHODS: Secondary data analyses were conducted using data from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of U.S. Veterans. Participants self-reported health professional-diagnosed obstructive respiratory disease (i.e., asthma, chronic bronchitis or chronic obstructive pulmonary disease). Veterans who reported obstructive respiratory disease (n = 502) were compared to veterans without this disease but with at least one or more other medical conditions-controls (n = 3169) on measures of sociodemographic, trauma, psychiatric, and physical health characteristics. Multivariable regression analyses examined independent associations between obstructive respiratory disease and psychiatric conditions and physical characteristics. RESULTS: A total 12.5% of the sample reported a diagnosis of obstructive respiratory disease. Compared to controls, veterans with obstructive respiratory disease were more likely to be female, unmarried/partnered, lower income, residing in the Midwest, receiving VA healthcare, and had greater lifetime and childhood trauma burden. In adjusted analyses, veterans with respiratory disease had 47-91% greater odds of screening positive for current posttraumatic stress, major depressive, and generalized anxiety disorders, and had 48% greater odds of current suicide ideation. They were also more likely to have lifetime nicotine use disorder and had more medical comorbidities and more severe somatic symptoms. CONCLUSIONS: Obstructive respiratory disease is prevalent among U.S. veterans and associated with significant mental and physical health burden. Results highlight the need for timely screening and treatment for psychiatric and medical conditions that are highly comorbid with obstructive respiratory disease in this population.

Co-occurring Chronic Pain and PTSD Among US Military Veterans: Prevalence, Correlates, and Functioning.

BACKGROUND: The prevalence of co-occurring chronic pain and posttraumatic stress disorder (PTSD) has yet to be established in a nationally representative sample of US veterans, and little is known about the individual contributing roles of these disorders to the psychiatric and functional burden of this comorbidity. OBJECTIVE: To determine the prevalence of chronic pain, PTSD, and co-occurring chronic pain and PTSD, and psychiatric comorbidities and psychosocial functioning in these groups. DESIGN: Data were analyzed from the National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of US veterans. PARTICIPANTS: Veterans (n=4069) were classified into four groups: control (i.e., no PTSD or chronic pain), chronic pain only, PTSD only, and co-occurring chronic pain and PTSD. MAIN MEASURES: A probable PTSD diagnosis was established using the PTSD Checklist for DSM-5, and a chronic pain diagnosis using a self-report item that queried health care professional diagnoses. Psychiatric and functional status were assessed using the Patient Health Questionnaire-4, Alcohol Use Disorders Identification Test, Screen of Drug Use, Suicide Behaviors Questionnaire-Revised, Short Form Health Survey-8, Brief Inventory of Psychosocial Functioning, and Medical Outcomes Study Cognitive Functioning Scale. KEY RESULTS: A total of 3.8% of veterans reported both probable PTSD and a diagnosis of chronic pain. Relative to veterans with chronic pain alone, those with co-occurring chronic pain and probable PTSD were more likely to screen positive for psychiatric disorders (odds ratios [ORs]=2.59-9.88) and scored lower on measures of psychosocial functioning (Cohen's ds=0.38-1.43). Relative to veterans with probable PTSD only, those with co-occurring chronic pain and probable PTSD were more likely to have attempted suicide (OR=4.79; 95%CI, 1.81-12.69). CONCLUSIONS: Results underscore the importance of whole health care that considers a broad range of health and functional domains in the assessment and treatment of co-occurring chronic pain and PTSD in veterans.

Well-Being Domains in U.S. Military Veterans: Identifying Modifiable Factors to Promote Whole Health.

The U.S. Department of Veterans Affairs is actively transitioning away from a disease-centric model of healthcare to one that prioritizes disease prevention and the promotion of overall health and well-being. Described as Whole Health, this initiative aims to provide personalized, values-centered care that optimizes physical, behavioral, spiritual, and socioeconomic well-being. To inform this initiative, we analyzed cross-sectional data from a nationally representative sample of primarily older U.S. military veterans to estimate levels of well-being across these domains, and identify sociodemographic, military, and potentially modifiable health and psychosocial correlates of them. Results revealed that, overall, veterans reported high domain-specific well-being (average scores ranging from 6.7 to 8.3 out of 10), with the highest levels in the socioeconomic domain and lowest in the physical domain. Several modifiable factors, including purpose in life, resilience, and social support, were strongly associated with the examined well-being domains. Interventions targeting these constructs may help promote well-being among U.S. veterans.

Randomized controlled trial of two internet-based written therapies for world trade center workers and survivors with persistent PTSD symptoms.

Posttraumatic stress disorder (PTSD) remains prevalent among individuals exposed to the 9/11 World Trade Center (WTC) terrorist attacks. The present study compared an Internet-based, therapist-assisted psychotherapy for PTSD to an active control intervention in WTC survivors and recovery workers with WTC-related PTSD symptoms (n = 105; 75% syndromal PTSD). Participants were randomized to integrative testimonial therapy (ITT), focused on WTC-related trauma, or modified present-centered therapy (I-MPCT), each comprising 11 assigned written narratives. The primary outcome was baseline-to-post-treatment change in PTSD symptoms on the PTSD Checklist for DSM-5 (PCL-5). Secondary measures included PTSD symptom clusters, depressive/anxiety symptoms, functioning, and quality of life. A significant main effect of time was observed for the primary outcome (average "large" effect size improvement, d = 1.49). Significant and "moderate-to-large" main effects of time were also observed for all PTSD symptom clusters, depressive symptoms, quality of life, and mental health-related functioning (d range=0.62-1.33). Treatment and treatment-by-time interactions were not significant. In planned secondary analyses incorporating 3-month follow-up measures, ITT was associated with significantly greater reductions than I-MPCT in PTSD avoidance and negative alterations in cognitions and mood, anxiety, and mental health-related functioning. Both therapies significantly lowered PTSD symptoms, suggesting they may benefit hard-to-reach individuals with chronic WTC-related PTSD symptoms.

Sex, Adverse Childhood Experiences, and Substance Use Disorders in US Military Veterans: Results From the National Health and Resilience in Veterans Study.

OBJECTIVES: US veterans report more adverse childhood experiences (ACEs) than nonveterans, and a greater number of ACEs has been linked to substance use disorders (SUDs). To date, however, no study has examined whether specific ACEs may be linked to SUDs in this population in a sex-related fashion. METHODS: We analyzed data from the National Health and Resilience in Veterans Study, a nationally representative survey of 4069 US veterans. ACEs, current alcohol use disorder (AUD), and current drug use disorder (DUD) were assessed using validated self-report measures. RESULTS: Being raised in a household with people with SUDs was independently associated with current AUD. Childhood sexual abuse and having an incarcerated family member were independently associated with current DUD. Sex moderated associations with specific ACEs. Specifically, female veterans who had experienced physical neglect in childhood or were raised with a mentally ill family member in the home were more likely to endorse current AUD and DUD, whereas male veterans who experienced sexual abuse in childhood or who were raised in a home with someone who used substances were more likely to endorse current AUD and DUD. CONCLUSIONS: Results underscore the importance of targeted and sex-sensitive interventions in addressing potentially unresolved childhood traumas as part of treatment efforts for SUDs in veterans.

Using the Moral Injury and Distress Scale to identify clinically meaningful moral injury.

Despite the proliferation of moral injury studies, a remaining gap is distinguishing moral injury from normative distress following exposure to potentially morally injurious events (PMIEs). Our goal was to leverage mental health and functional measures to identify clinically meaningful and functionally impairing moral injury using the Moral Injury and Distress Scale (MIDS). Participants who endorsed PMIE exposure (N = 645) were drawn from a population-based sample of military veterans, health care workers, and first responders. Using signal detection methods, we identified the optimally efficient MIDS score for detecting clinically significant posttraumatic stress and depressive symptom severity, trauma-related guilt, and functional impairment. The most efficient cut scores across outcomes converged between 24 and 27. We recommend a cut score of 27 given that roughly 70% of participants who screened positive on the MIDS at this threshold reported clinically significant mental health symptoms, and approximately 50% reported severe trauma-related guilt and/or functional impairment. Overall, 10.2% of respondents exposed to a PMIE screened positive for moral injury at this threshold, particularly those who identified as a member of a minoritized racial or ethnic group (17.9%) relative to those who identified as White, non-Hispanic (8.0%), aOR = 2.52, 95% CI [1.45, 4.42]. This is the first known study to establish a cut score indicative of clinically meaningful and impairing moral injury. Such scores may enhance clinicians' abilities to conduct measurement-based moral injury care by enabling them to identify individuals at risk of negative outcomes and better understand risk and protective factors for moral injury.

Functional significance of posttraumatic growth in U.S. military veterans.

BACKGROUND: Although many studies indicate that individuals who have experienced a traumatic event can experience posttraumatic growth (PTG), some researchers have questioned the significance of PTG in associations with functioning. The role of PTG in functioning following trauma may be better elucidated by accounting for its joint effects with posttraumatic stress disorder (PTSD) symptoms. METHODS: Data were analyzed from the National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 3847 trauma-exposed U.S. veterans. Participants completed assessments of potentially traumatic events, PTSD symptoms, and PTG, as well as a broad range of sociodemographic, military, trauma, health, personality, and psychosocial characteristics. RESULTS: PTG was independently and moderately associated with higher mental, cognitive, and psychosocial functioning, but not physical functioning. Results showed a similar pattern of findings when examining relations between subdomains of PTG and these aspects of functioning. Additionally, among veterans who screened positive for PTSD, those who endorsed PTG reported higher levels of mental, cognitive, and/or psychosocial functioning than those who did not endorse PTG. LIMITATIONS: Findings may be limited by the use of a cross-sectional design, retrospective self-reports of PTG, and a predominantly older white male veteran sample. CONCLUSION: Results provide support for the functional significance of PTG and highlight the importance of considering PTSD symptoms to better understand the role of PTG in functioning. Clinical interventions to foster PTG may help promote post-trauma functioning.

Problem Opioid Use Among US Military Veterans: Prevalence, Correlates, and Psychiatric Characteristics.

OBJECTIVE: Problem opioid use (POU) is a serious public health crisis in the United States. However, little research has examined the prevalence, correlates, and psychiatric characteristics of POU in vulnerable segments of the population, such as US military veterans. METHODS: Data were analyzed from the National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 2441 US veterans. Multivariable logistic regression models were conducted to identify correlates and psychiatric correlates of POU (defined as a positive screen on the Tobacco, Alcohol, Prescription Medication, and Other Substance Use Tool). RESULTS: A total 3.0% (95% confidence interval, 2.0%-4.5%) of US veterans screened positive for POU. Black, non-Hispanic race/ethnicity (odds ratio [OR], 3.83), lifetime alcohol use disorder (OR, 3.38), major depressive disorder (MDD; OR, 2.52), greater number of medical conditions (OR, 1.15), and disability in instrumental activities of daily living (IADL); OR, 1.86) were independently associated with POU. A significant interaction between IADL disability and MDD was observed (OR, 10.73)-among veterans with IADL disability, those with MDD had more than 6-fold greater POU than those without MDD (20.6% vs 3.2%). Furthermore, POU was associated with 2- to 3-folds greater odds of current generalized anxiety disorder and current posttraumatic stress disorder, and lifetime suicide attempt. CONCLUSIONS: POU affects 3.0% of US veterans and is associated with Black race/ethnicity, lifetime physical and mental health morbidities, as well as current psychiatric disorders and lifetime suicide attempts. Results underscore the importance of assessing physical and mental health disorders in veterans at-risk for POU and addressing co-occurring psychiatric disorders associated with POU in this population.

Obesity in Latinx and White U.S. military veterans: Mental health, psychosocial burden, non-suicidal self-injury and suicidal behavior.

Obesity disproportionately affects Latinx communities and is linked to an increased risk of mental health problems. Military veterans are more likely to develop mental health problems, but the role of Latinx ethnicity in moderating the association between obesity and these problems is unclear. To address this gap, this study examined psychiatric and psychosocial correlates of obesity in a nationally representative sample of Latinx and White U.S. military veterans. Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed 3524 Latinx and White veterans. Analyses revealed that Latinx ethnicity moderated associations between obesity and several measures. Specifically, among veterans with obesity, Latinx veterans had higher rates of major depression, generalized anxiety, post-traumatic stress disorders, drug use disorders, non-suicidal self-injury, and higher levels of childhood trauma, loneliness, and hostility relative to White veterans. These findings underscore the importance of culturally sensitive prevention and treatment efforts to help mitigate symptoms of internalizing disorders, drug use disorder, loneliness, and hostility, and to cultivate psychosocial resources such as resilience and coping self-efficacy among Latinx veterans with obesity.

Differences in the phenotypic expression of posttraumatic stress disorder symptoms in US military veterans with and without clinical insomnia.

STUDY OBJECTIVES: The goal of this study was to examine the phenotypic expression of posttraumatic stress disorder (PTSD) symptoms in veterans with probable PTSD and clinical insomnia relative to those with probable PTSD alone. METHODS: Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 4,069 US military veterans. RESULTS: A total of 3.9% of the full sample screened positive for probable PTSD and clinical insomnia and 3.2% for probable PTSD alone. Relative to veterans with probable PTSD alone, those with probable PTSD and clinical insomnia reported significantly greater severity of intrusions, avoidance, and anxious and dysphoric arousal symptoms. Post hoc analyses of individual symptoms revealed that trauma-related nightmares; flashbacks; trauma-related emotional and physiological reactivity; avoidance of trauma-related thoughts, feelings, and external reminders; exaggerated startle response; concentration difficulties; and trauma-related sleep difficulties differed between groups. A multivariable logistic regression analysis further revealed that trauma-related sleep difficulties, trauma-related physiological reactivity, and exaggerated startle response independently predicted probable PTSD and clinical insomnia relative to PTSD alone. CONCLUSIONS: Results of this study suggest that trauma-related reactivity and arousal symptoms differentiate veterans with probable PTSD and clinical insomnia from those with probable PTSD alone. They further underscore the importance of utilizing nuanced models of PTSD symptom expression as part of assessment and treatment planning efforts in this population. CITATION: DeViva JC, McCarthy E, Fischer I, Pietrzak RH. Differences in the phenotypic expression of posttraumatic stress disorder symptoms in US military veterans with and without clinical insomnia. J Clin Sleep Med. 2024;20(3):345-351.

Problematic Alcohol Use Trajectories in U.S. Military Veterans during a Public Health Crisis: Results from a 3-year, Nationally Representative, Longitudinal Study.

A growing number of studies have examined alcohol use during the COVID-19 pandemic. However, few longitudinal studies evaluated the prevalence and correlates of different trajectories of problematic alcohol use in vulnerable segments of the population, such as US veterans, over the 3-year course of the COVID-19 pandemic. Data were analyzed from the National Health and Resilience in Veterans Study, a nationally representative, longitudinal study of 2,441 US veterans. Latent growth mixture modeling was used to identify the trajectories and correlates of problematic alcohol use. Four trajectories were identified: consistent (N = 170, weighted 7.2%), decreasing (N = 38, weighted 2.2%), increasing (N = 22, weighted 1.2%), and low (N = 2,211, weighted 89.4%) problematic alcohol use. Greater household income, pre-pandemic drug use disorder (DUD), lower social support, and COVID-19 infection to self or non-household members were associated with an increasing relative to decreasing problematic alcohol use trajectory. Greater household income, adverse childhood experiences (ACEs), pre-pandemic DUD, lower social support, and greater COVID-related social restriction stress were associated with an increasing relative to a low problematic alcohol use trajectory. Younger age, male sex, ACEs, pre-pandemic DUD, lower pre-pandemic and greater decline in protective psychosocial characteristics, COVID-19 infection to non-household member, and lower COVID-related financial stress were associated with a consistent relative to a low problematic alcohol use trajectory. Overall, pre-pandemic greater income, DUD, and lower social support were associated with an increase in problematic alcohol use among US veterans during the COVID-19 pandemic. Results may help inform prevention efforts to mitigate problematic alcohol use during prolonged crises in this population.

Generalized anxiety and mild anxiety symptoms in U.S. military veterans: Prevalence, characteristics, and functioning.

Generalized anxiety disorder (GAD) is a mental disorder characterized by excessive anxiety and worries that impair daily functioning. While prior work has documented the prevalence and correlates of GAD and subthreshold GAD (SGAD) in clinical samples, contemporary data on the epidemiology of anxiety symptoms are lacking, particularly in higher-risk populations such as military veterans. To address this gap, we analyzed data from a large, nationally representative sample of U.S. veterans to examine the: prevalence of probable GAD and mild anxiety symptoms measured using a brief screener; sociodemographic and military characteristics associated with anxiety symptoms; and psychiatric and functional correlates of anxiety symptoms. Results revealed that a total of 7.9% (95% confidence interval [CI] = 6.7-9.3%) and 22.1% (95%CI = 20.5-23.9%) of veterans screened positive for probable GAD and mild anxiety symptoms, respectively. Relative to veterans without anxiety symptoms, those with probable GAD and mild anxiety symptoms were younger, more likely to be female and racial/ethnic minorities, and more likely to have served 2+ deployments. Further, a "dose-response" association was observed between anxiety symptom severity and clinical correlates, with robust associations observed between probable GAD and poorer mental health, suicidal thoughts and behaviors, and functional impairment. Mild anxiety symptoms showed intermediate magnitude associations with these outcomes. Results of this study suggest that 3-of-10 U.S. veterans report anxiety symptoms. While the use of a brief screener to assess mild anxiety symptoms and probable GAD is limited, findings underscore the importance of a dimensional approach to assessing anxiety symptoms and associated clinical and functional characteristics in veterans.

Differential associations of adverse childhood experiences and mental health outcomes in U.S. military veterans.

Adverse childhood experiences (ACEs) are robustly associated with adverse mental health outcomes across the lifespan. Military veterans may be particularly vulnerable to adverse mental health effects of ACEs given their potentially higher prevalence of childhood traumas and compounding effects of military service-related traumas. To date, however, scarce research has examined the differential impact of individual ACEs on mental health outcomes in population-based samples of veterans. To address this gap, we analyzed data from the National Health and Resilience in Veterans Study (NHRVS), which surveyed a nationally representative sample of 4069 U.S. veterans, to examine the association between specific ACEs and major depressive, generalized anxiety, and posttraumatic stress disorders, and suicidal thoughts and behaviors. Results of multivariable logistic regression analyses revealed that emotional neglect and sexual abuse were most consistently associated with these outcomes, even after adjustment for the number of ACEs endorsed. Collectively, results of this study underscore the importance of assessing for specific ACEs-most notably childhood emotional neglect and sexual abuse-and treating these potentially unresolved childhood traumas in veterans.

Health and psychiatric impairment associated with moral injury, military sexual trauma, and their co-occurrence in U.S. combat veterans.

BACKGROUND: Military sexual trauma (MST) and moral injury (MI) are associated with adverse psychiatric and health outcomes among military veterans. However, no known population-based studies have examined the incremental burden associated with the co-occurrence of these experiences relative to either alone. METHOD: Cross-sectional data were analyzed from the National Health and Resilience in Veterans Study, a nationally representative sample of 1330 U.S. combat veterans. Veterans reported on history of exposure to MST and potentially morally injurious events (PMIEs). Analyses estimated the lifetime prevalence of MST only, PMIEs only, and co-occurring MST and PMIEs; and examined associations between MST/PMIEs status and psychiatric and physical health comorbidities, functioning, and suicidality. RESULTS: The lifetime weighted prevalence of exposure to MST only, PMIEs only, and co-occurring MST and PMIEs were 2.7%, 32.3%, and 4.5%, respectively. Compared with all other groups, the co-occurring MST + PMIEs group reported greater severity of posttraumatic stress, depression, generalized anxiety, and insomnia symptoms. They also scored lower on measures of physical, mental, and psychosocial functioning, and reported a greater number of chronic medical conditions and somatic complaints. Veterans with co-occurring MST + PMIEs were more than twice as likely as those with MST only to report past-year suicidal ideation. CONCLUSIONS: The co-occurrence of MST and MI is associated with a greater psychiatric and health burden among combat veterans than either experience alone. Results underscore the importance of assessing and treating MST and MI in this population. Findings underscore the importance for future work to parse overlap between morally salient aspects of MST and the concept of moral injury.

Genetic and non-genetic predictors of risk for opioid dependence.

BACKGROUND: Elucidation of the interaction of biological and psychosocial/environmental factors on opioid dependence (OD) risk can inform our understanding of the etiology of OD. We examined the role of psychosocial/environmental factors in moderating polygenic risk for opioid use disorder (OUD). METHODS: Data from 1958 European ancestry adults who participated in the Yale-Penn 3 study were analyzed. Polygenic risk scores (PRS) were based on a large-scale multi-trait analysis of genome-wide association studies (MTAG) of OUD. RESULTS: A total of 420 (21.1%) individuals had a lifetime diagnosis of OD. OUD PRS were positively associated with OD (odds ratio [OR] 1.42, 95% confidence interval [CI] 1.21-1.66). Household income and education were the strongest correlates of OD. Among individuals with higher OUD PRS, those with higher education level had lower odds of OD (OR 0.92, 95% CI 0.85-0.98); and those with posttraumatic stress disorder (PTSD) were more likely to have OD relative to those without PTSD (OR 1.56, 95% CI 1.04-2.35). CONCLUSIONS: Results suggest an interplay between genetics and psychosocial environment in contributing to OD risk. While PRS alone do not yet have useful clinical predictive utility, psychosocial factors may help enhance prediction. These findings could inform more targeted clinical and policy interventions to help address this public health crisis.

Functional correlates of a novel 8-factor model of PTSD in U.S. military veterans: Results from the National Health and Resilience in Veterans Study.

Emerging evidence indicates that more nuanced models of posttraumatic stress disorder (PTSD) may better capture the condition's symptom structure. Recent theoretical and empirical work suggest that an 8-factor model of PTSD with separate internally- (e.g. flashbacks) and externally- (e.g. trauma-cue related physiological reactivity) generated intrusive symptom clusters may advance understanding of PTSD and its treatment and course. However, the model's functional and clinical significance still requires evaluation. To this end, we analyzed data from the National Health and Resilience in Veterans Study, a nationally representative sample of 3847 trauma-exposed U.S. military veterans. Multivariable regressions were performed to assess the relationship between the 8 PTSD symptom clusters, assessed using the PTSD Checklist for DSM-5, and clinical and functional measures. Results revealed that externally-generated intrusions were associated with higher odds of current depression and anxiety and worse mental, cognitive, and psychosocial functioning. Anhedonia (e.g., loss of interest in enjoyable activities) symptoms were associated with all the correlates tested, while negative affect (e.g., having strong negative feelings such as fear) symptoms were associated with all measures except depression. Avoidance symptoms were associated with lower odds of current anxiety while externalizing behavior symptoms were linked to higher odds of suicidal ideation. Anxious arousal symptoms were associated with lower odds of suicidal ideation but higher odds of PTSD-related impairment/distress, while dysphoric arousal symptoms were associated with higher odds of current depression, PTSD-related impairment/distress and worse mental and cognitive functioning. Results suggest that a more nuanced 8-factor model of PTSD symptoms may help inform understanding of the clinical and functional correlates of this multi-faceted disorder.