A pilot study of trauma-sensitive yoga and Breathe2Relax among service members in an intensive outpatient program.

Emerging research indicates that yoga is a promising adjunct to psychological trauma treatment. The current pilot study examined the associations between psychophysiological stress, diaphragmatic breathing (DB), and a trauma-sensitive yoga (TSY) regimen developed specifically for trauma-exposed service members in alignment with recent calls for precision in reporting therapeutic yoga protocols. Participants were 31 service members enrolled in a trauma-focused intensive outpatient program (IOP). Service members participated in a brief diaphragmatic breathing (DB) session using the Breathe2Relax (B2R) app followed by the TSY session. Heart rate (HR) and perceived stress were measured at baseline and after both the DB practice and the TSY session. We assessed Yoga and DB expectancies at baseline and post TSY. Participants also rated the acceptability and usability of the B2R app. Results of linear mixed effects regression models showed decreases in HR and perceived stress, compared to baseline, following DB (HR, b = -8.68, CI 95% = -13.34, -4.02; perceived stress, b = -1.77, CI 95% = -2.35, -1.18) and TSY (HR, b = -12.44, CI 95% = -17.15, -7.73; perceived stress b = -3.69, CI 95% = -4.29, -3.08). Higher levels of expectancies, compared to lower levels, related to stronger decreases in HR and perceived stress, particularly after TSY. Overall, participants rated the B2R usability as high; virtually all participants reported that "most would learn to use the app quickly," and 76.6% reported that they would use it frequently.

Assessing the dimensionality and construct validity of the military stigma scale across current service members.

US service members are at elevated risk for distress and suicidal behavior, compared to the general US population. However, despite the availability of evidence-based treatments, only 40% of Service members in need of mental health care seek help. One potential reason for the lower use of services is that service members experience stigma or concerns that the act of seeking mental health care from a mental health provider carries a mark of disgrace. The Military Stigma Scale (MSS) was designed to assess two theoretical dimensions of help-seeking stigma (public and self), specifically among service members. The goal of the current study was to further examine the validity of the MSS among 347 active duty service members. Examination of unidimensional, two-factor, and bifactor models revealed that a bifactor model, with a general (overall stigma), two specific factors (public and self-stigma), and one method factor (accounting for negatively worded items) provided the best fit to the data. Ancillary reliability analyses also supported the MSS measuring a broad stigma factor associated with seeking mental health care in the military. Subsequent model analyses showed that the MSS was associated with other stigma-related constructs. Overall, findings suggest that the MSS is a reliable and validated scale that can be used to assess military help-seeking stigma and to evaluate results of programs designed to reduce stigma.

Caring contacts for suicide prevention: A systematic review and meta-analysis.

Caring Contacts (CC), a low-cost intervention originally designed and tested by Jerome Motto in 1976, remains one of the few strategies to demonstrate efficacy in the prevention of suicide deaths. Interest in CC has increased steadily over the last several years in tandem with rising U.S. suicide rates and the acceleration of suicide prevention initiatives. There have been several efforts to design interventions modeled after Motto's strategy, and the recent publication of additional large-scale randomized controlled trials (RCTs) in alignment with the intent of Motto's original model afford an opportunity to systematically review efficacy findings. The current systematic review provides an updated and focused analysis of the evidence supporting the efficacy of CC. A systematic literature search of MEDLINE, EMBASE, PsycINFO, Cochrane Library, and ClinicalTrials.gov was conducted, and PRISMA, Cochrane, and GRADE guidelines were followed. Of 2,746 abstracts reviewed, 13 publications, comprising six randomized controlled trials (RCTs) met inclusion criteria. The studies encompassed 6,218 participants across four countries and military, veteran, and civilian health care systems. The primary outcome was suicide mortality; secondary outcomes were suicide attempts and emergency department (ED) presentations/hospitalizations. The DerSimonian-Laird random-effects univariate meta-analysis was used to estimate summary effect sizes and evaluate statistical heterogeneity. Summary risk ratio estimates ranged from 0.57 to 1.29 across outcomes and time points; most estimates indicated a protective effect. For suicide deaths and ED presentations/hospitalization, interval estimates at 1-year postrandomization were consistent with either an increase or a decrease in risk. A protective effect was observed for suicide attempts at 1-year postrandomization. Implications and methodological recommendations for future work in this area reviewed and discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Pilot outcomes of cognitive processing therapy implementation in military health system outpatient behavioral health clinics.

Enterprise data indicates that U.S. service members (SMs) with posttraumatic stress disorder (PTSD) may not receive an evidence-based treatment (EBT) or may receive an EBT with low fidelity to the core components. Successful delivery of EBTs requires provider training and ongoing supervision/consultation, adjustment of clinic processes and structure, and leadership support. The Department of Defense (DoD) Practice-Based Implementation (PBI) Network is a dedicated team of implementation science specialists that support the integration of EBTs into clinical practice in the Military Health System (MHS). The PBI Network conducted a Cognitive Processing Therapy (CPT) pilot to investigate the acceptability and feasibility of a novel trauma specialist implementation approach proposed by South Texas Research Organizational Network Guiding Studies on Trauma and Resilience (STRONG STAR). This approach, CPT Trauma Specialist (CPT-TS), called for training designated behavioral health (BH) therapists as the primary CPT providers in their clinics. In collaboration with the Uniformed Services University Center for Deployment Psychology, the PBI Network provided training and consultation to 26 providers across 13 MHS BH clinics and supported ongoing facilitation. Despite provider interest and clinic leadership support, less than half of the pilot provider participants were able to meet the consultation and CPT delivery requirements for designation as a CPT trauma trained specialist. Prevalent implementation barriers included lack of adequate clinic resources, provider challenges balancing clinical and military-related duties, the need to focus on high-risk patients, and other military system-related constraints. These findings highlight the need for implementation scientists to examine alternatives to traditional training models and identify fidelity-consistent adaptations that allow for delivery of evidence-based care within highly constrained systems of care. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Assessing the Clinical Utility of a Wearable Device for Physiological Monitoring of Heart Rate Variability in Military Service Members with Traumatic Brain Injury.

Introduction: Autonomic dysfunction has been implicated as a consequence of traumatic brain injury (TBI). Heart rate variability (HRV) may be a viable measure of autonomic dysfunction that could enhance rehabilitative interventions for individuals with TBI. This pilot study sought to assess the feasibility and validity of using the Zeriscope™ platform system in a real-world clinical setting to measure HRV in active-duty service members with TBI who were participating in an intensive outpatient program. Methods: Twenty-five service members with a history of mild, moderate, or severe TBI were recruited from a military treatment facility. A baseline assessment was conducted in the cardiology clinic where point validity data were obtained by comparing a 5-min recording of a standard 12-lead electrocardiogram (ECG) output against the Zeriscope platform data. Results: Compared with the ECG device, the Zeriscope device had a concordance coefficient (rc) of 0.16, falling below the standard deemed to represent acceptable accuracy in HR measurement (i.e., 0.80). Follow-up analyses excluding outliers did not significantly improve the concordance coefficient to an acceptable standard for the total participant sample. System Usability Survey responses showed that participants rated the Zeriscope system as easy to use and something that most people would learn to use quickly. Conclusions: This study demonstrated promise in ambulatory HRV measurement in a representative military TBI sample. Future research should include further refinement of such ambulatory devices to meet the specifications required for use in a military active-duty TBI population.

Adjustment disorders: A research gaps analysis.

Adjustment disorders are among the most commonly diagnosed mental health disorders in both civilian and military clinical settings. Despite their high prevalence, adjustment disorders have received little research attention. The many gaps in our understanding of this group of disorders hinder the development of adequate, evidence-based treatment protocols. This study utilizes a systematic methodology to identify and prioritize research gaps in adjustment disorders. We used authoritative source reports to identify gaps in research domains from foundational science to services research. Subject-matter experts conducted literature searches to substantiate and refine research gaps, and stakeholders assessed the importance and impact of this work for researchers and policy-makers. We identified 254 possible research-needs statements, which were ultimately reduced to 11 final, prioritized research gaps. Two gaps addressed prevention and screening and three addressed treatment and services research. Six gaps addressed foundational science, epidemiology, and etiology research domains, highlighting the need for basic research. Until some of the basic science questions are resolved (e.g., diagnostic clarity, valid screening, and assessment measures) about adjustment disorders, we may not be able to develop adequate evidence-based interventions for the disorders, and it will be difficult to understand the trajectory of these disorders throughout treatment. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A systematic analysis and prioritization of suicide prevention research gaps.

OBJECTIVE: This study identified and prioritized research gaps for suicide prevention in the Department of Defense to inform future research investments. METHODS: The 2019 VA/DoD Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide was the primary source document for research gaps, supplemented by an updated literature search. Institutional stakeholders rated the identified research gaps and ranked the gap categories. We used Q factor analysis to derive a list of the prioritized research gaps and category rankings. RESULTS: Thirty-five research gaps were identified and prioritized. The highest rated research gap topic was lethal means safety interventions and their effectiveness in increasing safety behaviors and/or reducing suicide-related outcomes. Research on the effectiveness of crisis response planning and several other non-pharmacological interventions (e.g., implementation of cognitive-behavioral therapy, technology-based behavioral interventions, and applications of dialectical behavior therapy to non-Borderline patients) were also rated highly by stakeholders. CONCLUSIONS: This work generated a list of priorities for future suicide research as evaluated by Departments of Defense and Veterans Affairs stakeholders. Our findings can help guide the efforts of suicide researchers and inform decisions about future research funding for suicide prevention.

Posttraumatic Stress Disorder Treatment Dropout Among Military and Veteran Populations: A Systematic Review and Meta-Analysis.

High treatment dropout rates reported in recent literature have brought into question the effectiveness of trauma-focused posttraumatic stress disorder (PTSD) treatments among military populations. The aim of the current systematic review was to evaluate PTSD treatment dropout rates among military populations by treatment type and other study-level variables. We searched four databases as well as gray literature for randomized controlled trials that evaluated evidence-based PTSD treatments in samples of active duty personnel and/or veterans. In total, 26 studies were included in this review, with a total of 2,984 participants. We analyzed dropout rates across treatment types using multivariate meta-analysis. Across all forms of treatment, the aggregated dropout rate was 24.2%. Dropout percentages based on treatment type were 27.1% for trauma-focused treatments, 16.1% for non-trauma-focused treatments, and 6.8% for waitlist groups. We found substantial heterogeneity between studies that was not explained by military status or other study-level covariates. Summary risk ratios (RRs) comparing relative dropout between treatment groups indicated that trauma-focused treatment groups had a higher risk of dropout compared to non-trauma-focused treatments, RR = 1.60. The statistical heterogeneity of within-treatment dropout risk ratios was negligible. Dropout rates among military patients receiving trauma-focused therapies were only slightly higher than those reported in the literature among civilian populations and were not explained by study-level covariates.

Women in combat: The effects of combat exposure and gender on the incidence and persistence of posttraumatic stress disorder diagnosis.

Recent expansions in the roles of women in combat have prompted increased interest in the psychological toll combat exposure may have on female service members as compared to males. This study examined the interactive effects of gender and combat exposure on transitions in posttraumatic stress disorder (PTSD) diagnostic status (presence or absence of PTSD diagnosis). We used administrative data of 20,000 U.S. Army soldiers whose combat exposure was assessed after return from deployment between January 1, 2008 and June 30, 2014; soldiers' PTSD diagnostic status was determined using International Classification of Diseases-9 diagnoses at four time points separated by 12 months. We used a mixed-effects logit transition model to examine the effects of combat and gender on incidence, persistence, and prevalence of PTSD diagnosis. Incidence and prevalence of PTSD diagnosis were higher among women, but persistence of PTSD diagnosis was higher in men. Higher rates of new PTSD diagnosis among women were not dependent on combat exposure, suggesting that other types of trauma may be responsible for increased rates among women. Gender differences in prevalence and persistence of PTSD diagnosis were greater among combat-exposed soldiers than among those not exposed to combat. Men maintained a PTSD diagnosis over longer periods of time than women suggesting greater PTSD persistence, and this pattern was particularly pronounced among soldiers exposed to combat. These results have implications for the recent policy changes and gender-based prevention strategies, and suggest that women in combat roles may be no more vulnerable to PTSD than are their male counterparts. Though the gender differences were small, they are indicative of healthcare utilization patterns that may be important for prevention and that warrant further exploration.

Changes in physiological reactivity in response to the trauma memory during prolonged exposure and virtual reality exposure therapy for posttraumatic stress disorder.

OBJECTIVE: A key symptom of posttraumatic stress disorder (PTSD) is hyperreactivity to trauma-relevant stimuli. Though physiological arousal is reliably elevated in PTSD, the question remains whether this arousal responds to treatment. Virtual reality (VR) has been posited to increase emotional engagement during prolonged exposure therapy (PE) for PTSD by augmenting imaginal exposures with trauma-relevant sensory information. However, the comparative effects of VR exposure therapy (VRE) have received limited empirical inquiry. METHOD: Ninety active-duty soldiers with combat-related PTSD participating in a randomized-controlled trial to receive PE, VRE, or a waitlist-control (WL) condition had their physiological reactivity, indexed by galvanic skin response (GSR), to their trauma memories assessed at pre-, mid-, and posttreatment. RESULTS: Although both VRE and PE conditions showed reduced GSR reactivity to trauma memories from pre- to posttreatment, only the VRE group differed significantly from WL. Across the sample, reductions in GSR were significantly correlated with reductions in self-reported PTSD and anxiety symptoms. CONCLUSIONS: This was the first study comparing effects of VRE and PE on psychophysiological variables. Given previous research finding limited differences between VRE and PE in PTSD symptom reduction, these findings lend support to the rationale for including VR in exposure therapy protocols while raising important questions about the potential benefits of VRE. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

More than expected? Assessing departures from additivity in health care utilization after mild traumatic brain injury in military personnel with pre-existing mental health conditions.

OBJECTIVE: Prior research indicates that there is an additive association between traumatic brain injury and mental health diagnoses on health-care utilization. This assumed additivity has not been formally assessed. The objective of this study was to estimate additive and multiplicative interactions associated with mild traumatic brain injury (mTBI) and pre-existing health conditions. METHOD: Active-duty military patient records over a nine-year period were sampled within four exposure groups (N = 4500 per group) defined jointly by incident mTBI and pre-existing mental health diagnoses. Outpatient and inpatient health encounters were compared between the four exposure groups using generalized linear models for count and proportion outcomes. Additive interactions were estimated using the interaction contrast ratio. Multiplicative interactions were estimated as a product term in the generalized linear models. RESULTS: The joint association of mTBI and pre-existing mental health diagnoses with health-care utilization, overall, was less than multiplicative and greater than additive. Patients with both exposures experienced more health-care utilization than expected under the assumed additivity (independence) of the two exposures. PTSD and anxiety diagnoses were the MH diagnoses associated with the largest interaction contrast values specific to total outpatient encounters. CONCLUSIONS: Studies of the interaction of two diagnoses on subsequent health-care utilization should examine both additive and multiplicative interactions. The greater-than-additive findings in this study indicate that there may be synergy, for at least some patients, between mTBI injury and mental health that complicates the treatment course.

Caring E-mails for Military and Veteran Suicide Prevention: A Randomized Controlled Trial.

OBJECTIVE: The purpose of this multisite study was to conduct a randomized controlled trial of an e-mail version of the caring letters (CL) suicide prevention intervention to determine whether the intervention is efficacious in preventing suicide behaviors among U.S. service members and veterans. METHOD: Psychiatric inpatients (N = 1,318) were recruited from four military medical centers and two VA hospitals and randomized to receive either 13 caring e-mails over two years or usual care. RESULTS: There were 10 deaths from any cause in the CL group (three suicides) and 14 in the usual care group (seven suicides) during the individual two-year follow-up intervals. There was no statistically significant difference in the rate of all-cause hospital readmission between the study groups (RR = 1.13; 95% CI = 0.94, 1.36). There were no differences observed between groups on self-reported psychiatric hospital readmissions, self-reported suicide attempts, or other measures associated with risk for suicide. CONCLUSIONS: No firm conclusions about the efficacy of the intervention can be made because the study was inadequately powered. There were no adverse events associated with the intervention, and implementation of the procedures was feasible in the military and veteran hospital settings. These results provide important methodological considerations for caring contact trials in military populations.

Prediction Models for Suicide Attempts and Deaths: A Systematic Review and Simulation.

Importance: Suicide prediction models have the potential to improve the identification of patients at heightened suicide risk by using predictive algorithms on large-scale data sources. Suicide prediction models are being developed for use across enterprise-level health care systems including the US Department of Defense, US Department of Veterans Affairs, and Kaiser Permanente. Objectives: To evaluate the diagnostic accuracy of suicide prediction models in predicting suicide and suicide attempts and to simulate the effects of implementing suicide prediction models using population-level estimates of suicide rates. Evidence Review: A systematic literature search was conducted in MEDLINE, PsycINFO, Embase, and the Cochrane Library to identify research evaluating the predictive accuracy of suicide prediction models in identifying patients at high risk for a suicide attempt or death by suicide. Each database was searched from inception to August 21, 2018. The search strategy included search terms for suicidal behavior, risk prediction, and predictive modeling. Reference lists of included studies were also screened. Two reviewers independently screened and evaluated eligible studies. Findings: From a total of 7306 abstracts reviewed, 17 cohort studies met the inclusion criteria, representing 64 unique prediction models across 5 countries with more than 14 million participants. The research quality of the included studies was generally high. Global classification accuracy was good (≥0.80 in most models), while the predictive validity associated with a positive result for suicide mortality was extremely low (≤0.01 in most models). Simulations of the results suggest very low positive predictive values across a variety of population assessment characteristics. Conclusions and Relevance: To date, suicide prediction models produce accurate overall classification models, but their accuracy of predicting a future event is near 0. Several critical concerns remain unaddressed, precluding their readiness for clinical applications across health systems.

Does Virtual Reality Increase Simulator Sickness During Exposure Therapy for Post-Traumatic Stress Disorder?

Purpose: Measurement of simulator-related side effects (SSEs) is an integral component of competent and ethical use of virtual reality exposure (VRE), but common SSEs may overlap with symptoms of anxiety. Limited research exists about the frequency of SSEs during VRE treatment for post-traumatic stress disorder (PTSD) and no research compares self-reported SSEs for those undergoing VRE with those participating in exposure therapy without virtual reality. This study compared the SSEs of active duty soldiers with PTSD randomly assigned to exposure therapy through traditional prolonged exposure or VRE.Methodology: A total of 108 soldiers participated in up to 10 sessions of exposure therapy. Of those, 93 provided data on simulator sickness both before and after initiation of imaginal exposure. Approximately half (n = 49) used the Virtual Iraq/Afghanistan system to support engagement with their trauma memory. Soldiers completed a 4-item, self-reported measure of SSE after each session.Results: Controlling for age, gender, baseline anxiety symptoms, and SSE symptom counts at the first two sessions of therapy (before initiating imaginal exposure), there was no statistically significant difference between the treatment groups in SSEs at the beginning of imaginal exposure or over the course of treatment.Conclusions: This finding suggests that caution should be exercised in the interpretation of SSE measurements during the use of VRE for PTSD. Virtual reality did not account for any increase in self-reported SSE. It is possible that anxiety accounts for a meaningful proportion of SSE reports during VRE.

Circumstances preceding suicide in U.S. soldiers: A qualitative analysis of narrative data.

To gain a better understanding of military suicide, we examined suicide narratives for 135 Soldiers extracted from two large-scale surveillance systems: the Department of Defense Suicide Event Report (DoDSER) and the Centers for Disease Control and Prevention's (CDC) National Violent Death Reporting System (NVDRS). Using coroner/medical examiner and law enforcement narratives captured in the NVDRS and mental health provider narrative data collected across multiple domains from the DoDSER, we examined circumstances surrounding military suicides using a qualitative content analysis approach. We identified five common proximal circumstances: (1) intimate partner relationship problems (63.0%); (2) mental health/substance abuse (51.9%); (3) military job-related (46.7%); (4) financial (17.8%); and (5) criminal/legal activity (16.3%). Evidence of premeditation was present in 37.0% of suicides. Decedents frequently struggled with multiple, high-stress problems and exhibited symptoms of coping and emotion regulation difficulties. Findings demonstrate potential points of intervention for suicide prevention strategies. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Financial hardship and risk of suicide among U.S. Army personnel.

Financial stress has been frequently identified as a risk factor for suicidal behavior, both in military and civilian groups. However, it remains unclear to what degree financial stress may be associated independently with suicide behavior when accounting for other risk factors. This study examined data on suicide and suicide attempt cases in the Department of Defense Suicide Event Report compared with service members who did not have recent suicide behavior. The resulting multinomial regression analysis found that financial distress had a weak association with suicide, and its relationship to suicide attempts was not statistically significant. Compared with financial distress, relationship problems and substance abuse history appeared to have much stronger associations with suicidal behavior, as did having a diagnosis of a mood disorder, such as major depressive disorder. The major conclusion from these data are that although financial distress may be a risk factor for suicidal behavior, the relationship is likely indirect and considerably less substantial than previously suspected. In addition, its relative influence is significantly less than other identified risk factors. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

An evaluation of mobile applications designed to assist service members and veterans transitioning to civilian life.

Mobile technologies may be able to provide service members and veterans with the knowledge necessary to transition to civilian life successfully in a cost-effective and accessible manner. Although a number of transition applications (apps) currently exist in the marketplace, to our knowledge, none of them has been evaluated for quality or effectiveness. For this study, 6 experts used the Mobile App Rating Scale (MARS; Stoyanov et al., 2015) to evaluate the quality of 16 transition apps. The majority of these apps focused on providing service members with resource lists, employment assistance, or assistance with disability applications. Only 2 apps had been downloaded more than 10,000 times on GooglePlay, with the majority being downloaded between 100 and 1,000 times. Only 1 app received an above-average overall quality rating, and half received below-average overall quality ratings. Based on these findings, the authors recommend that researchers and developers create more high-quality apps by focusing on education and health-care transition issues, as well as work to better disseminate their products. (PsycINFO Database Record

Suicides, homicides, accidents, and undetermined deaths in the U.S. military: comparisons to the U.S. population and by military separation status.

PURPOSE: To compare rates of external causes of mortality among individuals who served in the military (before and after separation from the military) to the U.S. METHODS: This retrospective cohort study examined all 3.9 million service members who served from 2002 to 2007. External cause mortality data from 2002 to 2009 were used to calculate standardized mortality ratios. Negative binomial regression compared differences in the mortality rates for pre- and post-separation. RESULTS: Accident and suicide mortality rates were highest among cohort members under 30 years of age, and most of the accident and suicide rates for these younger individuals exceeded expectation given the U.S. population mortality rates. Military suicide rates began below the expected U.S. rate in 2002 but exceeded the U.S. rate by 2009. Accident, homicide, and undetermined mortality rates remained below the U.S. rates throughout the study period. Mortality rates for all external causes were significantly higher among separated individuals compared with those who did not separate. Mortality rates for individuals after separation from service decreased over time but remained higher than the rates for those who had not separated from service. CONCLUSIONS: Higher rates of death for all external causes of mortality after separation suggest prevention opportunities. Future research should examine how preseparation characteristics and experiences may predict postseparation adverse outcomes to inform transition programs.

What's Changed? A Comparison of Army Suicide Surveillance Data to Cases from 1975 to 1982.

US Army suicide rates increased significantly in the last decade and have remained high. To inform future research hypotheses, Army suicide surveillance data (2012-2014) were compared to similar Army data for suicides from 1975 to 1982. Preliminary data suggest that suicide rates increased across most demographic groups, but may have decreased among divorced soldiers. Mental health utilization increased over time. Legal problems and physical health problems were identified in a higher percentage of cases in the recent data relative to the 1975-1982 era. Potential implications for suicide prevention are discussed.

Evaluation of a methodology to validate National Death Index retrieval results among a cohort of U.S. service members.

PURPOSE: Accurate knowledge of the vital status of individuals is critical to the validity of mortality research. National Death Index (NDI) and NDI-Plus are comprehensive epidemiological resources for mortality ascertainment and cause of death data that require additional user validation. Currently, there is a gap in methods to guide validation of NDI search results rendered for active duty service members. The purpose of this research was to adapt and evaluate the CDC National Program of Cancer Registries (NPCR) algorithm for mortality ascertainment in a large military cohort. METHODS: We adapted and applied the NPCR algorithm to a cohort of 7088 service members on active duty at the time of death at some point between 2001 and 2009. We evaluated NDI validity and NDI-Plus diagnostic agreement against the Department of Defense's Armed Forces Medical Examiner System (AFMES). RESULTS: The overall sensitivity of the NDI to AFMES records after the application of the NPCR algorithm was 97.1%. Diagnostic estimates of measurement agreement between the NDI-Plus and the AFMES cause of death groups were high. CONCLUSIONS: The NDI and NDI-Plus can be successfully used with the NPCR algorithm to identify mortality and cause of death among active duty military cohort members who die in the United States.