Lifetime Smoking Patterns and Preferences for Smoking Cessation Among Women Veterans Receiving Veterans Health Administration Care.

The objective of this study was to identify common themes among women veterans who smoke or recently quit and had used smoking cessation treatment within the Veterans Health Administration (VHA). The study built upon previous research by utilizing in-depth interviews to encourage disclosure of potentially stigmatized topics. Twenty women veterans enrolled in VHA care engaged in a quality improvement project focused on improving smoking cessation services. Qualitative analysis of de-identified interviews used a combination of content analysis and thematic analysis within the sociopharmacological model of tobacco addiction. Findings revealed that participants' smoking was influenced by woman veteran identity and by several gender-related contextual factors, including military sexual trauma and gender discrimination. Findings also highlighted other contextual factors, such as personal autonomy, emotional smoking triggers, and chronic mental health concerns. Findings are interpreted within the context of cultural power imbalances, and recommendations are provided for VHA smoking cessation for women veterans.

Pain Intensity and Pain Interference in Male and Female Iraq/Afghanistan-era Veterans.

BACKGROUND: Chronic pain conditions are common among both male and female Iraq/Afghanistan-era veterans and can have substantial negative impacts on quality of life and function. Although in general women tend to report higher levels of pain intensity than men, findings remain mixed on whether gender differences in pain exist in Iraq/Afghanistan-era veterans. Additionally, the relationships between functional impairment, pain intensity, and gender remain unknown. METHODS: This project examined gender differences in pain intensity and pain interference in 875 male and female Iraq/Afghanistan-era veterans. Nonparametric Wilcoxon rank-tests examined gender differences in pain scores. Multivariable generalized linear regression modeling was used to evaluate the magnitude of pain intensity and interference across levels of chronicity and gender, and to evaluate the role of chronicity in gender effects in measures of pain and function. RESULTS: Pain intensity and interference scores were significantly greater among both male and female veterans reporting chronic pain relative to acute pain. Women veterans endorsed higher levels of pain intensity and pain interference compared with men. Results derived from multivariable analyses implicated pain intensity as a factor underlying gender differences in functional impairment among chronic pain sufferers, indicating that gender differences in functional measures were eliminated after controlling statistically for pain intensity. CONCLUSIONS: Results demonstrate that the effects of functional impairment are impacted by pain intensity, and not by gender.

Gender Differences in Response to Acceptance and Commitment Therapy Among Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn Veterans.

BACKGROUND: Most of our knowledge base regarding treatment response among veterans comes from predominantly male samples. Evidence suggests, however, that women and men use different coping strategies, which may impact how effective treatments are for people of different genders. The purpose of this investigation was to examine gender differences in response to acceptance and commitment therapy, an empirically supported transdiagnostic psychotherapy. METHODS: Data were drawn from a multisite, randomized, controlled trial of acceptance and commitment therapy as compared with a psychotherapy control, namely, present-centered therapy (PCT), in veterans with emotional distress who served in Operations Enduring Freedom, Iraqi Freedom, or New Dawn (OEF/OIF/OND). Although the original trial did not find a difference between acceptance and commitment therapy and present-centered therapy, we were interested in examining whether gender differences may have been obscured in the original analyses. This secondary analysis included 117 participants for whom at least one post-baseline data point was available and examined the role of gender in treatment response. RESULTS: Gender differences were not observed on the primary outcome of general distress, but were observed in post-traumatic stress disorder symptoms (p < .01). CONCLUSIONS: These preliminary results suggest the possibility of gender differences in psychotherapy response and should motivate additional study of gender-specific care.

Timely access to mental health care among women veterans.

Using survey data on (N = 419) patients at Department of Veterans Affairs (VA) clinics we analyzed women veterans' reports of timely access to VA mental health care. We evaluated problems that patients might face in obtaining care, and examined subjective ratings of VA care as a function of timely access to mental health care. We found that 59% of participants reported "always" getting an appointment for mental health care as soon as needed. In adjusted analyses, two problems were negatively associated with timely access to mental health care: (a) medical appointments that interfere with other activities, and (b) difficulty getting questions answered between visits. Average subjective ratings of VA ranged from 8.2-8.6 out of 10, and 93% of participants would recommend VA care. Subjective ratings of VA were higher among women who reported timely access to mental health care. Findings suggest that overall experience of care is associated with timely access to mental health care, and that such access may be amenable to improvements related to clinic hours or mechanisms for answering patient questions between visits. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Self-Reported Pain in Male and Female Iraq/Afghanistan-Era Veterans: Associations with Psychiatric Symptoms and Functioning.

OBJECTIVE: To examine pain symptoms and co-occurring psychiatric and functional indices in male and female Iraq/Afghanistan-era veterans. DESIGN: Self-reported data collection and interviews of Iraq/Afghanistan-era veterans who participated in a multisite study of postdeployment mental health. SETTING: Veterans were enrolled at one of four participating VA sites. SUBJECTS: Two thousand five hundred eighty-seven male and 662 female Iraq/Afghanistan-era veterans. METHODS: Nonparametric Wilcoxon rank tests examined differences in pain scores between male and female veterans. Chi-square tests assessed differences between male and female veterans in the proportion of respondents endorsing moderate to high levels of pain vs no pain. Multilevel regression analyses evaluated the effect of pain on a variety of psychiatric and functional measures. RESULTS: Compared with males, female veterans reported significantly higher mean levels of headache ( P < 0.0001), muscle soreness ( P < 0.008), and total pain ( P < 0.0001), and were more likely to report the highest levels of headache ( P < 0.0001) and muscle soreness ( P < 0.0039). The presence of pain symptoms in Iraq/Afghanistan-era veterans was positively associated with psychiatric comorbidity and negatively associated with psychosocial functioning. There were no observed gender differences in psychiatric and functional indices when levels of pain were equated. CONCLUSIONS: Although female Iraq/Afghanistan-era veterans reported higher levels of pain than male veterans overall, male and female veterans experienced similar levels of psychiatric and functional problems at equivalent levels of reported pain. These findings suggest that pain-associated psychological and functional impacts are comparable and consequential for both male and female veterans.

Patient, Provider, and Combined Interventions for Managing Osteoarthritis in Primary Care: A Cluster Randomized Trial.

BACKGROUND: A single-site study showed that a combined patient and provider intervention improved outcomes for patients with knee osteoarthritis, but it did not assess separate effects of the interventions. OBJECTIVE: To examine whether patient-based, provider-based, and patient-provider interventions improve osteoarthritis outcomes. DESIGN: Cluster randomized trial with assignment to patient, provider, and patient-provider interventions or usual care. (ClinicalTrials.gov: NCT01435109). SETTING: 10 Duke University Health System community-based primary care clinics. PARTICIPANTS: 537 outpatients with symptomatic hip or knee osteoarthritis. INTERVENTION: The telephone-based patient intervention focused on weight management, physical activity, and cognitive behavioral pain management. The provider intervention involved electronic delivery of patient-specific osteoarthritis treatment recommendations to providers. MEASUREMENTS: The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score at 12 months. Secondary outcomes were objective physical function (Short Physical Performance Battery) and depressive symptoms (Patient Health Questionnaire). Linear mixed models assessed the difference in improvement among groups. RESULTS: No difference was observed in WOMAC score changes from baseline to 12 months in the patient (-1.5 [95% CI, -5.1 to 2.0]; P = 0.40), provider (2.5 [CI, -0.9 to 5.9]; P = 0.152), or patient-provider (-0.7 [CI, -4.2 to 2.8]; P = 0.69) intervention groups compared with usual care. All groups had improvements in WOMAC scores at 12 months (range, -3.7 to -7.7). In addition, no differences were seen in objective physical function or depressive symptoms at 12 months in any of the intervention groups compared with usual care. LIMITATIONS: The study involved 1 health care network. Data on provider referrals were not collected. CONCLUSION: Contrary to a previous study of a combined patient and provider intervention for osteoarthritis in a Department of Veterans Affairs medical center, this study found no statistically significant improvements in the osteoarthritis intervention groups compared with usual care. PRIMARY FUNDING SOURCE: National Institute of Arthritis and Musculoskeletal and Skin Diseases.

Differences in Depression Care for Men and Women among Veterans with and without Psychiatric Comorbidities.

BACKGROUND: Depression is common among primary care patients, affecting more women than men. Women veterans are an extreme but growing minority among patients seeking care from the Department of Veterans Affairs (VA), an organization historically designed to serve men. Little is known about gender differences in depression care quality within the VA primary care population. PURPOSE: This works assesses the gender differences in depression care among veterans using longitudinal electronic measures. METHODS: We undertook a cross-sectional study of all veteran VA primary care users with a new episode of depression from federal fiscal year 2010, covering nine geographically diverse regions. We assessed the quality of depression care based on receipt of minimally appropriate depression treatment within 1 year of a new episode of depression and on receipt of depression-related follow-up visits within 180 days. Minimally appropriate treatment and follow-up were operationalized as meeting or exceeding a minimally appropriate threshold for care, based on national quality measures and expert panel consensus. Regression models were used to produce predicted probabilities for each process outcome accounting for the presence or absence of other psychiatric comorbidities. All models were adjusted for model covariates and clinic clusters (404 sites). MAIN FINDINGS: In 2010, 110,603 veterans with a primary care visit had a new episode of depression; 10,094 (9%) were women. In multivariate analyses, women had modest yet significantly higher rates of minimally appropriate depression treatment than men, whether patients had depression only (79% of women vs. 76% of men; p < .001) or depression along with other psychiatric comorbidities (92% of women vs. 91% or men; p < .001). There were no significant gender differences for rate of receipt of follow-up for depression at 180 days. Interactions between gender and other psychiatric comorbidities were not significant. CONCLUSIONS: Our findings suggest that the VA is achieving comparable depression care between genders at minimally appropriate thresholds.

An exploratory pilot investigation of neurosteroids and self-reported pain in female Iraq/Afghanistan-era Veterans.

Female Veterans are the most rapidly growing segment of new users of the Veterans Health Administration (VHA), and a significant proportion of female Veterans receiving treatment from VHA primary care providers report persistent pain symptoms. Currently, available data characterizing the neurobiological underpinnings of pain disorders are limited. Preclinical data suggest that neurosteroids may be involved in the modulation of pain symptoms, potentially via actions at gamma-aminobutyric acid (GABA) and N-methyl-D-aspartate (NMDA) receptors. Dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulfate (DHEAS) are neurosteroids that modulate inhibitory GABA receptors and excitatory NMDA receptors, producing complex neuronal effects. Emerging evidence from male Iraq/Afghanistan-era Veterans suggests that reductions in neurosteroid levels are associated with increased pain symptoms and that neurosteroids may be promising biomarker candidates. The current exploratory study thus examined associations between self-reported pain symptoms in 403 female Iraq/Afghanistan-era Veterans and serum DHEAS and DHEA levels. Serum DHEAS levels were inversely correlated with low back pain in female Veterans (Spearman r = -0.103; p = 0.04). Nonparametric analyses indicate that female Veterans reporting moderate/extreme low back pain demonstrated significantly lower DHEAS levels than those reporting no/little low back pain (|Z| = 2.60; p = 0.009). These preliminary findings support a role for DHEAS in pain physiology of low back pain and the rationale for neurosteroid therapeutics in pain analgesia.

A Combined Patient and Provider Intervention for Management of Osteoarthritis in Veterans: A Randomized Clinical Trial.

BACKGROUND: Management of osteoarthritis requires both medical and behavioral strategies, but some recommended therapies are underused. OBJECTIVE: To examine the effectiveness of a combined patient and provider intervention for improving osteoarthritis outcomes. DESIGN: Cluster randomized clinical trial with assignment to osteoarthritis intervention and usual care groups. (ClinicalTrials.gov: NCT01130740). SETTING: Department of Veterans Affairs Medical Center in Durham, North Carolina. PARTICIPANTS: 30 providers (clusters) and 300 outpatients with symptomatic hip or knee osteoarthritis. INTERVENTION: The telephone-based patient intervention focused on weight management, physical activity, and cognitive behavioral pain management. The provider intervention involved delivery of patient-specific osteoarthritis treatment recommendations to primary care providers through the electronic medical record. MEASUREMENTS: The primary outcome was total score on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 12 months. Secondary outcomes were WOMAC function and pain subscale scores, physical performance (Short Physical Performance Battery), and depressive symptoms (Patient Health Questionnaire-8). Linear mixed models that were adjusted for clustering of providers assessed between-group differences in improvement in outcomes. RESULTS: At 12 months, WOMAC scores were 4.1 points lower (indicating improvement) in the osteoarthritis intervention group versus usual care (95% CI, -7.2 to -1.1 points; P = 0.009). WOMAC function subscale scores were 3.3 points lower in the intervention group (CI, -5.7 to -1.0 points; P = 0.005). WOMAC pain subscale scores (P = 0.126), physical performance, and depressive symptoms did not differ between groups. Although more patients in the osteoarthritis intervention group received provider referral for recommended osteoarthritis treatments, the numbers who received them did not differ. LIMITATION: The study was conducted in a single Veterans Affairs medical center. CONCLUSION: The combined patient and provider intervention resulted in modest improvement in self-reported physical function in patients with hip and knee osteoarthritis. PRIMARY FUNDING SOURCE: Department of Veterans Affairs, Health Services Research and Development Service.

Allopregnanolone Levels Are Inversely Associated with Self-Reported Pain Symptoms in U.S. Iraq and Afghanistan-Era Veterans: Implications for Biomarkers and Therapeutics.

BACKGROUND AND OBJECTIVES: Pain symptoms are common among Iraq/Afghanistan-era veterans, many of whom continue to experience persistent pain symptoms despite multiple pharmacological interventions. Preclinical data suggest that neurosteroids such as allopregnanolone demonstrate pronounced analgesic properties, and thus represent logical biomarker candidates and therapeutic targets for pain. Allopregnanolone is also a positive GABAA receptor modulator with anxiolytic, anticonvulsant, and neuroprotective actions in rodent models. We previously reported inverse associations between serum allopregnanolone levels and self-reported pain symptom severity in a pilot study of 82 male veterans. METHODS: The current study investigates allopregnanolone levels in a larger cohort of 485 male Iraq/Afghanistan-era veterans to attempt to replicate these initial findings. Pain symptoms were assessed by items from the Symptom Checklist-90-R (SCL-90-R) querying headache, chest pain, muscle soreness, and low back pain over the past 7 days. Allopregnanolone levels were quantified by gas chromatography/mass spectrometry. RESULTS: Associations between pain ratings and allopregnanolone levels were examined with Poisson regression analyses, controlling for age and smoking. Bivariate nonparametric Mann­Whitney analyses examining allopregnanolone levels across high and low levels of pain were also conducted. Allopregnanolone levels were inversely associated with muscle soreness [P = 0.0028], chest pain [P = 0.032], and aggregate total pain (sum of all four pain items) [P = 0.0001]. In the bivariate analyses, allopregnanolone levels were lower in the group reporting high levels of muscle soreness [P = 0.001]. CONCLUSIONS: These findings are generally consistent with our prior pilot study and suggest that allopregnanolone may function as an endogenous analgesic. Thus, exogenous supplementation with allopregnanolone could have therapeutic potential. The characterization of neurosteroid profiles may also have biomarker utility.

Functional correlates of military sexual assault in male veterans.

Despite research findings that similar numbers of male and female veterans are affected by military sexual trauma (MST), there has been considerably less research on the effects of MST specific to male veterans. The aim of the present study was to provide preliminary data describing functional correlates of military sexual assault (MSA) among male Iraq/Afghanistan-era veterans to identify potential health care needs for this population. We evaluated the following functional correlates: posttraumatic stress disorder (PTSD) symptoms, depression symptoms, alcohol use, drug use, suicidality, social support, violent behavior in the past 30 days, incarceration, disability eligibility status, and use of outpatient mental health treatment. We compared 3 groups: (a) male veterans who endorsed a history of MSA (n = 39), (b) a general non-MSA sample (n = 2,003), and (c) a matched non-MSA sample (n = 39) identified by matching algorithms on the basis of factors (e.g., age, education, adult premilitary sexual trauma history, childhood sexual and physical trauma history, and race) that could increase veterans' vulnerability to the functional correlates examined. MSA in men was associated with greater PTSD symptom severity, greater depression symptom severity, higher suicidality, and higher outpatient mental health treatment, above and beyond the effects of vulnerability factors. These findings suggest that, for male veterans, MSA may result in a severe and enduring overall symptom profile requiring ongoing clinical management.

Drug use and childhood-, military- and post-military trauma exposure among women and men veterans.

BACKGROUND: The current study was undertaken to examine whether posttraumatic stress symptoms (PTSS) and depressive symptoms mediated the association between trauma exposure (combat-related trauma and non-combat traumas occurring before, during, and after military service), and drug abuse symptoms use among male and female veterans. METHODS: Participants were 2304 (1851 male, 453 female) veterans who took part in a multi-site research study conducted through the Department of Veterans Affairs Mid-Atlantic Mental Illness Research, Education and Clinical Center (VISN 6 MIRECC). Path analytic models were used to determine the association between problematic past-year drug use and combat-related and non-combat trauma experienced before, during, or after the military and whether current post-traumatic stress symptoms or depressive symptoms mediated these associations. RESULTS: For both male and female veterans, depressive symptoms significantly mediated the effects of pre- and post-military trauma on drug abuse symptoms. CONCLUSION: Mental health providers who work with trauma-exposed Iraq and Afghanistan era veterans should assess for drug use, depressive symptoms, and life-span trauma (i.e., not only combat-related traumas) as part of a thorough trauma-based assessment for both men and women.

A pilot randomized placebo-controlled trial of adjunctive aripiprazole for chronic PTSD in US military Veterans resistant to antidepressant treatment.

Many individuals with post-traumatic stress disorder (PTSD) experience persistent symptoms despite pharmacological treatment with antidepressants. Several open-label monotherapy and adjunctive studies have suggested that aripiprazole (a second-generation antipsychotic) may have clinical utility in PTSD. However, there have been no randomized placebo-controlled trials of aripiprazole use for PTSD. We thus conducted a pilot randomized controlled trial of adjunctive aripiprazole versus placebo among Veterans with chronic PTSD serving in the US military since 11 September 2001 to assess the feasibility, safety, tolerability, and therapeutic potential of aripiprazole. Sixteen Veterans were randomized, and 14 completed at least 4 weeks of the study; 12 completed the entire 8-week trial. Outcome measures included the Clinician-Administered PTSD Scale (CAPS), PTSD Checklist, Beck Depression Inventory, Second Edition, and Positive and Negative Syndrome Scale scores. Aripiprazole was well-tolerated in this cohort, and improvements in CAPS, PTSD Checklist, Beck Depression Inventory, Second Edition, and Positive and Negative Syndrome Scale scores were as hypothesized. Although CAPS change scores did not reach statistical significance, aripiprazole outperformed placebo by 9 points on the CAPS in the last observation carried forward analysis compared with the placebo group (n = 7 per group), and by 20 points in the group randomized to aripiprazole that completed the entire study (n = 5) compared with the placebo group (n = 7). Results suggest promise for aripiprazole as an adjunctive strategy for the treatment of PTSD.

Exploratory investigation of biomarker candidates for suicide in schizophrenia and bipolar disorder.

BACKGROUND: Clozapine and lithium increase neurosteroids in rodents, and both drugs demonstrate antisuicidal actions. We therefore hypothesized that neurosteroid levels may be reduced in patients with schizophrenia or bipolar disorder who completed suicide. AIMS: To investigate neurosteroid levels in the parietal cortex and posterior cingulate in schizophrenia and bipolar patients who died by suicide, and compare them with patients with these disorders who died of other causes. METHOD: Neurosteroid levels were quantified by gas chromatography/mass spectrometry in the parietal cortex and posterior cingulate. Mann-Whitney analyses were conducted in exploratory post hoc analyses to investigate neurosteroids as possible biomarker candidates for suicide. RESULTS: The study showed that pregnenolone was significantly decreased in the parietal cortex in the combined group of patients with schizophrenia or bipolar disorder who died by suicide (n = 13) compared with patients with these disorders who died of other causes (n = 17, p = .02). Pregnenolone levels were also lower in the parietal cortex in the individual group of schizophrenia patients who died by suicide (n = 4) compared with schizophrenia patients who died of other causes (n = 11) p = .04). CONCLUSION: Pregnenolone alterations may be relevant to the neurobiology of suicide in schizophrenia and bipolar disorder.

Study design and protocol for a theory-based behavioral intervention focusing on maintenance of weight loss: the Maintenance After Initiation of Nutrition TrAINing (MAINTAIN) study.

BACKGROUND: Obesity is a significant public health problem. Although various lifestyle approaches are effective for inducing significant weight loss, few effective behavioral weight maintenance strategies have been identified. It has been proposed that behavior maintenance is a distinct state that involves different psychological processes and behavioral skills than initial behavior change. Previously, we created a conceptual model that distinguishes behavior initiation from maintenance. This model was used to generate Maintenance After Initiation of Nutrition TrAINing (MAINTAIN), an intervention to enhance weight loss maintenance following initiation. The effectiveness of MAINTAIN is being evaluated in an ongoing trial, the rationale and procedures of which are reported herein. METHODS/DESIGN: Veterans aged ≤ 75 with body mass index ≥ 30 kg/m(2) participate in a 16-week, group-based weight loss program. Participants who lose ≥ 4 kg by the end of 16 weeks (target n = 230) are randomized 1:1 to receive (a) usual care for 56 weeks or (b) MAINTAIN, a theoretically-informed weight loss maintenance intervention for 40 weeks, followed by 16 weeks of no intervention contact. MAINTAIN involves 3 in-person group visits that transition to 8 individualized telephone calls with decreasing contact frequency. MAINTAIN focuses on satisfaction with outcomes, weight self-monitoring, relapse prevention, and social support. We hypothesize that, compared to usual care, MAINTAIN will result in at least 3.5 kg less regain and better relative levels of caloric intake and physical activity over 56 weeks, and that it will be cost-effective. DISCUSSION: If effective, MAINTAIN could serve as a model for redesigning existing weight loss programs. CLINICALTRIALSGOV IDENTIFIER: NCT01357551.

Amino acids as biomarker candidates for suicidality in male OEF/OIF Veterans: relevance to NMDA receptor modulation and nitric oxide signaling.

Veteran populations are exposed to multiple stressful events, and suicidality among veterans is a serious problem. Identifying biomarkers of suicidality may enhance detection, prevention, and treatment. Multiple neurotransmitter systems are implicated in the neurobiology of suicidality, including amino acid neurotransmitter systems. Amino acids as biomarker candidates for suicidality were quantified using mass spectrometry in serum samples from 90 male U.S. Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans. Amino acid levels in veterans reporting suicidal ideation (SI) on the Beck Scale for Suicidal Ideation (BSS) (BSS score > 0, n = 19) were compared with those reporting no SI (BSS score = 0, n = 71). Glycine, an excitatory amino acid and N-methyl-d-aspartate receptor modulator, was significantly elevated in serum samples from veterans reporting SI (p = 0.043). Serine and aspartate/asparagine, also excitatory neurotransmitters, were nonsignificantly increased in veterans reporting SI (p = 0.082 and p = 0.097, respectively). In contrast, arginine (nitric oxide [NO] precursor) and citrulline (by-product of NO formation) were nonsignificantly decreased in veterans reporting SI (p = 0.097 and p = 0.093, respectively). Profiling amino acids as possible biomarker candidates for suicidality in OEF/OIF veterans may have clinical utility for identifying suicidal risk. Glutamatergic neurotransmission and NO signaling may be relevant to the neurobiology of suicidality in OEF/OIF veterans.

Acute effects of trauma-focused research procedures on participant safety and distress.

The ethical conduct of research on posttraumatic stress disorder (PTSD) requires assessing the risks to study participants. Some previous findings suggest that patients with PTSD report higher distress compared to non-PTSD participants after trauma-focused research. However, the impact of study participation on participant risk, such as suicidal/homicidal ideation and increased desire to use drugs or alcohol, has not been adequately investigated. Furthermore, systematic evaluation of distress using pre- and post-study assessments, and the effects of study procedures involving exposure to aversive stimuli, are lacking. Individuals with a history of PTSD (n=68) and trauma-exposed non-PTSD controls (n=68) responded to five questions about risk and distress before and after participating in research procedures including a PTSD diagnostic interview and a behavioral task with aversive stimuli consisting of mild electrical shock. The desire to use alcohol or drugs increased modestly with study participation among the subgroup (n=48) of participants with current PTSD. Participation in these research procedures was not associated with increased distress or participant risk, nor did study participation interact with lifetime PTSD diagnosis. These results suggest some increase in distress with active PTSD but a participant risk profile that supports a favorable risk-benefit ratio for conducting research in individuals with PTSD.

Differentiating Behavior Initiation and Maintenance: Theoretical Framework and Proof of Concept.

Although many interventions are effective for health behavior initiation, maintenance has proven elusive. Interventions targeting maintenance often extend the duration with which initiation content is delivered or the duration of follow-up without intervention. We posit that health behavior initiation and maintenance require separate psychological processes and skills. To determine the value of operationalizing maintenance as a process separate from initiation, we conducted a pilot study of a telephone-delivered intervention to assist people in transitioning from behavior initiation to maintenance. Participants were 20 veterans who had initiated lifestyle changes during a randomized controlled trial of a cholesterol reduction intervention. After completing the randomized controlled trial, these participants were enrolled in the pilot maintenance intervention, which involved three monthly telephone calls from a nurse interventionist focusing on behavioral maintenance skills. To evaluate the feasibility and acceptability of this intervention, we assessed recruitment and retention rates as well as 4-month pre-post changes in health behaviors and associated psychological processes. We also conducted individual interviews with participants after study completion. Although not powered to detect significant changes, there was evidence of improvement in dietary intake and of maintenance of physical activity and low-density lipoprotein cholesterol during the 4-month maintenance study. Participants found it helpful to plan for relapses, self-monitor, and obtain social support, but they had mixed reactions about reflecting on satisfaction with outcomes. Participants accepted the intervention and desired ongoing contact to maintain accountability. This pilot maintenance intervention warrants further evaluation in a randomized controlled trial.