Impact of an internet-based insomnia intervention on suicidal ideation and associated correlates in veterans at elevated suicide risk.

Improving public health approaches to suicide prevention requires scalable evidence-based interventions that can be easily disseminated. Given empirical data supporting the association between insomnia and suicide risk, internet-delivered insomnia interventions are promising candidates to meet this need. The purpose of this study was to examine whether an unguided internet-delivered cognitive-behavioral therapy for insomnia (iCBT-I) improved insomnia severity, suicidal ideation (SI), and suicide risk correlates (depression, post-traumatic stress disorder, anxiety, hostility, belongingness, hopelessness, agitation, irritability, concentration) in a sample of veterans. Secondary data analysis of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans (n = 50) with clinically significant insomnia and elevated SI drawn from a larger randomized controlled trial (RCT) of an iCBT-I, Sleep Healthy Using the Internet (SHUTi). Two-sample t-tests or Wilcoxon rank sum tests were used to evaluate between-group differences (SHUTi vs. Insomnia Education Website control) in symptom improvement from baseline to post-intervention. SHUTi participants experienced a significant improvement in insomnia severity (P < .001; d = -1.08) and a non-significant with small (subthreshold medium) effect size reduction of SI (P = .17, d = 0.40), compared to control participants. Significant improvement in hopelessness was observed (medium effect size), with non-significant small to medium effect size reductions in most remaining suicide risk correlates. Self-administered iCBT-I was associated with improvements in insomnia severity in veterans at elevated risk for suicide. These preliminary findings suggest that SI and suicide risk correlates may improve following an iCBT-I intervention, demonstrating the need for future well-powered iCBT-I RCTs targeted for populations at elevated suicide risk.

In this secondary data analysis, we examined improvements in insomnia severity, suicidal ideation (SI), and suicide risk correlates in veterans with clinically significant insomnia and elevated SI drawn from a larger randomized controlled trial (RCT) examining an unguided internet-delivered cognitive-behavioral therapy for insomnia (iCBT-I). Veterans in the iCBT-I group experienced greater improvements in insomnia severity and hopelessness than veterans in the Insomnia Education Website control. Although between-group differences in SI and other suicide risk correlates were not statistically significant, effect sizes suggest that SI and symptoms of depression, irritability, concentration, post-traumatic stress disorder, and hostility may improve following iCBT-I intervention. These results suggest that digital and iCBT-I interventions may be especially powerful tools for use in suicide prevention among veterans but highlight the critical need for additional large-scale studies to examine suicide-specific mechanisms and outcomes to guide implementation efforts.

Facility-Level and Racial Disparities in Access to Inpatient Psychiatric Occupational Therapy Services in the Veterans Health Administration.

IMPORTANCE: Veterans receiving inpatient psychiatric services with limitations in activities of daily living (ADLs) benefit from occupational therapy, yet disparities in access are unknown. OBJECTIVE: To investigate whether ADL limitations, an indicator of occupational therapy need, was associated with inpatient psychiatric occupational therapy utilization in the Veterans Health Administration (VHA) and whether this relationship differs by facility characteristics. DESIGN: Secondary analysis of VHA data. Modified Poisson regression modeled occupational therapy utilization as a function of ADL limitations, facility characteristics, and covariates. Interactions estimated whether the relationship between ADL limitations and occupational therapy utilization differed across facility characteristics. SETTING: VHA inpatient psychiatric setting. PARTICIPANTS: Veterans receiving VHA inpatient psychiatric care from 2015 to 2020 (N = 133,844). OUTCOMES AND MEASURES: Occupational therapy utilization. RESULTS: Veterans with ADL limitations were more likely to receive occupational therapy. Veterans receiving care in facilities with higher complexity and greater inpatient psychiatric care quality were more likely to receive occupational therapy. Additionally, Black veterans were less likely to receive occupational therapy relative to their White, non-Hispanic counterparts. Interactions indicated that the extent to which ADL limitations drove access to occupational therapy utilization was weaker within facilities with higher complexity and care quality. CONCLUSIONS AND RELEVANCE: Veterans with ADL limitations were more likely to access inpatient psychiatric occupational therapy, suggesting that such services are generally allocated to veterans in need. However, findings indicate disparities in access across patient-level (e.g., Black race) and facility-level (e.g., facility complexity) factors, informing efforts to eliminate barriers to accessing these valuable services. Plain-Language Summary: This is the first study, to our knowledge, to examine disparities in access to inpatient psychiatric occupational therapy in the Veterans Health Administration (VHA). The study findings show that access to inpatient psychiatric occupational therapy is partly driven by the needs of the patient. However, nonclinical factors, such as a patient's race and the characteristics of the facility at which they receive care (complexity, number of psychiatric beds available, and the quality of psychiatric care), are also important drivers of access. Identifying factors influencing access to these valuable services is the first step in developing strategies that reduce barriers to access for veterans in need.

Quantifying variation across 16S rRNA gene sequencing runs in human microbiome studies.

Recent microbiome research has incorporated a higher number of samples through more participants in a study, longitudinal studies, and metanalysis between studies. Physical limitations in a sequencing machine can result in samples spread across sequencing runs. Here we present the results of sequencing nearly 1000 16S rRNA gene sequences in fecal (stabilized and swab) and oral (swab) samples from multiple human microbiome studies and positive controls that were conducted with identical standard operating procedures. Sequencing was performed in the same center across 18 different runs. The simplified mock community showed limitations in accuracy, while precision (e.g., technical variation) was robust for the mock community and actual human positive control samples. Technical variation was the lowest for stabilized fecal samples, followed by fecal swab samples, and then oral swab samples. The order of technical variation stability was inverse of DNA concentrations (e.g., highest in stabilized fecal samples), highlighting the importance of DNA concentration in reproducibility and urging caution when analyzing low biomass samples. Coefficients of variation at the genus level also followed the same trend for lower variation with higher DNA concentrations. Technical variation across both sample types and the two human sampling locations was significantly less than the observed biological variation. Overall, this research providing comparisons between technical and biological variation, highlights the importance of using positive controls, and provides semi-quantified data to better understand variation introduced by sequencing runs. KEY POINTS: • Mock community and positive control accuracy were lower than precision. • Samples with lower DNA concentration had increased technical variation across sequencing runs. • Biological variation was significantly higher than technical variation due to sequencing runs.

Financial barriers and facilitators to secure firearm and medication storage among veterans with elevated suicide risk: a qualitative study.

OBJECTIVE: To explore financial barriers and facilitators to promoting secure firearm and medication storage among patients at risk for suicide. METHODS: Veterans seeking care in Veterans Affairs emergency care settings (N=28) participated in qualitative interviews on barriers and facilitators to adopting secure firearm and medication storage behaviours. Thematic analysis with inductive and iterative coding was used to identify themes pertaining to financial barriers and facilitators. Interviews were double-coded for reliability. RESULTS: We identified four themes-two related to financial barriers and two to financial facilitators. Barrier-related themes included: (1) the high cost of firearms and medications made owners less likely to dispose of medications, relinquish ownership of firearms or pursue out-of-home storage for firearms; (2) the high cost of out-of-home storage and preferred locking devices were barriers to secure storage. Facilitator-related themes included: (1) no-cost services or locking devices may help motivate secure firearm and medication storage and (2) preferences varied for no-cost locking devices versus coupons for devices. CONCLUSIONS: Addressing financial barriers and leveraging financial facilitators may motivate secure storage of lethal means, which could enhance suicide prevention efforts.

Longitudinal invariance of the Patient Health Questionnaire-9 among patients receiving pharmacotherapy for major depressive disorder: A secondary analysis of clinical trial data.

Comparing self-reported symptom scores across time requires longitudinal measurement invariance (LMI), a psychometric property that means the measure is functioning identically across all time points. Despite its prominence as a measure of depression symptom severity in both research and health care, LMI has yet to be firmly established for the Patient Health Questionnaire-9 depression module (PHQ-9), particularly over the course of antidepressant pharmacotherapy. Accordingly, the objective of this study was to assess for LMI of the PHQ-9 during pharmacotherapy for major depressive disorder. This was a secondary analysis of data collected during a randomized controlled trial. A total of 1,944 veterans began antidepressant monotherapy and completed the PHQ-9 six times over 24 weeks of treatment. LMI was assessed using a series of four confirmatory factor analysis models that included all six time points, with estimated parameters increasingly constrained across models to test for different aspects of invariance. Root-mean-square error of approximation of the chi-square difference test values below 0.06 indicated the presence of LMI. Exploratory LMI analyses were also performed for separate sex, age, and race subgroups. Root-mean-square error of approximation of the chi-square difference test showed minimal change in model fits during invariance testing (≤ 0.06 for all steps), supporting full LMI for the PHQ-9. LMI was also supported for all tested veteran subgroups. As such, PHQ-9 sum scores can be compared across extended pharmacotherapy treatment durations. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Association of Inpatient Occupational Therapy Utilization With Reduced Risk for Psychiatric Readmission Among Veterans.

OBJECTIVE: The authors sought to investigate whether utilization of inpatient occupational therapy (OT) was associated with reduced risk for 30-day psychiatric readmission in the Veterans Health Administration (VHA). METHODS: The authors conducted a secondary analysis of VHA medical record data for veterans who received inpatient psychiatric care from 2015 to 2020 (N=176,889). Mixed-effects logistic regression was used to model psychiatric readmission within 30 days of discharge (yes or no) as a function of inpatient psychiatric OT utilization (none, one, two, three, or four or more encounters) and other care utilization (e.g., previous psychiatric hospitalization), as well as clinical (e.g., primary diagnosis), sociodemographic (e.g., race-ethnicity), and facility (e.g., complexity) characteristics. Sensitivity analyses were conducted to evaluate the robustness of findings (e.g., stratification by discharge disposition). RESULTS: Relatively few veterans received inpatient psychiatric OT (26.2%), and 8.4% were readmitted within 30 days. Compared with veterans who did not receive inpatient psychiatric OT, those with one (OR=0.76), two (OR=0.64), three (OR=0.67), or four or more encounters (OR=0.64) were significantly (p<0.001) less likely to be readmitted within 30 days. These findings were consistent across all sensitivity analyses. CONCLUSIONS: Veterans who received inpatient OT services were less likely to experience psychiatric readmission. A clear dose-response relationship between inpatient psychiatric OT and readmission risk was not identified. These findings suggest that OT services may facilitate high-value inpatient psychiatric care in the VHA by preventing readmissions that stymie recovery and incur high costs. Future research may establish the causality of this relationship, informing policy regarding increased access to inpatient psychiatric OT.

A randomized clinical trial for a self-guided sleep intervention following moderate-severe traumatic brain injury: Study protocol.

BACKGROUND: Individuals with a history of moderate-severe traumatic brain injury (TBI) experience a significantly higher prevalence of insomnia compared to the general population. While individuals living with TBI have been shown to benefit from traditional insomnia interventions (e.g., face-to-face [F2F]), such as Cognitive Behavioral Therapy for Insomnia (CBTI), many barriers exist that limit access to F2F evidence-based treatments. Although computerized CBT-I (CCBT-I) is efficacious in terms of reducing insomnia symptoms, individuals with moderate-severe TBI may require support to engage in such treatment. Here we describe the rationale, design, and methods of a randomized controlled trial (RCT) assessing the efficacy of a guided CCBT-I program for reducing insomnia symptoms for participants with a history of moderate-severe TBI. METHODS: This is an RCT of a guided CCBT-I intervention for individuals with a history of moderate-severe TBI and insomnia. The primary outcome is self-reported insomnia severity, pre- to post-intervention. Exploratory outcomes include changes in sleep misperception following CCBT-I and describing the nature of guidance needed by the Study Clinician during the intervention. CONCLUSION: This study represents an innovative approach to facilitating broader engagement with an evidence-based online treatment for insomnia among those with a history of moderate-severe TBI. Findings will provide evidence for the level and nature of support needed to implement guided CCBT-I. Should findings be positive, this study would provide support for a strategy by which to deliver guided CCBT-I to individuals with a history of moderate-severe TBI.

Nutrition and Food Security Among Veterans: Operationalizing Nutritional Functioning.

OBJECTIVE: To assess injured military veterans' experiences, beliefs, and daily physical and psychosocial functioning in relation to food and nutrition. DESIGN: We used a convergent mixed-methods study design and the International Classification of Functioning, Disability, and Health to operationalize the core constructs and influencing factors related to physical and psychosocial functioning, food, and nutrition. SETTING: Three Veterans Affairs polytrauma rehabilitation centers. PARTICIPANTS: Veterans who served in the United States military on or after September 11, 2001, and whose medical diagnoses met the criteria for polytrauma; at least 1 mild traumatic brain injury and at least 1 associated comorbidity (eg, posttraumatic stress disorder, chronic musculoskeletal pain, vestibular disturbances), for a total N of 43. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Themes from survey responses and semistructured interview data were pooled into core constructs and influencing factors. RESULTS: Thirty-seven veterans completed all surveys and participated in recorded interviews. Based on qualitative and quantitative data, veterans' relation to food and nutrition (ie, nutritional functioning) was found to be characterized by 5 core constructs, including food background, nutrition knowledge, meal aptitude, resource navigation, and navigation to/of food spaces. Nutritional functioning was found to be shaped by 5 influencing factors, including injuries and health conditions, ideological and cultural exposures, relations, current beliefs, and current behaviors. CONCLUSIONS: Nutritional functioning (food background, nutrition knowledge, meal aptitude, resource navigation, navigation to/of food spaces) among injured veterans is complex and shaped by multiple physical, psychosocial, economic, and cultural factors.

Emerging concepts in alcohol, infection & immunity: A summary of the 2023 alcohol and immunology research interest group (AIRIG) meeting.

On December 8th 2023, the annual Alcohol and Immunology Research Interest Group (AIRIG) meeting was held at the University of Colorado Anschutz Medical Campus in Aurora, Colorado. The 2023 meeting focused broadly on how acute and chronic alcohol exposure leads to immune dysregulation, and how this contributes to damage in multiple tissues and organs. These include impaired lung immunity, intestinal dysfunction, autoimmunity, the gut-Central Nervous System (CNS) axis, and end-organ damage. In addition, diverse areas of alcohol research covered multiple pathways behind alcohol-induced cellular dysfunction, including inflammasome activation, changes in miRNA expression, mitochondrial metabolism, gene regulation, and transcriptomics. Finally, the work presented at this meeting highlighted novel biomarkers and therapeutic interventions for patients suffering from alcohol-induced organ damage.

The Veterans Crisis Line: Relations among immediate call outcomes and treatment contact and utilization following the call.

OBJECTIVE: Crisis line callers experience reductions in distress and suicidal ideation and utilize more health care following calls. The purpose of this study was to determine whether changes in distress and suicidal ideation during a call are associated with later healthcare contact and utilization. METHOD: Veterans Crisis Line calls from 599 veterans were extracted with call dates between 12/1/2018 and 11/30/2019. Calls were coded for changes in distress and suicidal ideation and linked with VA medical records to obtain healthcare data. Generalized Linear Mixed Modeling was used to examine the associations of changes in distress and suicidal ideation with healthcare contact (yes/no) and utilization (days of treatment) in the month (30 days) following the call. RESULTS: Reductions in distress were associated with behavioral (i.e., mental and substance use) healthcare utilization, F(1, 596) = 4.52, p = 0.03, and reductions in suicidal ideation were associated with any healthcare utilization, F(1, 596) = 6.45, p = 0.01. Changes in distress and suicidal ideation were not associated with healthcare contact. CONCLUSION: Responders need to help resolve distress and suicidal ideation and link callers with treatment. Unresolved distress and suicidal thoughts may signify later problems with treatment utilization. Research is needed to determine causality.

Suicide risk screening and evaluation among patients accessing VHA services and identified as being newly homeless.

OBJECTIVE: To evaluate universal suicide risk screening and evaluation processes among newly homeless Veterans. STUDY SETTING: Not applicable. STUDY DESIGN: Examination of Veterans Health Administration (VHA) using newly homeless patients' health record data in Calendar Year 2021. DATA COLLECTION: Not applicable. DATA SOURCE: Health record data. PRINCIPAL FINDINGS: Most patients received suicide risk screening and/or evaluation in the year prior to and/or following homeless identification (n = 49,505; 87.4%). Smaller percentages of patients were screened and/or evaluated in close proximity to identification (n = 7358; 16.0%), 1-30 days prior to identification (n = 12,840; 39.6%), or 1-30 days following identification (n = 14,263; 34.3%). Common settings for screening included primary care, emergency and urgent care, and mental health services. Of positive screens (i.e., potentially elevated risk for suicide), 72.6% had a Comprehensive Suicide Risk Evaluation (CSRE) completed in a timely manner (i.e., same day or within 24 h). Age, race, and sex were largely unrelated to screening and/or evaluation. CONCLUSIONS: Although many newly identified homeless patients were screened and/or evaluated for suicide risk, approximately 13% were not screened; and 27% of positive screens did not receive a timely CSRE. Continued efforts are warranted to facilitate suicide risk identification to ensure homeless patients have access to evidence-based interventions.

Harmonizing federal interagency traumatic brain injury research data to examine depression and suicide-related outcomes.

OBJECTIVE: This proof-of-concept study was conducted to establish the feasibility of compiling Federal Interagency Traumatic Brain Injury Research (FITBIR) data pertaining to depression and suicide risk, with the secondary goal of improving understanding regarding these outcomes. FITBIR is a national repository of participant-level traumatic brain injury (TBI) data designed to address methodological limitations (e.g., small sample size, heterogeneity of injuries). METHOD: FITBIR studies with TBI severity and measures related to depression and suicidal ideation were identified. Data were harmonized across relevant studies and grouped to identify "probable depression" and suicidal ideation, resulting in a large, combined sample. Rates of probable depression and suicidal ideation were described across the available studies, considering the influence of demographic and/or injury-related factors on outcomes. RESULTS: Cross-sectional studies meeting criteria included four studies with depression outcomes and two with suicidal ideation outcomes. Two studies reported data appropriate for comparative analyses on depression. Combined results suggested that approximately 71% of participants were categorized as having probable depression. Participants with a history of mild TBI had 2.54 greater odds of probable depression (95% confidence interval [1.93, 3.34]) than those without a history of TBI. CONCLUSIONS: Methods, harmonization code, and meta-databases related to TBI, probable depression, and suicidal ideation are now publicly available on the FITBIR website. Even with limited data, harmonization of FITBIR studies can serve as the basis for ongoing TBI and mental health research. Analyses will be more robust in the future as more studies with relevant outcome data are added to the FITBIR database. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Airborne Exposure to Pollutants and Mental Health: A Review with Implications for United States Veterans.

PURPOSE OF REVIEW: Inhalation of airborne pollutants in the natural and built environment is ubiquitous; yet, exposures are different across a lifespan and unique to individuals. Here, we reviewed the connections between mental health outcomes from airborne pollutant exposures, the biological inflammatory mechanisms, and provide future directions for researchers and policy makers. The current state of knowledge is discussed on associations between mental health outcomes and Clean Air Act criteria pollutants, traffic-related air pollutants, pesticides, heavy metals, jet fuel, and burn pits. RECENT FINDINGS: Although associations between airborne pollutants and negative physical health outcomes have been a topic of previous investigations, work highlighting associations between exposures and psychological health is only starting to emerge. Research on criteria pollutants and mental health outcomes has the most robust results to date, followed by traffic-related air pollutants, and then pesticides. In contrast, scarce mental health research has been conducted on exposure to heavy metals, jet fuel, and burn pits. Specific cohorts of individuals, such as United States military members and in-turn, Veterans, often have unique histories of exposures, including service-related exposures to aircraft (e.g. jet fuels) and burn pits. Research focused on Veterans and other individuals with an increased likelihood of exposure and higher vulnerability to negative mental health outcomes is needed. Future research will facilitate knowledge aimed at both prevention and intervention to improve physical and mental health among military personnel, Veterans, and other at-risk individuals.

Impact of Implementation Facilitation on the REACH VET Clinical Program for Veterans at Risk for Suicide.

OBJECTIVE: In 2017, the Veterans Health Administration (VHA) implemented a national suicide prevention program, called Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET), that uses a predictive algorithm to identify, attempt to reach, assess, and care for patients at the highest risk for suicide. The authors aimed to evaluate whether facilitation enhanced implementation of REACH VET at VHA facilities not meeting target completion rates. METHODS: In this hybrid effectiveness-implementation type 2 program evaluation, a quasi-experimental pre-post design was used to assess changes in implementation outcome measures evaluated 6 months before and 6 months after onset of facilitation of REACH VET implementation at 23 VHA facilities. Measures included percentages of patients with documented coordinator and provider acknowledgment of receipt, care evaluation, and outreach attempt. Generalized estimating equations were used to compare differences in REACH VET outcome measures before and after facilitation. Qualitative interviews were conducted with personnel and were explored via template analysis. RESULTS: Time had a significant effect in all outcomes models (p<0.001). An effect of facilitation was significant only for the outcome of attempted outreach. Patients identified by REACH VET had significantly higher odds of having a documented outreach attempt after facilitation of REACH VET implementation, compared with before facilitation. Site personnel felt supported and reported that the external facilitators were helpful and responsive. CONCLUSIONS: Facilitation of REACH VET implementation was associated with an improvement in outreach attempts to veterans identified as being at increased risk for suicide. Outreach is critical for engaging veterans in care.

Experiences of young adults with cerebral palsy in pediatric care transitioning to adult care.

AIM: To increase understanding regarding the experiences and values of young adults with cerebral palsy (CP), and their caregivers, regarding pediatric rehabilitation-related care, including perceived barriers and potential facilitators to transition to adult care. METHOD: This was a qualitative descriptive study that used 20 semi-structured interviews (13 caregivers and seven patient-caregiver dyads). RESULTS: We identified four major themes: (1) the value and security of long-term relationships; (2) feeling 'rudderless' navigating the logistics of transition; (3) differences in pediatric versus adult models of care; and (4) perceived lack of provider expertise and comfort in adult care settings. Young adults with CP who had not yet transitioned to adult rehabilitation care and their caregivers placed high value on provider relationships and expertise, advanced planning, communication, and coordination of care. INTERPRETATION: Identified barriers and potential facilitators to the transition to adult rehabilitation care reflected the uncertainty that accompanies leaving an established healthcare relationship. Challenges related to the logistics of this transition, differences in models of care, and perceived lack of provider comfort and expertise in adult care settings were also noted. Our findings could be used to develop and study patient-centered and family-centered transition processes for individuals with CP to promote age-appropriate and developmentally appropriate lifespan care.

Association of Blast Exposure in Military Breaching with Intestinal Permeability Blood Biomarkers Associated with Leaky Gut.

Injuries and subclinical effects from exposure to blasts are of significant concern in military operational settings, including tactical training, and are associated with self-reported concussion-like symptomology and physiological changes such as increased intestinal permeability (IP), which was investigated in this study. Time-series gene expression and IP biomarker data were generated from "breachers" exposed to controlled, low-level explosive blast during training. Samples from 30 male participants at pre-, post-, and follow-up blast exposure the next day were assayed via RNA-seq and ELISA. A battery of symptom data was also collected at each of these time points that acutely showed elevated symptom reporting related to headache, concentration, dizziness, and taking longer to think, dissipating ~16 h following blast exposure. Evidence for bacterial translocation into circulation following blast exposure was detected by significant stepwise increase in microbial diversity (measured via alpha-diversity p = 0.049). Alterations in levels of IP protein biomarkers (i.e., Zonulin, LBP, Claudin-3, I-FABP) assessed in a subset of these participants (n = 23) further evidenced blast exposure associates with IP. The observed symptom profile was consistent with mild traumatic brain injury and was further associated with changes in bacterial translocation and intestinal permeability, suggesting that IP may be linked to a decrease in cognitive functioning. These preliminary findings show for the first time within real-world military operational settings that exposures to blast can contribute to IP.

Study protocol: Identifying transcriptional regulatory alterations of chronic effects of blast and disturbed sleep in United States Veterans.

Injury related to blast exposure dramatically rose during post-911 era military conflicts in Iraq and Afghanistan. Mild traumatic brain injury (mTBI) is among the most common injuries following blast, an exposure that may not result in a definitive physiologic marker (e.g., loss of consciousness). Recent research suggests that exposure to low level blasts and, more specifically repetitive blast exposure (RBE), which may be subconcussive in nature, may also impact long term physiologic and psychological outcomes, though findings have been mixed. For military personnel, blast-related injuries often occur in chaotic settings (e.g., combat), which create challenges in the immediate assessment of related-injuries, as well as acute and post-acute sequelae. As such, alternate means of identifying blast-related injuries are needed. Results from previous work suggest that epigenetic markers, such as DNA methylation, may provide a potential stable biomarker of cumulative blast exposure that can persist over time. However, more research regarding blast exposure and associations with short- and long-term sequelae is needed. Here we present the protocol for an observational study that will be completed in two phases: Phase 1 will address blast exposure among Active Duty Personnel and Phase 2 will focus on long term sequelae and biological signatures among Veterans who served in the recent conflicts and were exposed to repeated blast events as part of their military occupation. Phase 2 will be the focus of this paper. We hypothesize that Veterans will exhibit similar differentially methylated regions (DMRs) associated with changes in sleep and other psychological and physical metrics, as observed with Active Duty Personnel. Additional analyses will be conducted to compare DMRs between Phase 1 and 2 cohorts, as well as self-reported psychological and physical symptoms. This comparison between Service Members and Veterans will allow for exploration regarding the natural history of blast exposure in a quasi-longitudinal manner. Findings from this study are expected to provide additional evidence for repetitive blast-related physiologic changes associated with long-term neurobehavioral symptoms. It is expected that findings will provide foundational data for the development of effective interventions following RBE that could lead to improved long-term physical and psychological health.

A framework for inferring and analyzing pharmacotherapy treatment patterns.

BACKGROUND: To discover pharmacotherapy prescription patterns and their statistical associations with outcomes through a clinical pathway inference framework applied to real-world data. METHODS: We apply machine learning steps in our framework using a 2006 to 2020 cohort of veterans with major depressive disorder (MDD). Outpatient antidepressant pharmacy fills, dispensed inpatient antidepressant medications, emergency department visits, self-harm, and all-cause mortality data were extracted from the Department of Veterans Affairs Corporate Data Warehouse. RESULTS: Our MDD cohort consisted of 252,179 individuals. During the study period there were 98,417 emergency department visits, 1,016 cases of self-harm, and 1,507 deaths from all causes. The top ten prescription patterns accounted for 69.3% of the data for individuals starting antidepressants at the fluoxetine equivalent of 20-39 mg. Additionally, we found associations between outcomes and dosage change. CONCLUSIONS: For 252,179 Veterans who served in Iraq and Afghanistan with subsequent MDD noted in their electronic medical records, we documented and described the major pharmacotherapy prescription patterns implemented by Veterans Health Administration providers. Ten patterns accounted for almost 70% of the data. Associations between antidepressant usage and outcomes in observational data may be confounded. The low numbers of adverse events, especially those associated with all-cause mortality, make our calculations imprecise. Furthermore, our outcomes are also indications for both disease and treatment. Despite these limitations, we demonstrate the usefulness of our framework in providing operational insight into clinical practice, and our results underscore the need for increased monitoring during critical points of treatment.

Factors Influencing Adherence to Insomnia and Obstructive Sleep Apnea Treatments among Veterans with Mild Traumatic Brain Injury.

OBJECTIVE: To understand factors influencing adherence to recommended treatment for insomnia and obstructive sleep apnea (OSA) among Veterans with mild traumatic brain injury (mTBI). METHOD: Semi-structured interviews (n = 49) with 29 clinical stakeholders and 20 Veterans were conducted. Clinical stakeholders included Veterans Health Administration providers and policymakers involved in the management of mTBI and/or sleep disorders. Veterans included those with a clinician-confirmed mTBI with a recent history of insomnia disorder and/or OSA treatment. Themes were identified using a Descriptive and Interpretive approach. RESULTS: Barriers to sleep disorder treatment adherence included factors associated with the patient (e.g., negative appraisal of treatment benefit), intervention (e.g., side effects), health conditions (e.g., cognitive challenges), health care system (e.g., limited availability of care), and socioeconomic status (e.g., economic instability). Similarly, facilitators of adherence included patient- (e.g., positive appraisal of treatment benefit), intervention- (e.g., flexible delivery format), condition- (e.g., accommodating cognitive impairments), health care system- (e.g., access to adherence support), and socioeconomic-related factors (e.g., social support). CONCLUSIONS: Interviews revealed the multi-faceted nature of factors influencing adherence to sleep disorder treatment among Veterans with mTBI. Findings can inform the development of novel interventions and care delivery models that meet the complex needs of this population.