Gender as a moderator of associations between military sexual trauma and posttraumatic stress disorder treatment utilization.

The present study sought to investigate whether gender moderates the relationship between military sexual trauma (MST) and posttraumatic stress disorder (PTSD) treatment utilization, among veterans with clinically significant PTSD symptoms. Participants were 2,664 veterans with probable PTSD from a nationwide, population-based survey. Participants reported sociodemographic information, history of MST (including military sexual harassment and military sexual assault), and lifetime receipt of PTSD psychotherapy and medication treatment. We found that gender significantly moderated relationships between (a) military sexual harassment and PTSD psychotherapy, (b) military sexual assault and PTSD psychotherapy, and (c) military sexual harassment and PTSD medication. For women, MST was associated with a greater likelihood of receiving treatment, but for men, MST was not associated with PTSD treatment. Future research is needed to better understand gender differences in how experiences of MST may affect engagement in PTSD treatment. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Which veterans with PTSD are most likely to report being told of their diagnosis?

Veterans who do not know about their posttraumatic stress disorder (PTSD) diagnosis experience a fundamental barrier to accessing effective treatment. Little is known about the characteristics that influence veterans' PTSD diagnosis knowledge (i.e., report of being told they have a PTSD diagnosis by a healthcare provider). Veterans who met probable and provisional criteria for PTSD on the self-report PTSD checklist for DSM-5 were identified from the Comparative Health Assessment Interview Research Study (n = 2335). Weighted logistic regression was performed to identify demographic variables, clinical characteristics, and social determinants of health (e.g., economic instability, homelessness, healthcare coverage) associated with PTSD diagnosis knowledge among post-9/11 veterans. Approximately 62% of veterans with probable and provisional PTSD had PTSD diagnosis knowledge. Predictors with the strongest associations included another mental health diagnosis (OR = 6.10, CI95:4.58,8.12) and having Veterans Affairs (VA) healthcare coverage (OR = 2.63, CI95:1.97,3.51). Veterans with combat or sexual trauma were more likely to have PTSD diagnosis knowledge than those with different trauma types. Results suggest veterans with VA healthcare coverage and military-related trauma are more likely to be informed by a healthcare professional about a PTSD diagnosis. Further research is needed to improve PTSD diagnosis knowledge for those with non-military-related trauma and those without VA healthcare coverage.

Factors associated with receipt of minimally adequate psychotherapy for PTSD at the Veterans Health Administration.

BACKGROUND: Despite Veterans Health Administration (VHA) efforts, many Veterans do not receive minimally adequate psychotherapy (MAP) for posttraumatic stress disorder (PTSD). It is important to understand factors associated with receipt of PTSD MAP (at least eight sessions) so that we may tailor efforts to increase treatment utilization for those who experience the greatest barriers to care. METHODS: Participants were 2008 post-9/11 Veterans who participated in a nationwide survey and had a PTSD diagnosis documented in the VHA electronic health record (EHR) before 2018. Participants self-reported sociodemographic information and trauma history. Service utilization data (e.g., PTSD MAP) were obtained from EHR. Logistic regression was used to model factors associated with PTSD MAP. RESULTS: Only 24% of Veterans (n = 479) received PTSD MAP. Veterans who reported that they were not employed and had reported history of military sexual trauma were more likely to have received PTSD MAP. CONCLUSIONS: Understanding and addressing barriers to PTSD care for Veterans who are employed could help improve PTSD treatment utilization for this group.

Advancing health equity by understanding race disparities and other factors associated with PTSD symptom improvement following evidence-based psychotherapy.

Several studies found that Black veterans demonstrate less posttraumatic stress disorder (PTSD) symptom improvement than White veterans following PTSD evidence-based psychotherapies (EBPs). We aimed to understand this disparity among veterans receiving EBPs by modeling race with demographic, clinical, and service utilization factors. Using electronic health records, we employed a cohort study of Iraq and Afghanistan War Veterans who initiated PTSD EBP treatment and completed > 2 PTSD symptom measures (N = 21,751). Using hierarchical Bayesian logistic regressions, we modeled the probability of PTSD symptom improvement. Black race was associated with less PTSD improvement (mean posterior odds ratio [MPOR] = 0.92; 95 % plausibility interval [PI] = 0.84, 1.0), as was group therapy (MPOR = 0.67; 95 % PI = 0.62, 0.73). Factors associated with greatest improvement included prolonged exposure (MPOR = 1.35; 95 % PI = 1.25, 1.45) and treatment density (MPOR = 1.40; 95 % PI = 1.36, 1.45). On average, Black veterans evidenced PTSD EBP improvement disparities. Clinical and utilization did not fully account for these disparities, although disproportionate representation of Black veterans in group CPT may explain some of these differences. Understanding experiences such as race-based trauma and chronic racism and discrimination is critical to provide Black veterans with the most effective PTSD care.

Military sexual trauma among Veterans using and not using VA justice-related programing: A national examination.

Veterans accessing Department of Veterans Affairs (VA) Veterans Justice Program (VJP) services have high rates of depression, substance misuse, and posttraumatic stress disorder. Although factors that may confer risk for mental health sequelae among these Veterans have been identified (e.g., childhood abuse, combat exposure), limited research has examined report of military sexual trauma (MST) among Veterans accessing VJP services. As survivors of MST experience myriad chronic health conditions which necessitate identification and referral to evidence-based care, identifying MST survivors among those accessing VJP services may facilitate referral to appropriate services. We examined whether MST prevalence differed between Veterans with and without a history of VJP service use. Sex-stratified analyses were conducted with 1,300,252 male (13.34% accessing VJP) and 106,680 female (10.14% accessing VJP) Veterans. In crude models, male and female Veterans accessing VJP services were significantly more likely to screen positive for MST (PR = 3.35 and 1.82 respectively). Significance was maintained in models that adjusted for age, race/ethnicity, VA service use, and VA mental health use. VJP service settings may serve as a critical intercept for identifying male and female survivors of MST. Using a trauma-informed approach to screen for MST in VJP settings is likely warranted. Moreover, integration of MST programing into VJP settings may be beneficial.

Relationship of social determinants of health with symptom severity among Veterans and non-Veterans with probable posttraumatic stress disorder or depression.

PURPOSE: Social determinants of health (SDoH) refer to the conditions in the environments in which people live that affect health outcomes and risks. SDoH may provide proximal, actionable targets for interventions. This study examined how SDoH are associated with posttraumatic stress disorder (PTSD) and depression symptoms among Veterans and non-Veterans with probable PTSD or depression. METHODS: Four multiple regressions were conducted. Two multiple regressions with Veterans examined the impact of SDoH on PTSD symptoms and on depression symptoms. Two multiple regressions with non-Veterans examined the impact of SDoH on PTSD symptoms and on depression symptoms. Independent variables included demographic characteristics, adverse experiences (in childhood and adulthood), and SDoH (discrimination, education, employment, economic instability, homelessness, justice involvement, and social support). Correlates that were statistically significant (p < 0.05) and clinically meaningful (rpart >|0.10|) were interpreted. RESULTS: For Veterans, lower social support (rpart = - 0.14) and unemployment (rpart = 0.12) were associated with greater PTSD symptoms. Among non-Veterans, greater economic instability (rpart = 0.19) was associated with greater PTSD symptoms. In the depression models, lower social support (rpart = - 0.23) and greater economic instability (rpart = 0.12) were associated with greater depression for Veterans, while only lower social support was associated with greater depression for non-Veterans (rpart = - 0.14). CONCLUSION: Among Veterans and non-Veterans with probable PTSD or depression, SDoH were associated with PTSD and depression symptoms, particularly social support, economic instability, and employment. Beyond direct treatment of mental health symptoms, addressing social support and economic factors such as instability and employment in the context of PTSD and depression are potential intervention targets that would benefit from future research.

Treatment Utilization for Posttraumatic Stress Disorder in a National Sample of Veterans and Nonveterans.

OBJECTIVE: The current study sought to compare rates of posttraumatic stress disorder (PTSD) treatment utilization (medication and psychotherapy) among veterans and nonveterans-and to investigate which factors are associated with treatment utilization among veterans versus nonveterans. METHODS: Participants were 2775 individuals (veteran, n=2508; nonveteran, n=267) meeting criteria for probable PTSD (determined by the PTSD Checklist) drawn from a nationwide, population-based survey. Participants reported demographic information, trauma history, mental health symptoms, insurance coverage, and treatment history. RESULTS: Analyses revealed that the majority of veterans and nonveterans with probable PTSD had not received any PTSD treatment (56% of veterans and 86% of nonveterans). Population-weighted logistic regression models demonstrated that veterans with probable PTSD were substantially more likely to receive medication and psychotherapy for PTSD than nonveterans with probable PTSD. Logistic regression models demonstrated that, among veterans, having Veterans Affairs health care coverage was most strongly associated with receiving PTSD medication and psychotherapy. Black (vs. White) veterans were less likely to have received PTSD medication and psychotherapy. In contrast, among nonveterans, being married or divorced (vs. never married) was most strongly associated with receiving PTSD medication, and reporting a history of sexual trauma was most strongly associated with receiving PTSD psychotherapy. CONCLUSION: Given that most individuals do not receive PTSD treatment, additional understanding of treatment barriers and facilitators for both veterans and nonveterans is needed to improve intervention reach.

Effectiveness and comparative effectiveness of evidence-based psychotherapies for posttraumatic stress disorder in clinical practice.

BACKGROUND: While evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD) is a first-line treatment, its real-world effectiveness is unknown. We compared cognitive processing therapy (CPT) and prolonged exposure (PE) each to an individual psychotherapy comparator group, and CPT to PE in a large national healthcare system. METHODS: We utilized effectiveness and comparative effectiveness emulated trials using retrospective cohort data from electronic medical records. Participants were veterans with PTSD initiating mental healthcare (N = 265 566). The primary outcome was PTSD symptoms measured by the PTSD Checklist (PCL) at baseline and 24-week follow-up. Emulated trials were comprised of 'person-trials,' representing 112 discrete 24-week periods of care (10/07-6/17) for each patient. Treatment group comparisons were made with generalized linear models, utilizing propensity score matching and inverse probability weights to account for confounding, selection, and non-adherence bias. RESULTS: There were 636 CPT person-trials matched to 636 non-EBP person-trials. Completing ⩾8 CPT sessions was associated with a 6.4-point greater improvement on the PCL (95% CI 3.1-10.0). There were 272 PE person-trials matched to 272 non-EBP person-trials. Completing ⩾8 PE sessions was associated with a 9.7-point greater improvement on the PCL (95% CI 5.4-13.8). There were 232 PE person-trials matched to 232 CPT person-trials. Those completing ⩾8 PE sessions had slightly greater, but not statistically significant, improvement on the PCL (8.3-points; 95% CI 5.9-10.6) than those completing ⩾8 CPT sessions (7.0-points; 95% CI 5.5-8.5). CONCLUSIONS: PTSD symptom improvement was similar and modest for both EBPs. Although EBPs are helpful, research to further improve PTSD care is critical.

Psychosocial Outcomes Among Veteran and Non-Veteran Survivors of Sexual Assault.

Although it is well-established that sexual assault results in variable and long-lasting negative impacts on emotional well-being, perceptions of physical health, and relationship functioning, these "psychosocial" outcomes may vary based on the type(s) of sexual trauma experienced. To identify the differential impact of sexual trauma type(s) on psychosocial outcomes among veterans and non-veterans, we conducted a secondary analysis of data from the Comparative Health Assessment Interview Research Study, a large, national survey study sponsored by the Department of Veterans Affairs. Participants included veterans (n = 3588) and non-veterans (n = 935) who endorsed experiencing childhood sexual assault (CSA), adult sexual assault (ASA, outside of military service for veteran participants), and/or military sexual assault (MSA). Eight measures were used to assess psychosocial outcomes: Well-Being Inventory (WBI) health satisfaction and physical health functioning items, Posttraumatic Stress Disorder Checklist, Patient Health Questionnaire (depression symptoms), Generalized Anxiety Disorder Questionnaire, WBI social satisfaction items, WBI social functioning items, and the Multidimensional Scale of Perceived Social Support (social). A profile analysis was used to determine how sexual trauma type(s) influenced the pattern of responding to the eight psychosocial outcome measures. Veteran sexual assault survivors reported poorer psychological outcomes compared to non-veteran sexual assault survivors. Non-veteran sexual assault survivors reported poorer outcomes on the majority of social variables compared to veteran sexual assault survivors. Survivors of MSA-only reported poorer psychosocial outcomes compared to veteran and non-veteran survivors of CSA-only and ASA-only on most of the variables assessed. Survivors of ASA-only reported similar or modestly worse psychosocial outcomes when compared to survivors of CSA-only on the majority of variables assessed. Survivors of different types of sexual trauma reported distinct psychosocial outcomes, suggesting that assessment and treatment needs may differ by trauma type.

Childhood Sexual Abuse and Military Sexual Trauma Interact to Increase Suicide Risk: Results from a Nationally Representative Veteran Sample.

Childhood sexual abuse (CSA) and military sexual trauma (MST) are prevalent among veterans. Such exposures are associated with adverse mental-health sequelae, including elevated risk for suicidal thoughts and behaviors. Nonetheless, prior studies have largely focused upon discrete experiences of CSA or MST in circumscribed samples. In the current study, we analyzed data from a large, nationally representative sample of 4,069 US military veterans to examine main and interactive effects of CSA and MST in relation to suicidal thoughts and behaviors. After accounting for sociodemographics, psychiatric comorbidity, and trauma-related characteristics, we detected a significant interaction between MST and CSA as it related to report of past-year suicidal ideation, lifetime suicide attempt, and risk for future suicide attempt. These findings underscore the impact of sexual trauma throughout the lifespan, highlighting the continued importance of screening for trauma exposure and connecting veterans to appropriate, evidence-based treatment to decrease their risk for suicidal thoughts and behaviors.

Institutional Betrayal and Closeness Among Women Veteran Survivors of Military Sexual Trauma: Associations with Self-Directed Violence and Mental Health Symptoms.

Institutional betrayal is defined as harm caused by an institution to an individual in the context of trust and dependence. High institutional betrayal is associated with poorer health outcomes, and high levels of trust, dependence, or identification with the institution (institutional closeness) may exacerbate the negative effects of institutional betrayal. While military sexual trauma is prevalent among women Veterans and associated with high rates of institutional betrayal, studies of the impact of military sexual trauma-related institutional betrayal have been limited in size and scope and have not examined the potential role of institutional closeness. We conducted a secondary analysis of national survey data collected from women Veterans who screened positive for military sexual trauma (n = 229). Hierarchical logistic and linear regression were used to examine associations between predictor variables (institutional betrayal, institutional closeness, and their interaction) and outcomes of interest and adjusted for age, education, and military sexual assault history. Institutional betrayal was associated with increased odds of suicidal ideation and suicide attempt during or following military service, as well as more severe symptoms of depression and posttraumatic stress disorder (PTSD). Institutional betrayal was not associated with non-suicidal self-injury or lifetime substance misuse. Counter to hypotheses, institutional closeness did not moderate relationships between institutional betrayal and mental health symptoms or self-directed violence. Results underscore the necessity of preventing and addressing institutional betrayal among women Veterans who experience military sexual trauma.

Moral injury and chronic pain in veterans.

Posttraumatic stress disorder (PTSD) and chronic pain are highly prevalent and co-morbid among veterans. Moral injury (MI), which results from traumatic experiences that conflict with deeply held moral beliefs, is also associated with pain. However, relationships between different types of exposures to potentially morally injurious events (PMIEs) and pain have not yet been investigated. In the current study, we investigated these relationships between exposure to PMIEs (betrayal, witnessing, and perpetration) and different types of pain (joint pain, muscle pain, and overall pain intensity), while controlling for other relevant variables (including PTSD symptoms, combat exposure, adverse childhood experiences, age, gender, and race/ethnicity). We also examined gender differences in these associations. Participants were 11,871 veterans drawn from a nationwide, population-based survey who self-reported exposure to PMIEs, PTSD symptoms, frequency of adverse childhood experiences, combat exposure, sociodemographic information, past six-month joint pain, past six-month muscle pain, and past week overall pain intensity. Population weighted regression models demonstrated that PMIEs were not significantly associated with joint or muscle pain, but that betrayal was associated with past week overall pain intensity, even when controlling for all other variables. Models investigating men and women separately found that for women, betrayal was associated with joint pain and pain intensity, but for men, betrayal was not associated with any pain outcome. These findings suggest that it may be especially important to assess betrayal when treating patients with a history of trauma and chronic pain.

Association between post-traumatic stress disorder severity and death by suicide in US military veterans: retrospective cohort study.

BACKGROUND: There is mixed evidence regarding the direction of a potential association between post-traumatic stress disorder (PTSD) and suicide mortality. AIMS: This is the first population-based study to account for both PTSD diagnosis and PTSD symptom severity simultaneously in the examination of suicide mortality. METHOD: Retrospective study that included all US Department of Veterans Affairs (VA) patients with a PTSD diagnosis and at least one symptom severity assessment using the PTSD Checklist (PCL) between 1 October 1999 and 31 December 2018 (n = 754 197). We performed multivariable proportional hazards regression models using exposure groups defined by level of PTSD symptom severity to estimate suicide mortality rates. For patients with multiple PCL scores, we performed additional models using exposure groups defined by level of change in PTSD symptom severity. We assessed suicide mortality using the VA/Department of Defense Mortality Data Repository. RESULTS: Any level of PTSD symptoms above the minimum threshold for symptomatic remission (i.e. PCL score >18) was associated with double the suicide mortality rate at 1 month after assessment. This relationship decreased over time but patients with moderate to high symptoms continued to have elevated suicide rates. Worsening PTSD symptoms were associated with a 25% higher long-term suicide mortality rate. Among patients with improved PTSD symptoms, those with symptomatic remission had a substantial and sustained reduction in the suicide rate compared with those without symptomatic remission (HR = 0.56; 95% CI 0.37-0.88). CONCLUSIONS: Ameliorating PTSD can reduce risk of suicide mortality, but patients must achieve symptomatic remission to attain this benefit.

Veterans receiving a second course of cognitive processing therapy or prolonged exposure therapy: is it better to switch or stay the same?

Cognitive processing therapy (CPT) and prolonged exposure therapy (PE) are effective psychotherapies for post-traumatic stress disorder (PTSD). However, these treatments also have high rates of dropout and non-response. Therefore, patients may need a second course of treatment. We compared outcomes for patients who switched between CPT/PE and those who repeated CPT/PE during a second course of treatment. We collected data from Iraq and Afghanistan war veterans (n = 2,958) who received a second course of CPT/PE in the Veterans Health Administration from 2001 to 2017 and had symptom outcomes (PTSD checklist; PCL). We measured the association between treatment sequence and change in PCL score over the second course of treatment using hierarchical Bayesian regression, adjusted for sociodemographic and clinical characteristics. All treatment sequences showed a significant reduction in PCL score over time (ß = -4.80; HDI95: -5.74, -3.86). Veterans who switched from CPT to PE had modestly greater PCL reductions during the second course than those who repeated CPT. However, no significant difference in PCL change during the second course was observed between veterans who repeated PE and those who switched from PE to CPT. Veterans participating in a second course of CPT/PE can benefit, and switching treatment may be slightly more beneficial following CPT.

Reducing Barriers to Behavioral Treatments for Insomnia: A Qualitative Examination of Veterans' Perspectives of BBTI.

Objective: Although behavioral treatments are recommended for treating insomnia disorder, these treatments are not the most commonly provided treatments due to numerous barriers (e.g., treatment length, time limitations). Brief Behavioral Treatment for Insomnia (BBTI) was developed, in part, to help overcome these barriers. The purpose of the current study was to qualitatively examine the treatment experiences of veterans with insomnia disorder participating in BBTI.Methods: All veterans (n=46) who were randomized to receive BBTI as part of a randomized clinical trial participated in 10-20 minute semi-structured interviews one week after completing treatment. Rapid analysis procedures were used for qualitative analysis.Results: Thirteen qualitative themes were identified: BBTI provided veterans with the skills they believed they needed to continue improving independently post-treatment; beginning BBTI with in-person sessions was valued; phone sessions helped participation; veterans did not perceive that they could cover the same content during phone and in-person sessionsl; materials could be more portable; BBTI created accountability; BBTI required discipline and willingness; BBTI facilitated buy-in; BBTI was aligned with military culture; loved ones could provide important support; BBTI could be improved with more personalization; BBTI challenged expectations of mental health; and BBTI improved awareness of health behaviors beyond sleep.Conclusions: BBTI was successful in overcoming barriers to behavioral insomnia treatment and interviews identified critical treatment aspects that should be maintained to preserve acceptability (e.g., in-person session first). Areas in which BBTI did not fully meet the needs of veterans and targets for improvement (e.g., ameliorating understanding and expectations of phone sessions) were also identified.

Trends in Medication Prescribing in Patients With PTSD From 2009 to 2018: A National Veterans Administration Study.

OBJECTIVE: To evaluate longitudinal prescription practice trends for patients diagnosed with posttraumatic stress disorder (PTSD) using a national cohort of veterans who engaged in Veterans Health Administration (VHA) care from 2009 to 2018. METHODS: Using ICD-9 and ICD-10 codes to determine diagnoses, 1,353,416 patients diagnosed with PTSD in VHA care were retrospectively identified who were not diagnosed with bipolar or psychotic spectrum disorder. Veterans were included in the analytic sample starting in the year of their first PTSD diagnosis for each year that they were active in VHA care. Outpatient prescription records were examined from 2009 to 2018 for medications that are commonly used as recommended (selective serotonin reuptake inhibitors [SSRIs], serotonin-norepinephrine reuptake inhibitors [SNRIs]) or second-line/adjunctive (atypical antipsychotics [AAPs], mirtazapine, prazosin, trazodone, tricyclic antidepressants, and non-benzodiazepine hypnotics) medications for PTSD. Benzodiazepine prescriptions were also examined. RESULTS: From 2009 to 2018, the percentage of patients active in VHA care who received at least one of the examined recommended or second-line/adjunctive medications for PTSD in a calendar year declined by 9.0% (absolute change). The largest absolute change in rates of prescribing for medication classes over the last decade were observed among SSRIs (-12.3%) and SNRIs (+6.4%). AAP use decreased 5.4% from 2009 to 2018, with most of this change (-4.3%) occurring from 2009 to 2013. CONCLUSIONS: Consistent with clinical practice guidelines, SSRIs/SNRIs were the most common prescriptions for patients in the current study. Reductions in the percentage of patients receiving PTSD medications may reflect concerns regarding effectiveness, adverse side effects, increases in access to evidence-based psychotherapy for PTSD, and/or symptom improvement such that medication was no longer needed.

A Factor Analysis of the Suicide Cognitions Scale in Veterans with Military Sexual Trauma-Related Posttraumatic Stress Disorder.

The Suicide Cognitions Scale (SCS) assesses suicide-specific cognitions which may drive suicide risk. Nonetheless, prior work has been mixed regarding optimal factor structure. Additionally, this measure has not been validated for use with veterans with military sexual trauma-related posttraumatic stress disorder (MST-related PTSD), a population that is at elevated risk for suicidal self-directed violence (SDV). This study sought to determine the optimal factor structure of the SCS for use with veterans with MST-related PTSD as well as its psychometric properties. An exploratory factor analysis revealed a four-factor structure, including unlovability, unbearability, unsolvability, and negative urgency. The SCS also demonstrated excellent internal consistency and good convergent validity. This study identified a novel factor, negative urgency, which may explain some of the predictive power of the SCS found in previous research. This paper provides initial support for a four-factor structure of the SCS among those with MST-related PTSD. Additional work remains necessary in evaluating the SCS as a tool for detecting risk for future suicidal SDV among veterans with MST-related PTSD.

Predictors of Unbearability, Unlovability, and Unsolvability in Veterans With Military-Sexual-Trauma-Related Posttraumatic Stress Disorder.

Military sexual trauma (MST) and posttraumatic stress disorder (PTSD) both increase risk for suicidal self-directed violence (SDV). Suicide cognitions (i.e., unbearability, unlovability, and unsolvability) are strong predictors of future suicidal SDV. The present study investigated potential predictors of unbearability, unlovability, and unsolvability in veterans with MST-related PTSD. Suicide cognitions, depression, PTSD, quality of life, trauma-related negative cognitions, physical health functioning, mental health functioning, and childhood sexual assault were assessed in 12 male and 103 female veterans with MST-related PTSD. Higher depression scores, greater trauma-related negative cognitions about self, and poorer physical health functioning predicted increased unbearability scores. Greater trauma-related negative cognitions about self and self-blame, higher level of education, and higher depression scores predicted increased unlovability scores. Higher depression scores and greater trauma-related negative cognitions about self predicted increased unsolvability scores. In veterans with MST-related PTSD who express unbearability, unlovability, and unsolvability, assessing and addressing depression, trauma-related negative cognitions about self and self-blame, and physical health functioning may be an important step in reducing SDV.