Mental Health and Cognition in Women Veterans Enrolled in the Health of Vietnam Era Veteran Women's Study (HealthViEWS).

Objective: This analysis explored relationships between mental health symptoms and conditions and cognitive function in a cohort of Vietnam-era women veterans from the Health of Vietnam Era Veteran Women's Study (HealthViEWS). Methods: Vietnam-era women veterans completed a mail survey assessing self-reported symptom severity of posttraumatic stress disorder (PTSD) and depression. A telephone-based structured interview assessed mental health conditions and cognitive function (telephone interview for cognitive status [TICS]). Participants were categorized using a TICS threshold of ≤29 to designate possible cognitive impairment versus nonimpaired. Separate logistic regression models were used to determine associations between possible cognitive impairment and each self-reported and interviewer-rated assessment of PTSD and depression while adjusting for age, education, race, marital status, and wartime service location. Results: The sample consisted of 4,077 women veterans who were ≥60 years old and completed the TICS. Of these women, 7.20% were categorized with possible cognitive impairment. Logistic regression models indicated that self-reported PTSD and depression symptom severity were each significantly associated with higher odds of possible cognitive impairment (adjusted odds ratios [aOR]: 1.03 [95% confidence interval [CI]: 1.02-1.04] and 1.07 [95% CI: 1.04-1.09], respectively). Women veterans with a probable diagnosis of depression had higher odds of possible cognitive impairment compared to those without depression (aOR: 1.61 [95% CI: 1.07-2.42]). No association was found for probable diagnosis of PTSD. Conclusions: Although further examination remains necessary, results suggest that Vietnam-era women veterans with self-reported PTSD and depression symptom severity or a probable diagnosis of depression may benefit from screening of cognitive function to inform clinical care.

Associations between Posttraumatic Stress Disorder and Diabetes in Vietnam-Era Women Veterans in the HealthViEWS Study.

Background: Posttraumatic stress disorder (PTSD) is associated with incident diabetes. However, past studies have often included predominantly male samples, despite important sex and gender differences in diabetes. To address this limitation, this study examined the association between PTSD and diabetes in older Veteran women, a population with a high burden of PTSD. Materials and Methods: Data were collected from 4,105 women (Mage = 67.4 years), participating in the Health of Vietnam-Era Veteran Women's Study (HealthViEWS; Department of Veterans Affairs Cooperative Studies Program #579). Participants completed self-report measures of demographics, health conditions, and health behaviors. Information on military service was obtained through service records. A structured clinical interview was conducted by telephone to assess current and lifetime PTSD and other mental health disorders. Weighted descriptive and logistic regression analyses were used to examine associations between PTSD and diabetes. Results: The prevalence of diabetes was 28.4% among women with current full PTSD compared to 23.4%, 17.6%, and 17.5% for current subthreshold, remitted, and no PTSD. In unadjusted analyses, women with current full and subthreshold PTSD were 1.87 [1.49; 2.33] and 1.44 [1.11; 1.85] times more likely to have diabetes compared to women with no PTSD. Remitted PTSD was not associated with increased odds of diabetes. Effects were attenuated but remained significant after adjustment for relevant covariates. Conclusions: Vietnam-era women with current PTSD, including subthreshold symptoms, had a greater likelihood of diabetes compared to women without PTSD. These findings suggest that women with PTSD may benefit from increased diabetes prevention efforts.

Who responds to a multi-component treatment for cannabis use disorder? Using multivariable and machine learning models to classify treatment responders and non-responders.

BACKGROUND AND AIMS: Treatments for cannabis use disorder (CUD) have limited efficacy and little is known about who responds to existing treatments. Accurately predicting who will respond to treatment can improve clinical decision-making by allowing clinicians to offer the most appropriate level and type of care. This study aimed to determine whether multivariable/machine learning models can be used to classify CUD treatment responders versus non-responders. METHODS: This secondary analysis used data from a National Drug Abuse Treatment Clinical Trials Network multi-site outpatient clinical trial in the United States. Adults with CUD (n = 302) received 12 weeks of contingency management, brief cessation counseling and were randomized to receive additionally either (1) N-Acetylcysteine or (2) placebo. Multivariable/machine learning models were used to classify treatment responders (i.e. two consecutive negative urine cannabinoid tests or a 50% reduction in days of use) versus non-responders using baseline demographic, medical, psychiatric and substance use information. RESULTS: Prediction performance for various machine learning and regression prediction models yielded area under the curves (AUCs) >0.70 for four models (0.72-0.77), with support vector machine models having the highest overall accuracy (73%; 95% CI = 68-78%) and AUC (0.77; 95% CI = 0.72, 0.83). Fourteen variables were retained in at least three of four top models, including demographic (ethnicity, education), medical (diastolic/systolic blood pressure, overall health, neurological diagnosis), psychiatric (depressive symptoms, generalized anxiety disorder, antisocial personality disorder) and substance use (tobacco smoker, baseline cannabinoid level, amphetamine use, age of experimentation with other substances, cannabis withdrawal intensity) characteristics. CONCLUSIONS: Multivariable/machine learning models can improve on chance prediction of treatment response to outpatient cannabis use disorder treatment, although further improvements in prediction performance are likely necessary for decisions about clinical care.

Therapeutic and Economic Benefits of Service Dogs Versus Emotional Support Dogs for Veterans With PTSD.

OBJECTIVE: This work aimed to assess the therapeutic and economic benefits of service dogs versus emotional support dogs for veterans with posttraumatic stress disorder (PTSD). METHODS: Veterans with PTSD (N=227) participating in a multicenter trial were randomly assigned to receive a service or emotional support dog; 181 veterans received a dog and were followed up for 18 months. Primary outcomes included overall functioning (assessed with World Health Organization Disability Assessment Scale II [WHODAS 2.0]) and quality of life (Veterans RAND 12-Item Health Survey [VR-12]). Secondary outcomes included PTSD symptoms (PTSD Checklist for DSM-5), suicidal ideation, depression, sleep quality, health care costs and utilization, medication adherence, employment, and productivity. RESULTS: Participants paired with a dog had a mean±SD age of 50.6±13.6 years (range 22-79), and most were male (80%), White (66%), and non-Hispanic (91%). Adjusted linear mixed repeated-measures models indicated no difference between the two groups on WHODAS 2.0 or VR-12 scores. Participants with service dogs had a 3.7-point greater reduction in PTSD symptoms versus participants with emotional support dogs (p=0.036). No reduced health care utilization or cost was associated with receiving a service dog. Veterans with service dogs had an increase of 10 percentage points in antidepressant adherence compared with those with emotional support dogs (p<0.01). CONCLUSIONS: Both groups appeared to benefit from having a service or emotional support dog. No significant differences in improved functioning or quality of life were observed between the groups. Those in the service dog group had a greater reduction in PTSD symptoms and better antidepressant adherence, improvements that should be explored further.

Risk factors for suicide in the Vietnam-era twin registry.

BACKGROUND: The risk of suicide among Veterans is of major concern, particularly among those who experienced a combat deployment and/or have a history of PTSD. DESIGN AND METHODS: This was a retrospective cohort study of post-discharge suicide among Vietnam-era Veterans who are members of the Vietnam Era Twin (VET) Registry. The VET Registry is a national sample of male twins from all branches of the military, both of whom served on active duty between 1964 and 1975. Military service and demographic factors were available from the military records. Service in-theater was based on military records; combat exposure and PTSD symptoms were assessed in 1987 by questionnaire. Mortality follow-up, from discharge to 2016, is identified from Department of Veterans Affairs, Social Security Administration, and National Death Index records; suicide as a cause of death is based on the International Classification of Death diagnostic codes from the death certificate. Statistical analysis used Cox proportional hazards regression to estimate the association of Vietnam-theater service, combat exposure, and PTSD symptoms with suicide while adjusting for military service and demographic confounding factors. RESULTS: From the 14,401 twins in the VET Registry, there were 147 suicide deaths during follow-up. In adjusted analyses, twins who served in the Vietnam theater were at similar risk of post-discharge suicide compared with non-theater Veterans; there was no association between combat and suicide. An increase in severity of PTSD symptoms was significantly associated with an increased risk of suicide in adjusted analyses (hazard ratio = 1.13 per five-point increase in symptom score; 95% CI: 1.02-1.27). CONCLUSIONS: Service in the Vietnam theater is not associated with greater risk of suicide; however, PTSD symptom severity poses a degree of risk of suicide in Vietnam-era Veterans. Adequate screening for PTSD in Veterans may be promising to identify Veterans who are at increased risk of suicide.

An Exploration of Useful Telemedicine-Based Resources for Clinical Research.

Background: Clinical trials are key to ensuring high-quality, effective, and safe health care interventions, but there are many barriers to their successful and timely implementation. Difficulties with participant recruitment and enrollment are largely affected by difficulties with obtaining informed consent. Teleconsent is a telemedicine- based approach to obtaining informed consent and offers a unique solution to limitations of traditional consent approaches. Methods: We conducted a survey among 134 clinical trial researchers in academic/university-, industry-, and clinically based settings. The survey addressed important aspects of teleconsent, potential teleconsent enhancements, and other telehealth capabilities to support clinical research. Results: The majority of respondents viewed teleconsent as an important approach for obtaining informed consent and indicated that they would likely use teleconsent if available. Consenting participants at remote sites, increasing access to clinical trials, and consenting participants in their homes were viewed as the greatest opportunities for teleconsent. Features for building, validating, and assessing understanding of teleconsent forms, mobile capabilities, three-way teleconsent calls, and direct links to forms via recruitment websites were viewed as important teleconsent enhancements. Other telehealth capabilities to support clinical research, including surveys, file transfer, three-way video, screenshare, and photo capture during telemedicine visits, and proposed telemedicine capabilities such as video call recording, ID information capture, and integration of medical devices, were also viewed as important. Conclusions: Teleconsent and telemedicine are promising solutions to some common challenges to clinical trials. Many barriers to study recruitment and enrollment might be overcome by investing time and resources and further evaluating this technology.

Impact of Wartime Stress Exposures and Mental Health on Later-Life Functioning and Disability in Vietnam-Era Women Veterans: Findings From the Health of Vietnam-Era Women's Study.

OBJECTIVE: The effect of stress exposures and mental health sequelae on health-related outcomes is understudied among older women veterans. We examined a) the impact of wartime stress exposures on later-life functioning and disability in Vietnam-era women veterans and b) the extent to which mental health conditions known to be associated with stress-posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and generalized anxiety disorder (GAD)-are associated with additional later-life functioning and disability. METHODS: Data were collected in 2011 to 2012 using a mail survey and telephone interview of 4219 women veterans who were active duty during the Vietnam Era. Health functioning was assessed using the Veterans RAND 36-Item Health Survey, and disability was assessed using the World Health Organization Disability Assessment Schedule 2.0. Wartime exposures were assessed using the Women's War-Zone Stressor Scale-Revised; the Composite International Diagnostic Interview, version 3.0 was used to assess PTSD, MDD, and GAD. RESULTS: Several wartime stress exposures-including job-related pressures, dealing with death, and sexual discrimination and harassment-were associated with worse later-life health (ß ranges, -0.04 to -0.26 for functioning, 0.05 to 0.30 for disability). Current PTSD was linked with lower health functioning (physical, ß = -0.06; mental, ß = -0.15) and greater disability (ß = 0.14). Current MDD and GAD were also associated with lower mental health functioning (MDD, ß = -0.29; GAD, ß = -0.10) and greater disability (MDD, ß = 0.16; GAD, ß = 0.06). CONCLUSIONS: Results underscore the importance of detection and treatment of the potential long-term effects of wartime stressors and mental health conditions among women veterans.

Four Decades after War: Incident Diabetes among Women Vietnam-Era Veterans in the HealthViEWS Study.

OBJECTIVES: We analyzed long-term differences in incident diabetes associated with military service in a warzone among women who served during the Vietnam War era. METHODS: For HealthViEWS, the largest later-life study of women Vietnam War-era U.S. veterans, a population-based retrospective cohort who served during 1965-1973 completed a health interview in 2011-2012. This cohort included women deployed to Vietnam, near Vietnam, or who served primarily in the United States. We hypothesized a warzone exposure gradient: Vietnam (highest exposure), near Vietnam, and the United States (lowest exposure). We used an extended Cox regression to test for differences in incident diabetes by location of wartime service. RESULTS: Of 4,503 women in the analysis, 17.7% developed diabetes. Adjusting for demographics and military service characteristics, hazard of incident diabetes was significantly lower initially in the Vietnam group compared with the U.S. group (hazard ratio, 0.33; 95% confidence interval, 0.15-0.69). However, lower diabetes hazard in the Vietnam group was not constant over time; rather, hazard accumulated faster over time in the Vietnam group compared with the U.S. group (hazard ratio, 1.38; 95% confidence interval, 1.11-1.72). No significant difference in diabetes hazard was found between the near Vietnam and U.S. groups. Older age during military service, minority race/ethnicity, and lower military rank were associated with a higher diabetes hazard. CONCLUSIONS: Women deployed to a warzone might have protective health factors that lower risk for diabetes early in their military career, but delivery systems for long-term health should consider that a lower risk for chronic diseases like diabetes can wane quickly in the decades that follow warzone service.

Examining Long-Term Mental Health in a Rural Community Post-Disaster: A Mixed Methods Approach.

Psychological stressors have been observed immediately following disasters, yet less is known about the long-term effects on the mental health of vulnerable communities. In 2005, Graniteville, S.C. was ravaged by a train derailment that leaked approximately 60 tons of chlorine gas and left several people dead in the small community. The purpose of this study was to examine the mental health of Graniteville-area residents in the nine years following the train disaster using a mixed methods approach. Using the photovoice method, participants reported compromised mental health with symptoms consistent with depression, post-traumatic stress disorder, fear, and anxiety. Medical records analysis indicated that mental health-related hospital encounters generally increased post-disaster. Mental health concerns should be anticipated in the long-term aftermath of disasters. Addressing these concerns is particularly vital in resource-poor communities. Our findings can be useful in developing mental health disaster management protocols and policies for communities in the long-term post-disaster period.

A classical twin study of PTSD symptoms and resilience: Evidence for a single spectrum of vulnerability to traumatic stress.

BACKGROUND: To examine shared genetic and environmental risk factors across PTSD symptoms and resilience. METHODS: Classical twin study of 2010-2012 survey data conducted among 3,318 male twin pairs in the Vietnam Era Twin Registry. Analyses included: (a) estimates of genetic and environmental influences on PTSD symptom severity (as measured by the PTSD Checklist) and resilience (assessed with the Connor-Davidson Resilience Scale-10); (b) development of a latent model of traumatic stress, spanning both PTSD and resilience; and (c) estimates of genetic and environmental influences on this spectrum. RESULTS: The heritability of PTSD was 49% and of resilience was 25%. PTSD and resilience were correlated at r = -.59, and 59% of this correlation was attributable to a single genetic factor, whereas the remainder was due to a single non-shared environment factor. Resilience was also influenced by common and unique environmental factors not shared with PTSD, but there was no genetic factor specific to resilience. Confirmatory factor analysis supported the Development of a revised phenotype reflecting the broader dimension of traumatic stress, with biometric models suggesting increased heritability (66%) of this spectrum compared to PTSD or resilience individually. CONCLUSIONS: Genetic factors contribute to a single spectrum of traumatic stress reflecting resilience at one end and high symptom severity at the other. This carries implications for phenotype refinement in the search for molecular genetic markers of trauma-related psychopathology. Rather than focusing only on genetic risk for PTSD, molecular genetics research may benefit from evaluation of the broader spectrum of traumatic stress.

Physical Health Conditions Among a Population-Based Cohort of Vietnam-Era Women Veterans: Agreement Between Self-Report and Medical Records.

BACKGROUND: Little is known about medical morbidity among women Vietnam-era veterans, or the long-term physical health problems associated with their service. This study assessed agreement comparing data on physical health conditions from self-report and medical records from a population-based cohort of women Vietnam-era Veterans from the Health of Vietnam Era Women's Study (HealthViEWS). MATERIALS AND METHODS: Women Vietnam-era veterans (n = 4219) self-completed a survey and interview on common medical conditions. A subsample (n = 900) were contacted to provide permission to obtain medical records from as many as three of their providers. Medical record reviews were conducted using a standardized checklist. Agreement and kappa (agreement beyond chance) were calculated for physical health condition groups. RESULTS: Of the 900, 449 had medical records returned, and of those, 412 had complete surveys/interviews. The most commonly reported conditions based on self-report or medical record review included hypertension, hyperlipidemia, or arthritis. Kappa scores between self-reported conditions and medical record documentation were 0.75-0.91 for hypertension, diabetes, most cancers, and neurological conditions, but lower (k = 0.29-0.55) for cardiovascular diseases, musculoskeletal, and gastrointestinal conditions. Generally, agreement did not significantly vary by different sociodemographic groups. CONCLUSIONS: There was relatively high agreement for physical health conditions when self-report was compared with medical record review. As more women are increasingly represented in the military and more veterans in general seek care outside the Veterans Health Administration, accurate measurement of physical health conditions among population-based samples is crucial.

Design and challenges for a randomized, multi-site clinical trial comparing the use of service dogs and emotional support dogs in Veterans with post-traumatic stress disorder (PTSD).

Posttraumatic stress disorder (PTSD) is a leading cause of impairments in quality of life and functioning among Veterans. Service dogs have been promoted as an effective adjunctive intervention for PTSD, however published research is limited and design and implementation flaws in published studies limit validated conclusions. This paper describes the rationale for the study design, a detailed methodological description, and implementation challenges of a multisite randomized clinical trial examining the impact of service dogs on the on the functioning and quality of life of Veterans with PTSD. Trial design considerations prioritized participant and intervention (dog) safety, selection of an intervention comparison group that would optimize enrollment in all treatment arms, pragmatic methods to ensure healthy well-trained dogs, and the selection of outcomes for achieving scientific and clinical validity in a Veteran PTSD population. Since there is no blueprint for conducting a randomized clinical trial examining the impact of dogs on PTSD of this size and scope, it is our primary intent that the successful completion of this trial will set a benchmark for future trial design and scientific rigor, as well as guiding researchers aiming to better understand the role that dogs can have in the management of Veterans experiencing mental health conditions such as PTSD.

Assessment of a Revised Wartime Experiences Scale for Vietnam-Era Women: The Health of Vietnam-Era Women's Study (HealthViEWS).

PURPOSE: Few wartime experiences scales capture unique issues related to women's service, address their military roles, or have been validated with women. The Women's Wartime Stressor Scale was developed for use with women who served during the Vietnam era, primarily as nurses in Vietnam. We revised this measure by modifying existing items, adding new items, and revising response formats to create a scale less nursing specific and nondeployment specific, and conducted a preliminary assessment of the revised scale. METHODS: The Women's Wartime Exposure Scale-Revised (WWES-R) was included in a mail survey as part of the U.S. Department of Veterans Affairs Health of Vietnam-Era Women's Study (HealthViEWS) study. Construct and criterion validity, and internal consistency, were assessed with a sample of 4,839 women veterans using exploratory factor analysis, analysis of variance, and multiple linear regression. RESULTS: Six wartime experience factors consistent with previous research were identified and scales were created based on salient item loadings. Compared with women serving in the United States, women serving in Vietnam had higher mean scores on all scales, and nurses had significantly higher scores on three scales than non-nurses. CONCLUSIONS: Evaluation of the WWES-R suggests service and/or deployment location and service in a military health care versus a non-health care role may predict women veterans' reports of certain wartime experiences. Further psychometric evaluation of the WWES-R is recommended with later era veterans and through comparisons to other wartime exposure measures.

Military service member and veteran reintegration: A critical review and adapted ecological model.

Returning military service members and veterans (MSMVs) experience a wide range of stress-related disorders in addition to social and occupational difficulties when reintegrating to the community. Facilitating reintegration of MSMVs following deployment is a societal priority. With an objective of identifying challenges and facilitators for reintegration of MSMVs of the current war era, we critically review and identify gaps in the literature. We searched 8 electronic databases and identified 1,764 articles. Screening of abstracts and full-text review based on our inclusion/exclusion criteria, yielded 186 articles for review. Two investigators evaluating relevant articles independently found a lack of clear definition or comprehensive theorizing about MSMV reintegration. To address these gaps, we linked the findings from the literature to provide a unified definition of reintegration and adapted the social ecological systems theory to guide research and practice aimed at MSMV reintegration. Furthermore, we identified individual, interpersonal, community, and societal challenges related to reintegration. The 186 studies published from 2001 (the start of the current war era) to 2015 included 6 experimental studies or clinical trials. Most studies do not adequately account for context or more than a narrow set of potential influences on MSMV reintegration. Little evidence was found that evaluated interventions for health conditions, rehabilitation, and employment, or effective models of integrated delivery systems. We recommend an ecological model of MSMV reintegration to advance research and practice processes and outcomes at 4 levels (individual, interpersonal, organizational, and societal). (PsycINFO Database Record

Perspectives of veterans with mild traumatic brain injury on community reintegration: Making sense of unplanned separation from service.

For veterans separated from the military as a result of acquired mild traumatic brain injury (mTBI), the transition from a military identity to a civilian one is complicated by health, cognitive, and psychosocial factors. We conducted in-depth interviews with 8 veterans with mTBI to understand how they perceived the experience of departure from the military, rehabilitation services provided at a Department of Veterans Affairs (VA) Polytrauma Network Site, and reentry into civilian life. Two distinct patterns of thinking about community reintegration emerged. The first pattern was characterized by the perception of a need to fade one's military identity. The second pattern, conversely, advanced the perception of a need to maintain the integrity of one's military identity though living in a civilian world. These perceptions may be linked to individuals' roles while in the military and whether violent acts were committed in carrying out the mission of service, acts not consonant with positive self-appraisal in the civilian world. The crisis of unplanned, involuntary separation from the military was universally perceived as a crisis equal to that of the precipitating injury itself. The perception that civilians lacked understanding of veterans' military past and their current transition set up expectations for interactions with health care providers, as well as greatly impacting relationships with friend and family. Our veterans' shared perceptions support existing mandates for greater dissemination of military culture training to health care providers serving veterans both at VA and military facilities as well as in the civilian community at large. (PsycINFO Database Record

Trauma is a public health issue.

Exposure to trauma is pervasive in societies worldwide and is associated with substantial costs to the individual and society, making it a significant global public health concern. We present evidence for trauma as a public health issue by highlighting the role of characteristics operating at multiple levels of influence - individual, relationship, community, and society - as explanatory factors in both the occurrence of trauma and its sequelae. Within the context of this multi-level framework, we highlight targets for prevention of trauma and its downstream consequences and provide examples of where public health approaches to prevention have met with success. Finally, we describe the essential role of public health policies in addressing trauma as a global public health issue, including key challenges for global mental health and next steps for developing and implementing a trauma-informed public health policy agenda. A public health framework is critical for understanding risk and protective factors for trauma and its aftermath operating at multiple levels of influence and generating opportunities for prevention.

La exposición al trauma es general en las sociedades de todo el mundo y está asociada con costos sustanciales para el individuo y la sociedad, lo que la convierte en un importante problema mundial de salud pública. Presentamos evidencia del trauma como problema de salud pública al destacar el papel de las características que operan en múltiples niveles de influencia -individuo, relación, comunidad y sociedad- como factores que explican tanto la ocurrencia del trauma como sus secuelas. En el contexto de este marco multi-nivel, destacamos objetivos para la prevención del trauma y sus consecuencias posteriores, y ofrecemos ejemplos de los casos en que los abordajes preventivos de salud pública han tenido éxito. Por último, describimos el papel esencial de las políticas de salud pública a la hora de abordar el trauma como problema de salud pública mundial, incluyendo los retos clave para la salud mental global y los próximos pasos para desarrollar e implementar una agenda de políticas de salud pública. Un marco de salud pública es fundamental para comprender los factores de riesgo y de protección para el trauma y sus secuelas, que operan en múltiples niveles de influencia y generan oportunidades de prevención.

Prevention and public health approaches to trauma and traumatic stress: a rationale and a call to action.

BACKGROUND: The field of trauma and traumatic stress is dominated by studies on treatments for those who experience adversity from traumatic experiences. While this is important, we should not neglect the opportunity to consider trauma in a public health perspective. Such a perspective will help to develop prevention approaches as well as extend the reach of early interventions and treatments. The purpose of this paper is to provide an introduction to a public health approach to trauma and traumatic stress and identify key opportunities for trauma professionals and our professional societies (such as the International Society for Traumatic Stress Studies [ISTSS] and the European Society for Traumatic Stress Studies [ESTSS]) to increase our societal impact by adopting such an approach. METHOD: This paper reviews and summarizes key findings related to the public health impact of trauma. The special case of children is explored, and a case example of the Norwegian terrorist attacks in 2011 illustrates the potential for improving our response to community level traumatic events. We also discuss how professional organizations such as ESTSS and ISTSS, as well as individual trauma professionals, can and should play an important role in promoting a public health approach. RESULTS: Trauma is pervasive throughout the world and has negative impacts at the personal, family, community, and societal levels. A public health perspective may help to develop prevention approaches at all of these levels, as well as extend the reach of early interventions and treatments. CONCLUSIONS: Professional organizations such as ESTSS and ISTSS can and should play an important role in promoting a public health approach. They should promote the inclusion of trauma in the global public health agenda and include public health in their activities.

Design and methods for the Better Resiliency Among Veterans and non-Veterans with Omega-3's (BRAVO) study: A double blind, placebo-controlled trial of omega-3 fatty acid supplementation among adult individuals at risk of suicide.

Suicide remains the 10th leading cause of death among adults in the United States (U.S.). Annually, approximately 30 per 100,000 U.S. military Veterans commit suicide, compared to 14 per 100,000 U.S. civilians. Symptoms associated with suicidality can be treatment resistant and proven-effective pharmaceuticals may have adverse side-effects. Thus, a critical need remains to identify effective approaches for building psychological resiliency in at-risk individuals. Omega-3 highly unsaturated fatty acids (n-3 HUFAs) are essential nutrients, which must be consumed in the diet. N-3 HUFAs have been demonstrated to reduce symptoms of depression, anxiety, and impulsivity - which are associated with suicide risk. Here we present the design and methods for the Better Resiliency Among Veterans and non-Veterans with Omega-3's (BRAVO) study, which is a double blind, randomized, controlled trial among individuals at risk of suicide of an n-3 HUFA versus placebo supplementation in the form of all natural fruit juice beverages. The BRAVO study seeks to determine if dietary supplementation with n-3 HUFAs reduces the risk for serious suicidal behaviors, suicidal thinking, negative emotions, and symptoms associated with suicide risk. Sub-analyses will evaluate efficacy in reducing depressive symptoms, alcohol, and nicotine use. A sub-study utilizes functional magnetic resonance imaging (fMRI) to evaluate the neuropsychological and neurophysiological effects of n-3 HUFAs. We also outline selection of appropriate proxy outcome measures for detecting response to treatment and collection of ancillary data, such as diet and substance use, that are critical for interpretation of results.