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Both homelessness and criminal justice involvement can impact mental health symptoms and increase risk for suicide. Despite this, few studies have examined their cumulative impact. Moreover, no studies to date have examined the impact of these social determinants of health on post-9/11 veterans, a population with high rates of housing insecurity and justice involvement. The current study sought to better understand the adverse impacts of homelessness and justice involvement on mental health symptoms and suicide risk among post-9/11 veterans. We carried this out by conducting a secondary analysis of cross-sectional data from a 2018 national survey of men and women post-9/11 veteran users and non-users of Veterans Health Administration (VHA) services (N = 15,067). Gender-stratified Poisson and multivariate regressions examined mental health symptoms and suicide risk based on history of homelessness and justice involvement. Models adjusted for sociodemographics, military-related variables, and trauma exposure. Homelessness and justice involvement were both independently associated with more severe posttraumatic, depressive, and substance use symptoms as well as increased rates of suicidal ideation and attempt relative to those with no history of homelessness or justice involvement. Veterans with a history of both homelessness and justice involvement reported the most severe mental health symptoms and suicide risk. This study found consistent positive associations with mental health symptoms for homelessness and justice-involved veterans. Enhancing and increasing access to services that address complex mental health presentation among those with histories of justice involvement and housing instability remain necessary.

Background Suicide rates are higher among veterans than non-veterans; this difference is particularly salient for females. Knowledge is sparse regarding correlates of suicidal ideation (SI) among female veterans, particularly in non-VHA samples. As such, and given that SI confers a strong risk for subsequent suicidal behavior, this study aimed to: (1) compare prevalence of recent SI by sex; and (2) determine whether deployment stressors, mental health symptoms, and recent psychosocial stressors are associated with recent SI, by sex, among post-9/11 veterans. Methods A sex-stratified analysis of cross-sectional data from 809 post-9/11, deployed veterans was conducted using the Survey of Experiences of Returning Veterans (SERV); statistical interactions between sex and correlates of interest were assessed. Results Self-reported prevalence of recent SI did not differ by sex. A statistically significant interaction between sex and combat was observed; greater combat experience was associated with increased SI for females only. While significant interactions were not observed for other correlates, differences in significant predictors and predictor effect sizes were noted across sex-stratified models. Recent housing and financial concerns were only associated with increased SI prevalence among females, whereas concern about other recent stressful life events was associated with increased SI prevalence only among males. Limitations This is a cross-sectional analysis of a national survey with limited power to detect statistical sex interactions. Conclusions While correlates of SI are relatively consistent for males and females notable differences suggest that tailored assessment and intervention based on sex may hold merit in mitigating SI among post-9/11 era Veterans.

Women veterans experience disproportionately high rates of military sexual trauma (MST). Nonetheless, many MST survivors delay or forgo health care, particularly within Veterans Health Administration (VHA) settings. Institutional betrayal (IB) has been posited as a potential explanation for this. Objective The current study examined if IB was associated with women veterans' willingness to seek VHA and non-VHA mental health and medical care, prior use of VHA care, past year use of VHA care, and use of VHA and non-VHA MST-related care. Method Participants were 242 women veterans who screened positive for MST and completed self-report measures of IB and willingness to seek VHA and non-VHA mental health and medical care. Use of VHA care was assessed through VA Corporate Data Warehouse data. Results IB was associated with lower willingness to use VHA medical care and higher willingness to use non-VHA mental health care. Although IB was not significantly associated with prior use of VHA care, participants who reported more IB were more likely to have used VHA care in the past year and to have used both VHA and non-VHA MST-related care. Conclusion These findings illuminate the relationship between the institutional response to MST with women's help-seeking willingness and use. Addressing IB may be important for increasing women MST survivors' willingness to use VHA medical care. Additionally, as IB was associated with greater willingness to use non-VHA mental health care, non-VHA institutions and providers should be prepared to serve women veterans who have experienced MST-related IB. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Objective Justice-involved veteran research remains largely limited to men and those using Veterans Health Administration (VHA) services. Research inclusive of women and those not using VHA care is critical to understanding mental health and suicide risk among justice-involved veterans. This study examined whether lifetime justice involvement was associated with symptoms of posttraumatic stress disorder (PTSD) and depression, recent suicidal ideation, and lifetime suicide attempt. Method We conducted a secondary analysis of 812 post-9/11 male and female veterans. The sample included veterans eligible and not eligible for VHA care. Participants were administered the PTSD Checklist for DSM-IV, the Patient Health Questionnaire-8, and the Columbia-Suicide Severity Rating Scale. Additional questions assessed justice involvement, military characteristics, demographics, and recent use of VHA mental health care. Results History of justice involvement was associated with more severe PTSD and depression symptoms as well as suicidal ideation and suicide attempt. Associations were maintained after adjusting for sex, combat exposure, service branch, recent use of VHA mental health care, and education. Sex-stratified exploratory analyses revealed consistent findings among males; justice involvement was associated with suicide attempt among females. Current probation or parole was particularly related to depressive symptoms, suicidal ideation, and suicide attempt. Conclusions Justice-involved veterans appear to be a vulnerable population experiencing heightened psychiatric symptoms and increased risk for recent suicidal ideation and lifetime suicide attempt. Programs within VHA and the community are important for connecting justice-involved veterans to mental health services and mitigating suicide risk. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

There are a number of evidence-based therapies for posttraumatic stress disorder (PTSD; e.g., cognitive processing therapy; prolonged exposure therapy). Many patients with PTSD present to treatment at elevated risk for suicide. In such circumstances, navigating evidence-based treatment for PTSD can be challenging, requiring nuanced approaches to ensure optimal therapeutic outcome while ensuring patient safety. This manuscript describes the evidence for treating PTSD in the context of elevated risk for suicide. Methods of navigating clinical complexity (e.g., multimorbidity, psychosocial stressors) while maintaining fidelity to evidence-based protocols are discussed. We conclude by noting gaps in understanding, as well as necessary future research directions to ensure optimal care for this clinical population.

Background The extent to which female veterans are willing to seek Veterans Health Administration (VHA) and non-VHA care when they are suicidal or experiencing mental health (MH) concerns is unknown. Objectives The objectives of this study were to: (1) examine whether current, past, and never VHA using female veterans' willingness to seek VHA care differs from their willingness to seek non-VHA care if suicidal or experiencing MH symptoms; (2) examine if VHA use, military sexual trauma, and suicidal ideation and attempt are associated with female veterans' willingness to use VHA and non-VHA care when experiencing suicidal thoughts or MH symptoms. Research design A cross-sectional anonymous survey. Subjects Four hundred thirty nine female veterans, including current, past, and never VHA users were included. Measures General Help-Seeking Questionnaire, Self-Injurious Thoughts and Behaviors Interview, and the VA Military Sexual Trauma Screening Questions. Results Current VHA users reported more willingness to use VHA than non-VHA care; conversely, past and never VHA users reported less willingness to use VHA care relative to non-VHA care. Military sexual assault and none or past VHA use were associated with lower willingness to use VHA care if suicidal or experiencing MH symptoms. In contrast, those with none or past VHA use reported greater willingness to use non-VHA care if suicidal or experiencing MH symptoms, while prior suicide attempt was associated with lower willingness. Conclusions Ensuring that acceptable and effective suicide prevention services are available to female veterans in both VHA and community settings is critical. Increasing help-seeking intentions among female veterans who have attempted suicide or experienced military sexual assault is also essential.

Military sexual trauma (MST), which is defined as sexual harassment and/or assault during a person's military service, is associated with suicidal self-directed violence. Suicide risk assessment and intervention with survivors of MST should be patient-centered and informed by an understanding of the impact of interpersonal trauma and military service on the survivor's lived experience. Considerations for assessing and intervening upon suicide risk with survivors of MST are discussed, with a particular focus on safety planning, lethal means safety, and psychotherapy. We conclude by discussing necessary future research in suicide prevention in this population. [ Psychiatr Ann . 2020;50(10):437–443.]

Background Suicide rates among female veterans have continued to increase, particularly among those not using Veterans Health Administration (VHA) care. Nonetheless, suicide research has rarely focused on female veterans, particularly non-VHA users. The present study examined the prevalence and onset of suicidal ideation (SI), suicide attempt (SA), and non-suicidal self-injury (NSSI) in relation to military service among female veterans. Additionally, current, past, and never VHA users were compared in regard to SI, SA, and NSSI prevalence. Methods Female veterans (n = 439) participated in a national, cross-sectional survey. Results Lifetime prevalence of SI (47.9%), SA (17.7%), and NSSI (13.2%) were high. Participants were more likely to report experiencing SI and SA following separation, compared to preceding (SI, SA) or during (SI only) military service, controlling for time at risk. However, onset was more likely to occur prior to military service, compared to after separation, for SI, SA, and NSSI. In age-adjusted analyses, current and past users of VHA care were more likely to report experiencing lifetime SI, compared to those who never used VHA care. However, when adjusting for service era, past and never VHA users did not significantly differ. Limitations Cross-sectional design, retrospective recall, and convenience sample. Conclusions For female veterans, onset of SI, SA, and NSSI appears to most commonly occur before military service. However, SI and SA prevalence are highest following separation, suggesting a period warranting additional support and intervention. Results underscore the need for continued suicide surveillance, prevention, and intervention efforts for female veterans, especially current VHA users.

Suicide is a significant public health concern for veterans residing in rural communities. Although various initiatives have been implemented to prevent suicide among veterans, efforts specific to rural veterans remain limited. To aid such efforts, we examined stigma as a potential barrier to community readiness in the implementation of a community-based suicide prevention program for rural veterans. In this qualitative study, community readiness interviews were conducted with 13 participants in a rural community. Themes included lack of awareness regarding veteran suicide, rare discussions of veteran suicide, and suicide-related stigma within the community. Results suggest that prioritizing destigmatization may be particularly important to implementing community-based suicide prevention programming in rural communities. In particular, addressing community misconceptions regarding veteran suicide, while increasing knowledge of the extent to which veteran suicide occurs locally may facilitate increased awareness and thus community readiness to prevent suicide among rural veterans.

BACKGROUND: Suicidal self-directed violence among Veterans experiencing homelessness remains a significant public health concern. To prevent suicide in this population, concerted clinical and research efforts remain necessary. OBJECTIVE: This paper serves as a consensus statement by the recently-formed Department of Veterans Affairs (VA) Suicide Prevention among Veterans Experiencing Homelessness Workgroup. We provide a brief overview of current initiatives to prevent suicide among Veterans experiencing homelessness. We also discuss methods of studying this complex subset of the Veteran population, as well as future research endeavors necessary to inform gaps in understanding. CONCLUSIONS: Veterans experiencing homelessness are a complex subset of the Veteran population whose risk for suicide may be exacerbated by a number of factors (e.g., multimorbidity, rurality). While the VA has implemented a number of initiatives to prevent suicide among Veterans experiencing homelessness (e.g., universal screening for suicidal ideation and recent suicide attempts, Suicide Prevention Gatekeeper Training), there is a continued need to understand how best to tailor these initiatives to Veterans experiencing homelessness. Moreover, because Veterans experiencing homelessness often access a number of services within the community (e.g., community-based clinics, homeless shelters), collaboration between the VA and community is necessary.

A recent evidence map focused on women veterans underscored the limited number of articles published on mental health comorbid with physical health conditions in this population. The quality of this small body of research has yet to be evaluated. The aim of this systematic review was to evaluate and synthesize research published between 2008 and 2015 and identified in the Women Veterans' Health Research Evidence Map as related to mental and physical health comorbidities among women veterans. Following PRISMA guidelines, 23 published studies were identified and 21 were included in the review. In general, significant associations between several mental health conditions (e.g., depression, posttraumatic stress disorder, substance use disorders) and physical health disorders (e.g., cardiovascular disease, diabetes, gastrointestinal disorders, hypertension, obesity, pain, and urinary symptoms) and health behaviors (e.g., preventative care and treatment adherence) were noted. The majority of studies were rated as low risk of bias, with selection and detection bias most frequently observed across studies. Additionally, gaps in the recent literature were observed, including the need for further investigation of the role of medical conditions in complicating mental health symptoms and care provision. Results underscore the importance of healthcare providers attending to women veterans' mental and physical health simultaneously and irrespective of setting. Further, while the Department of Veterans Affairs continues to make sizable gains in its focus on women veterans' health, continued research on several health domains is needed to ensure adequate understanding of the health needs of women veterans.

Posttraumatic stress disorder (PTSD) is associated with increased risk for suicide, and clinicians often encounter acute suicide risk during the process of intervening upon PTSD. Although the Department of Veterans Affairs (VA) and the Department of Defense (DoD) have disseminated evidence-based treatments for PTSD, prior clinical trials have used inconsistent definitions and unclear assessment methods of suicide risk. Consequently, translating findings from PTSD treatment research to clinical practice remains challenging. This article describes challenges inherent to the current PTSD interventional research literature related to concurrent acute suicide risk among veterans and active duty service members. We reviewed prior trials and how their assessment methods and nomenclature compare with strategies and definitions mandated within the VA/DoD. Furthermore, we describe methodological recommendations for future research, including consistent use of mandated universal suicide nomenclature, standardization for classifying suicide risk, transparency in reporting assessment means and measures, and examination of current models of PTSD treatment in the context of acute suicide risk.

Many veterans do not complete evidence-based treatments (EBTs) for posttraumatic stress disorder (PTSD). Veterans with military sexual trauma (MST)-related PTSD were shown to have higher than average rates of dropout from PTSD treatment in a national study of EBT implementation. Although predictors of dropout from EBTs have been identified, these factors are largely unmodifiable (e.g., age, service era). The purpose of the present study was to identify dynamic psychosocial predictors of dropout among female veterans from cognitive processing therapy (CPT). Data were utilized from 56 female veterans who participated in a randomized clinical trial investigating the effectiveness of CPT for MST-related PTSD. Dropout was defined continuously (i.e., number of sessions attended) and dichotomously (i.e., attending six or more sessions). Potential predictors included sociodemographic factors, psychotherapist fidelity, PTSD-related service connection, psychiatric symptom severity (i.e., PTSD, depression), trauma-related negative cognitions (about self, self-blame, world), and treatment expectations. Higher trauma-related negative cognitions about self-blame and lower trauma-related negative cognitions about self were protective against dropout. The current study generated testable hypotheses for further research on dynamic predictors of dropout from CPT in female veterans with MST-related PTSD. With replication, results may assist with identifying pre-treatment strategies to reduce dropout in this clinical population.

Background As increasing research demonstrates that military sexual trauma (MST) is associated with suicidal ideation and attempts, discerning factors that place MST survivors at risk for these outcomes is critical. The present study aimed to: (1) characterize suicidal ideation and attempts among MST survivors; (2) identify factors associated with post-MST suicide attempts, post-MST suicidal ideation, and past-week suicidal ideation. Methods A convenience sample of 108 veterans (66 women, 42 men) who reported a history of MST participated in this cross-sectional study. Pre-MST suicidal ideation and attempt, childhood physical and sexual abuse, military sexual assault, institutional betrayal, and posttraumatic cognitions about self, world, and self-blame were examined, with age and gender as covariates. Results Seventy-five percent of participants reported experiencing post-MST suicidal ideation, and 40.7% reported attempting suicide following MST. Pre-MST suicide attempt and posttraumatic cognitions about self were associated with post-MST suicide attempt. Pre-MST suicidal ideation, military sexual assault, childhood physical abuse, and posttraumatic cognitions about self were associated with post-MST suicidal ideation. Lastly, pre-MST suicidal ideation and posttraumatic cognitions about self were associated with past-week suicidal ideation; results were unchanged when accounting for recent PTSD or depressive symptoms. Limitations The cross-sectional design, retrospective self-report, and small sample are limitations. Conclusions Addressing negative posttraumatic beliefs about self may be important for managing suicide risk among MST survivors. Assessing for pre-MST suicidal ideation and attempt is likely also warranted. Further understanding of the longitudinal impact of posttraumatic beliefs about self on subsequent risk for suicidal ideation and attempt is warranted.

From 2005 to 2016, the Veteran suicide rate increased 25.9%. Reducing this rate is a top priority for the Department of Veterans Affairs. In 2017, a policy change expanded emergent mental health services to include previously ineligible Veterans discharged under other than honorable conditions. To date, research examining the relationship between military discharge type and suicide risk has been limited.This study aimed to examine the association between discharge type (honorable versus administrative) and active suicide ideation among Veterans participating in the Survey of Experiences of Returning Veterans (N=850, data collection 2012-2015 and data analysis 2017-2018) using logistic regression. Stratified analyses explored whether gender, time since military separation, or recent mental health service use moderated this relationship.The prevalence of suicide ideation was significantly higher (p0.01) among Veterans reporting administrative discharge (23.1%, 95% CI=12.8, 33.3 vs 10.6%, 95% CI=8.4, 12.8). However, after accounting for lifetime suicide attempt history, combat experiences, posttraumatic stress disorder symptoms, depression, and drug dependence, discharge was no longer associated with suicide ideation. Recent mental health service use and time since separation significantly modified this relationship. The relationship was only significant among Veterans not using mental health services (OR=4.8, 95% CI=1.3, 18.2) and among transitioning Veterans2years from separation (OR=3.6, 95% CI=1.4, 9.2).These findings suggest that recognized risk factors for suicide, such as a history of mental health conditions, account for the increased prevalence of suicide ideation among Veterans with administrative discharges and that mental health services may have the potential to mitigate such risk in this high-risk Veteran population.

Racial disparities across various domains of health care are a long-standing public health issue that affect a variety of clinical services and health outcomes. Mental health research has shown that prevalence rates of posttraumatic stress disorder (PTSD) are high for Black veterans compared with White veterans, and some studies suggest poorer clinical outcomes for Black veterans with PTSD. The aim of this study was to examine the impact of racial disparities longitudinally in the U.S. Department of Veterans Affairs (VA) residential rehabilitation treatment programs (RRTPs).Participants included 2,870 veterans treated nationally in VA PTSD RRTPs in fiscal year 2017. Veterans provided demographic data upon admission to the program. Symptoms of PTSD and depression were collected at admission, discharge, and 4-month follow-up. Hierarchical linear modeling was used to examine symptom change throughout and after treatment.Black veterans experienced attenuated PTSD symptom reduction during treatment as well as greater depression symptom recurrence 4 months after discharge, relative to White veterans.This study adds to the body of literature that has documented poorer treatment outcomes for Black compared with White veterans with PTSD. Although both Black and White veterans had an overall reduction in symptoms, future research should focus on understanding the causes, mechanisms, and potential solutions to reduce racial disparities in mental health treatment.

Objective The Suicide Cognitions Scale (SCS) may be beneficial for suicide risk assessment. However, research has identified diverging factor structures and focused primarily on samples composed of males. Given limited prior research with female veterans, who have experienced increased rates of suicide, we examined the factor structure of the SCS among a national sample of female veterans. Method Four-hundred thirty-one female veterans using and not using Veterans Health Administration care participated in an anonymous survey. Results Exploratory factor analysis identified a three-factor solution, consistent with some prior research. This factor structure was not replicated in a confirmatory factor analysis. Conclusions Findings did not identify a consistent factor structure for the SCS among a sample of female veterans. Research is warranted to determine if suicide-specific cognitions differ among female veterans and to identify SCS items that should be added or removed to produce a more consistent factor structure among female veterans.HighlightsA consistent factor structure of the SCS among female Veterans was not identifiedSuicide-specific cognitions may differ among female VeteransAddition or removal of SCS items may be warranted in this population.

Background Female veterans experience interpersonal violence (ie, physical and sexual violence) more often than male veterans and nonveteran females. There is limited knowledge of types of interpersonal violence across the lifespan in relation to suicidal ideation and suicide attempt. Prior research has also focused on those accessing the Veterans Health Administration (VHA) care. Objective This study examined if physical and sexual violence at differing time points (ie, premilitary, during military service) were associated with suicidal ideation and a suicide attempt at subsequent time points. We anticipated that violence would be associated with an increased risk of suicidal ideation and attempt; however, given limited prior research, we were uncertain which types of violence and time points would be associated with risk. Research design Data from a cross-sectional national survey. Subjects A total of 407 female veterans using, formerly using, or who never used VHA care. Measures Suicidal ideation, suicide attempt, physical violence, and sexual violence were assessed. Results Premilitary sexual, but not physical, violence was associated with military suicidal ideation. Both premilitary and military sexual and physical violence were associated with postmilitary suicidal ideation. Premilitary and military sexual, but not physical, violence were associated with a postmilitary suicide attempt. These results were maintained after accounting for VHA use. A significant model for military suicide attempt was not generated. Conclusions Assessment of premilitary and military sexual violence among female veterans is warranted within the context of suicide risk assessment and prevention. Preventing sexual violence among female veterans may be important for preventing suicidal ideation and attempt.

Rates of suicide and posttraumatic stress disorder remain high among United States military personnel and veterans. Building upon prior work, we conducted a systematic review of research published from 2010 to 2018 regarding: (1) the prevalence of suicidal ideation, suicide attempt, and suicide among United States military personnel and veterans diagnosed with posttraumatic stress disorder; (2) whether posttraumatic stress disorder was associated with suicidal ideation, suicide attempt, and suicide among United States military personnel and veterans. 2,106 titles and abstracts were screened, with 48 articles included. Overall risk of bias was generally high for studies on suicidal ideation or suicide attempt and low for studies on suicide. Across studies, rates of suicidal ideation, suicide attempt, and suicide widely varied based on study methodology and assessment approaches. Findings regarding the association between posttraumatic stress disorder diagnosis with suicidal ideation and suicide were generally mixed, and some studies reported that posttraumatic stress disorder was associated with lower risk for suicide. In contrast, most studies reported significant associations between posttraumatic stress disorder and suicide attempt. These findings suggest complex associations between posttraumatic stress disorder and suicidal ideation, suicide attempt, and suicide, which are likely influenced by other factors (e.g., psychiatric comorbidity). In addition, most samples were comprised of veterans, rather than military personnel. Further research is warranted to elucidate associations between posttraumatic stress disorder and suicidal ideation, suicide attempt, and suicide, including identification of moderators and mediators of this relationship. Addressing this among United States military personnel, by gender, and in relation to different trauma types is also necessary.

Although rates vary, approximately 38.4% of women and 3.9% of men report experiencing military sexual trauma (MST). MST is associated with numerous psychosocial consequences, increased propensity for physical and mental health diagnoses, suicide, and an elevated likelihood of revictimization. Consequently, medical and mental health care for MST-related health sequelae is often warranted for individuals who have experienced MST; however, many MST survivors forgo or delay MST-related care, despite the fact that the Veterans Health Administration (VHA) provides free healthcare for MST-related health conditions. One potential explanation for this phenomenon is that survivors of MST feel betrayed by the military institution that they served when the MST occurred due to the institutional response to MST or perceptions that the institution failed to prevent MST from occurring. Perceptions of institutional betrayal may, in turn, decrease survivors' likelihood of disclosing MST and utilizing necessary treatment through VHA or affiliated institutions. A theoretical model of the role of institutional betrayal on help-seeking is proposed in which institutional betrayal serves as a potential barrier to utilizing MST-related healthcare. Potential mediators of this association (e.g., distrust, beliefs about safety) are also posited. This model offers utility in conceptualizing institutional factors that may influence helping-seeking following MST. By testing and refining such models, institutions and providers may be better-equipped to support MST survivors in obtaining necessary healthcare.

Deployment sexual trauma is associated with post-deployment suicidal ideation. No studies have examined the role of social support in this association. The present study examined if perceived unit support and post-deployment support influenced the association between deployment sexual trauma and suicidal ideation. 824 post-9/11 veterans (480 men, 344 women) from the Survey of Experiences of Returning Veterans completed the Deployment Risk and Resilience Inventory-2 and Columbia-Suicide Severity Rating Scale. Age, possible depression, posttraumatic stress disorder symptoms, and lifetime suicide attempt were covaried. Among men, post-deployment support moderated the association between deployment sexual trauma and suicidal ideation; deployment sexual trauma predicted suicidal ideation only for men reporting low post-deployment support. Among women, post-deployment support mediated the association between deployment sexual trauma and suicidal ideation. Unit support neither moderated nor mediated the association between deployment sexual trauma and suicidal ideation. Among men who experience deployment sexual trauma, those with low perceived post-deployment support may be at particularly elevated risk for suicidal ideation and may benefit from more intensive monitoring and interventions that bolster social support. Increasing perceived post-deployment support for women who experience deployment sexual trauma is also warranted. Determining optimal ways to strengthen post-deployment support for sexual trauma survivors is essential.

Posttraumatic stress disorder (PTSD) is associated with suicidal ideation (SI) and suicidal self-directed violence (SDV). Military sexual trauma (MST) is a common precursor to PTSD among veterans. Survivors of MST are more likely to be diagnosed with PTSD and are at greater risk for SI than survivors of other forms of trauma. Suicide-specific beliefs (e.g., unlovability, unbearability, unsolvability) have been shown to be strong predictors of SI and future suicidal SDV. Suicide-specific beliefs were examined over the course of treatment and follow-up in 32 veterans (23 women, 9 men) who received cognitive processing therapy (CPT) for MST-related PTSD. Hierarchical linear models revealed that veterans who received CPT had significant reductions in suicide-specific cognitions regarding unbearability, unlovability, and unsolvability. These preliminary findings warrant replication in a randomized controlled trial with a larger sample that includes participants with more acute suicidal intent.

Cognitive Processing Therapy (CPT) is an effective evidence-based treatment for many, but not all, veterans with posttraumatic stress disorder (PTSD). Understanding the factors that contribute to poorer response to CPT is important for providing the best care to veterans diagnosed with PTSD. Researchers investigating the effectiveness of CPT for individuals with comorbid personality symptoms have found that borderline personality disorder (BPD) characteristics do not negatively affect treatment outcome; however, participants in those studies were not diagnosed with BPD. The current pilot study investigated the effect of a BPD diagnosis on CPT dropout and outcomes. Data were compiled from a larger randomized clinical trial. Twenty-seven female veterans with military sexual trauma-related PTSD received CPT. Dropout was evaluated by treatment completion and number of sessions attended. Treatment outcome was assessed by the Clinician Administered PTSD Scale (CAPS) and the PTSD Checklist (PCL). No significant differences were observed between veterans with and without BPD comorbidity for number of treatment sessions attended, and there was not a significant relationship between comorbidity status and treatment completion. A hierarchical linear modeling approach was used with BPD entered as a level 2 predictor of outcome. In our sample, veterans with BPD had higher PTSD symptom severity on the CAPS at baseline compared to veterans without BPD comorbidity. CPT was effective in reducing PTSD symptoms; however, BPD diagnosis did not influence treatment response over time on the CAPS or PCL. Our results provide initial support for the use of CPT in female veterans with MST-related PTSD and comorbid BPD.

Cognitive Processing Therapy (CPT) is an evidence-based treatment (EBT) for posttraumatic stress disorder (PTSD) which has been validated for female veterans with military-related PTSD. Existing trials have enrolled predominantly White veterans with some studies documenting higher rates of early termination from EBTs among Black females when compared to White females. Data from a previously published randomized clinical trial were used to evaluate the effectiveness of CPT for Black female veterans with military sexual trauma (MST)-related PTSD. Reductions in PTSD symptom severity, number of sessions attended, and early termination rates were compared between Black (n = 20) and White (n = 16) female veterans. A hierarchical linear modeling approach was used, with PTSD symptom severity over the course of treatment and follow-up entered as a level-1 variable and race (Black or White) entered as a level-2 predictor. Piecewise growth curves analyses revealed that both Black and White female veterans experienced significant reductions in PTSD symptom severity over the course of treatment and gains were maintained up to 6 months post-treatment. Race was not found to be a significant predictor of change in the slope of PTSD symptom severity over the course of CPT treatment. Additionally, number of sessions attended and rates of early termination did not significantly differ based on race. Results suggest that CPT was a well-tolerated and effective psychotherapeutic treatment for this sample regardless of racial self-identification.

Veterans with military sexual trauma (MST) are at risk for a variety of psychiatric conditions, including posttraumatic stress disorder (PTSD) and depression. Survivors of MST are also likely to ex...

Background/Objective Male veterans ages 55–74 comprise a disproportionate number of suicide deaths among United States veterans, for whom a majority of suicides are firearm-related. Little is known about the firearm-related experiences and beliefs of veterans, which could be informative for firearm-related lethal means safety interventions. The aim of this qualitative study was to identify themes relevant to developing such interventions among older male veterans. Methods We conducted semi-structured qualitative interviews with seventeen United States male veterans, ages 50–70, who were eligible to receive Veterans Health Administration services, and were current or former firearm owners or users. Transcripts were analyzed via thematic analysis using an inductive approach. Results Six themes were identified: 1) Firearm experiences were usually facilitated by male family members and occurred at an early age; 2) Safety lessons during early firearm encounters focused on preventing unintentional injuries through safe firearm handling and using “common sense;” 3) Firearms serve an important social function across veterans’ lifespans (e.g., hunting with friends); 4) Veterans perceive firearms as useful for protection; 5) Veterans believe that not everyone should have access to firearms, and some described scenarios in which they acted to limit others’ access during unsafe situations; and 6) Veterans have preferences for who is involved in firearm safety discussions. Conclusions We identified themes relevant to developing firearm-specific lethal means safety interventions among older male veterans. Findings suggest potential obstacles (e.g., sociocultural value of firearms) to affecting changes in firearm behaviors, and factors that could potentially facilitate interventions (e.g., family involvement). Consideration of these findings may be important for developing personalized, effective interventions for this population.

Military sexual trauma is a potentially traumatic experience that can lead to a litany of negative mental health and psychosocial sequelae. In this chapter, we review research that has examined the association between military sexual trauma with suicidal ideation, suicide attempts, and suicide. We also describe research delineating factors associated with suicidal ideation and suicide attempts among survivors of military sexual trauma. We conclude by proposing an agenda for future research. Extant research has often found that military sexual trauma is associated with suicidal ideation, suicide attempt, or suicide. In addition, cognitive-affective, interpersonal, and institutional factors appear to be associated with suicidal ideation among veterans who have experienced military sexual trauma. Although knowledge in this area is growing, prior research has been limited by small sample sizes, measurement of suicide-related constructs and military sexual trauma, cross-sectional designs, and a tendency to focus on suicidal ideation. Several key questions remain. Longitudinal research is needed to identify trajectories and predictors of suicidal ideation and suicide attempts following military sexual trauma. Research on protective factors has also been sparse. Lastly, there remains a need for interventional research aimed at translating knowledge into prevention of suicidal self-directed violence among military sexual trauma survivors.

Female veterans are at elevated risk for dying by suicide compared to female civilians. Yet understanding of processes that place female veterans at risk for suicide remains limited. An epidemiological advance in knowledge of suicide among female veterans has revealed important subgroup differences and changes over time regarding age and receipt of Veterans Health Administration (VHA) care. Research on factors associated with suicide in female veterans, which has typically has been exploratory and theoretical, has largely focused on psychiatric diagnoses and stressful and traumatic events. This limits understanding of suicide among female veterans, as well as knowledge of modifiable risk and protective factors for suicide in this population. Applying current theories of suicide may help to address this. The Interpersonal-Psychological Theory of Suicide, Fluid Vulnerability Theory, Three-Step Theory, Cultural Model of Suicide, and Minority Stress Model may be relevant for understanding why female veterans who experience certain types of traumatic events or mental health experiences are at heightened risk for suicide. These theories also provide insight into previously understudied domains among female veterans. Nonetheless, given the paucity of theory-driven suicide research with female veterans, research is needed to determine optimal theories to better understand and prevent suicide among female veterans.

The Department of Veterans Affairs (VA) has implemented initiatives to promote veterans' recovery from the health sequelae of military sexual trauma (MST), including posttraumatic stress disorder (PTSD). MST can impact emotion regulation, interpersonal functioning, and perceptions of trust and safety, as well as increase risk for psychiatric comorbidity, which may impede PTSD treatment.. VA PTSD Residential Rehabilitation Treatment Programs (RRTPs) may facilitate the therapeutic process by offering increased structure, support, and adjunctive services. Limited research has examined the effect of MST on PTSD RRTP outcomes. Utilizing data from 7918 men and women veterans participating in a VA PTSD RRTP, the impact of the experience of MST on rates of program completion and changes in PTSD symptoms during and after treatment were examined. Rates of program completion were similar between those who did and did not report experiencing MST. Multilevel modeling was utilized to examine the impact of MST on PTSD symptoms after accounting for gender, age, race/ethnicity, and program completion. MST survivors endorsed more severe PTSD symptoms at admission; however, PTSD symptom severity scores were similar to those who did not report experiencing MST by discharge. Additionally, MST survivors had larger initial reductions in PTSD symptoms, followed by a greater recurrence of PTSD symptoms over time, compared to those who did not report experiencing MST. MST survivors appear able to participate in and benefit from PTSD RRTPs. Nonetheless, the increased recurrence of PTSD symptoms following discharge from residential treatment indicates the need for strategies to maintain post-treatment gains among MST survivors.

Background:Cognitive processing therapy (CPT) is an effective treatment for posttraumatic stress disorder (PTSD), including for veterans with military sexual trauma (MST)-related PTSD. Most CPT research to date has focused on pre- to post-treatment change in total PTSD symptoms; however, PTSD symptom criteria may not change equivalently over the course of treatment. For example, changes in re-experiencing symptoms have been shown to precede changes in other PTSD criteria during other PTSD treatments (i.e. virtual reality exposure therapy, venlafaxine ER). An improved understanding of the mechanism of change in PTSD symptoms during CPT may assist in optimizing treatment.Aims:The purpose of this study was to identify the pattern and temporal precedence of change in PTSD symptom criteria during and after CPT using cross-lagged panel analyses.Method:Data from veterans (n = 32) enrolled in a randomized clinical trial investigating the effectiveness of CPT for MST-related PTSD were utilized for this secondary analysis. Using hierarchical linear modelling, each symptom criterion was entered as a predictor of subsequent change in the other PTSD symptom criteria.Results:All symptom criteria followed a logarithmic pattern of change. Hyperarousal symptoms were found to both predict and temporally precede change in avoidance symptoms, but not re-experiencing symptoms. Re-experiencing and avoidance symptoms did not predict change in other PTSD symptom criteria.Conclusions:These findings provide initial support that targeting and reducing hyperarousal symptoms may be a key component of PTSD intervention with CPT. Additional research is needed to identify factors that predict change in PTSD-related re-experiencing symptoms.

No part of the world is immune from major disasters—be they natural disasters, industrial and technological accidents, or intentional human-caused incidents including acts of terrorism. Therefore, disaster preparedness is of paramount importance for all communities everywhere. Several decades of mental health research regarding disasters have generated essential data informing community response to the mental health needs of survivors of disaster. This research has generated principles for disaster mental health response and informed the development of operationalized procedures for the response using an established framework for emergency and medical response to mass casualty incidents. This article first reviews the research foundation for these principles and operationalized procedures and then summarizes recommendations for conducting an organized disaster mental health response. [ Psychiatr Ann. 2017;47(3):124–127.]

Although housing instability moderates suicide risk among military veterans, it is unknown whether suicide methods differ between stably and unstably housed veterans. The Veterans Health Administration screened 5,849,870 veterans for housing instability between October 1, 2012 and September 30, 2016. Death data were from the National Death Index. Unstably housed veterans had greater hazards of suicide mortality by jumping from a height (aHR = 3.07, 95%CI = 1.20–7.98) and unspecified means (aHR = 2.80, 95%CI = 1.63–4.80) than stably housed veterans. Translating these findings into optimal suicide prevention programming tailored to unstably housed veterans is essential.

Background Veterans who experience military sexual trauma are at increased risk for experiencing suicidal ideation, suicide attempt, and suicide. Yet few studies have attempted to discern factors that relate to suicidal ideation and suicide attempts among survivors of military sexual trauma. The present study aimed to identify psychiatric and interpersonal correlates of suicidal ideation (primary aim) and suicide attempt (secondary aim) among survivors of military sexual trauma. Methods This cross-sectional analysis included 115 veterans (56 females; mean age = 53.24) who participated in the National Health and Resilience in Veterans Study and reported experiencing military sexual trauma. Self-report measures assessed psychological distress, hazardous alcohol use, social support, loneliness, social acknowledgment following one’s worst trauma, suicidal ideation, and suicide attempts. Results Military sexual trauma survivors who reported more severe psychological distress (OR = 2.88), hazardous alcohol use (OR = 1.14), and perceived general disapproval from others (OR = 1.14) were significantly more likely to report experiencing suicidal ideation in the past two weeks. Hazardous alcohol use (OR = 1.19) and perceived general disapproval from others (OR = 1.36) were associated with being more likely to report attempting suicide in adulthood. Conclusions Addressing alcohol misuse, psychological distress, and perceived general disapproval from others in relation to one’s worst traumatic event is recommended when assessing and managing suicide risk among veterans who have experienced military sexual trauma. Findings also contribute to a growing literature highlighting the importance of understanding perceptions of the interpersonal response to trauma. Considering the cross-sectional design, longitudinal research is needed to further elucidate the roles of these constructs in predicting suicidal ideation and suicide attempt following military sexual trauma.

Although the Veterans Health Administration (VHA) provides free health care related to military sexual trauma (MST), many veterans forgo or delay such care, underscoring the need for research aimed at understanding MST survivors' perceptions and concerns regarding VHA care. This study employed a qualitative phenomenological approach to describe MST survivors': (a) perceptions of VHA care, (b) concerns about VHA care, and (c) suggestions for how VHA can facilitate recovery from MST. Fifty veterans (32 women, 18 men) with histories of MST participated in semistructured interviews. Transcripts were analyzed using thematic analysis. The pattern of themes was examined by gender and MST type. The majority of participants described neutral or positive perceptions of VHA care; however, a subset of participants described negative perceptions and reservations about using VHA care. Participants expressed concerns regarding distrust, provider compassion, privacy, stigma, shame, and continuity of care. Some women, particularly those who experienced military sexual assault, also described gender-related distress (e.g., feeling anxious or out of place, desire for separate facilities). Both men and women described wanting nonspecific support, improved continuity of care, and the ability to choose from a variety of treatment options (e.g., holistic, gender-specific). Further research is needed to examine if these findings are replicated in other samples. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Nonsuicidal self-injury (NSSI) has been understudied among survivors of military sexual trauma (MST). The aims of the current study were to: (1) describe characteristics of NSSI among survivors of MST and (2) determine if MST survivors who have engaged in NSSI differ from those who have never engaged in NSSI in terms of the severity of posttraumatic stress disorder (PTSD) and depressive symptoms, trauma-related cognitions, and recent suicidal ideation. Participants were 107 veterans (65 females, 42 males) with a history of MST who completed measures of NSSI, PTSD and depressive symptoms, recent suicidal ideation, and trauma-related cognitions. Approximately one-fourth of participants (n = 27; 25.23%) endorsed a history of NSSI. The majority of participants who engaged in NSSI reported that they first engaged in NSSI following MST (n = 18; 66.67%). MST survivors with a history of NSSI reported more severe PTSD symptoms, recent suicidal ideation, and trauma-related cognitions. NSSI was relatively common in the sample and was associated with a more severe clinical presentation. Longitudinal research is needed to understand the development, maintenance, and function of NSSI in MST survivors, especially as it pertains to risk for suicidal self-directed violence.

Differences in four adjustment stressors (family, interpersonal, career, and academic), and depression and anxiety symptoms were examined between White, non-Hispanic and White, Hispanic undergraduate college female students. White, Hispanic female college students reported significantly greater academic and family adjustment stressors than White, non-Hispanic students. None of the socioeconomic or demographic variables predicted adjustment stress, depression, or anxiety. Findings are discussed in terms of college mental health outreach and future research directions.

Military sexual trauma (MST) increases vulnerability for posttraumatic stress disorder (PTSD). Sexual trauma is also associated with increased risk for developing borderline personality disorder (BPD). Research has also documented a significant link between PTSD and BPD; however, there is a paucity of information examining this relationship among veterans with MST-related PTSD. In particular, we sought to examine whether comorbid BPD-PTSD compared with veterans with PTSD and no BPD resulted in increased PTSD and depression symptomatology. We also examined psychiatric, previous sexual trauma, and demographic factors to determine what—if any—factors were associated with comorbid BPD diagnosis. Using data from a recently conducted randomized clinical trial, we examined electronic medical records of the local Veterans Affairs Medical Center. Data from 90 veterans with MST-related PTSD were obtained. More than 22% ( n = 20) of the sample had a historical diagnosis of BPD. Participants were administered measures to assess psychiatric symptomatology (PTSD and depression), trauma-related negative cognitions (NCs), and previous sexual traumatization (e.g., childhood and civilian sexual exposure). An analysis of variance was conducted, which found that veterans with comorbid MST-related PTSD and BPD had significantly greater PTSD criterion B (avoidance) symptoms, depressive symptomatology, and NC scores than participants without comorbid BPD. In addition, a binary stepwise logistic regression found that veterans’ BPD was also positively associated with NCs about self and the world; however, self-blame, depression, PTSD, sociodemographic variables (e.g., gender, age), and previous sexual traumatizations were not significant predictors. Implications are discussed with regard to clinical care and future research directions.

The widely used posttraumatic stress disorder (PTSD) Checklist (PCL) has established reliability and validity, but it does not differentiate posttraumatic symptom frequency from intensity as elements of posttraumatic symptom severity. Thus, the PCL in its existing form may not provide a comprehensive appraisal of posttraumatic symptomatology. Because of this, we modified the PCL to create the PCL-I/F that measures both frequency and intensity of PTSD symptoms via brief self-report. To establish validity and internal consistency of the PCL-I/F, we conducted a pilot study comparing PCL-I/F scores to structured diagnostic interview for PTSD (the Clinician Administered PTSD Scale [CAPS]) in a male combat veteran sample of 92 participants. Statistically significant correlations between the PCL-I/F and the CAPS were found, suggesting initial validation of the PCL-I/F to screen and assess frequency and intensity of combat-related PTSD symptoms. Implications are discussed for screening and assessment of PTSD related to combat and non-combat trauma.

History of childhood sexual assault (CSA) may result in poorer emotion regulation and interpersonal functioning, potentially affecting the tolerability and effectiveness of evidence-based treatments (EBTs) for posttraumatic stress disorder (PTSD). Survivors of military sexual trauma (MST) have an increased incidence of CSA; however, research examining the role of CSA in EBTs for veterans with MST-related PTSD is limited. Data from 32 (9 male; 23 female) veterans with MST-related PTSD were used from a previously conducted randomized clinical trial examining the efficacy of an outpatient PTSD EBT (i.e., cognitive processing therapy [CPT]). Self-rated PTSD symptom severity was assessed at pretreatment, during treatment, and up to 6 months following treatment completion. Number of CPT sessions attended and treatment completion were also examined. Using a hierarchical linear modelling approach, results indicated both veterans with and without a history of CSA were found to benefit from CPT, and history of CSA did not significantly predict treatment response. Additionally, number of sessions attended and treatment completion did not significantly vary based on history of CSA. These preliminary findings provide support for the tolerability and efficacy of outpatient CPT in veterans with MST-related PTSD regardless of CSA history.

Reductions in trauma-related negative cognitions during Cognitive Processing Therapy (CPT) are theorized to precede posttraumatic stress disorder (PTSD) symptom reduction. This mechanism of change has not been validated for veterans with military sexual trauma-related PTSD. Using data from a previously published randomized clinical trial (n = 32), changes in trauma-related negative cognitions about self, self-blame, and the world were entered as predictors of change in PTSD symptoms for cross-lagged panel analyses. From baseline to 6-months posttreatment, only changes in self-blame predicted and temporally preceded changes in PTSD symptoms, highlighting a potential mechanism of change in CPT for military sexual trauma-related PTSD.

Objective The current study examined 11 male veterans with military sexual trauma (MST)-related posttraumatic stress disorder (PTSD) who participated in a larger randomized control trial comparing cognitive processing therapy (CPT) to a well-established control treatment (Present Centered Therapy; PCT) among men and women with MST-related PTSD. Method All participants ( n = 11) completed a 12 session protocol of CPT. The Clinician Administered PTSD Scale (CAPS), PTSD Checklist (PCL), and Quick Inventory of Depressive Symptomatology (QIDS) were administered at baseline and post-treatment sessions 2, 4, and 6 months after CPT completion. Additionally, the PCL and QIDS were administered every two sessions during CPT treatment. Results Piecewise growth curve analyses revealed that significant change over time in both PTSD and depressive symptoms was associated with the active treatment phase and that participants maintained treatment gains over the 6-month follow-up period. Conclusions CPT effectively reduced self-reported symptoms of PTSD as well as depressive symptoms for men with MST-related PTSD. Additionally, participants maintained the gains they made during treatment over a 6-month follow-up period. It is recommended that future studies examine patient characteristics that might impact outcome in order to improve understanding of who benefits the most from treatment.