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This study evaluated whether lifetime traumatic stress compared to deployment-related traumatic stress differentially affected the likelihood of insomnia in military personnel.Data were obtained from the Army Study to Assess Risk and Resilience in Servicemembers (unweighted N = 21,499; weighted N = 670,335; 18-61 years; 13.5% Female). DSM-5 criteria were applied to the Brief Insomnia Questionnaire to determine past month insomnia diagnostic status. A lifetime stress survey was used to assess traumatic stress encountered outside of the military, and a deployment-related stress survey assessed for various types of deployment-related traumatic stress.Adjusting for sex and psychiatric disorders, lifetime traumatic stress increased the prevalence for insomnia among those who endorsed combat death of close friend or relative, 1.021 (95% CI, 1.02-1.02), followed by those who reported other experiences that put them at risk of death or serious injury, 1.013 (95% CI, 1.01-1.01), whereas deployment-related traumatic stress showed that the prevalence for insomnia was highest for those who reported being sexually assaulted or raped, 1.059 (95% CI, 1.04-1.08), followed by those who endorsed being hazed or bullied by one or more members of their unit 1.042 (95% CI, 1.04-1.05).The cross-sectional nature of the assessment limits causal inferences and there was no clinician determined diagnosis for insomnia.Findings suggest that traumas over both one's lifetime and during deployment are associated with a higher prevalence for insomnia among Army soldiers. Results highlight the importance of considering both lifetime and deployment traumas into mental health assessment and treatment for active-duty soldiers.

Insomnia is a prevalent experience for individuals with serious mental illness, and is one of the most common reasons for mental health referrals in the Veterans Health Administration. Insomnia also critically impacts psychiatric, cognitive and somatic outcomes. However, there is limited information about how people with serious mental illness (i.e. schizophrenia spectrum, bipolar, or major depressive disorders, with serious functional impairments) understand and respond to problems with their own sleep. Bringing this information to light will yield novel methods of research and treatment. The purpose of this study was to examine reactions to insomnia among veterans with serious mental illness and insomnia. An inductive phenomenological approach was used to collect data from 20 veterans with serious mental illness and insomnia using semi-structured interviews. Six themes were identified: Becoming Aware that Insomnia is a Problem; Response to and Dissatisfaction with Medications; Strategies to Get Better Sleep: Contrary to Usual Guidelines; Personal Responsibility for Getting Sleep; Resigned and Giving Up; and Acceptance and Persistence. These results provide insight into the process of identifying insomnia and the subsequent cognitive and behavioural responses that are used to manage sleep disturbances among veterans with serious mental illness, a group often excluded from gold-standard treatments for chronic insomnia. Clinical implications and recommendations for improving treatment efficacy are discussed.

Peer specialists, or individuals with lived experience of mental health conditions who support the mental health recovery of others, often work side-by-side with traditional providers (non-peers) in the delivery of treatment groups. The present study aimed to examine group participant and peer provider experiences with peer and non-peer group co-facilitation. Data from a randomized controlled trial of Living Well, a peer and non-peer co-facilitated intervention for medical illness management for adults with serious mental illness, were utilized. A subset of Living Well participants (n = 16) and all peer facilitators (n = 3) completed qualitative interviews. Transcripts were coded and analyzed using a general inductive approach and thematic analysis. The complementary perspectives of the facilitators, teamwork between them, skillful group pacing, and peer facilitator self-disclosure contributed to a warm, respectful, and interactive group atmosphere, which created an environment conducive to social learning. Guidelines for successful co-facilitation emerging from this work are described.

Up to 80% of patients with schizophrenia experience sleep disturbances, which negatively impact daytime functioning. Given that the glutamatergic system is involved in the pathophysiology of schizophrenia as well as normal sleep-wake neurobiology, the current project aimed to determine whether sleep quality was related to brain glutamate levels in schizophrenia. The Pittsburgh Sleep Quality Index (PSQI) was used to assess subjective sleep quality and proton magnetic resonance spectroscopy (MRS) was used to quantify glutamate in the bilateral anterior cingulate, left parietal cortex, and left hippocampus. Results indicate that global PSQI scores were negatively correlated with the anterior cingulate and parietal glutamate levels. In patients with schizophrenia, poorer sleep quality correlated with greater positive symptom severity. Our findings suggest that poor sleep quality is related to greater positive symptom severity and lower levels of anterior cingulate glutamate in individuals with schizophrenia. Interventions to enhance sleep quality may prove beneficial for patients. Future studies will examine whether glutamate relates to objective measures of sleep quality, and whether glutamate may mediate the relationship between sleep quality and symptom severity across the schizophrenia-spectrum.

Purpose/objective To determine the rate of insomnia among active-duty soldiers with and without a history of traumatic brain injury (TBI). Research Method and Design: Data were extracted from the All Army Study (AAS), a cross-sectional, self-report survey completed by a representative sample of 21,499 U.S. Army soldiers from 2011 to 2013 as part of the Army Study to Assess Risk and Resilience in Servicemembers. History and severity of TBI were determined by participants' responses to questions regarding postinjury symptomology (i.e., loss of consciousness [LOC], amnesia, etc.). Insomnia symptoms were defined using DSM-5 criteria as measured by the Brief Insomnia Questionnaire. Results Approximately 63% of respondents reported lifetime history of mild TBI (mTBI), with ∼7% endorsing a history of moderate to severe TBI. Insomnia symptom prevalence rate increased with brain injury severity and number of TBIs with LOC, with ∼51% of those with mTBI and ∼55% of those with moderate to severe TBI demonstrating clinically elevated insomnia symptoms, compared to ∼37% insomnia prevalence rate among servicemembers without TBI. Conclusion/implications Results suggest high (> 50%) prevalence rates of insomnia symptoms among servicemembers with a lifetime history of brain injury, underscoring the need for behavioral sleep medicine interventions among active-duty personnel. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Purpose Poor sleep and pain are common in veterans with serious mental illness (SMI), yet it is unclear how these may impact dimensions of quality of life. As such, this study examined independent and additive contributions of sleep and pain difficulties on quality of life (QoL) among a sample of veterans with SMI and insomnia. Method Participants were 57 veterans with SMI (schizophrenia spectrum, bipolar, or major depressive disorders with significant functional impairment) and at least subthreshold insomnia (Insomnia Severity Index ≥8). Measures assessed sleep quality (Pittsburgh Sleep Quality Index), pain intensity (Pain Numeric Rating Scale [PNRS]), pain interference (Short Form 12 Health Survey), and QoL (World Health Organization Quality of Life-BREF). Multivariate multiple regression analyses examined the effects of sleep quality and pain on QoL. Results Forty-one veterans (71.9%) reported moderate-to-severe pain (PNRS ≥4). Poorer sleep quality was associated with greater pain interference and worse physical, emotional, and environmental QoL. Sleep quality, not pain, explained significant variance in environmental QoL (b = -2.30; 95% confidence interval [CI: -4.16, -.43]). Pain interference, not sleep quality, explained significant variance in physical health-related QoL (b = -.23; 95% CI [-.38, -.08]). Conclusions Results reveal the importance of screening for insomnia and chronic pain among veterans with SMI. For these veterans who already struggle with daytime functioning, interventions such as integrated cognitive-behavioral therapy for pain-related insomnia are warranted. Such treatments must account for how sleep disturbance and chronic pain may differentially impact multiple facets of QoL. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

OBJECTIVE: Many adults with serious mental illness exhibit significant medical illness burden and poor illness self-management. The present study examined Living Well, a group-based illness self-management intervention for adults with serious mental illness, co-facilitated by two providers, one who has lived experience with co-occurring mental health and medical conditions. METHODS: Adults with serious mental illness (N=242) were randomized to Living Well or an active control. Participants completed assessments of quality of life, health attitudes, self-management behaviors, and symptoms at baseline, post-treatment, and follow-up. Emergency room use was assessed via chart review. Mixed effects models examined group by time interactions on outcomes. RESULTS: In Living Well, compared to the control, there were greater improvements at post-treatment in mental health related quality of life (t=2.15, df=619, p=.032), self-management self-efficacy (t=4.10, df=622, p

Study Objectives The present study characterized a sample of 4,667 Army soldiers based on their patterns of insomnia before, during, and after deployment, and explored pre-deployment factors predictive of these patterns. Methods Data were analyzed from the Army Study to Assess Risk and Resilience in Service members (STARRS)—Pre/Post Deployment Study (PPDS), using surveys that captured data approximately 1–2 months pre-deployment, and 3- and 9-month post-deployment from soldiers deployed to Afghanistan. Patterns of insomnia across time were examined. Theoretically derived variables linked to sleep disturbance were examined as predictors of the insomnia patterns. Results Five longitudinal patterns of insomnia characterized the majority of the sample: “No Insomnia” (no insomnia symptoms at any timepoint; 31%), “Deployment-related Insomnia” (no pre-deployment insomnia, developed insomnia symptoms during deployment and recovered; 40%), “Incident Insomnia” (development insomnia during or shortly after deployment that did not remit; 14%), “Chronic Insomnia” (insomnia both pre- and post-deployment; 11%), and “Other Insomnia” (reported insomnia at ≥1 timepoint, but no clear pattern across the deployment cycle; 4%). Several pre-deployment factors were predictive of insomnia trajectories, including lifetime major depressive episodes, traumatic brain injury history, posttraumatic stress disorder, and past year personal life stressors. Conclusions Distinct longitudinal patterns of insomnia were identified, with more than half of the sample reporting insomnia at some point in the deployment cycle. Identifying mental health conditions that are associated with different insomnia patterns prior to deployment can inform targeted interventions to reduce long-term sleep difficulty.

Introduction Military personnel are at an increased risk for suicide compared to the general population, making it important to develop a deeper understanding of which factors contribute to this elevated risk. Given that suicidal ideation (SI) is one of the strongest predictors of suicide attempts, understanding factors that underlie SI may improve prevention efforts. Insomnia and depression both serve as independent risk factors for SI, and therefore the aim of this study was to examine the extent to which depressive symptoms moderate the association between insomnia and SI. Methods Data were obtained from the All Army Study of the Army Study to Assess Risk and Resilience in Servicemembers (STARRS). Soldiers (n=21,450) completed questions related to suicidal ideation (5 items), depressive symptoms (9 items), and insomnia (5 items) based on symptom presence in the past 30 days. Items in each domain were summed to create a total severity score. GEE models using a negative binomial linking function were conducted to examine the impact of depression, insomnia, and their interaction on SI. Results Both depression (χ2 =117.56, p Conclusion In a large sample of Army soldiers, depression significantly moderated the association between SI and insomnia, such that insomnia seems to amplify the effects of depression on SI. These findings highlight the importance of addressing insomnia severity as a mean of reducing SI in those with depression, potentially allowing for intervention prior to a suicide attempt. Support (if any) Perlis: K24AG055602 & R01AG041783. This publication is based on public use data from Army STARRS (Inter-university Consortium for Political and Social Research, University of Michigan- http://doi.org/10.3886/ICPSR35197-v1), funded by U.S. NIMH-U01MH087981.

This chapter is designed to provide a comprehensive overview of the regulation of sleep and circadian rhythms so that readers are well equipped to assess a broad number of sleep and circadian rhythm disruptions (SCRD). Whilst often not given a lot of attention in clinical or neuropsychology training, SCRD transcend numerous diagnostic boundaries and have grave implications for functioning, coping and prognosis, and should thus form an essential part of any assessment in psychosis. The aims of this chapter are to inform basic understanding of sleep and circadian rhythm biology (including a brief synopsis on the two-process model, the biological clock in the brain, and individual differences in sleep timing), before examining what disruption to this process can involve. Given that people with psychosis often have many coexisting problems (e.g. depression, anxiety, posttraumatic stress disorder), this chapter provides a brief overview of SCRD across the diagnostic spectrum before focusing on the most commonly found SCRD in psychosis. This should give readers a deeper understanding of the neurobiology underpinning SCRD, how SCRD manifests in people with psychosis, and the optimal assessment options to grapple with SCRD.

Psychosis-like experiences (PLEs), or attenuated positive symptoms of psychosis, present along a severity continuum and have been associated with distressing thoughts and impairments in functioning. Although knowledge of the clinical importance of PLEs is expanding, risk factors for their expression are still poorly understood. Sleep disturbances are one known factor that exacerbate PLEs expression and distress, and trauma exposure is associated with occurrence of PLEs, as well as increased risk of later sleep difficulties. This study examined the joint influences of sleep and trauma on PLEs in an undergraduate sample. Self-report questionnaires on presence and distress of PLEs, sleep problems, and occurrence of previous traumatic experiences were completed by participants (N=409). In order to determine the unique impact of sleep on PLEs, three sets of predictors: sociodemographic, psychosocial (including trauma), and sleep were entered in steps into a hierarchical multiple regression model. In the final model, specific sleep domains uniquely predicted PLEs, while previous trauma exposure, which was a significant predictor when entered in step two with other psychosocial variables, was no longer a significant predictor. Results suggest the possibility that disruptions in sleep following or occurring alongside a traumatic experience may somehow contribute to, or exacerbate the presence of PLEs.

Background: Insomnia has been identified as a key risk factor for suicide, though most studies have been limited to global measures of these constructs. The aim of the present study was to evaluate...

Objective Individuals with serious mental illness endorse many more medical and psychosocial barriers to physical activity (PA) than the general population. However, it is unknown if older adults with serious mental illness are at greater risk of experiencing barriers to PA than their younger counterparts. Method The present study utilized a national VA dataset to compare veterans with serious mental illness ages 55 and older (n = 9,044) to veterans with serious mental illness ages 54 and younger (n = 8,782) on their responses to a questionnaire assessment of barriers to PA. Results Older veterans were more likely to endorse arthritis and cardiopulmonary disease, and less likely to endorse work schedule, as barriers to PA. Conclusions and implications for practice Interventions designed to increase PA for young/middle-aged adults with serious mental illness may be broadly useful for older adults with serious mental illness, with some modification to address specific health concerns. (PsycINFO Database Record

Introduction Emotion-regulation and sleep-related difficulties are intertwined. Most research has focused on the impact of poor sleep on internalizing symptoms (e.g. depression, anxiety) but a few studies have found a that increased insomnia is associated with more externalizing symptoms (e.g. anger). This relationship may be particularly salient for military personnel, for whom poor sleep is endemic. It is important that this relationship be further investigated in order to understand the issues that Army servicemembers face. Methods Data were acquired from the All Army Study of the Army Study to Assess Risk and Resilience in Servicemembers (STARRS; N=21,449; 18–61 years old; 86.5% male). Participants completed the Brief Insomnia Questionnaire, an 11-item irritability and anger-related questionnaire and a 10-item questionnaire on anger attacks. Pearson correlations were used to examine the relationship between insomnia symptoms and emotional and behavioral components of anger, while controlling for depressive symptom severity. Results Insomnia severity in the past 30 days was significantly correlated with both emotional and behavioral expressions of anger (all p Conclusion In a nationally-representative sample of Army servicemembers, insomnia severity, particularly EMA, was associated with higher levels of irritability and anger (outbursts and anger attacks) over and above the effects of depression. These findings highlight the importance of treating insomnia in order to regulate anger expression within a military population. Support (if any) This publication is based on public use data from Army STARRS (Inter-university Consortium for Political and Social Research, University of Michigan-http://doi.org/10.3886/ICPSR35197-v1), funded by U.S. NIMH-U01MH087981.

Introduction Sleep dysfunction is pervasive in people with psychosis. Insomnia worsens psychotic symptoms and functioning, though treating insomnia can improve functioning. Cognitive Behavioral Therapy for Insomnia (CBT-I) is an effective treatment, but there has been limited research on CBT-I in persons with psychosis. There is mounting evidence that sleep disturbances in people with psychiatric disorders do not improve with treatment of psychiatric illness. The present study 1) developed empirical guidelines for tailoring CBT-I to the needs of people with psychosis and insomnia; 2) conducted a preliminary efficacy study of CBT-I with these novel guidelines for psychosis; and 3) utilized objective and subjective insomnia and functional measures. Methods Novel psychosis guidelines were developed in response to illness-related, environmental, and practical challenges for engaging in traditional components of CBT-I, identified via a series of 25 qualitative interviews and an uncontrolled acceptability trial. A preliminary efficacy study of CBT-I with novel psychosis guidelines was conducted against an active treatment comparison group. Forty-seven Veterans with insomnia and co-occurring psychotic-spectrum disorder completed sleep measures, including the Insomnia Severity Index (ISI), at baseline, post-treatment, and 3-month follow-up. Results Psychosis guidelines for CBT-I included supporting integrated care (e.g., with case managers, prescribers, etc.), simplifying instructions on all treatment materials, reminder handouts, reality testing with sleep-related experiences, cognitive restructuring guidance for common sleep-related cognitions held by people with psychosis, techniques for use during psychotic experiences at bedtime. At post-treatment and follow-up, there was a large effect of CBT-I on ISI scores (d = 1.00, 1.18, respectively). Further, a clinically significant reduction in mean ISI score of participants was observed in the CBT-I condition (> 6), but not in the control condition. Participants in the CBT-I group reported reductions in daily functional impairment due to sleep problems (from 89% to 50%), while the control group reported a slight increase in functional impairment (from 86% to 88%). Conclusion CBT-I delivered with guidelines for psychosis should be further investigated with a larger randomized controlled trial over a longer time period of 6 months. Support (if any) Time on this project was supported by the U.S. Department of Veterans Affairs, Rehabilitation Research and Development Service-1IK2RX001836, PI: Elizabeth A. Klingaman.

Objective The study was designed to explore patterns of prescriber communication behaviors as they relate to consumer satisfaction among a serious mental illness sample. Methods Recordings from 175 antipsychotic medication-monitoring appointments between veterans with psychiatric disorders and their prescribers were coded using the Roter Interaction Analysis System (RIAS) for communication behavioral patterns. Results The frequency of prescriber communication behaviors (i.e., facilitation, rapport, procedural, psychosocial, biomedical, and total utterances) did not reliably predict consumer satisfaction. The ratio of prescriber to consumer utterances did predict consumer satisfaction. Conclusions Consistent with client-centered care theory, antipsychotic medication consumers were more satisfied with their encounters when their prescriber did not dominate the conversation. Practice implications Therefore, one potential recommendation from these findings could be for medication prescribers to spend more of their time listening to, rather than speaking with, their SMI consumers.

Study objectives Insomnia is pervasive among people with serious mental illnesses (SMI) and has a profound negative impact on their psychiatric symptom management and recovery. However, little is known about the factors that affect severity of insomnia in those with SMI. In addition, very few studies have explored whether evidence-based interventions developed for those without SMI are appropriate for or applicable to individuals with SMI. The purpose of this study was to test the role of arousal, dysfunctional cognitions about sleep, and sleep-related behaviors in predicting severity of insomnia in a sample of 60 Veterans who were receiving care in Veterans Health Administration mental health and psychosocial rehabilitation programs and who reported subjective insomnia. In addition, information was collected regarding the types of insomnia treatments provided to these Veterans. Methods Participants completed assessments of insomnia severity and sleep-related arousal, behaviors, and cognitions. Medical records were reviewed to determine whether participants had been screened/assessed for insomnia and whether treatments for insomnia were provided before the date of referral to the study. Multiple regression was used to predict insomnia severity on the basis of these factors. Results Most participants (81.7%) reported moderate to severe insomnia, although only 3.3% had a diagnosis of insomnia in their medical records. Worry and helplessness about sleep were predictive of insomnia severity; better self-reported sleep hygiene and higher levels of arousal were also associated with greater severity of insomnia. Education about sleep hygiene and medication were the only types of insomnia treatment received. Conclusions Similar to insomnia among individuals without SMI, insomnia in Veterans with SMI is associated with dysfunctional sleep-related behaviors and cognitions. Many of the Veterans also lacked access to settings and resources conducive to healthy sleep. Veterans with SMI should be regularly assessed for insomnia. Research is needed concerning optimal evidence-based insomnia interventions for addressing behaviors and cognitions in this population in the context of these challenges.

Black consumers with serious mental illness (SMI) face significant challenges in obtaining quality mental health care and are at risk for experiencing significant disparities in mental health care outcomes, including recovery from mental illness. Patient-provider interactions may partly contribute to this disparity. The purpose of the current study was to understand the effects of race, psychosis, and therapeutic alliance on mental health recovery orientation among Veterans with SMI. Participants were Veterans who had an SMI being treated at two Veteran Affairs outpatient mental health clinics by a psychiatrist or nurse practitioner. Participants completed the Behavior and Symptom Identification Scale (BASIS-24), Mental Health Recovery Measure, and patient-report Scale to Assess the Therapeutic Relationship (STAR-P) which includes three subscales: positive collaboration, positive clinician input, and non-supportive clinician input. Regression analyses were used to determine interactive effects of race, psychosis severity, and therapeutic alliance variables. The sample was 226 Veterans (50% black, 50% white). Black participants were slightly older (p < .05), had higher baseline psychosis (p < .05), higher mental health recovery (p < .05), and perceived less non-supportive clinician input (p < .01) than white participants. Regression analyses indicated a significant three-way interaction among race, psychosis, and positive collaboration (p < .01). Greater positive collaboration attenuated the negative effect of higher levels of psychosis on mental health recovery orientation for black participants. Conversely, for white participants, positive collaboration had little effect on the negative relationship between psychosis severity and mental health recovery orientation. Increased levels of psychosis may inhibit patients’ perceptions of their ability to recover from SMI. However, for black participants, positive collaboration with mental health providers may moderate the effects of psychotic symptomatology.

Sleep problems are prominent and pervasive clinical issues experienced by many people with psychotic disorders, often causing distress and functional impairment. Sleep problems are also related to psychosis-like experiences (PLE; non-diagnosable phenomenon such as transient perceptual disturbances, unusual thoughts, periodic suspiciousness) in epidemiological studies. Prior studies in this field have used brief measures that precluded the ability to test (1) whether risk for psychosis-like experiences are related to specific sub-types of sleep disturbance, and (2) whether sleep disturbance is specifically related to clinically significant (i.e., distressing) psychosis-like experiences. The current project examined the relation between specific sleep issues, and PLEs and distress associated with PLEs, in a college sample. Participants (N=420) completed the Prodromal Questionnaire-Brief (PQ-B), which assesses PLEs and associated distress, and the Iowa Sleep Disturbances Inventory - extended version (ISDI-E), which assesses thirteen separate disturbed sleep domains. Symptoms of fragmented sleep, sleep hallucinations, and night anxiety significantly correlated with PLEs, and several sleep domains were significantly associated with PLE-related distress.

Older adults with serious mental illness (SMI) are an understudied population with complex care needs and high rates of obesity/overweight. Little is known about the experiences of older adults with SMI with weight management. The present study is an observational study of veterans ages 55 and over with a body mass index in the overweight or obese range, comparing Veterans with schizophrenia or bipolar disorder (n = 9044) to their same-age peers with no mental health disorders (n = 71156), on their responses to a questionnaire assessment of medical and psychosocial factors related to weight management. Responses to the questionnaire between August, 2005 and May, 2013 were used to examine the following: demographics, clinical characteristics, medical barriers to weight management, current weight loss plan, reliability of social support, reasons for being overweight, and weight loss barriers. Physical health concerns were highly prevalent in both groups. Veterans in the SMI group endorsed more medical issues and were significantly more likely to endorse experiences that indicated that their medical conditions were poorly controlled (e.g., shortness of breath). Veterans in the SMI group were more likely to endorse many barriers to healthy eating and physical activity, across medical, psychological, social, and environmental domains. Even within a sample at medically high-risk for complications related to obesity and metabolic syndrome, older veterans with SMI and overweight/obesity experience more challenges with weight management than their same-age peers with overweight/obesity and no mental health disorders. Weight management interventions for this population should take a multifaceted approach. (PsycINFO Database Record

Objective People with serious mental illness have dramatically reduced life expectancy that is largely attributed to elevated rates of chronic medical conditions. Several group interventions have been developed and implemented in recent years to improve health and wellness among people with mental health conditions. Unfortunately, attendance in these interventions is often low, and there is limited understanding of factors that influence patient engagement in this treatment modality. Method Participants (N = 242) were enrolled in 1 of 2 group-based health and wellness treatment programs. Using descriptive statistics and regression, we assessed treatment attendance and a range of potential predictors of attendance. Results We found lower attendance among people who were younger, people with more medical conditions, and people with more emergency room visits in the 6 months prior to the beginning of treatment. Younger age was a particularly strong predictor of low attendance and was the only variable significantly associated with attending zero treatment sessions. Conclusions and implications for practice These results highlight the need for strategies to improve engagement of patients with poorer objective indicators of medical health and patients with younger age. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Purpose Obesity disproportionately burdens individuals with serious mental illness (SMI), especially women. This observational study investigated whether there were sex differences in weight loss and program participation among veterans with SMI enrolled in the Veterans Health Administration's (VHA) MOVE! weight management program. Procedures Participants were identified from a national cohort of 148,254 veterans enrolled in MOVE! during fiscal years 2008 through 2012 who attended two or more sessions within 12 months of enrollment. The cohort included those with International Classification of Disease, 9th Edition, Clinical Modification (ICD-9-CM) diagnoses for SMI, age less than 70 years, and weight data at baseline and one or more follow-up timepoints within approximately 1 year of enrollment ( n = 8,943 men; n = 2,245 women). Linear mixed models assessed associations of sex with 6- and 12-month weight change from baseline, adjusting for demographic- and site-level variables. Findings Both sexes averaged 6.4 (standard deviation, 4.6) sessions within 12 months; however, women with and without SMI participated at rates double their respective proportion rates among all VHA users. Participants averaged statistically significant weight loss at 6 months (men, −2.5 lb [95% CI, −2.8 to −2.1]; women, −2.4 lb [95% CI, −3.1 to −1.7]) and 12 months (men, −2.5 lb [95% CI, −2.8 to −2.2]; women, −2.9 lb [95% CI, −3.6 to −2.2]), but no sex-based difference in absolute weight loss at either timepoint. Slightly more women achieved 5% or greater (clinically significant) weight loss at the 12-month follow-up than did men (25.7% vs. 23.0%; p Conclusions Women with SMI participated in MOVE! at rates equivalent to or greater than men with SMI, with comparable weight loss. More women were Black, single, had bipolar and posttraumatic stress disorder, and higher service-connected disability, suggesting areas for program customization.

Objective Person-centered psychiatric services rely on consumers actively sharing personal information, opinions, and preferences with their providers. This research examined predictors of consumer communication during appointments for psychiatric medication prescriptions. Methods The Roter Interaction Analysis System was used to code recorded Veterans Affairs psychiatric appointments with 175 consumers and 21 psychiatric medication prescribers and categorize communication by purpose: biomedical, psychosocial, facilitation, or rapport-building. Results Regression analyses found that greater provider communication, symptomology, orientation to psychiatric recovery, and functioning on the Repeatable Battery for the Assessment of Neuropsychological Status Attention and Language indices, as well as consumer diagnostic label, were positive predictors of consumer communication, though the types of communication impacted varied. Conclusions and implications for practice Provider communication is the easiest variable to intervene on to create changes in consumer communication. Future research should also consider how cognitive and symptom factors may impact specific types of consumer communication in order to identify subgroups for targeted interventions. (PsycINFO Database Record

Semi-structured qualitative interviews were conducted with 26 African American men with serious mental illness who were consumers of community mental health services and 26 members of their social support networks. All participants were asked what they believed had caused the consumers’ mental illness. Consumer participants most commonly identified chronic life stressors as a causal factor, while social supports most often identified intrinsic factors such as genetics or biology as causes of mental illness. Some support participants believed that unintentional drug use had precipitated the onset of mental illness or had no causal theories. The fact that some support participants could not identify a causal explanation may indicate failure on the part of mental health care systems to engage with consumers’ social support networks and provide education about mental illness and its causes. The implications of etiology beliefs on mental health service utilization are discussed.

Background Three-quarters of Iraq and Afghanistan veterans enrolled in Veterans Health Administration (VHA) care are overweight or obese. The VHA MOVE!® weight management program can mitigate the risks of obesity-related morbidity. However, many Iraq and Afghanistan veterans experience barriers to VHA services, which may affect participation, especially among those with posttraumatic stress disorder (PTSD) and/or depression. Little is known about MOVE! engagement among recent veterans. We describe a retrospective evaluation of MOVE! participation among Iraq and Afghanistan veterans with and without mental health problems. Methods As part of a national VHA mental health evaluation study, we accessed VHA patient care databases to identify Iraq and Afghanistan veterans receiving care from 2008–2013 who had ≥1 MOVE! visit(s) and ≥1 weight measurements (N=24,899). We used logistic regression to determine whether mental health conditions were associated with having 12 visits/year (desirable dose of care), adjusting for demographic, health, and utilization factors. Results Among Iraq and Afghanistan veterans enrolled in MOVE!, 4% had a desirable dose of participation. In adjusted models, desirable MOVE! participation was more likely among those without PTSD; those who were older, female, and unmarried; and those who had higher baseline weight, more medical comorbidities, no pain, psychotropic medication use, higher disability ratings, and more mental health visits. Limitations We used administrative ICD-9 codes. Sample only included veterans in VHA care. Conclusions Iraq and Afghanistan veterans, particularly those with PTSD, had low participation in VHA weight management programming. Correlates of MOVE! participation were identified, highlighting opportunities to tailor MOVE! to improve participation for these veterans.

STUDY OBJECTIVE To investigate the influence of sleep disordered breathing (SDB) on weight loss in overweight/obese veterans enrolled in MOVE!, a nationally implemented behavioral weight management program delivered by the National Veterans Health Administration health system. METHODS This observational study evaluated weight loss by SDB status in overweight/obese veterans enrolled in MOVE! from May 2008-February 2012 who had at least two MOVE! visits, baseline weight, and at least one follow-up weight (n = 84,770). SDB was defined by International Classification of Diseases, Ninth Revision, Clinical Modification codes. Primary outcome was weight change (lb) from MOVE! enrollment to 6- and 12-mo assessments. Weight change over time was modeled with repeated-measures analyses. RESULTS SDB was diagnosed in one-third of the cohort (n = 28,269). At baseline, veterans with SDB weighed 29 [48] lb more than those without SDB (P < 0.001). On average, veterans attended eight MOVE! visits. Weight loss patterns over time were statistically different between veterans with and without SDB (P < 0.001); veterans with SDB lost less weight (-2.5 [0.1] lb) compared to those without SDB (-3.3 [0.1] lb; P = 0.001) at 6 months. At 12 mo, veterans with SDB continued to lose weight whereas veterans without SDB started to re-gain weight. CONCLUSIONS Veterans with sleep disordered breathing (SDB) had significantly less weight loss over time than veterans without SDB. SDB should be considered in the development and implementation of weight loss programs due to its high prevalence and negative effect on health.

Introduction Most research conducted on insomnia and its development in military personnel focuses on cross-sectional data, precluding examination of the course of sleep changes over time. The present study characterized Army Soldiers based on insomnia symptom status trajectory from pre to post-deployment and explored baseline factors predictive of these trajectories in a sample of 7,245 soldiers across 3 Brigade Combat Teams. Methods Data were analyzed from the Army Study to Assess Risk and Resilience in Service members (STARRS)-All-Army Study (AAS) Pre Post Deployment Study, using surveys that captured 1-2 months pre-deployment, during deployment, and 6-months post-deployment. Insomnia symptom status was defined at each timepoint as insomnia symptoms that interfered with one or more domains of functioning at least some of the time in the past month. Theoretically-derived variables linked to sleep disturbance were selected as predictors of insomnia symptom trajectory and evaluated using a general linear selection model. Results Four trajectories characterized the majority of the sample: ‘good sleepers’ (no insomnia symptoms across time; 44.4%), ‘non-remitting new onset insomnia’ (no pre-deployment insomnia, developed insomnia symptoms during deployment that remained at 6 months; 22.8%), ‘deployment-only insomnia symptoms’ (no pre-deployment insomnia, developed insomnia during deployment but recovered by follow-up; 12.8%), and ‘chronic insomnia’ (insomnia both pre- and post-deployment; 7.4%). Several pre-deployment factors predicted insomnia trajectory, the strongest of which were past six-month attention deficit disorder symptoms, number of lifetime exposures to potentially traumatic events, and past month depression symptoms. Conclusion Insomnia is one of the most common reasons that military personnel seek behavioral health treatment and is associated with poorer military readiness. Better characterization and identification of insomnia symptoms over time can improve intervention during post-deployment transitions, particularly for those with new onset insomnia that does not remit. Support Cooperative agreement U01MH087981 (Department of the Army; U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Mental Health); U.S. Department of Veterans Affairs, Clinical Science Research and Development-IK2CX001874-PI:Katherine E. Miller, IK2CX001501-PI:Elaine M. Boland; Rehabilitation Research and Development-1IK2RX001836-PI:Elizabeth A. Klingaman. The views expressed here are those of the authors and do not represent the Department of Veterans Affairs.

Active duty service members as well as retired veterans are at greater risk for insomnia and/or sleep-disordered breathing (SDB) than the general population. Difficulties such as these may facilitate the development of or exacerbate psychiatric symptoms, as well as difficulties with cognition, and are a hallmark feature of mental health problems in this population. Cognitive behavioral therapy for insomnia (CBT-I) is an effective psychotherapeutic intervention for insomnia, while continuous positive airway pressure (CPAP) is effective in treating sleep-disordered breathing. While CBT-I is successful in ameliorating psychiatric symptoms in addition to sleep, less is known about its efficacy in individuals with psychosis, particularly in the veteran population. Regular screening is important among veterans with psychiatric disorders, but is not regularly assessed in clinics. Similarly, older adults are particularly susceptible to SDB, and early identification of the presence of sleep-disordered breathing may improve cognitive functioning and prevent rapid cognitive decline. The Veterans Health Administration is diligently working to improve access to sleep services, which will ultimately enhance the quality of life for many veterans.

OBJECTIVE Although dissatisfaction is a primary reason for disengagement from outpatient psychiatric care among consumers with serious mental illnesses, little is known about predictors of their satisfaction with medication management visits. The primary purpose of this study was to explore how dimensions of consumer preferences for shared decision making (i.e., preferences for obtaining knowledge about one's mental illness, being offered and asked one's opinion about treatment options, and involvement in treatment decisions) and the therapeutic relationship (i.e., positive collaboration and type of clinician input) were related to visit satisfaction. METHODS Participants were 228 Veterans with serious mental illnesses who completed a 19-item self-report questionnaire assessing satisfaction with visits to prescribers (524 assessments) immediately after visits. In this correlational design, a 3-level mixed model with the restricted maximum likelihood estimation procedure was used to examine shared decision-making preferences and therapeutic alliance as predictors of visit satisfaction. RESULTS Preferences for involvement in treatment decisions was the unique component of shared decision making associated with satisfaction, such that the more consumers desired involvement, the less satisfied they were. Positive collaboration and prescriber input were associated with greater visit satisfaction. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE When consumers with serious mental illnesses express preferences to be involved in shared decision making, it may not be sufficient to only provide information and treatment options; prescribers should attend to consumers' interest in involvement in actual treatment decisions. Assessment and tailoring of treatment approaches to consumer preferences for shared decision making should occur within the context of a strong therapeutic relationship.

This study evaluated internet use among 239 veterans with serious mental illness who completed questionnaires assessing demographics and internet use in 2010-2011. The majority of individuals (70 %) reported having accessed the internet and among those, 79 % had accessed it within the previous 30 days. Those who were younger and more educated were more likely to have accessed the internet, as were those with a schizophrenia spectrum disorder, bipolar disorder, or major depressive disorder, compared to individuals with PTSD. Veterans with serious mental illness commonly use the internet, including to obtain health information, though use varies across demographic characteristics and clinical diagnosis.

Objective The objective was to determine whether obesity screening and weight management program participation and outcomes are equitable for individuals with serious mental illness (SMI) and depressive disorder (DD) compared to those without SMI/DD in Veterans Health Administration (VHA), the largest integrated US health system, which requires obesity screening and offers weight management to all in need. Methods We used chart-reviewed, clinical and administrative VHA data from fiscal years 2010–2012 to estimate obesity screening and participation in the VHA's weight management program (MOVE!) across groups. Six- and 12-month weight changes in MOVE! participants were estimated using linear mixed models adjusted for confounders. Results Compared to individuals without SMI/DD, individuals with SMI or DD were less frequently screened for obesity (94%–94.7% vs. 95.7%) but had greater participation in MOVE! (10.1%–10.4% vs. 7.4%). MOVE! participants with SMI or DD lost approximately 1 lb less at 6 months. At 12 months, average weight loss for individuals with SMI or neither SMI/DD was comparable (−3.5 and −3.3 lb, respectively), but individuals with DD lost less weight (mean=−2.7 lb). Conclusions Disparities in obesity screening and treatment outcomes across mental health diagnosis groups were modest. However, participation in MOVE! was low for every group, which limits population impact.

Objective:This evaluation compared the effectiveness of MOVE!, a U.S. Veterans Health Administration (VHA) weight management program, among veterans with posttraumatic stress disorder (PTSD), other mental conditions, or no mental health diagnoses.Methods:VHA administrative data from 2008 to 2012 were used to estimate adjusted six- and 12-month weight change and ≥5% weight loss among 20,819 veterans with “intense and sustained” MOVE! participation (14% of 148,963 MOVE! participants, regardless of mental health status).Results:Compared with veterans with no mental health diagnoses, veterans with PTSD lost significantly less weight at six and 12 months (p

The objective of this study was to investigate the rates, predictors and correlates of insomnia in a national sample of US Army soldiers. Data were gathered from the cross-sectional survey responses of the All-Army Study, of the Army Study to Assess Risk and Resilience in Service members. Participants were a representative sample of 21 499 US Army soldiers who responded to the All-Army Study self-administered questionnaire between 2011 and 2013. Insomnia was defined by selected DSM-5 criteria using the Brief Insomnia Questionnaire. The results highlight significant functional difficulties associated with insomnia among US soldiers, as well as insights into predictors of insomnia specific to this population. Insomnia was present in 22.76% of the sample. Predictors of insomnia status in logistic regression included greater number of current mental health disorders, less perceived open lines of communication with leadership, less unit member support and less education. Insomnia had global, negative associations with health, social functioning, support, morale, work performance and Army career intentions. The results provide the strongest evidence to-date that insomnia is common in a military population, and is associated with a wide array of negative factors in the domains of health, military readiness and intentions to remain in military careers.

Background There has been a great deal of research on the comorbidity of insomnia and psychiatric disorders, but much of the existing data is based on small samples and does not assess the full diagnostic criteria for each disorder. Further, the exact nature of the relationship between these conditions and their impact on cognitive problems are under-researched in military samples. Method Data were collected from the All Army Study of the Army Study to Assess Risk and Resilience in Service members (unweighted N = 21, 449; weighted N = 674,335; 18–61 years; 13.5% female). Participants completed the Brief Insomnia Questionnaire to assess for insomnia disorder and a self-administered version of the Composite International Diagnostic Interview Screening Scales to assess for psychiatric disorders and cognitive problems. Results Military soldiers with current major depressive episode (MDE) had the highest prevalence of insomnia disorder (INS; 85.0%), followed by current generalized anxiety disorder (GAD; 82.6%) and current posttraumatic stress disorder (PTSD; 69.7%), respectively. Significant interactions were found between insomnia and psychiatric disorders; specifically, MDE, PTSD, and GAD status influenced the relationship between insomnia and memory/concentration problems. Limitations: Cross-sectional nature of the assessment and the absence of a comprehensive neurocognitive battery. Conclusion Psychiatric disorders moderated the relationship between insomnia and memory/concentration problems, suggesting that psychiatric disorders contribute unique variance to cognitive problems even though they are associated with insomnia disorder. Results highlight the importance of considering both insomnia and psychiatric disorders in the diagnosis and treatment of cognitive deficits in military soldiers.

Weight loss programs for veterans living with schizophrenia have demonstrated mixed efficacy, highlighting unique obstacles faced by this population. Data from a large national sample provide an opportunity to characterize the unique factors related to weight loss for veterans with schizophrenia. The present study compared veterans living with schizophrenia (n = 5,388) to veterans with no mental health diagnoses (n = 81,422) on responses to the MOVE!23, a multidimensional assessment of factors related to weight management.Responses to the MOVE!23 between August, 2005 and May, 2013 by veterans with a body mass index in the overweight or obese range were used to describe clinical characteristics, current strategies, perceived barriers, stages of readiness, and importance of and confidence to change behaviors related to their weight management.Both groups reported similar stages of readiness and high ratings of importance and confidence regarding weight loss behaviors. Compared with veterans with no mental health diagnoses, over 5 times as many veterans living with schizophrenia reported smoking to control weight, and a greater number endorsed 18 of the 21 barriers to modifying eating and physical activity.RESULTS highlight the necessity of addressing healthy lifestyles from a holistic perspective for all veterans. Adding regular physical activity as part of daily treatment may address the accessibility, safety concerns, and lack of social support reported as physical activity barriers. Increased access to healthier food choices and addressing smoking in conjunction with weight loss are also warranted.

The majority of people with serious mental illness experience insomnia, and insomnia is one of the most frequent reasons for mental health referrals in the Veterans Health Administration. Insomnia also represents a critical obstacle to mental health recovery. Little is known about how military veterans with mental health problems conceptualize their sleep and sleep problems; such information may uncover new avenues for research and treatment. Therefore, the purpose of this study was to explore how veterans with serious mental illness and insomnia experience and understand their sleep, towards the aim of identifying these new avenues. Participants included 20 veterans with insomnia and serious mental illness (i.e. schizophrenia spectrum, bipolar or major depressive disorders, with serious functional impairments). Data were collected via an inductive phenomenological approach using semi-structured interviews. We identified five themes: Sleep to Recharge; Sleep as a Fight; Sleep as Safety or Escape; Sleep as Dangerous; and Military Influence. Participants' relationship with sleep was complex; many associated it with intrusive and troubling hallucinations, paranoia and military experiences, yet at the same time desired sleep for its potential to liberate them from distress. Military mindsets both helped and hindered sleep. These results extend existing models of insomnia development and maintenance, and illuminate phenomena previously unidentified in this underserved veteran population. Clinical and theoretical implications are discussed, as well as new research directions for enhancing therapeutic efficacy.

The authors used social cognitive career theory (Lent, Brown, & Hackett, 1994) as the basis for examining the person and contextual variables of gender, ethnicity, educational and career barriers, and career-related parent support for incoming 1st-year African American, Asian, Latino, and White college students. Women, as compared to men, perceived significantly higher levels of career barriers but similar levels of coping efficacy in dealing with these barriers. Women also reported receiving more career-related emotional support from parents than did men. For all participants, career-related parent support accounted for a significant portion of the variance for perceptions of educational and career barriers and coping efficacy with educational and career barriers.

Adherence to recommendations for monitoring of metabolic side effects of antipsychotic medications has been historically low. This randomized controlled trial tested whether a computerized, patient-centered intervention that educated Veterans with serious mental illness about these side effects and encouraged them to advocate for receipt of monitoring would increase rates of monitoring compared to enhanced treatment as usual. The mean proportion of days adherent to monitoring guidelines over the one-year study was similarly high and did not differ between the intervention (range: 0.81 – 0.98) and comparison (range: 0.76 – 0.96) groups. Many individuals in both groups had persistent abnormal metabolic parameter values despite high rates of monitoring, contact with medical providers, and receipt of cardiometabolic medications. Participants exposed to the intervention were interested in receiving personalized information about their cardiometabolic status, demonstrating the preliminary feasibility of brief interventions for enhancing involvement of individuals with serious mental illness in health care decision making.

The current study explored the relation of ethnic identity achievement and career development progress among a sample of 2,432 first-year college students who completed the Career Decision Profile and Phinney's Multigroup Ethnic Identity Measure. Among students of color, correlational analyses revealed a series of statistically significant, but small positive correlations between higher levels of ethnic identity achievement and career decidedness, choice comfort, indecisiveness, and choice importance. Additionally, racial group was found to moderate the relation between ethnic identity achievement and career decidedness. For Black and Asian American students, those with higher levels of ethnic identity achievement were found to have significantly higher levels of career decidedness, whereas ethnic identity achievement had no significant relation with the decidedness of White and Latina/o students. It is suggested that for first-year students of color, ethnic identity achievement may play a meaningful, but limited role in being decided in one's career decisions. Research and practice implications are discussed.

This study characterized and compared Veterans of the United States Armed Forces with posttraumatic stress disorder (PTSD) to Veterans with no mental health disorders on self-reported measures of factors that influence success in weight management programs.We examined the relation of PTSD diagnosis with weight loss plan, reasons for overweight/obesity and barriers to dieting and physical exercise among 171,884 Veterans. Statistically significant variables in chi-square tests (P.05) with at least a small effect size were then compared via multivariate logistic regression analyses.Both groups reported high ratings of importance and confidence regarding changing weight loss behaviors and were preparing or actively engaging in efforts to manage their weight. Compared to Veterans without mental health disorders, more Veterans with PTSD endorsed 27 of the 28 barriers to changing eating and physical habits.The results of this study help to explain the lower rates of success of Veterans with PTSD in weight loss programs. Results suggest that a comprehensive, integrated approach to promoting weight loss in Veterans with PTSD is needed.

Up to 80 % of individuals with schizophrenia spectrum disorders experience sleep disturbances, which impact physical and mental health, as well as quality of life. In this paper, we review and integrate emerging literature, published between 2012 and 2014, regarding approaches to diagnosis and treatment of major sleep disorders for people with schizophrenia spectrum disorders, including insomnia, obstructive sleep apnea (OSA), circadian rhythm dysfunction, and restless legs syndrome (RLS). We advocate for (1) the need to evaluate the utility of nonpharmacological approaches in people with schizophrenia spectrum disorders; (2) documentation of guidelines to assist providers in clinically tailoring such interventions when their clients experience positive, negative, and/or cognitive symptoms; (3) research on the best ways providers can capitalize on clients’ self-identified needs and motivation to engage in sleep treatments through shared decision making; and (4) the importance of investigating whether and how mental health and sleep treatment services should be better connected to facilitate access for people with schizophrenia spectrum disorders. Assessment and tailored treatment of sleep disorders within mental health treatment settings has the potential to reduce sleep problems and improve functioning, quality of life, and recovery of this population.

Stigma sentiments are the attitudes held toward a culturally devalued label or group. The present study measures schizophrenia stigma sentiments and self-identity to assess self-stigma experienced by people with schizophrenia.Ninety individuals with schizophrenia and 23 controls with no history of psychosis rated the evaluation, potency, and activity of "A person with schizophrenia or schizoaffective disorder," (stigma sentiments) and of "Myself as I really am" (self-identity). t tests, correlations, and regression analysis were used to (a) test relationships among stigma sentiments and self-identity in the groups separately; (b) test a model for predicting self-identity in the schizophrenia group, using stigma sentiments, current symptoms, and current functioning; and (c) compare the participant groups' stigma sentiments and self-identities.The evaluation category of self-identity and of stigma sentiment were correlated in the schizophrenia group, r(88) = .44, p.001, but not in the control group. Current symptoms and the evaluation category of stigma sentiments were significant predictors of the evaluation category of self-identity in the schizophrenia group. The evaluation and potency stigma sentiments reported by the 2 groups did not differ; the control group rated itself more favorably on evaluation and potency than did the schizophrenia group.Self-evaluation of individuals with schizophrenia was less favorable than self-evaluation of individuals with no psychosis history, and evaluation attitudes held by individuals with schizophrenia regarding the schizophrenia label were associated with their self-identity. Results suggest preliminary utility of this simple measure in identifying self-stigma experienced by individuals with schizophrenia.

This study evaluated preferences for shared decision making with respect to mental health treatment in a sample of veterans who were diagnosed as having serious mental illness.Participants were 239 outpatients receiving care from the Department of Veterans Affairs who completed self-report questionnaires assessing demographic factors, shared decision-making preferences, psychiatric symptom severity, and the therapeutic relationship with their second-generation antipsychotic prescribers (N=21). Preferences were assessed in regard to three components of decision making: knowledge about mental illness, options about mental health treatment, and decisions about mental health care.Most participants (85%) indicated that they preferred to be offered options and to be asked their opinions about mental health treatment. More variability was noted in preferences for obtaining knowledge and making final treatment decisions; 61% preferred to rely on their providers' knowledge and 64% preferred their provider to make treatment final decisions. Greater preferences for participation in shared decision making were found among African American clients, those currently working for pay, those with college or higher education, those with other than a schizophrenia spectrum diagnosis, and those who reported a poorer therapeutic relationship with their prescribers.The degree to which veterans with serious mental illness desired to participate in their mental health care differed in terms of the aspect of care and across demographic and clinical factors. A thorough assessment of shared decision-making preferences is an important component of recovery-oriented, client-centered care.